1 

a 

H  Presented  by 

§Alfons  I.  Wray,  B.  0.,  F.  0.   C.  0. 


A^L 


COl  LEGE    OF    OSTEOPATHIC     PHYSICIANS 
VND  SURGEONS  •    LOS  ANGELES,  CALIFORNIA 


AN  AMERICAN  TEXT-BOOK 
OF  DISEASES  OF  THE  EYE, 
EAR,  NOSE,  AND  THROAT7 

EDITED  BY 

G.  E.  deSCHWEINITZ,  A.M.,  M.  D. 

Professor  of   Ophthalmology  In  the   Jefferson    Medical  College,  Philadelphia  ;    Consulting 

Ophthalmologist  to  the    Philadelphia    Polyclinic;    Ophthalmic   Surgeon   to 

the    Philadelphia    Hospital    and    to  the    Orthopedic    Hospital 

and    Infirmary  for   Nervous   Diseases 


AND 


B.  ALEX.  RANDALL,  M.A.,  M.  D.,  Ph.D. 

Clinical    Professor   of   Diseases   of  the    Ear   in   the    University   of   Pennsylvania;     Professor 

of   Diseases  of   the    Ear   in  the    Philadelphia    Polyclinic  ;     Ophthalmic   and 

Aural    Surgeon   to  the    Methodist   and    Children's   Hospitals, 

Philadelphia 


ILLUSTRATED  WITH  766  ENGRAVINGS, 
59  OF  THEM  IN  COLORS 


PHILADELPHIA 

W.    B.    SAUNDERS 

925  Wai  mi    Stri 
1899 


Copyright,  1899, 
By   W.     B.    SAUNDKRS. 


ELECTBOTYPEO   BY  PRESS  OF 

WESTCOTT  &  THOMSON,   PHILAOA.  W.   B.   8AUNDERS.    PHILAOA. 


CONTRIBUTORS. 


HENRY   A.  ALPERTOX,  M.  D.,  Brooklyn,  N.  Y. 

Chief  of  Aural  Clinic,  Polhemus  Memorial  Clinic,  Long  Island  Medical  College  :    \ural 
Surgeon  to  the  Brooklyn  Eye  and  Ear  Hospital. 

HARRISON  ALLEN,  M.  D„  Philadelphia.  Pa. 

Late  Professor  of  Comparative  Anatomy,  University  of  Pennsylvania:  late  Professor 
of  Diseases  of  the  Nose  and  Throat,   Philadelphia  Polyclinic. 

ERANK   ALLPORT.  M.  D.,  Chicago,  III. 

Professor   of  Ophthalmology,    Chicago    Polyclinic  ;    Professor   of  Ophthalmology  and 
Otology,  Northwestern  University,  Woman's  Medical  College. 

MORRIS  J.  ASCH,   M.  D.,  New  York  City. 

Surgeon  to  the  Throat  Department  of  the  New  York  Eye  and  Ear  Infirmary ;  Surgeon 
to  the  Throat  Department,  Manhattan  Eye  and  Ear  Hospital. 

S.  C.  AYRES,  M.  D.,  Cincinnati,  Ohio. 

Professor  of  Ophthalmology  and  Otology,  Medical  College  of  Ohio,  Medical  Department 
of  the  University  of  Cincinnati. 

R.  O.  BEARD,  M.  D.,  MINNEAPOLIS,  MlNN. 

Professor  of  Physiology  in  the  Department  of  Medicine  of  the  University  of  Minnesota. 

CLARENCE   J.   BLAKE.    M.  D.,  Bosto.v.  Mass. 

Professor  of  Otology,  Harvard  Medical  School;   Aural  Surgeon  to  the  Massachusetts 
Charitable  Eye  and  Ear  Infirmary. 

ARTHUR    AMES    BLISS.   A.  M.,   M.   D.,  PHILADELPHIA,  Pa. 

Larynjjolojfist  and  Aurist  to  the  German    Hospital  ;    late  Attending  Laryngologisl   to 
the  Pennsylvania   Institution  for  the  Deaf  and  Dumb. 

A.  P.   BRIT5AKER.   M.    I).,  PHILADELPHIA,  l'\. 

Adjunct  Professor  of  Physiology  and  Hygiene,  Jefferson  Medical  College;  Professor  of 
Physiology  and  General  Pathology,  Pennsylvania  College  of  Dental  Surgery. 

J.   H.    BRYAN.   M.    I)..  WASHINGTON,  \>.  i\ 

Late   Passed    issistanl  Surgeon,  U.  S.  Navy;  Surgeon  to  the  Throat  and   Ear  Depart- 
ment, Garfield  Memorial  Hospital. 

ALBERT   IL  BUCK,  M.  !>..  New  York  city. 

Clinical  Professor  of  Diseases  of  the  Ear,  College  of  Physicians  and  Surgeons,  Medical 
Department  of  Columbia  University;  Consulting  Aural  Surgeon,  New  York  Eye  and  Ear 

Intirmary. 

F.  BULLER.    M.    I)..  MONTREAL,  CANADA. 

Professor  of  Ophthalmology  and  Otology,  McGill  University;  Ophthalmic  and  Aural 
Surgeon  t"  the  Royal  Victoria  Hospital. 

SWAN    M.   BTTBNETT.  M.  D..  Washington,  D.  C. 

Professor  of  <  (phthalmology  and  <  ttology,  Medical  Department,  <  teorgetown  I'niv. 
Director  of  the  Eye  and  Ear  Clinic,  Central  Dispensary  and  Emergency  Hospital. 

FLEMMING    CAEEOW,   M.   D..  Ann    \ri:..r,  MlCH. 

Professor  of  Ophthalmology  and  Otology,  University  of  Michigan. 

3 


Li  xJ   .A  G  %J 


4  CONTRIBUTORS. 

\Y.  E.  i   ISSELBEEEY,  M.  D..  Chicago,  III. 

Professor  of  Laryngology  and  Ehinology,  Northwestern  University  Medical  School. 

COLMAN  W.  CUTLEB,   M    D.,  New  York  City. 

Attending  Ophthalmologist  to  St.  Luke's  and  II.  I.  Hospitals:  Assistanl  Surgeon,  New 
York  Eye  and  Ear  Infirmary. 

EDWAED  B.  I»K\<II.  Ph.  B.,  M.  D.,  New  York  City. 

Professor  of  Otology,  University  and  Bellevue  Hospital  .Medical  College;  Consulting 
Otologist  to  St.   Luke's  Hospital. 

\\M.  S.  DENNETT,  A.  B.,  M.  If.  New  York  City. 

Surgeon  to  the  New  York  Eye  and  Ear  Infirmary. 

G.  E.  de  S<  HWEINITZ,  A.  M..  M.  D.,  Philadelphia,  Pa. 

Professor  of  Ophthalmology,  Jefferson  "Medical  College;  Ophthalmic  Surgeon  to  the 
Philadelphia  Hospital  :  Consulting  Ophthalmologist  to  the  Philadelphia  Polyclinic. 

Al.l'.X AM'Li;    DTJANE,  M.  I)..  New  York  City. 

Assistant  Surgeon  and  Instructor  in  Physiological  Optics,  New  York  Ophthalmic  and 
Aural    Institute. 

JOHN  W.  FABLOW,  M.  D.,  Boston,  Mass. 

Physician  for  Diseases  of  the  Nose  and  Throat.  Boston  City  Hospital ;  Instructor  in  Lar- 
yngology, Harvard  University,  Boston. 

WALTEB  J.  FEEEMAN,  M.  D.,  Philadelphia,  Pa. 

Professor  of  Diseases  of  the  Nose  and  Throat.  Philadelphia  Polyclinic;  Laryngologist 
to  the  Orthopedic  and  Children's  Hospitals. 

H.  GIFFOBD,  B.  S.,  M.  D.,  Omaha,  Neb. 

Professor  of  Ophthalmology  and  Otology,  Omaha  Medical  College. 

W.  C.  GLASGOW,  M.  1)..  St.  Louis,  Mo. 

Professor  of  the  Practice  of  Medicine,  Diseases  of  the  Chest,  and  Laryngology,  Missouri 
Medical  ( lollege. 

.1.  ORNE  GEEEN,  M.  1)..  Boston,  M  \~. 

Clinical  Professor  of  Otology,  Harvard  University;  Visiting  Aural  Surgeon.  Boston 
City   Hospital. 

\V\i;l)  A.   HOLDEN,  \.  M.,  M.  D.,  New  York  City. 

Assistant  in  the  Lye  Department  of  the  Vanderbilt  clinic.  College  of  Physicians  and 
Surgeons,  Columbia  University:  Pathologist  to  the  New  York  Ophthalmic  and  Aural 
Institute. 

(  HEIST]  \n   i;    HOLMES,  M.  if.  Cincinnati, o. 

Professor  of  Otology,  Miami  Medical  College  :  ophthalmic  Surgeon.  Cincinnati  Hospital. 

WILLIAM    E.    HOPKINS.    M.    If.  "^    FRANCISCO,  CAL. 

Professor  of  Ophthalmology,  Post-Graduate  Medical  Department,  University  of  Cali- 
fornia; Associate  Professor  of  Ophthalmology  and  Laryngology,  Universitj  of  California. 

I     C    HOTZ,   M.   If.  '  ""  x'"-  '"•■ 

Profi  bthalmology  and  Otology,  Bush  Medical  College ;  Professor  of  Ophthal- 

mology, <  'hicago  Polyclinic. 

LUCTEN    HOWL.   M     \  .  M.   D.,  M.    R.  C.  S.,  ENG.,  Bl  i  FALO,  N.  Y. 

Professor  of  Ophthalmology,  University  of  Buffalo. 

ALYIN    A     HUBBELL    M.    D.,  Ph.   If.  BUFFALO,  N    Y 

clinical  Professoi  of  Ophthalmology  and  Otology,  Medical  Department.  University  of 
Buffalo. 

i.dw  \i;d  3  \«  k<(i\.    \    m ..  m.ii  Denv]  k,  Col. 

Emeritus  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic 

.1    ELLIS  JENNINGS,  M.  D..  St.  Loi  [S,  Mo 

Formerly  Clinical  Assistant.  Royal  London  Ophthalmic  Hospital,  Moorflelds;  Lecturer 
..n  <  Iphthalmoscopy  and  Chief  of  the  Eye  Clinic  in  the  Beaumonl  Hospital  Medical  <  Allege. 


CONTRIBUTORS.  5 

HERMAN    ENAPP,    M.    M.  New   FoBK  I 

1 ' i-. .it  --. >i-  of  i  Ophthalmology,  College  of  Physicians  and  Surgeons,  Columbia  University  ; 
Surgeon  to  the  New  York  Ophthalmic  and  Aural  Institute. 

I  BARLES  W.  EOLLOCK,  M.   1)..  Charleston,  S.  C. 

Lecturer  on  Diseases  of  the  Eye  and  Ear  in  the  Charleston  Medical  School ;  Ophthalmic 
Surgeon  to  the  Charleston  City  Hospital. 

(i.    \.  LELAND,  A.  M  .  M.  D.,  Boston,  Mass. 

Aural  Surgeon  bo  <  >ut-Patient  Department,  and  Assistant  in  Throat  Department,  Boston 
City  Hospital;  Professor  of  Laryngology  and  Otology,  Dartmouth  Medical  School. 

J.   A.   LIPPINCOTT,  A.  B.,  M.  D.,  PlTTSBUBG,  Pa. 

Ophthalmic  and  Aural  Surgeon,  Allegheny  General  Hospital. 

G.  HUDSON  MAKUEN,  M.  D..  Philadelphia,  Pa. 

Professor  of  Defects  of  Speech,  Philadelphia  Polyclinic  and  College  for  Graduates  in 
Medicine;  Laryngologist  to  St.  Mary's  Hospital  and  to  the  Frederick  Douglass  Memorial 
Hospital. 

JOHN   H.  McCOLLOM,  M.  D.,  Boston,  Mas& 

Instructor  in  Contagious  Diseases,  Harvard  University;  Resident  Physician.  Smith 
Department,  Boston  City  Hospital. 

HOEA(  E   G.  MILLER.  A.  M..  M.  D.,  Providence,  R.  I. 

Ophthalmic  and  Aural  Surgeon  to  the  Rhode  Island  Hospital :  Consulting  Ophthalmic 

and  Aural  Surgeon  to  St.  Joseph's  Hospital. 

B.  L.  MILLION,  M.  D.,  Cleveland,  Ohio. 

Professor  of  Ophthalmology,  Medical  Department.  Western  Reserve  University  ;  oph- 
thalmic Surgeon  to  Lakeside  Hospital. 

EOBEET   C.   MYLES,   M.  D.,  New  Yoek  City. 

Professor  of  ( >tology  and  Adjunct  Professor  of  Rhinology  and  Laryngology,  New  York 
Polyclinic:    Assistant  Surgeon    to   the    .Nose.    Throat,  and    Ear   Department  of   the    New 

Amsterdam   Eye  and  Ear  Hospital. 

JAMES   E.  NEWCOMB,  M.  D.,  New  Yoke  City. 

Attending  Laryngologist  to  the  Out-Patieut  Department,  Roosevelt  Hospital,  and  to 
the  Demilt  Dispensary;  Instructor  in  Laryngology,  Cornell  University  Medical  College. 

R.  J.  PHILLIPS.  M.  D.,  Philadelphia,  Pa. 

Ophthalmic  Surgeon  to  the   Presbyterian  Hospital,  the  Presbyterian  Orphanage,  ami 

the   Friend-'   Home  for  Children. 

GEORGE  A.  PIEESOL,  M.  D..  Philadelphia,  Pa. 

Professor  of  Anatomy.  University  of  Pennsylvania. 

w.  PEYEE  POB<  BEE,   M.  D.,  Chaeleston,  S.  C. 

Lecturer  on  Diseases  of  the  Throat  and  Nose,  Charleston  Medical  School;  \i-it iiiLT 
Laryngologisl   to  city  Hospital. 

B.  ALEX.  BANDALL,  M.  A.,  M.  D.,  Philadelphia,  Pa. 

Clinical  Professor,  Diseases  of  the  Ear.  University  of  Pennsylvania;  Professor  of 
Diseases  of  the  Ear,  Philadelphia  Polyclinic. 

ROBERT   I..  RANDOLPH,   M.  D.,  Baltimore,  Md. 

Associate  in  Ophthalmology  and  Otology,  Johns  Hopkins  University;  Associate  Oph- 
thalmic and  Aural  Surgeon  to  the  Johns  Hopkins  Hospital. 

JOHN   <».  ROE    M.  I)..  Rochest]  b,  N.  Y. 

Laryngologisl  to  the  Rochester  City  Hospital. 

CHAS.  F.  de  M.  SAJOUS,  M.  l>..  Philadelphia,  Pa. 

Fellow  of  the  American,  British,  and   French  Laryngological  Associations. 

J.  E.  SHEPPARD,   M.   D.,  Bbooki  \  v  N    Y. 

clinical   Professor  of  Diseases  of  the   Ear,  Long   Island  College  Hospital ;   Prof 
Otology,  New  York  Polyclinic  Medical  School  and  Hospital. 


6  CONTBIBUTORS. 

i:    I..  SHTJRLY,  M.  D..  Detkoit,  Mich. 

Professor  of  Laryngology  and  Clinical  Medicine,  Detroit  Collegefof  Medicine;  Consult- 
ing Physician  to  St.  Luke's  Hospital. 

W.    M.   SWEET,    M.    D.,  PHILADELPHIA,  PA. 

Associate  in  Ophthalmology,  Philadelphia  Polyclinic;   Instructor  in  Ophthalmology 
Jefferson  Medical  College. 

SAMUEL  THEOBALD,   M.  I>.,  Baltimore,  Md. 

Clinical  Professor  of  Ophthalmology  and  Otdlogy,  Johns  Hopkins  University;  Oph- 
thalmic and  Aural  Surgeon  to  the  Johns  Hopkins  Hospital. 

ARCHIBALD  G.  THOMSON,  M.  D,  Philadelphia,  Pa. 

Ophthalmic  Surgeon  to  the  Children's  Hospital;  Assistant  Ophthalmic  Surgeon,  Wills 
Eye  Hospital. 

CLARENCE   A  VEASEY,  A.  M.,  M.  D.,  Philadelphia,  Pa. 

Adjunct  Professor  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic;  Demonstrator  of 
Ophthalmology,  Jefferson  Medical  College. 

JOHN    E.  WEEKS,   M.  D.,  New  York  City. 

Surgeon  to  the  New  York  Eye  and  Ear  Infirmary,  Ophthalmic  Department  ;  Clinical 
Professor  of  Ophthalmology  and  Otology,  Woman's  Medical  College  of  the  New  York 
Infirmary. 

CASEY    A  Wood.  c.  M..  M.  D,  Chicago,  III. 

Professor  of  Ophthalmology,  Chicago  Post-Graduate  Medical  School  ;  Ophthalmic  Sur- 
geon to  the  l'assavant  Memorial  Hospital. 

JONATHAN    WRIGHT,  M.   D.,  Bb £LYN,  N.  Y. 

Clinical  Professor  of  Diseases  of  the  Nose  ami  Throat,  Woman's  Medical  College  of  the 
New  York  Infirmary. 

H.  V.  WtJRDEMANN,  M.  D.,  Milwaukee,  Wis. 

Ophthalmic  and  Aural  Surgeon  to  the  Milwaukee  Children's  Hospital  and  to  the 
Milwaukee   County    Hospital    for    the    Chronic    Insane. 


PREFACE. 


This  book  is  offered  to  students  and  practitioners  of  medicine  and  surgery 
in  general,  and  to  those  especially  interested  in  the  subjects  of  which  it  treats 
in  particular,  in  the  hope  that  it  may  take  rank  with  the  other  volume-  of 
the  "American  Text-book"  series,  which  have  demonstrated  their  worth  and 
have  had  their  reward  in  the  appreciative  reception  which  has  been  accorded 
to  them. 

In  the  portion  of  the  work  devoted  to  the  Eye,  its  Embryology,  Anatomy, 
Histology,  Physiology,  Diseases,  and  Injuries  are  discussed  in  twenty-four 
sections  by  twenty-four  authors;  its  Operative  Surgery  in  <c\'(jn  section-  by 
as  many  authors  ;  while  certain  practical  details  in  the  Examination  for  ( 'olor- 
blindness  among  Railroad  Employes,  etc.,  receive  attention  in  an  Appendix 
containing  five  sections. 

In  the  portion  of  the  work  devoted  to  the  Ear,  its  Anatomy,  Physiology, 
Diseases,  and  Injuries  are  discussed  in  thirteen  sections  by  fourteen  author- ; 
while  Diseases  of  the  Nose  and  Throat  are  described  in  twenty  sections  by 
nineteen  authors. 

Certain  novel  features,  not  usually  found  in  text-books,  may  be  noted  : 
Special  articles  on  The  Standards  of  Form  and  Color-vision  Required  in 
Railway  Service,  The  Rontgen  Rays  in  Ophthalmic  Surgery,  The  Practice  of 
Ophthalmic  Operations  on  Animal>'  Eyes,  The  Most  Important  .Micro-organ- 
isms having  Etiological  Relationship  to  Ocular  Disorders,  etc. 

It  is  unnecessary  to  discuss  the  "collaboration-method"  thus  employed, 
which  ha-  too  often  demonstrated  its  value  to  need  either  defence  or  explana- 
tion in  thi-  place,  except  to  point  out  its  greatest  use,  and  the  one  to  which  no 

doubt  it  is  indebted  for  it-  suec< namely,  that   by  it-  mean-,  in   the  words 

of  Dr.  W.  H.  Howell,  "the  student  gains  the  point  of  view  of  ;i  number  of 
teachers,  reaping,  in  ;i  measure,  the  -nine  benefit  as  would  be  obtained  by 
following  courses  of  instruction   under  different    teachers." 

Thi-  work  i-  essentially  a  text-book  on  the  one  hand,  and.  on  the  other,  a 
volume  of  reference  to  which  the  practitioner  may  turn  and  find  a  series  of 
article-  written  bv  men  who  are  authorities  on  the  subjects  portrayed  by  them. 

Therefore  the  practical  side  of  the  question  has  been  brought  into  pr inen< 

— i.  e.  Functional  Testing,  Etiology,  Symptomatology,  Diagnosis,  and  Ti 
ment,  but  never  to  the  neglect  of  Pathology  or  the  important  facts  coi 
in  the  special  chapters  on  Embryology,  Anatomy,  Physiology,  Physi 


8  PREFACE. 

Optics,  etc.,  to  which,  indeed,  special  attention  is  directed.  Thus  it  is  hoped 
thai  the  student  will  receive  nol  only  the  point  of  view  of  a  number  of 
teachers,  but  a  number  of  points  of  view    of  each  subject. 

A  word  should  be  said  with  reference  to  the  effort  t<>  comprise  within  one 
volume  studies  of  the  Eye,  Ear,  Nose,  and  Throat — an  effort  which  may  chal- 
lenge criticism  in  this  day  of  highly  differentiated  specialties.  Yet  it  has 
seemed  to  the  Editors  that  each  of  these  branches  could  receive  text-hook 
treatment  within  the  space  here  assigned,  while  their  important  correlations 
could  he  better  brought  out  by  such  juxtaposition.  Specialism  has  often  been 
carried  much  too  far  in  the  exclusion  of  attention  to  the  adjacent  tields.  The 
oculist  cannot  dispense  with  a  fair  working  knowledge  of  affections  of  the 
nose  and  it-  accessory  cavities  ;  nor  should  the  aurist  have  to  learn  at  second 
hand  the  important  teachings  of  the  ophthalmoscope  as  to  his  cases.  Indeed, 
no  practitioner,  general  or  special,  should  be  unfamiliar  with  all  the  types  of 
disease  and  the  most  precise  methods  of  their  study,  for  it  must  often  happen 
that  he  cannot  avail  himself  of  help  from  others.  He  should,  like  Brougham's 
educated  man.  "know  a  little  of  everything  and  all  about  some  one  thing." 
The  latter  part,  as  to  the  specialties  here  treated,  the  reader  must  seek  in 
more  voluminous  encyclopedic  works;  hut  it  is  hoped  that  the  labors  of  the 
eminent  teachers  here  brought  shoulder  to  shoulder  will  afford  a  good  intro- 
duction for  the  beginner,  as  before  stated,  a  valuable  handy  reference-hook  for 
the  practitioner,  and  at  least  quicken  some  weakening  memories  in  the 
advanced  specialist. 

Each  author  i-  responsible  for  the  statements  and  opinions  in  his  article  : 
occasional  editorial  comment  is  always  suitably  marked.  For  the  most  part, 
wherever  the  same  subject  receives  consideration  in  different  articles,  cross 
references  have  been  supplied,  again  with  the  idea  of  facilitating  a  study  of 
the  point  of  view.  It  seems  proper  to  note  that  there  has  been  complete 
division  of  the  editorial  labor  and  responsibility,  that  of  the  Ophthalmic 
portion  being  assumed  by  Dr.  de  Schweinitz,  and  that  of  the  Otological  and 
Laryngological   sections  by   Dr.    Randall. 

We  have  to  note  and  diploic  the  loss  to  ourselves  and  to  the  profession 
in  the  death,  during  the  preparation  of  this  work,  of  Dr.  Harrison  Allen, 
robbing  us  of  his  finishing  touches  to  hi-  own  contribution  and  the  continu- 
ance of  hi-  friendly  counsel  ;i-  to  other  portions  of  the  hook.  Of  the  greater 
loss  in  hi-  many  field-  of  activity  we  cannot  here  speak. 

In  conclusion,  the  Editors  desire  to  express  their  hearty  thanks  to  all  the 
contributors  for  their  uniform  courtesy  and  for  the  presentation  of  the  sub- 
jects  entrusted  to  them  in  a  manner  which,  they  fed  sure,  cannot  fail  to  be 
satisfactory  to  -indent-.  Also,  their  thank-  are  due  to  Mr.  T.  V.  Dagney 
.•ind   Mr.    \l.   \V.  Greene  for  their  efficient   aid  and  constanl   kindness. 

l  i"i  Locusi  Street.     , 

.,.,   -    ..  I'iiii.  \  DELPHIA. 

1604   \\  A  I. Ml   M  l;l  l   i.    | 

Februarj    L899 


CONTENTS. 


PART   I.— THE   EYE. 


PAGE 

EMBRYOLOGY,  ANATOMY,  AND    HISTOLOGY   OF   THE    EYE.    .      17 

By  George  A.  Piersol,  M.  D.,  Philadelphia,  Pa. 

GENERAL   PHYSIOLOGY   OF   VISION 88 

By  Albert  P.  Brubaker,  M.  I).,  Philadelphia,  I'a. 

GENERAL    OPTICAL    PRINCIPLES:     KATOPTRICS,    DIOPTRICS, 

PHYSIOLOGICAL   OPTICS 102 

By  William   S.  Dennett,  M.  I>.,  and   Colman  Ward  Cutler,  M.  D.,  New 
York  (  ity. 

EXAMINATION   OF    THE   PATIENT   AND   EXTERNAL   EXAMI- 
NATION  OF   THE   EYE;    FUNCTIONAL   TESTING     ...     142 
By  G.  E.  de  Schweinitz,  A.  M.,  M.  D.,  Philadelphia,  Pa. 

THE  OPHTHALMOSCOPE  AND  ITS  USE;  THE  NORMAL  EYE- 
GROUND     171 

By  B.  Alex.  Randall.  A.  M.,  M.  D.,  Philadelphia,  I'a. 

mfthods  OF  DETERMINING  THE  refraction  of  the 
EYE:  OPHTHALMOMETRY;  OPHTHALMOSCOPY,  SKI- 
ASCOPY, OPTOMETRY;    THK   USE   OF   MYDRIATICS.    .    196 

By  Edward  Jackson,  A.  M.,  M.  I).,  Denver,  Oil. 

NORMAL  AND  ABNORMAL  REFRACTION:  EMMETROPIA; 
AMETROPIA,    HYPEROPIA,     MYOPIA,    ASTIGMATISM, 

PRESBYOPIA 212 

By  Edward  Jackson,  A.M.,  M.  I>..  Denver,  Col. 

SPECTACLES   AND   THEIR    ADJUSTMENT 

By  R.  J.  Phillips,  M.  I»,  Philadelphia,  Pa. 

DISEASES  OF  THE    EYELIDS -11 

By  B.  L.  Mii.likin.  M.  I>.  Cleveland,  Ohio. 

DISEASES  OF  Till:    LACHRYMAL   APPARATUS 201 

By  Samuel  Theobald,  M.  I>.,  Baltimore,  Md. 

DISEASES  OF   THE  CONJUNCTIVA 

By  John  E.  Weeks,  M.  I'..  New  York  City. 

DISEASES  OF   THE  CORNEA    AND  SCLERA     

FJy  Swan   M    Burnett,  .M.  I>.,  Ph.  I».,  Washington,  I>  < '. 


l,i  COX  TENTS. 

PAGE 

DISEASES    OF    THE     [BIS,    CILIARY     BODY,    AND    CHOROID; 

SYMPATHETIC    INFLAMMATION    AND    IRRITATION    .    331 
By   Robert  L.  Randolph,  M.  I».,  Baltimore,  Md. 

INJURIES  OF  THE    EYE   AND    ITS   APPENDAGES 358 

By  Ai.vin   A.  Hi  bbell,  M.  D.,  I'll.  D.,  Buffalo,  X.  Y. 

GLAUCOMA •■•    373 

By  .1.  A.  Lippincott,  A.  B.,  M.  D.,  Pittsburg,  Pa. 

DISEASES  OF  THE  CRYSTALLINE    FENS 386 

By  William  E.  Hopkins,  M.  1».,  San  Francisco,  Cal. 

DISEASES  OF  THE    VITREOUS 398 

By  Flemming  Carkow,  M.  I>.,  Ami  Arbor,  Mich. 

DISEASES   OF   THE    RETINA 405 

By  Lttcien  Howe,  M.  D.,  Buffalo,  N.  Y. 

DISEASES  OF  THE  OPTIC    NERVE 432 

By  Haiku. i)  Gipford,  M.  D.,  Omaha,  Neb. 

AMBLYOPIA,    AMAUROSIS,    AND    DISTURBANCES    OF    VISION 

WITHOUT  OPHTHALMOSCOPIC  CHANGE 157 

By  Casey  A.  Wood,  M.  D.,  Chicago,  111. 

AMBLYOPIA  OF    THE  VISUAL  FIELD,  SCOTOMAS,  AND  HEMI- 

ANOPIA 470 

By    II.  V.  WtJRDEMANN,  M.  I  >..  Milwaukee,  Wis. 

INTRAOCULAR  GROWTHS 189 

By  Ward  A.  Holden,  A.  M„  M.  I  >..  New  York  City. 

MOVEMENTS  OF  THE    EYEBALLS,  AND   THEIR  ANOMALIES       197 
By  Alexander  Dcane,  M.  I>.,  New  York  City. 

[NJURIES    AND    DISEASES  OF    THE  ORBIT 523 

By   F.  Bi  i.i.i.i:.  M.  !».,  Montreal,  <  lanada. 

OPERATIONS 539 

Fn 'par; it  ion  of  the  Region  <>f*  <  >peration,  the  [nstruments,  and  the 

Dressings;    Anesthesia 539 

By  G.  E.  de  Si  hweinitz,  A.  M.,  M.  I».,  Philadelphia,  Pa. 

Operations  upon  the  Eyelids "»ll 

By   1  ■'.  C.  Ilmv.  M.  D.,  Chicago,  111. 

Operations  upon  the  Conjunctiva,  Cornea,  and  Sclera;   Enucleation 

and  Evisceration -~»<  1 1 

By  Charles  W.  Kollock,  M.  D.,  Charleston,  S.  C. 

Operations  upon  the  Iris  and  the  Crystalline  Body -~>~  I 

By   Herman   Knapp,  M.  I».,  New  York  City. 

Operations  upon  the  Eye-muscles "»ST 

By  S.  < '.  Ayres,  M.  I '.,  «  incinnati,  I  ►hio, 

Operations  upon  the  Lachrymal  Apparatus 596 

r.     Samuel  Th  bob  ild,  M.  I  >..  Baltimore,  Md. 


CONTENTS.  1  1 

PAGE 

Operations  upon  the  Orbit      599 

By  F.  I'.i  1. 1.1:1:,  M.  I).,  Montreal,  Canada. 

APPENDIX gog 

The  ."Methods  for  Detecting  Color-blindness,  with  Special  Reference 

to  the  Examination  of  Railroad  Employed 603 

By  .).  Ellis  Jennings,  M.  D.,  St.  Louis,  Mo. 

Standards  of  Form  and  Color-vision  Required  in  Railway  Service  .    605 
By  A.  G.  Thomson,  M.  D.,  Philadelphia,  Pa. 

The  Rontgen  Rays  in  Ophthalmic  Surgery 607 

By  William  M.  Sweet,  M.  D.,  Philadelpliia,  Pa. 

The  Practice  of  Ophthalmic  Operations  on  Animals' Eyes (ill 

By  Clarence  A.  Veasey,  A.  M.,  M.  D.,  Philadelphia,  Pa. 

The  Most  Important  Micro-organisms  having-  Etiological  Relation- 
ship to  Ocular  Diseases    614a 

By  G.  E.  de  Schweinitz.  A.M.,  M.  I).,  Philadelphia,  Pa. 


PART   II.— THE    EAR. 


THE    ANATOMY    OF    THE    P]AR,    INCLUDING    EMBRYOLOGY 

AND  HISTOLOGY^ 617 

By  B.  Alex.  Randall,  M.  A.,  M.  I).,  Philadelphia,  Pa. 

THE   PHYSIOLOGY7   OF  THE   EAR <;:;i 

By  Frank  Allport,  M.  D.,  Chicago,  111.,  and  R.  O.  Beard,  M.  I>..  Minneap- 
olis, Minn. 

ETIOLOGY   AND   PATHOLOGY   OF   EAR   AFFECTIONS 647 

By  C.  R.  HOLMES,  M.  D.,  Cincinnati,  Ohio. 

EXAMINATION      OF      PATIENTS;      SYMPTOMATOLOGY      AND 
DIAGNOSIS;    [NSTRUMENTS  NEEDED,  AND  METHODS 

OE   THEIR    EMPLOYMENT 665 

By  John   E.  Sheppard,  M.  I>..  Brooklyn,  X.  Y. 

THE  GENERAL  THERAPEUTICS  OF   EAR    AFFECTIONS  ....    684 
By  Clarence  .1.  Blake,  M.  P..  Boston,  Mass. 

AFFECTIONS   OF  THE    EXTERNAL    EAR     691 

By  Samuel  Theobald,  M.  D.,  Baltimore,  Md. 

INJURIES   AND    DISEASES  <  >V  THE    DRUMHEAD 711 

By   II.  Y.  Wi  1:1.1  mann.  M.  I).,  Milwaukee,  Wis. 

ACUTE  AFFECTIONS    OF    Till'.  TYMPANIC    CAVITY    AND    EU- 
STACHIAN   TUBE Tl") 

By   Horace  Cx.  Mii.u  r,  A.  M..  M.  P..  Providence.  R    1. 


12  CONTENTS. 

PAGE 

(  BRONIC  (ATA  Kill  I    OF   THE    MIDDLE    EAE 726 

By  Edward  B.  Dench,  Ph.  B.,  M.  D.,  New  York  City. 

CHRONIC  SUPPURATION   OF  THE    MIDDLE    EAR 739 

By    Albert  II.  Buck,  M.  D.,  New  York  City. 

COMPLICATIONS   OF    TYMPANIC    INFLAMMATION 749 

By  Herman   Knapp,  M.  I'..  New  York  City. 

DISEASES  OF    THE  SOUND-PERCEIVING   APPARATUS 765 

By   Henry  A.  Alderton,  M.  I>..  Brooklyn,  N.  Y. 

OPERATIONS 782 

By  •).  Orne  Green,  A.  M..  M.  !>..  Boston,  .Mass. 


PART   III.— THE    NOSE   AND   THROAT. 


ANATOMY  OF  THE    UPPER  AIR-PASSAGES,  INCLUDING    IIIS- 

TOLOGY    AND    EMBRYOLOGY 807 

By  Harrison   Allen,  M.  I>.  LL.  I>..  an.!  Arthub   A.  Bliss,  A.M..  M.  IX, 
Philadelphia,  Pa. 

PHYSIOLOGY   <>F  THE    UPPER    AIR-PASSAGES 835 

By  Walteb  J.  Freeman,  M.  I».  Philadelphia,  Pa. 

GENERAL     ETIOLOGY    AND    PATHOLOGY    OF     DISEASES    OF 

TIM:   UPPEB    RESPIRATORY  TRACT 844 

By  J.  II.  Bryan,  M.  D.,  Washington,  D.  ( '. 

METHODS    OF    EXAMINATION     AND    DIAGNOSIS    IN    AFFEC- 
TIONS OF   THE    NOSE    AND   THROAT 855 

By  John  \V.  Farlow,  M.  D.,  Boston,  Mass. 

THERAPEUSIS   AND    PROGNOSIS     874 

By  Geo.  A.  Leland,  A.  M.,  M.  I»..  Boston,  Mas-. 

ACUTE    AFFECTIONS  OF   THE    NOSE 89J 

By  William   !■'..  <  vsselberry,  M.  1  >..  I  hicago,  III. 

CHRONIC   AFFECTIONS   OF   THE    NOSE      905 

B\    M  irris  J.    \-  ii.  M.  I».,  New  York  <  ity. 

DISEASES  OF  THE   TONSILS,    PALATE,  AND   PHARYNX     .   .   .     921 
By  James  Edward  Newcomb,  M.  D.,  New  York  City. 

ATROPHIC    RHINITIS 957 

By    W.    I'l  J  l:l      PORCHER,   M.    I  »..  <   liar].  stOD,  8.  (  '. 

DISEASES  OF   THE   ACCESSORY   SINUSES  OF  THE   NOSE  .   .   .     966 
By  Roberi  Cunningham   Myles,  M.  D.,  New  York  City. 

ACUTE   AFFECTIONS  OF  THE    LARYNX    AND  TRACHEA.   .    .      985 
By  William  E.  Hopkins,  M.  D.,  S:m  Francisco,  Cal. 


CONTENTS.  13 

PACE 

CHRONIC    IXKl.AM.MATiHiV    DISEASES    OF   THE    LARYNX     .    .      !)!ix 
By  C.  E.  de  M.  Sajoi  s,  M.  D.,  Philadelphia,  Pa. 

DIPHTHERIA   OF   THE   AIR-PASSAGES 1010 

By  J.  II.  McColxom,  M.  I>..  Boston,  Ma--. 

TUBERCULOSIS  OF   THE   AIR-PASSAGES 1034 

By  E.  L.  Shurly,  .M.  D.,  Detroit,  Mich. 

SYPHILIS  OF  THE   AIR-PASSAGES 1067 

By  William  ('.  Glasgow,  M.  I»..  St.  Louis,  Mo. 

NEOPLASMS   OF  THE    UPPER    AIR-PASSAGES 1075 

By  Jonathan  Wright,  M.  D.,  Brooklyn,  X.  Y. 

INJURIES  AND  DEFORMITIES  OF  THE   NOSE  AXD  THROAT  .    1116 
By  John  O.  Roe,  M.  D.,  Rochester,  X.  Y. 

NEUROSES  OF  THE   UPPER   AIR-PASSAGES 1140 

By  Jonathan  Wright,  M.  D.,  Brooklyn,  N.  Y. 

THE   VOICE— ITS   PRODUCTION   AND   HYGIENE 1171 

By  G.  Hudson  Makuen,  M.  D.,  Philadelphia.  Pa. 

OPERATIONS 1180 

By  John  O.  Roe,  M.  I).,  Rochester,  X.  Y. 


THE  EYE. 


THE    EYE. 

THE  EMBRYOLOGY,  ANATOMY,  AND  HISTOLOGY 

OF  THE  EYE. 

By  GEORGE  A.  PIERSOL,  M.  D., 

OF    PHILADELPHIA. 

THE    DEVELOPMENT    OF    THE    EYE. 

The  initial  stages  in  the  formation  of  the  visual  organ  are  so  intimately 
related  to  those  of  the  brain,  that  a  brief  sketch  of  the  early  development  of 
the  nervous  system  may  with  advantage  precede  the  more  detailed  account 
of  the  development  of  the  eye. 

The  first  definite  trace  of  the  embryo  within  the  embryonal  area  appears 
as  a  pair  of  slightly  converging  folds,  the  medullary  plate*,  which  partially 


Mesoderm 


Visceral 
mesoderm 


Pleuropericar-        Perit  ardial 

dial  cavity.  plates. 

Fig.  1.— Transverse  section  of  a  sixteen-and-a  half-day  slice),  embryo  (Bonnet). 


Extension 
of  celom. 


enclose  the  anterior  end  of  the  transienl  primitive  streak.  Originally  widely 
separated  and  low,  the  folds  rapidly  increase  in  height,  while  the  included 
neural  groove  becomes  correspondingly  deepened  (Fig.  1).  Very  soon  the 
growing  medullary  plates  manifesi  a  tendency  to  approximate  their  freeed 
along  the  dorsal  aspecl  of  the  embryo,  a  disposition  which  eventually  results 
in  their  fusion  and  the  conversion  of  the  open  neural  groove  into  the  cl< 

17 


18      EMBRYOLOGY,    ANATOMY,    AND   HISTOLOGY  OF  EYE. 

neural  canal  (Figs.  2  and  3).  The  poinl  nt  which  this  fusion  earliest  occurs 
does  ii"t  coincide  with  the  anterior  extremity  of  the  canal,  but  with  a  point 
somewhat  farther  hack  ;  from  this  latter  situation  closure  progresses  toward 
the  caudal  pole. 

The  anterior  extremities  of  the  medullary  folds  remain  ununited  for  some 


Medullary 
furrow. 


I  'ucleft 
Ectoderm.        mesoderm.         Amnion. 


Fig. 


Visceral 
mesoderm. 


Notochord.  Somite.     Cut  entoderm. 

Trans\  erse  section  of  a  sixteen-and-a  half-day  sheep  embryo  possessing  six  somites  (Bonnet). 


time  after  the  more  caudally  situated  parts  of  the  folds  'have  undergone  con- 
crescence and  closure;  the  anterior  portion  of  the  folds,  on  the  other  hand, 
has  meanwhile  become  locally  expanded  in  such  manner  that  even  before  the 
fusion  of  the  folds  indications  of  three  distinct  dilatations — the  primary  brain- 


Ectoderm 


Closing 
neural  canal. 


Amnion. 


Cell -mass  for 
Wolffian  body. 


Notochord. 
'  m  of  a  fifteen-and-a-half-day  sheep  embryo  po  en  somites  (Bonnel 


vesicles — have  become  apparent.  The  foremosl  of  these,  the  anterior  brain- 
sac,  occupies  the  extreme  end  of  the  neural  canal,  and  i-  of  large  size,  the 
succeeding  middle  ami  posterior  vesicles  being  less  expanded,  although  of 
greater  length. 


PRIMARY  OPTIC    VESICLES. 


L9 


The  primary  cerebral 

since   the  anterior  and   tl 

Anterior  brain-vesicle. 


Middle  brain-vesicle. - 
Posterior  brain-vesicle. . 

Fore-brain. 
Primary  optic  vesicle. 

Stalk  of  optic  vesicle. 

Inter-brain. 

Mid-brain. 

Hind-brain. 

After-brain. 
Fore-brain. 

Primary  optic  vesicle. 

Inter-brain. 

Mid-brain, 

Hind-brain. 

After-brain. 


vesicles,  however,  soon  undergo  further  chan 
c  posterior  each  become  subdivided,  the  cephalic 
segmentof  the  neural  tube  being  then  repre- 
sented by  the  five  secondary  brain-vesi- 
cles. These  latter  are  designated,  from 
before  backward,  as  the  fore-brain,  or 
prosencephalon  ;  the  inter-brain,  orthalam- 
encephalon  ;  the  mid-brain,  or  mesenceph- 
alon ;  the  hind-brain,  or  epencephalon  ;  and 
the  after-brain,  or  metencephalon  (Figs.  4 


Fig.  4.— Diagrams  illustrating  the  pri- 
mary and  secondary  segmentation  of  the 
brain-tube  (Bonnet). 


Fig.  5.  — .4,  brain  of  two-day  chick  embryo;  />',  brain  of 
human  embryo  of  three  weeks  (His);  shows  the  develop 
ment  of  the  optic  vesicles  and  brain-vesicles;  fb,  lore 
brain;  ib,  inter-brain:  ov,  optic  vesicle. 


and  5).  The  remains  of  the  greatly  modified  and  relatively  reduced  cavities 
of  these  early  brain-segments  are  represented  respectively  by  the  lateral  ven- 
tricles, the  third  ventricle,  the  aqueduct  of  Sylvius,  and  the  fourth  ventricle  : 
while  from  the  walls  of  the  secondary  brain-vesicles  are  developed  the  struc- 
tures situated  around  the  corresponding  part  of  the  ventricular  -pace. 

Coincidently  with  the  development  of  the  primary  cerebral  vesicles,  even 
before  the  complete  closure  of  the  neural  canal,  the  anterior  brain-sac  becomes 
distinguished  by  the  evagination  of  a  conspicuous  diverticulum  on  either  side, 
which  extends  almost  at  right  angles  to  the  general  cerebral  axis.  These 
outgrowths  fron  the  hinder  part  of  the  early  anterior  cerebral  segmenl  are 
the  primary  <>/>fi<-  vesicles,  from  which  the  nervous  tunic  of  the  eye  is  largely 
developed.  The  optic  vescicle  at  first  open-  so  widely  into  the  brain-sac  thai 
there  i-  little  differentiation  of  the  ocular  rudiment  from  the  general  cavity 
of  the  brain-segment;  soon,  however,  the  communication  between  the  two 
becomes  uarrowed  and  the  optic  vesicle  better  defined  as  an  independenl 
organ.  The  (>/>//<■  stalk,  which  results  from  this  constriction,  lies  almost 
transversely  placed  when  first  formed,  but  gradually  assumes  a  more  oblique 
axis  as  its  development    progresses.     The  relation- of  the  optic  -talk-  to  the 

brain-segments  also  somewhat  change,  si when  definitely  formed  the  stalks 

open  into  tie-  inter-brain,  or  thalaraencephalon,  having  seemingly  become  pos- 
teriorly removed  during  their  growth. 

In  attaining  ii-  full  expansion  the  primary  optic  vesicle  has  encroached 
to  such  an  extent  on  the  mesoderm  lying  between  the  eye-sac  and  the  surt 
of  the  embryo,  that   in  mammal-  an  extremely  thin  stratum  of  mesodi 
tissue  alone  separates  the  optic  vesicle  from  the  surface  ectoderm:  in  : 
even  this  is  wanting,  the  mesoderm  being  entirely  displaced  and  the  ectod 


20      EMBRYOLOGY,    ANATOMY,    AND   HISTOLOGY  OF  EYE. 

of  the  exterior  ami  anterior  wall  of  the  <>|>tic  vesicle  coming  into  apposition 
(Fig.  6). 

Bach  optic  vesicle  may  lie  regarded  as  possessing  four  walls — a  lateral  oi 
outer  wall,  including  the  area  in  apposition  to  the  surface  :  a  nu isial  or  inner 
wall,  [narked  by  the  position  of  the  early  optic  stalk  ;  a  lower  wall,  on  a  level 
with  the  floor  of  the  inter-brain  ;  and  an  upper  wall. 

After  meeting  the  surface  layers  in  its  outward  expansion,  the  primary 
optie  vesicle  becomes  profoundly  modified  by  the  invagination  of  its  lateral 


-  i  tion  through  head  of  ten-day 
rabbit  embryo, exhibiting  primary  optic  ves- 
icle [0)  protruding  from  fore  brain  /.''.  ami 
coming  m  contact  with  surface  ectoderm  (e); 
in.  surrounding  mesi  derm    Piersi  il  i. 


Fki.  7.— Section  through  developing  eye  of 
eleven-day  rabbil  embryo  (Piersol) :  /.'.  fore 
t  Tail  i  connected  by  stalls  with  optic  vesic] 
whose  anterior  wall  is  partly  invaginated ;  I, 
thickened  ami  depressed  lens  area. 


or  outer  wall,  in  consequence  of  which  pushing  in,  the  cavity  of  the  primary 
vesicle  is  gradually  reduced,  and,  finally,  obliterated  by  the  application  of 
the  invaginated  portion  of  the  wall  of  the  vesicle  to  the  mesial  segment  of  the 
same,  which  has  not  suffered  displacement.  The  space  which  results  from 
the  invagination  of  the  outer  portion  of  the  primary  eye-sac  gradually  ac- 
quires a  cupped  form,  and  is  known  as  the  secondary  <>/itir  vesicle,  or,  more 
appropriately,  as  the  optic  cup  (Figs.  7  and  8). 

Coincidently   with  the  changes  in  the  optic  vesicle  which  result  in  the 
production  of  the  optic  cup,  the  ectoderm  lying  over  the  optic  vesicle  exhibits 

proliferation  of  its  elements  and  becomes 
thickened,  and.  at  the  same  time,  sink-  into 
the  subjacent  invaginating  optic  vesicle,  thus 
forming  a  depression  known  ,-i~  the  lens-pit. 
The  thickened  ectoderm  lining  the  bottom 
and  sides  of  the  pit  i-  accurately  applied  to 
the  receding  lateral  wall  of  the  optic  vesicle, 
separated  in  mammals,  however,  by  a  thin 
-heei  ofmesodermic  tissue.     The  invagina- 

ti f  the  early  lens-pil   increases,  and,  at 

the  same  time,  the  margins  of  the  depression 
become  approximated  and  eventually  united, 
so  that  the  lens-pit  is  converted  into  the 
lens-vesicle,  a  structure  from  which  the  fu- 
ture crystalline  lens  is  developed  in  a  manner 
presently  to  he  described.  The  lens-sac 
thus  formed  for  a  time  remains  connected 
with  the  ectoderm  :  later,  the  union  between 
the  tw<>  i-  severed,  and  the  primarj  lens- 
rudimenl  lie-  :i-  an  isolated  ectodermic  vesicle  completely  Burrounded  by 
mesoderm.     The  mesodermic  stratum  which  separates  the  lens-sac  from  the 


3i  ction  through  developing  eye 
ind-a-half-day   rnhhit    embryo 
brain    connected    with 
■  .1  bj  appo- 
ited  anterior  Begmenl  i  r) 
with  ill  (jp) ;  /,  lens  sac  com- 

pletely closed  and  separated   from  ecto- 
derm ;  i.  tissue  within  secondary  optic  cup 
m  surrounding  mesoderm. 


rum rn ve  viTRKors  chamber. 


21 


overlying  ectoderm  later  contributes  the  conneetive-tis<ue  stroma  of  the  cornet, 
while   the   correspond  inn-  ectodermic   area   becomes  the  corneal  epithelium 

Returning  to  the  consideration  of  the  changes  involving  the  optic  vesicle, 
we  have  to  follow  modifications  which  result  in  the  formation  of  the  most 
important  parts  of  the  nervous  tunic  of  the  eyeball.  As  already  sketched, 
tin1  lateral  wall  of  the  primary  optic  vesicle  becomes  invaginated  as  the  lens- 
sac  is  developed  :  while  in  the  early  stages  the  two  invaginations  progress 
with  uniform  rapidity,  there  comes  a  time,  after  the  lens-sac  has  reached 
completion,  when  the  expansion  of  the  inner  wall  of  the  latter  no  longer 
keeps  pace  with  the  pushing-in  of  the  optic  vesicle,  in  consequence  of  which 
disparity  a  space,  the  primitive  vitreous  chamber,  appears  between  the  lens- 
vesicle  and  the  retreating  wall  of  the  optic  vesicle.  The  completion  of  the 
invagination  results  in  the  approximation  of  the  lateral  folded-in  wall  toward 
the  mesial  wall  of  the  vesicle,  until  the  two  layers  are  in  contact  and  the 


Fig.  9.— Section  through  the  optic  vesicle,  the  optic  stalk  and  adjoining  parts  of  the  cerebral  vesicle  of 
a  five-weeks'  human  fetus  (His):  R,  P,  retinal  and  pigment  layers  of  optic  vesicle  ;  Sp,  cleft  for  entrance 
ol  central  artery  :  T.c,  tuber  cinereum,  with  recessus  infundibuli  [X.i.) :  W.c,  basal  conns;  /,'.«..  rei 
opticus.    The  lower  part  of  the  figure  corresponds  to  the  nasal  side  the  upper  t"  the  temporal. 

included  cavity  of  the  primary  optic  vesicle  is  obliterated.     The  secondary 
vesicle,  or  the  optic  <-<i[j,  is  now  bounded  by  a  double-layered  wall. 

Almost  from  the  beginning  of  the  process  of  involution  involving  the 
primary  optic  vesicle  the  portion  of  the  wall  of  the  .sic  so  affected  exhibits  ;t 
disposition  in  undergo  proliferation  and  thickening,  in  consequence  of  which 
change  tin-  developing  optic  cup  is  immediately  bounded  by  a  disproportion- 
ately thick  stratum,  which  from  the  resulting  structures  is  appropriately  termed 
the  retinal  layer.  In  marked  contrasl  to  i  he  inner,  the  outer  l.i\  er  "I'  the  optic 
cup  not  only  fails  to  increase  in  thickness,  but  becomes  attenuated  in  conse- 
quence of  the  general  expansion  of  the  growing  primitive  visual  organ,  so  that 

by  the  time  the  retinal  layer  comes  in tad  with  the  outer  layer  of  the  optic 

cup,  the  latter  hits  become  reduced  to  a  delicate  stratum  <»!'  cells  which  would 
be  inconspicuous  were  it  not  lor  it-  characteristic  dark  tint  due  to  the  presenct 
of  rapidly  augmenting  pigment-particles.  The  pigmented  conditiou  of  the 
cells  of  the  outer  layer  early  foreshadows  the  subsequent  fate  of  this  portion 
of  the  optic  vesicle,  which  eventually  forms  the  single  layer  of  pigmi 


22     EMBRYOLOGY,   ANATOMY,   AND   HISTOLOGY  OF  EYE. 

retinal  epithelium.  From  the  thickened  inner  layer  aA  derived  the  essential 
nervous  elements  of  the  retina,  including  the  rods  and  cones,  the  various 
ganglion-cells  and  the  nerve-fibers  proceeding  from  them,  together  with  the 
supporting  neurogliar  tissue. 

The  invagination  described  in  the  preceding  paragraphs  as  affecting  the 
lateral  or  outer  wall  of  the  primary  optic  vesicle  is  not  limited  to  that  portion 
of  the  eye-sac,  but  involves  also  the  lower  wall  of  the  vesicle  and  its  hollow 
stalk.  Reference  to  the  accompanying  figure  (9,  Sp)  will  show  that  the  lower 
wall  of  the  double-layered  vesicle  is  not  complete,  but  is  pushed  in — in 
frontal  sections  this  inferior  groove  appearing  as  a  hiatus  in  the  vesicle,  the 
choroidal  cleft.  This  latter  slit  establishes  communication  between  the  sur- 
rounding mesoderm  and  the  interior  of  the  optic  cup,  and  affords  entrance  of 
the  mesodermic  tissue  which  constitutes  the  primary  vitreous  stroma  ;  it 
soon  becomes  greatly  narrowed  and  finally  closes. 

In  consequence  of  the  infolding  of  its  lower  wall  the  optic  stalk,  at  firsl 
cylindrical,  become-  deeply  grooved  ;  the  groove,  which  is  occupied  by 
vascular  mesodermic  tissue,  after  attaining  a  certain  depth,  gradually  closes 
!>v  the  approximation  and  final  union  of  its  lips,  the  imprisoned  mesoderm 
and  the  included  blood-vessels  being  later  represented  by  the  arteria  centralis 
retina,'  and  the  associated  connective  tissue  occupying  the  central  area  of  the 
optic  nerve. 

The  Development  of  the  I,ens.— The  earliest  phases  of  the  forma- 
tion of  the  crystalline  lens,  including  the  conversion  of  the  lens-pit  into  the 
closed  lens-sac,  have  been  already  described  ;  the  subsequent  development  of 
the  lens  is  largely  the  history  of  the  growth  and  differentiation  of  the  walls 
of  the  lenticular  vesicle.  By  the  time  the  lens-sac  has  become  completely 
isolated  from  its  attachment  with  the  surface  ectoderm  its  walls  consist  of 
two  or  three  layers  of  epithelial  cells,  externally  limited  by  a  delicate  mem- 
brane, the  earliest  suggestion  of  the  lens-capsule.  Very  soon  the  inner 
portion  of  the  wall  of  the  lens-sac  becomes  conspicuous  by  reason  of  its 
greater  thickness — a  disparity  which  becomes  progressively  more  marked  as 
development  proceeds.  The  early  mammalian  lens-vesicle  contains  a  mass 
of  -mall  cells  derived  from  the  proliferation  of  the  surface  elements  of  the 
primitive  epidermis.  These  cells  are  unimportant,  being  transient,  and  later 
underuoinu-  defeneration  and  absorption. 

The  obliteration  of  the  cavity  of  the  lens-sac  and  the  conversion  of  the 
organ  intoa  -olid  ma—  are  effected  by  the  phenomenal  growth  and  elongation 
of  the  epithelial  elements  composing  the  posterior  or  internal  wall  of  the  sac. 
These  cells  rapidly  increase  in  length,  becoming  converted  into  the  primitive 
lens-fibers.  At  first  the  thickened  inner  wall  projects  into  the  lens-vesicle, 
the  greatly  reduced  cavity  of  the  sac  intervening  between  it  and  tin-  anterior 
wall.  With  the  growth  of  the  liber-ma—  this  -pace  i-  gradually  reduced. 
until  finally  the  now  great!}  thickened  and  specialized  posterior  wall  comes 
into  contact  with  the  anterior  layer  and  the  lens  becomes  solid. 

The  thickening  and  growth  which  have  characterized  the  changes  affecting 
the  posterior  or  inner  wall  of  the  lens-sac  are  in  marked  contrast  to  the  pro- 

gressive  attenuation  of  the  anterior  or  outer  wall.     The  col ar  type  ot  the 

early  cell-  of  tlii-  region  i-  replaced  by  the  low  cuboidal  form  which  charac- 
terizes these  elements  in  later  stages. 

After  the  primitive  lens  bei -  -olid  in  consequence  of  the  obliteration 

of  iln-  cavity  of  the  lens-vesicle  by  the  growth  and  i lification  of  the  posterior 

wall,  the  subsequent  increase  in  the  size  of  the  lens  take-  place  by  the  con- 
version of   the  cell-  of   the   anterior  wall,  which  are    later    known  a-    the 


DEVELOPMENT  OF  THE  LENS.  23 

epithelium  of  the  anterior  capsule,  into  Lens-fibers,  and  the  addition  of  tl 
as  peripheral  increments.  The  transformation  of  the  epithelial  cells  into 
fibers  take-  place  at  the  equatorial  zone,  where  the  low  columnar  elements 
may  be  seen  elongating  and  assuming  the  peculiarities  of  young  fibers.  The 
appositional  growth  <>t'  the  lens  which  thus  takes  place  results  in  the  forma- 
tion of  layers  of  lens-fibers  which  cover  the  surface  of  the  organ  and  enclose 
the  lens-core.  In  consequence  of  their  mode  of  equatorial  formation  the 
young  fibers  extend  from  the  anterior  to  the  posterior  surface  of  the  lens, 
their  ends  meeting  along  definite  radiating  lines  which  in  the  embryo  and  the 
new-born  animal  constitute  three-rayed  figures  known  as  the  lens-stars.  The 
-tar  of  the  anterior  surface  always  has  it-  superior  limb  directed  vertically. 
the  remaining  rays  diverging  laterally  at  an  angle  of  120°.  The  ray-  of  the 
posterior  star  are  disposed  in  such  manner  that  they  fall  between  those  of  the 
anterior  figure,  the  vertical  limit  being  below  and  the  others  extending  upward 
and  outward.  In  the  adult  lens  the  figures  lose,  their  former  simplicity  by 
the  appearance  of  other  and  secondary  ray-,  the  adult  lens-stars  being  indis- 
tinct aud  uncertain  in  their  outlines.  The  modifications  of  the  -tars  in  the 
fully-grown  lens  are  largely  due  to  the  fact  that  in  the  enlarged  organ  the 
fibers  are  no  longer  capable  of  spanning  the  entire  distance  between  the 
anterior  and  posterior  surface-,  as  do  the  young  embryonal   fibers. 

The  lens-eapsult  i-  early  suggested  by  the  appearance  of  a  delicate  mem- 
brane, which  limits  the  outer  surface  of  the  lens-vesicle,  and  afterward 
undergoes  thickening,  becoming  apparently  homogeneous  and  of  elastic 
character,  which  distinguishes  this  part  of  the  eye.  Two  opposed  view-  exist 
regarding  the  source  of  the  capsule  :  according  to  one,  the  capsule  is  developed 
a-  a  secretion  from  the  cells  of  the  lenticular  vesicle,  while  the  other  regards 
it — and,  the  author  believes,  correctly — as  derived  from  the  mesodermic  tissue 
surrounding  the  primitive  lens. 

It  will  be  noted  from  the  foregoing  description  that  the  entire  lens, 
excluding  its  capsule,  is  of  ectodermic  origin. 

The  unusual  demands  made  by  the  young,  rapidly-growing  and.  at 
the  same  time,  non-vascular  lens  on  surrounding  tissues  for  its  nutrition 
result  in  the  provision  of  a  special,  although  temporary,  structure  designed 
to  meet  that  need.  The  structure  so  developed  consists  of  an  envelope 
of  vascular  mesodermic  tissue,  the  tunica  vasculosa  h  ntis,  which  com- 
pletely surrounds  the  young  lens  from  the  second  month  to  toward  the 
end  of  gestation,  at  which  latter  period  it  has  usually  atrophied  and  dis- 
appeared. 

The   tunica  vasculosa  is   closely  associated  with    the  vitreous,  since    its 
blood-vessels  are  derived  from  those  of  that  body.     The  large  vessels  over 
the    posterior    surface   of  the  lens  break   up  into  smaller   branches,   which. 
bending  around  the  equator  of  the  lens,  ramify  within  the  mesodermic  sheet 
covering   the   anterior    surface,  proceeding  almost  as  far   as   the  center  of 
the  pupil,  where  they  end   in    terminal   loop-.     The  different   part-  of  the 
vascular    membrane  of  the  lens  bear  particular  name-,    in  consequence  of 
having  been  first  observed  at  differenl  times.      The  portion  of  the  membrane 
opposite  the  pupil  was  called  the  membrana  pupillaris;  the  more  peripherally 
situated  zone  constituted  the  membrana  capsulo-pupiUaris  ;  while  thai  cover- 
ing the  posterior  surface  was  designated  the   membrana   capsularis.      I 
evident  that  these  are  but  parts  of  one  and  the  same  vascular  sheet  whi< 
now  appropriately  called  the  tunica  vasculosa  lentis.     Usually  this  strucl 
is  best  developed  at  about  the  seventh  month,  after  which  time  it  und 
atrophy  and  absorption,  so  that  at,  or  even  before,  birth  it  has  entii 


24      EMBRYOLOGY,    ANATOMY,   A  XD  HISTOLOGY  OF  EYE. 

appeared.  Exceptionally,  parts  of  the  embryonal  structure  remain  after 
birth,  the  anterior  portions,  when  present,  constituting  the  persistent  pupil- 
lary membrane.     (See  page  331.) 

The  early  infolding  of  the  lower  wall  of  the  optic  vesicle  is  closelv  related 
t<>  an  outgrowth  of  the  surrounding  mesoderm,  which  occupies  the  invagina- 
tion, and  thus  gains  entrance  into  the  secondary  optic  vesicle  or  optic  cup,  in 
which  space  it  rapidly  expands  until  the  actively  proliferating  mesodermic 
tissue  completely  till-  the  space  between  the  primitive  lens  and  the  retinal 
layer  of  the  optic  cup.  In  structure  the  primary  vitreous  corresponds  to  an 
embryonal  form  of  connective  tissue,  in  which  a  delicate  network  of  branched 
connective-tissue  elements  is  conspicuous.  At  a  later  stage  these  cell-  atro- 
phy, while  numerous  leukocytes,  derived  from  the  ingrowing  blood-vessels, 
invade  the  vitreous  tissue.  Coincidently  with  the  growth  of  the  primitive 
vitreous  an  extension  of  the  artery  occupying  the  young  optic  nerve,  which 
later  becomes  the  arteria  centralis  retina,  take-  place,  the  vessel  invading  the 
vitreous  passing  to  the  posterior  pole  of  the  young  lens  as  the  hyaloid  artery. 
With  the  appearance  of  the  latter  vessel  the  vitreous  becomes  abundantly 
supplied  with  capillaries,  from  which  not  only  the  leukocytes  already  men- 
tioned pass  into  the  proliferating  mesoderm,  hut  also  the  watery  constituents 
which  later  give  to  the  vitreous  tissue  it-  characteristic  semi-fluid  condition 
I  Fig.  10). 


Fig.  10.— Projection  from  nasal  side  of  the  stalk  of  the  optic  vesicle  and  the  centra]  artery  of  the  retina 
L, lens;  A,  anterior  continuation  of  the  central  artery  to  the  vascular  tunic  of  the  lens;  /.'.  /'. 
nervous  and  pigment  lamella  of  the  optic  vesicle  ;  St,  optic  stalk,  with  i  ntranci  -i  cen 
iral  artery. 

In  addition  to  providing  the  vitreous  tissue  with  capillaries  for  it>  direct 
nutrition  during  the  early  stages  of  its  active  growth,  the  hyaloid  artery  rami- 
fies within  the  mesodermic  layer  covering  the  posterior  surface  of  the  lens, 
thus  first  supplying  that  portion  of  the  tunica  vasculosa  lentis  known  as  the 
membrana  capsularis.  From  tin-  portion  of  the  lens  envelope,  a-  already 
mentioned,  the  blood-vessels  extend  forward,  and  finally  spread  out  within 
the  anterior  segmenl  over  the  corresponding  surface  of  the  lens,  to  constitute 
the  vessels  of  the  membrana  pupillaris. 

During   the    last   weeks  of   fetal  life  the  1.1 l-vessels  of  the   vitreous, 

together  with  the  tunica  lentis,  disappear,  the  onlv  indication  of  this  elaborate 
intraocular  vascular  network  which  persists  being  the  remain-  of  the  hyaloid 
artery  within  a  passage,  the  hyaloid  canal,  which  extend-  from  the  optic, en- 
trance to  the  posterior  pole  of  the  lens.  Sometimes,  however,  the  hyaloid 
arter)  undergoes  less  atrophy,  and  is  then  represented  by  ;i  cord  which 
extend-  toward  the  lens,  and  may  be  provided  with  ;i  lumen  for  a  portion 
of  it-  length;  in  such  cases  the  persistenl  hyaloid  artery  may  form  a  con- 
spicuous objeel   when   viewed  with  the  ophthalmoscope.     (Sec  page    U)3.) 


DEVELOPMENT  OF  THE  RETINA. 


25 


Development  of  the  Retina. — In  the  foregoing  consideration  of  the 
initial  changes  in  the  formation  of  the  optic  cup  the  early  conspicuous  differ- 
entiation of  the  inner  and  the  outer  layer.-  composing  its  walls  has  Keen  pointed 
out.  By  the  time  the  infolded  portion  of  the  vesicle  has  been  closely  applied 
to  the  uninvoluted  segment,  the  former,  or  inner  layer,  has  attained  a  thick- 
oess  of  many  times  thai  of  the  outer  layer:  the  latter,  however,  has  become 
conspicuous,  notwithstanding  its  attenuation,  by  reason  of  the  pigment-granules 
which  early  accumulate  within  its  cells.  The  pigment  appears  earliesl  near 
the  anterior  margin  or  lip  of  the  optic  cup,  gradually  extending  toward  the 
posterior  pole,  until  the  entire  outer  layer  appears  uniformly  dark.  This 
layer  becomes  the  future  'pigmented  retinal  epithelium   (Fig.  11). 

The  fate  of  the  greatly  thickened  inner  layer  is  largely  identical  with  the 
history  of  the  development  of  the  retina,  since  it  contributes  the  most  import- 
ant parts  of  the  nervous  tunic.  The  early  stages  in  the  development  of  the 
retina  resemble  closely  those  seen  else- 
where in  the  walls  of  the  young  brain- 
vesicles,  active  proliferation  of  the 
cells  lining  the  neural  tube  being  a 
conspicuous  feature.  As  in  other  parts 
of  the  young  cerebro-spinal  tube,  the 
differentiation  of  the  cells  constituting 
the  inner  layer  of  the  optic  cup  results 
in  the  formation  of  two  varieties  of 
tissues — the  nervous  elements  and  the 
sustentacular  tissue. 

The  differentiation  of  the  nervous 
constituents  results  in  the  formation 
of  two  groups  of  elements — the  nerve- 
cells  and  their  outgrowths,  the  nerve- 
fibers,  and  the  retinal  neuro-epitlielittni ; 
the  latter  eventually  becomes  special- 
ized as  the  layer  of  rods  and  cones  and 
the  outer  nuclear  layer,  these  two 
strata  together  constituting  the  layer 
of  visual  cells,  as  the  sensory  epithe- 
lium is  here  appropriately  called.  The 
further  development  of  the  sustentac- 
ular tissue  produces  the  characteristic 
radial  fibers  of  Miiller,  which  extend 
throughout  the  thickness  of  the  retina 
and  afford  support  and  connection  to 
the  nervous  elements.  In  addition  to  the  derivatives  from  the  involuted 
ectoderm,  ingrowths  of  true  connective  tissue  take  place  from  the  surround- 
ing mesodermic  tissue  which  accompanies  the  ramifications  of  the  early  arteria 
centralis  retinae. 

While  the  developmental  changes  jusl  described  affeel  the  far  greater  part 
of  the  optic  cup,  the  anterior  zone,  corresponding  to  the  double-layered  lips 
of  the  cup,  differ-  materially  in  it-  growth  and  fate.  Coincidently  with  the 
increase  of  surface  which  the  general  expansion  of  the  developing  eye  effects, 

the  anterior  zone  of  il ptic  cup  becomes  greatly  thinned,  the  inner  layer 

becoming  reduced  to  a  single  layer  of  low  columnar  elements,  in  marked 

contrasl  to  the  conspici -  thickening  which  this  layer  undergoes  throughout 

the  posterior  -egnient  of  the  cup. 


Fir..  11.— Section  through  developing  eye  of 
thirteen-day  raM>it  embryo  i  Piersol  \:e,  ectoderm  ; 
I,  lens,  consisting  of  anterior  nucleated  division 
represent  in<_r  thin  fronl  wall  of  lens-sac,  ami 
greatly  thickened  posterior  division  completely 
filling  cavity  of  sac  by  elongated  tii>ers  whose 
uuclei  present  crescentic  zone  («);  p,  posterior 
pigmented  layer;  /■.  specialized  anterior  retinal 
layer;  i",  point  where  layers  of  optic  vesii 
come  continuous;  n,  extreme  peripheral  section 
of  tissue  of  primitive  optic  nerve  connected  \\  iih 
vascular  tunic  v),  occupying  posterior  surface  <>t" 
lens:  //j.  surrounding  mesoderm,  which  (at  h 
grow  -  betw  een  lens  and  retina. 


26      EMBRYOLOGY,    ANATOMY,   AND   HISTOLOGY  OF  EYE. 

Che  extension  of  the  anterior  marginal  zone  of  the  optic  cup  is  intimately 
associated  with  the  changes  within  the  surrounding  mesoderm,  which  lead  to 
the  development  of  the  structures  composing  the  ciliary  region  and  the  iris: 
the  forward  growth  of  the  attenuated  Lips  of  the  cup  contributes  the  double- 
layered,  and  later  deeply  pigmented,  epithelial  investment  covering  the  inner 
surface  of  the  ciliary  body  and  the  iris  as  tar  as  the  pupil.  Thenars  ciliaris 
/■(  tina  and  the  pars  n  Una  iridica,  which  include  the  deeply  pigmented  stratum 
covering  these  respective  regions,  are,  therefore,  representatives  of  the  ante- 
rior zone  of  the  ectodermic  optic  cup.  The  line  of  demarcation  between  the 
posterior  visual  and  the  anterior  rudimentary  segments  of  the  optic  cup  i>  at 
first  not  sharply  marked,  but  later,  when  the  conspicuous  differences  in  the 
growth  of  the  layers  in  the  two  regions  become  established,  the  anterior  limit 
of  the  retinal  area  gradually  becomes  well  defined  at  the  position  later  indi- 
cated by  the  <>rn  S(  rrata. 

Development  of  the  Optic  Nerve. — The  early  optic  stalk,  which 
establishes  connection  between  the  primary  optic  vesicle  and  the  inter-brain, 
i-  involved  in  its  ocular  end  in  the  invagination  which  affects  the  lower  wall 
of  the  optic  vesicle  and  results  in  the  formation  of  the  choroidal  fissure. 
This  folding-in — in  addition  to  affording  a  means  of  entrance  into  the  interior 
of  the  future  optic  nerve  for  the  vascular  mesoderm,  from  which  later  are 
produced  the  central  retinal  blood-vessels — is  rendered  necessary  by  the  new 
relations  of  the  layers  composing  the  walls  of  the  optic  cup:  without  the 
corresponding  readjustment  of  the  walls  of  the  optic  stalk,  as  effected  by  the 
invagination  along  its  lower  margin,  the  walls  of  the  stalk-tube  would  be 
continuous  with  the  outer  layer  of  the  optic  vesicle  alone.  In  consequence 
of  the  folding-in  of  the  lower  wall  of  the  stalk  and  the  subsequent  obliteration 
of  its  lumen  by  the  apposition  of  its  walls  the  layers  composing  the  latter 
remain  continuous  with  the  invaginated  portion  of  the  optic  cup,  as  well  as 
with  that  possessing  the  original  relation  ;  hence  the  connection  is  maintained 
not  only  with  the  thickened  retinal  sheet,  but  also  with  the  attenuated  outer 
stratum. 

The  early  lumen  of  the  primary  optic  stalk  soon  disappears,  and  is 
replaced  by  a  solid  condition  of  the  young  optic  nerve.  This  solidification  is 
effected  by  two  processes,  one  of  which  affects  the  greater  central  part  of  the 
stalk  a-  far  as  its  cerebral  attachments,  while  the  other,  which  includes  the 
end  applied  to  the  optic  vesicle,  is  limited  to  the  peripheral  and  smaller  seg- 
ment of  the  nerve.  The  greater  part  of  the  hollow  .-talk  is  converted  into  a 
solid  cord  by  the  gradual  thickening  of  its  walls,  due  to  active  proliferation 
of  the  elements,  which  results  in  the  subsequent  apposition  and  final  oblitera- 
tion of  the  lumen.  The  solidification  of  the  ocular  portion  of  the  stalk  i>  the 
result  of  both  invagination  and  proliferation  :  the  early  invagination  of  the 
Iow.t  wall  of  the  -t.-dk  when  completed  effects  the  closure  of  the  lumen  of 
the  tube  by  the  appo-ition  and  final  fusion  of  the  wall-  of  the  tube;  while 
the  proliferation  of  the  margin-  of  the  furrow  results  in  the  approximation 
and  complete  closure  of  thegroove,  the  growth  of  the  so  imprisoned  mesoderm, 
together  with  t  he  accompanying  blood-vessels,  producing  the  connective  tissue 
surrounding  the  central  retinal  blood-vessels  as  they  occupy  the  interior  of 

till'    opt  IC    l|el'\  e. 

The  development  of  the  nerve-fibers  is  a  secondary  but  coincident  process, 
the  newly-formed  liber-  occupying  the  wall-  of  the  rapidly  closing  stalk. 
The  older  views  which  regarded  the  optic  liber-  as  being  produced  in  loco 
along  the  course  of  the  optic  stalk  are  no  longer  accepted  since  the  investiga- 
tions of  Muller,  Kolliker,  His,  and  others  showing  that  the  young  liber-  grow 


DEVELOPMENT  OF  THE  FIBROUS  AND   VASCULAR   GOATS.    27 

into  the  optic  stalk  from  the  nerve-cells  Located  al  it-  extremities.  The 
great  majority  of  fibers  of  the  optic  nerve  may  be  regarded  as  the  centrally 
directed  outgrowths  of  the  young  neuroblasts  situated  within  the  developing 
retina:  the  axis-cylinder  processes  of  these  element-  are  guided  in  their 
journey  to  form  central  relations  with  the  brain-centers  by  the  supporting 
tissue  contributed  by  the  <>|>tie  stalk.  In  addition,  however,  to  the  centrally 
growing  fibers,  there  are  other-  which  pass  in  the  opposite  direction,  and 
represent  the  peripherally  directed  axis-cylinder  processes  of  the  neuroblasts 
situated  within  the  brain.  Further  complexity  of  structure  later  arises  from 
the  ingrowth  of  the  vascular  connective  tissue  constituting  the  pial  sheath 
of  the  optic  nerve,  the  extensions  of  which  tissue  form  the  septa  subdivid- 
ing the  nerve  into  the  variously  sized  bundles  which  are  so  conspicuous  in 
transverse  sections.  The  posterior  parts  of  the  optic  stalks  become  the  optic 
tracts,  while  their  middle  portions  unite  to  form  the  optic  chiasm.  The 
sheaths  of  the  optic  nerve  are  produced  by  the  direct  continuation  of  the 
mesodermic  investment  from  which  the  cerebral  dura,  arachnoid,  and  pia 
are  derived. 

Development  of  the  Fibrous  and  Vascular  Coats. — With  the 
exception  of  the  corneal  epithelium,  the  lens,  and  the  nervous  tunic  with  its 
cerebral  attachments,  which  are  derived  from  the  ectoderm,  all  parts  of  the 
eyeball  are  developed  from  the  mesoderm  surrounding  the  primary  optic 
vesicle.  Coincidently  with  the  changes  affecting  the  optic  vesicle,  as  already 
noted,  the  surrounding  mesoderm  exhibits  a  differentiation,  marked  by  active 
cell-proliferation  and  condensation,  which  results  in  the  production  of  a  dis- 
tinct envelope  of  actively  growing  embryonal  connective  tissue.  The  posterior 
segment  of  this  mesodermic  capsule  undergoes  further  differentiation  into  an 
outer,  relatively  dense  tunic,  which  becomes  the  sclerotic,  and  an  inner  coat, 
which  later  is  distinguished  by  a  looser  texture  and  greater  vascularity. 

Very  early  in  the  history  of  the  eye  the  lens-sac  is  separated  from  the 
overlying  ectoderm  by  a  thin  stratum  of  mesodermic  tissue;  later  this  layer 
becomes  cleft,  one  part  remaining  as  a  thin  mesodermic  sheet  over  the  outer 
surface  of  the  young  lens,  the  other  adhering  to  the  inner  surface  of  the  ecto- 
derm. The  strata  of  mesoderm  so  formed  constitute  the  pupillary  membrane 
and  the  substantia  propria  of  the  cornea,  the  intervening  cleft  being  the 
earliest  indication  of  the  future  anterior  chamber.  The  forward  growth  of 
the  thin  double-layered  lip  of  the  optic  cup  beyond  the  equator  of  the  young 
lens  and  over  its  anterior  surface  is  accompanied  by  a  proliferation  of  the 
adjacent  mesoderm  and  the  extension  of  the  primitive  choroidal  stratum 
which  accompanies  the  retinal  tissue  in  its  growth  forward.  This  anterior 
extension  of  the  lip  of  the  optic  cup  and  the  associated  mesoderm  give-  rise 
to  the  rudiments  of  the  iris  and  ciliary  body,  this  expansion  progressing  until 
almost  the  entire  anterior  surface  of  the  lens  i<  covered  :  the  central  unoccu- 
pied area  thus  corresponds  to  a  circular  aperture  within  the  retino-iridial 
sheel  which  remains  as  the  pupil.  In  the  early  stages  this  opening  is  closed 
by  tin-  vascular  pupillary  membrane,  ;i  temporary  structure  which  disappear-; 
before  birth. 

The  active  growth  of  the  thin  lip-  of  the  optic  cup  results  in  -till  greater 
attenuation  of  the  component  strata  of  epithelial  cells  until   these  are  repre- 
sented by  the  low  columnar  and  cuboidal  element-  of  the  par-  ciliaris  and 
pars  iridica  retinas;  the  pigmentation  of  these  epithelial  cell-  also  incn 
until    the  anterior   portion  of  both   layers  is  loaded  with  color-particles 
the  conspicuous  pigment   layer  covering  the  posterior  surface  "f  th 
produced.     The  accompanying  mesodermic  layer  thickens  and  gives  '" 


28      EMBRYOLOGY,    ANATOMY,    A  .YD  HISTOLOGY  OF  EYE. 

the  stroma  and  muscular  tissue  of  the  iris  and  ciliary  body,  and  for  a  time  is 
also  continuous  with  the  vascular  tunic  of  the  lens. 

About  the  beginning  of  the  third  month,  in  consequence  of  an  unusual 
active  lateral  expansion,  the  epithelial  layers  are  thrown  into  a  series  of  radial 
folds  which  surround  the  equator  of  the  lens  :  these  plications  arc  the  earliest 
suggestion  of  the  future  ciliary  processes,  and  into  them  shortly  afterward 
delicate  processes  of  mesodermic  tissue  extend;  later  these  become  more 
robust,  and  in  them  the  characteristic  richly  vascular  structures  of  the  ciliary 
processes  develop.  In  contrast  to  the  deep  pigmentation  involving  both 
epithelial  layers  of  the  pars  iridica  retinae,  only  the  outer  stratum  of  the  pars 
ciliaris  contain-  pigment,  the  elements  of  the  inner  layer  remaining  uncolored 
and  retaining  to  a  greater  extent  their  original  columnar  form. 

The  corneal  stroma  becomes  Mended  with  that  of  the  sclerotic  tunic,  so 
that  eventually  the  two  become  continuous.  With  the  formation  of  the  ante- 
rior chamber  the  mesodermic  elements  immediately  in  contact  with  the 
lymph-space  differentiate  into  flattened  cells  which  become  the  posterior 
endothelium  of  the  cornea  and  the  anterior  endothelium  of  the  iris.  The 
formation  of  the  spaces  of  Fontana  and  of  the  trabecular  of  the  ligamentum 
pectinatum  iridis  is  closely  associated  with  the  differentiation  of  the  ante- 
rior extremity  of  the  primitive  choroidal  tract  and  the  production  of  the 
membrane  of  Descemet;  to  this  tract  the  name  pars  uvealis  cornea  has  been 
applied. 

Development  of  the  Vitreous  Body. — This  is  intimately  related  with 
the  primary  changes  of  the  optic  vesicle.  As  already  described,  the  invagina- 
tion of  the  latter  sac  involves  not  only  the  external  portion  directed  toward  the 
surface,  bu1  affects  likewise  its  inferior  wall,  resulting  in  the  production  of 
the  choroidal  fissure,  which  leads  from  the  exterior  into  the  cavity  of  the 
secondary  optic  vesicle.  The  surrounding  mesoderm  takes  advantage  of  the 
deft  -o  established  to  gain  entrance  into  the  interior  of  the  optic  cup,  which 
soon  becomes  filled  with  an  extremely  delicate  mesodermic  tissue  occupying 
the  space  between  the  young  lens  and  the  retina.  The  primitive  vitreous 
early  becomes  vascular  by  the  multiplication  and  extension  of  the  branches 
of  the  hyaloid  artery,  which  is  continued  from  the  central  retinal  vessel-  as 
far  forward  a-  the  inner  and  posterior  surface  of  the  lens,  where  they  spread 
out  to  aid    in   forming   the   vascular   tunica    lentis. 

The  vitreous  body,  therefore,  musl  be  regarded  as  composed  of  modified 
mesoderm,  and  presents  the  characteristics  of  embryonal  connective  tissue 
throughout  the  earlier  periods  of  it-  growth.  Later,  the  blood-vessels  of  the 
vitreous  disappear  and  the  structural  elements  become  reduced  to  atrophic 
cells  of  irregular  form  and  distribution  :  the  remains  of  the  hyaloid  vessels 
are  sometimes  observed  even  after  birth  asa  delicate  c<>\'(\  stretching  from  the 
optic-nerve  entrance  toward  the  lens.     (See  page   !'»•"».) 

The  peripheral  zone  of  the  young  vitreous  becomes  condensed,  and  pro- 
duces the  hyaloid  membrane  which  limit-  the  vitreous  on  all  sides  except 
behind  the  lens,  mid  is  continued  forward  to  fade  away  over  the  ciliary 
regii  >n. 

Development  of  the  Eyelids.— This  begins  quite  early  a-  an  upper 
and  lower  fold  of  i  he  integumentary  layer,  which  gro'H  over  the  corneal  surface 
until  they  meet  and  fuse.  The  fusion  of  the  palpebral  fold-  in  man  takes 
place  early  in  the  third  month  of  fetal  life,  the  union  continuing  until  shortly 

before  birth,  when  the  permanent  separation  is  effected  by  cleavage  through 
the  common  epithelial   layer  formed   by  the  union  of  the  ectoderm  along  the 

line  of  juncture. 


ANATOMY  OF  THE  EYE.  29 

During-  the  period  of  fusion  the  mesoderm  contained  within  the  palpebral 
folds,  bounded  externally  and  internally  by  coverings  of  ectoderm,  dilleren- 
tiates  into  thin  layers,  which  give  rise  t<»  the  subcutaneous  tissues,  the  mus- 
cular structures,  and  the  subconjunctival  or  tarsal  stratum.  The  Meibomian 
and  other  glands  contained  within  the  lid  are  derived  as  ingrowth-  and  pro- 
liferations of  the  ectoderm  covering  the  adjacent  surface  of  the  immature  lid. 
The  tear-gland  appears  during  the  third  month  as  a  solid  ingrowth  of  the 
conjunctival  ectoderm  close  to  the  upper  lid  ;  later  the  epithelial  ramifications 
acquire  a  lumen.  The  ocular  muscles,  together  with  the  various  structures 
contained  within  the  orbit,  with  the  exception  of  the  nerve-fibers,  primarily 
are  derivatives  of  the  mesoderm. 

The  foregoing  sketch  of  the  development  of  the  eyeball  shows  that  the 
derivatives  of  the  outer  and  middle  blastodermic  layers  may  be  grouped  as 
follows  : 

A.  From  the  ectoderm  are  derived — 

Anterior  epithelium  of  the  cornea  and  its  conjunctival  continuation. 
Crystalline  lens,  including  the  epithelium  of  its  anterior  capsule. 
Retina,  including  the  anterior  extensions  forming  the  pars  ciliaris  and 

pars  iridica. 
Sustentacular  tissue  of  the  optic  nerve. 

B.  From  the  mesoderm  are  derived — 
Corneal  stroma  and  endothelium. 
Sclerotic  coat. 

Vascular  tunic,  including  the  choroid  and  the  connective-tissue  stroma 
of  the  ciliary  region  and  iris. 

Vitreous  body. 

Suspensory  apparatus  of  the  lens. 

Connective-tissue  investments  of  the  optic  nerve. 

Vascular  tissues  of  the  retina. 
The  epithelial  tissues  of  the  eyelids  and  conjunctival   sac,  including  the 
lid-glands,   the   lachrymal   gland,   and   the   lining  of  the  tear-channels,   are 
derivatives  of  the  ectoderm  ;  the  surrounding  connective  tissues  are  products 
of  the  mesoderm. 

ANATOMY  OF  THE  EYE. 

The  Orbits. — The  orbits  are  horizontally-placed  pyramidal  fossse,  the 
anteriorly  and  somewhat  outwardly  directed  bases  of  which  correspond  with 
the  facial  plane,  their  apices  being  occupied  by  the  inner  extremity  of  the  sphe- 
noidal fissure.  The  angles  between  the  four  conventional  walls  of  the  space 
are  not  sharply  marked,  but  rounded  off,  so  thai  the  surfaces  pass  gradually  one 
into  the  other,  each  orbital  cavity  approaching  often  more  closely  the  conical 
than  the  pyramidal  form.  The  inner  walls,  composed  of  the  nasal  process 
of  the  superior  maxilla,  the  lachrymal,  the  ethmoid,  and  Lhe  body  of  the 
sphenoid,  lie  generally  parallel  with  each  other;  the  external  walls,  formed 
by  the  orbital  surface  of  the  malar  bone  and  great  wing  of  the  sphenoid, 
on  the  contrary,  form  almost  a  right  angle  between  their  plane-.  The  roof 
and  floor,  composed  respectively  of  i  lie  frontal  and  small  wing  of  the  sphenoid 
and  of  the  malar,  the  superior  maxillary,  and  the  palate  bone-,  gradually 
converge   toward   the  apex   of  the  generally    conical   cavity. 

The  orbital  axes  do  not  correspond  accurately  with  the  horizontal  plane, 
since  ;it  their  posterior  pole-  they  lie  from  L5'  to  li < >  above;  when  prolonged 
backward,  the  axes  meet  in  the  vicinity  of  the  sella  Turcica  and  include  an 
angle  of  about   43°.     The  distance  between  the  anterior  ends  of  thi  orbital 


30      EMBRYOLOGY.    AXATn.MY,   AND  HISTOLOGY  OF  EYE. 


axes  is  approximately  60  mm.  The  depth  of  the  orbit  varies  from  40-45 
Him.,  being  usually  from  3-5  mm.  greater  in  the  male  than  in  the  female 
skull.      The  capacity  of  the  adull   orbit    approximates  :}()  c.cm. 

The  irregularly  quadrilateral  base  *  > t *  the  orbit,  corresponding  to  the 
facial  apertures,  is  bounded  by  the  thickened,  rounded,  and  partially  over- 
hanging margins  contributed  by  the  frontal,  malar,  and  superior  maxillary 
bones.  The  apex  is  occupied  by  the  inner  and  wider  extremity  of  the 
sphenoidal  fissure,  the  narrower  continuation  of  which  extends  upward  and 
outward  as  a  conspicuous  cleft  separating  the  roof  and  outer  wall  of  the 
orbit  throughout  the  posterior  half  of  their  line  of  meeting.  The  optic 
foramen  lie-  slightly  to  the  inner  and  upper  side  of  the  apex  of  the  orbit, 
within  tin'  -mailer  ala  of  the  sphenoid.  The  angle  between  the  external  wall 
and  the  floor  i-  occupied  throughout  it-  posterior  three-fourths  by  the  narrow 
and  elongated  sphenomaxillary  fissure,  which  communicates  with  the  spheno- 
maxillary fossa  at  its  posterior  inner  end,  and  with  the  zygomatic  fossa  at  its 
anterior  outer  extremity.  The  posterior  part  of  the  orbital  floor  i-  grooved 
by  the  beginning  of  the  infraorbital  canal  ;  the  contour  of  the  anterior 
mar-in  of  the  root'  is  interrupted  by  the  supraorbital  noteh  or  foramen  ;  the 
inner  wall  below  lodges  the  lachrymal  groove,  formed  by  the  lachrymal  and 
superior  maxillary  bones,  while  higher,  in  close  relation  with  the  internal 
boundary  of  the  arched  roof,  is  the  depression  occupied  by  the  pulley  of  the 
superior  oblique  muscle.  Behind  the  external  angular  process  lies  the 
lachrymal  fossa  for  the  accommodation  of  the  tear-gland. 

The  Eyelids  and  the  Conjunctiva. — The  eyelids  are  two  broad  mov- 
able folds  of  integument  supplemented  and  strengthened  by  muscular  bundles 
and  dense  fibrous  tissue,  and  lined  by  a  mucous  membrane:  they  are  attached 
to  the  upper  and  lower  orbital  margins,  and  aid  in  covering  in  the  structures 
at  the  base  of  the  orbit  and  the  projecting  anterior  segment  of  the  eyeball. 

A-  already  noted,  the  eyelids  develop  as  duplications  of  integument  which 
gradually  approach,  and,  finally,  about  the 
end  of  the  third  month,  fuse  along  the  ap- 
proximated edges  to  form  a  closed  sac  sur- 
rounding  the  anterior  segment  of  the  eye- 
ball.     Before   birth    the  permanent   scpara- 


irallj  opened,  from  a 
graph  i  Merkel  i.    Horizontal  pla  nrough  inner 

cantb 


the  eye- 
lids  separated  by  hooks  (Quair  Merkel  i  Rs, 
plica  semilunaris :  PI  ior  ami  in 

i]   Lachrymal  puncta;  Oar,  lachrymal  car- 
uncle: Lpm,  internal  tarsal  ligament. 


Hon  of  the  lid-  take-  place,  by  which  lime  the  -kin  in    relation  to  the  eyeball 

has  lost  its  original   integ entary  characteristics,  and  has  assumed  those  of 

a  mucous  membran* — the  conjunctiva. 

The  palpebral   fissure,  bounded   by  the  arched   free  margins  of   the  eyelids, 

resembles  an  almond   in   it-  general   form  (Fig.  L2).     It-  Length,  measured 


EYELIDS   AND    CONJUNCTIVA.  31 

from  its  extreme  angles,  is  usually  between  2<S  and  30  mm.,  and  its  greatest 
width  when  open  is  about  13  nun. 

Individual  variations  from  these  measurements  are  very  common,  shorten- 
ing and  narrowing  of  the  opening  being  not  infrequent  to  the  extent  of 
several  millimeters ;  slight  differences  in  the  palpebral  clefts  of  the  two  eyes 
exist  in  many  instances. 

The  symmetry  of  the  palpebral  opening  is  broken  by  the  variation  in  its 
two  angles,  the  outer  or  lateral  canthus  being  bounded  by  the  converging  borders 
which  directly  continue  the  arches  of  the  lids  until  they  meet  at  an  acute 
angle,  while  the  inner  or  mesial  canthus  is  situated  at  the  junction  of  the 
slightly  arching  and  almost  parallel  margins  which  enclose  the  diverticulum 
known  as  the  locus  lacrymalis,  or  tear-lake.  The  latter  is  formed  by  the 
sharp  deviation  which  the  free  lid -margins  undergo  about  5  mm.  before  reach- 
ing their  mesial  juncture,  their  subsequent  direction  being  almost  horizontal 
until  they  converge  just  before  uniting  (Fig.  12). 

The  space  included  between  the  rounded  mesial  extremities  of  the  eyelids, 
or  lachrymal  lake,  is  partly  occupied  by  a  low,  spongy-looking  elevation  of 


Fig.  14.— Relations  of  the  palpebral  opening  to  the  eveball  (blue),  conjunctival  sac  iredt,  and  orbit  (yelluwt 

(Merkel). 

reddish  color,  the  caruncula  lacrymalis ;  the  caruncle  is  an  isolated  area  of 
skin  containing  a  few  large  modified  sweat-glands,  in  addition  to  -ebaceous 
follicles  connected  with  the  follicles  of  the  minute  hairs  which  spring  from 
the  summit  of  the  elevation.  Fat-cells  and  involuntary  muscular  tissue  are 
also  usually  present.  The  lateral  or  outer  extremity  of  the  lachrymal  car- 
uncle sinks  into  the  surrounding  conjunctival  tissue,  which  in  this  position 
presents  a  vertically  placed  crescentic  fold,  the  plh-a  semilunaris  (Fig.  13). 
This  duplieature  represents  a  rudimentary  nictitating  membrane,  or  third  eye- 
lid, which  in  many  lower  types,  as  birds  or  amphibians,  attains  conspicuous 
dimensions.  Minute  cartilaginous  plate-  and  a  lew  glandular  acini  lodged 
within  the  base  of  the  semilunar  fold  are  additional  rudimentary  representa- 
tives of  the  crescentic  cartilage  and  I  birder'-  gland  of  the  lower  animals. 

The  relation  of  the  anterior  segment  of  the  eyeball  to  the  palpebral  open- 
ing varies  with  the  position  of  the  eyeball  and  the  approximation  of  tin  lid.-,. 
\\  hen  the  eyelid-  are  apart  and  the  eye  directed  horizontally  forward  toward 
distant  objects,  the    cornea    lie-  midway  between    the    lateral    canthus  mid  the 


32     EMBRYOLOGY,   ANATOMY,   AND   HISTOLOGY  OF  EYE. 


-  b 


lachrymal  puncta,  or  slightly  external  to  the  middle  of  the  line  joining  the 
canthi.  The  axis  of  the  palpebral  cleft  does  not  quite  coincide  with  the 
horizontal,  since  the  mesial  canthus  lies  a  little  lower  than  the  external. 
The  cornea  is  unequally  covered  by  the  two  lids,  the  lower  lid  usually  not 
quite  reaching  the  corneal  margin,  while  the  upper  lid  covers  a  small  variable 
segment  of  the  periphery  above.  The  extent  to  which  the  cornea  is  covered 
by  the  upper  lid  i-  an  important  factor  in  producing-  staring  or  somnolent 
expressions  ( Fig.  14). 

Closure  of  the  eye  is  chiefly  effected  by  the  upper  lid,  which  from  its 
larger  size  and  general  mobility  covers  about  three-fourths  of  the  exposed 
portion  of  the  eyeball.  The  excursion  made  by  the  upper  lid  in  closing  and 
opening  the  palpebral  orifice  measures  about  .']  mm.,  the  distance  traversed 
by  the  lower  lid  being  some- 
what less.  When  the  eyelids 
are  closed  during  sleep  the  eye- 
ball is  rotated,  so  that  the  cornea 
lies  above  and  slightly  to  the 
median  side  :  closure  of  the  lids 
while  awake,  however,  is  not 
attended  with  such  change,  the 
position  of  the  cornea  being 
then  maintained.  The  slit- 
like palpebral  fissure  of  the 
closed  lids  lies  below  the  hori- 
zontal line  drawn  through  the 
mesial  canthus,  the  arched  mar- 
gin of  the  upper  lid  being  di- 
rected downward,  or  just  the 
opposite  to  it-  form  when  the 
eye  is  open. 

The  eyelid  in  the  vicinity 
of  its  free  border  presents 
three  principal  strata  when 
examined  in  section:  (1)  the 
skin  and  subcutaneous  tissue; 
{-\  the  muscular  layer  ;  (3)  and 
the  tarsal  plate  covered  with 
tin-  conjunctiva  (  Fig.  1  5). 

The  integument  of  the  eyelid 
presents  the  usual  details  of 
delicate  skin  in  other  locations, 
tin'  bair-follicles  and  surface 
hair-  being,  however,  extremely 
small  and  the  subcutaneous  tis- 
sue devoid  of  fit.  The  rounded 
outer  margins  of  the  lids  bear 
conspicuous  large  hairs,  the 
e\  elashes  or  cilia  ;  t  hose  of  t  he 
upper  lid  are  larger  and  more 
numerous  than  those  of  the 
lower,   the    former    measuring 

from  9-12  nun.  in  length  and  numbering  about  150,  while  the  latter  are  only 
half  as  many  and  only  from  6  8  mm.  long.     The  hair-follicle-  of  the  cilia 


Pig.  15     Vertical  section   through    the   upper   eyelid 
(Waldi  mi  :  b,  cut   Bbera  oi   the  orbicularis  ;  6  . 

bundle  of  orbicularis ;  c,  muscle  (involuntai 
Muller;  d,  conjunctiva;  >.  tarsal   plate   in  which  are  lm 

bedded  thi    Meil lian  gland  g,  sebaceous  glands  near 

haira  of  Integument  ;  j,  sweat  glands ;  k, 
indi 


/: ) '  EL  WS    A  ND   CONJUNCTl  I ' .  I . 


33 


are  arranged  in  double  or  triple  rows  near  the  anterior  border  of  the  lid. 
The  average  life  of  an  eyelash  is  probably  about  four  months,  the  older  and 
thicker  cilia  being  constantly  replaced  by  the  young  and  slender  hairs. 

The  muscular  layer  <>t*  the  eyelid  consists  essentially  of  the  palpebral  por- 
tion of  the  orbicularis  palpebrarum,  which  is  arranged  as  concentric  fibers, 
which  occupy  the  interval  between  the  subcutaneous  tissue  and  the  tarsal 
plate  and  its  associated  tendons.  The  elliptical  muscular  bundles,  when 
cut  in  Longitudinal  section  of  the  eyelid,  appear  as  irregular  groups  of  trans- 
versely cut  fibers.  The  innermosl  of  the  concentric  bundles  of  the  orbicularis 
lies  close  to  the  inner  margin  of  the  lid,  and  constitutes  a  robust  and  partly 
isolated  group  of  fibers  known  as  the  ciliary  muscle  or  mnscle  of  Riolan. 
The  fibers  composing  these  bundles  surround  the  structures  occupying  this 
part  of  the  border  of  the  lid,  including  the  hair-follicles,  sebaceous  glands, 
glands  of  Moll,  and  the  ducts  of  the  Meibomian  glands  (Fig.  15). 


Fir,,  ic. —Dissection  of  the  tarsal  plates  and  their  ligaments  (Testut):  1,  2,  upper  and  lower  tarsus; 
3,  4,  external  and  internal  tarsal  ligaments;  5,  expanded  tendon  of  levator  palpebra  ;  6,  6',  septum  orbi- 
tale  ;  7,  lachrymal  >a<- ;  8,  supraorbital  vessels  and  nerve  ;  9,  lachrymal  artery  and  nerve  ;  10, 11,  openings 
for  supra- ami  infratrochlear  nerves;  12,  opening  for  the  angular  vein;  13,  tendon  of  superior  oblique 

muscle. 


The  fibrous  stratum  of  the  eyelid  has  as  its  principal  constituent  the 
crescentic  plate  of  firm  fibrous  tissue  known  as  the  tarsus  or  tarsal  cartilage. 
This  structure,  composed  entirely  of  dense  connective  tissue  and  without 
cartilage-cells,  exists  in  both  eyelids  as  a  sustaining  band,  which  is  important 
in  maintaining  the  proper  form  of  the  lid-margins.  The  tarsal  plates  vary 
in  .-izc  in  the  two  eyelids,  the  upper  tarsus  being  broader  and  more  arched 
than  that  within  the  lower  lid.  The  extremities  of  the  tarsi  are  united  to 
each  other  and  to  the  orbital  walls  by  firm  band-  of  fibrous  tissue,  the  mesial 
and  lateral  palpebral  ligaments:  The  upper  tarsus,  corresponding  with  the 
greater  width  of  the  superior  lid,  is  wider  than  the  lower  plate,  measuring 
about  10  mm.  al  the  point  of  its  greatest  breadth,  or  about  twice  the  width 
of  the  lower.  In  length  the  tarsi  are  almosl  equal,  ami  extend  along  nearly 
the  entire  lid-margin,  aboul  the  middle  of  which  tiny  p..--.--  their  greatesi 
thickness,  diminishing  toward  either  end  as  well  as  toward  their  convex 
b<  >rders. 

The  tendon  of  the  levator  palpebral,  as  it-  lower  broadened  end  expands 

3 


34      EMBRYOLOGY,   ANATOMY,   AND   HISTOLOGY  OF  EYE. 

into  the  upper  eyelid,  becomes  closely  related  to  the  inward  extension  of  the 
orbital  fascia,  which,  as  the  septum  orbitale,  passes  from  its  peripheral  attach- 
ment at  the  orbital  margin  into  the  eyelids,  forming  a  partition  which  closes 
in  the  periocular  structures  and  prevents  the  extrusion  of  the  orbital  fat  be- 
tween  the  eyeball  and  orbit  (Fig.  16). 

In  the  upper  lid  the  septum  orbitale  or  palpebral  fascia  blends  with  the 
tendon  of  the  levator  palpebral,  the  two  forming  a  layer  of  connective  tissue 
which  intervenes  between  the  orbicularis  and  the  conjunctiva  above,  and  is 
largely  inserted  into  the  tarsus  below,  some  bundles  passing  in  front  of  the 
tarsal  plate.  In  the  lower  lid  the  septum  joins  the  tarsus  in  common  with 
fascial  expansion  connected  with  the  inferior  straight  and  oblique  muscles. 

'Idie  relations  of  the  upper  tarsal  plate  to  the  expanded  tendon  of  the 
levator  palpebral  muscle  are  most  intimate.  The  fibrous  tissue  of  the  tendon 
of  this  muscle  is  arranged  in  three  layers — the  upper,  which  expands  into 
bundles  which  are  inserted  into  the  summit  of  the  conjunctival  fornix  and 
adjacent  part  of  the  orbital  portion  of  the  lid,  while  in  the  tarsal  portion  the 
fibrous  bundles  interlace  with  the  nuisele-fihers  of  the  orbicularis  palpebrarum, 
on  the  inner  surface  of  which  they  form  an  imperfect  fibrous  sheet. 

The  middle  part  of  the  levator  aponeurosis  contains  bundles  of  involun- 
tary muscle,  the  so-called  superior  palpebral  muscle  of  Miiller,  which  are 
inserted  principally  into  the  upper  margin  of  the  tarsal  plate.  The  lower 
stratum  of  the  tendon  consists  of  bundles  of  fibrous  tissue,  and  is  attached  at 
various  points  to  the  conjunctiva,  and  is  closely  blended  with  the  fascial  pro- 
cess connected  with  the  superior  rectus  muscle.  In  the  lower  lid  the  expan- 
sions of  the  fascial  process  connected  with  the  inferior  rectus  replace  the 
levator  aponeurosis  of  the  upper  lid.  Bundles  of  involuntary  muscle  occur 
also  in  the  lower  lid,  and  constitute  the  inferior  palpebral  muscle,  while  the 
fibrous  bundles  are  interwoven  with  the  fasciculi  of  the  orbicularis  palpe- 
brarum. 

I'he  ocular  surface  of  the  tarsal  plates,  when  inspected  during  life  after 
eversion  of  the  eyelids,  presents  numerous  parallel  vertical  rows  of  small 
yellowish  granules:  these  latter  are  the  acini  of  the  Meibomian  or  tarsal 
(//anils  seen  through  the  conjunctiva.  When  examined  more  carefully  the 
tarsal  glands  are  seen  to  be  enlarged  and  modified  sebaceous  glands  imbedded 
within,  and  occupying  almost  the  entire  thickness  of,  the  dense  connective 
tissue  forming  the  tarsi  :  they  number  between  thirty  and  forty  in  the  upper 
lid  ami  from  twenty  to  thirty  in  the  lower.  Each  eland  consists  of  a  straight 
or  slightly  sinuous  vertical  duet,  from  the  sides  of  which  open  numerous 
diverticula  or  alveoli.  The  Meibomian  glands  occupying  the  middle  of  the 
tarsi  are  longer  and  more  vertically  disposed  than  those  placed  nearer  the 
extremities  of  the  plate-,  where  the  glands,  in  addition  to  being  shorter,  not 
infrequently  terminate  by  sharply  bending  on  themselves.  The  ducts  ter- 
minate as  minute  puncta  arranged  in  a  row  along  the  margin  of  the  eyelid 
near  n-  -harp  inner  border,  ami  are  lined  by  a  direct  continuation  of  the 
stratified  squamous  epithelium  of  the  adjacent  integument;  the  acini  of  the 
glands  are  clothed  with  cuboidal  cell-  which  resemble  the  elements  found  in 
other  sebaceous  glands,  containing  numerous  fat-droplet-  within  their  proto- 
plasm. 

The  free  margins  of  the  eyelids  present  an  outer  and  inner  border,  which 
differ  in  their  forms  and  relations ;  t  he  outer  border  is  somewhat  rounded  and 
besel  with  tie'  long  curved  cilia,  while  the  inner  I-  sharply  defined  by  the 
line  of  juncture  of  integument  and  conjunctiva,  along  which  open  the  orifices 
of  the  Meibomian  elands.      In  addition  to  the  hair-follicle-  and  associated 


EYELIDS   AND  CONJUNCTIVA.  35 

sebaceous  glands  lodged  within  the  palpebral  margin,  a  Dumber  of  enlarged 
and  modified  sweat-glands,  or  glands  of  Moll,  lie  about  midway  between  the 
two  borders  of  the  lid,  and  open  in  close  proximity  to  or  into  the  mouths  of 
the  hair-follicles  ;  the  glands  of  Moll  in  the  upper  lid  extend  into  the  sur- 
rounding tissue  to  a  depth  equal  to  the  extremities  of  the  hair-follicles  in 
the  lower  lid — indeed,  exceeding  the  hair-follicles  in  length.  The  ends  of  the 
hair-follicles,  sebaceous  glands,  and  glands  of  Moll  are  surrounded  l>v  the 
deepest  filters  of  the  ciliary  muscle  of  Riolan,  the  greater  part  of  the  group 
of  muscular  bundles  lying  between   the  glands  of  Moll  and   the  tarsus. 

The  conjunctiva  invests  the  ocular  surface  of  the  eyelids  and  the  anterior 
segment  of  the  eyeball,  and  is,  therefore,  appropriately  divided  into  the  -pal- 
pebral and  bulbar  portions.  The  annular  fold  which  marks  the  peripheral 
limit  of  the  conjunctival  sac  is  known  as  the  fornix  conjunetivce. 

The  palpebral  conjunctiva  presents  a  further  subdivision  into  the  tarsal 
and  orbital  areas,  based  on  the  differences  which  characterize  these  two  seg- 
ments. The  conjunctiva  covering  the  tarsus,  directly  continuous  with  the 
integument  at  the  lid-margin,  so  closely  adheres  to  the  firm  fibrous  tarsal  plate 
that  the  conjunctival  membrane  is  immovably  attached  to  the  fibrous  lamella  ; 
the  Meibomian  glands  indistinctly  show  through  the  conjunctiva  as  vertically 
arranged,  parallel,  yellowish-white  lines. 

The  orbital  conjunctiva,  covering  the  fascial  and  tendinous  expansions 
which  are  blended  with  the  arched  border  of  the  tarsi,  is  attached  by  the 
loose  subconjunctival  connective  tissue  to  the  subjacent  structures,  upon  which 
it  freely  moves.  In  contrast  to  the  velvety  appearance  of  the  tarsal  portion, 
the  orbital  conjunctiva  is  smooth  and  glistening,  although  less  firmly  fixed  to 
the  underlying  tissues. 

The  peculiar  velvety  appearance  of  the  tarsal  conjunctiva  depends  upon 
the  presence  of  minute  interlacing  furrows  and  intervening  ridges  and 
papillae;  the  latter  are  especially  well  developed  near  the  orbital  border  of 
the  tarsus.  The  lymphoid  characteristics  of  the  subepithelial  layer  of  the 
tarsal  conjunctiva  are  conspicuous  in  the  situations  in  which  the  tarsal 
papillae  are  best  developed;  hence  in  the  vicinity  of  the  tarsal  border  the 
general  lymphoidal  infiltration  is  often  replaced  by  local  aggregations  of  cells 
in  the  form  of  lymph-follicles  or  trachoma-gland-.  These  structures,  how- 
ever, are  very  variable  in  their  position,  number,  and  size,  and  may  be  entirely 
wanting  or  found  in  other  parts  of  the  conjunctival  sac. 

At  the  mesial  canthus  the  conjunctiva  lines  the  lachrymal  lake,  and  on 
the  caruncle  maintains  its  primary  integumentary  character.  Just  external 
or  lateral  to  the  punota  the  conjunctiva  presents  a  well-marked  vertical  cres- 
centie  fold,  the  plica  semilunaris,  which  represents  a  rudimentary  nictitating 
membrane. 

The  conjunctiva  covering  the  tarsi  and  the  cornea  is  more  fixed  than  else- 
where, being  in  these  situations  so  inseparably  attached  to  the  subjacent 
structure-  that    it   follows  the  frequent    movements  of  these  parts. 

The  remaining  portions  of  the  conjunctiva  are  separated  from  the  under- 
lying structures  by  the  subconjunctival  tissue,  which,  on  account  of  it<  loose 
ami  elastic  nature,  allows  the  conjunctiva  to  be  moved  to  and  fro  with  readi- 
ness. The  same  loose  character  of  this  areolar  ti<<ue  permits  the  accumula- 
tion, and  consequent  distortion,  of  extra vasated  fluids  to  an  enormous  degree. 

The  epithelium  lining  the  several  portion-  of  the  conjunctival  sac  varies  ; 
thus,  over  the  tarsal  region  the  cell-  retain  the  stratified  squamous  character 
of  the  adjacent  palpebral  integument;  shortly  beyond  the  attached  border 
ol   the  tarsi   the  cells  assume  a  columnar  form,  which   thev  retain  over  the 


36      EMBllYoUHiV,   AXATOMY,    AND   HISTOLOGY  OF  EYE. 

fornix  on  to  the  bulbar  surface,  where  the  cells  again  become  squamous. 
This  latter  type  includes  the  elements  constituting  the  anterior  epithelium 
of  the  cornea.  The  subepithelial  stroma  throughout  the  orbital  conjunctiva 
is  especially  rich  in  elastic  fibers,  which  are  well  represented  in  the  fornix 
and  bulbar  conjunctiva  almost  as  far  as  the  corneal  margin.  In  the  latter 
vicinity  the  tunica  propria  of  the  conjunctiva  ends  by  blending  with  the 
sclerotic,  while  the  epithelium  alone  continues  uninterruptedly  over  the 
corneal  surface:  the  termination  of  the  conjunctival  stroma  is  sometimes 
indicated  l>v  an  annular  thickening-  which  corresponds  to  the  limbus  cornese 
in  position. 

Glands  have  been  described  within  the  more  concealed  portions  of  the 
conjunctival  sac,  those  of  the  fornix  very  closely  resembling  the  tear-gland 
in  structure.  Adipose  tissue  not  infrequently  occurs  as  groups  of  fat-cells; 
in  advanced  age  the  accumulation  becomes  conspicuous  as  a  yellowish  patch 
(dose  to  the  corneal  margin. 

The  blood-vessels  of  the  eyelids  are  derived  from  several  sources  (Fig.  17), 


Pio.17.— Bl  of  the  eyelids  (Testut) :  t,  supraorbital  artery  and  vein ;  2,  nasal  artery,  anas- 

tomosing wiiii  terminal  branch  of  angular  (3)  of  facial  artery  (4);  5,  Infraorbital  artery:  6,  superficial 
temporal  artery;  6',  malar  branches  oi  transverse  facial:  7.  lachrymal;  8,  superior  palpebral  artery, 
with  secondary  arch  (8')>  and  anastomoses  (9)  with  temporal  and  lachrymal ;  10,  Inferior  palpebral  artery  ; 
ii.  facial  vein;  12, angul  r  vein;  13, superficial  temporal  vein. 

since  all  the  surrounding  neighboring  arteries  contribute  branches  which 
more  or  less  directly  take  pari  in  the  supply  of  the  palpebral  folds.  The 
principal  blood-supply  of  the  eyelids  is  from  the  internal  and  external  pal- 
pebral arteries;  the  former  are  direct  branches  from  the  ophthalmic,  usually 

by  a  con n  trunk  given  off  jusi  before  the  ophthalmic  artery  divides  into 

ii-  frontal  and  nasal  branches,  and  the  latter  are  derived  from  the  lachrymal. 
The  interna]  palpebral  arteries,  commonly  somewhat  larger  than  the  external, 
include  a  superior  and  inferior,  which  after  piercing  the  palpebral  fascia  as 
the  marginal  arteries,  inn  along  the  free  margin  of  the  corresponding  eyelid, 
from  2.5  •">  mm.  removed,  ami  anastomose  with  the  external  palpebral  vessels 
to  form  the  upper  and  lower  tarsal  arches.  The  transverse  facial  and  super- 
ficial temporal  contribute  branches  which  join  in  the  anastomotic  circuit  at 
tin-  outer  margin  of  the  orbit. 


CONTENTS  OF  THE  Oh' HIT.  37 

In  the  upper  eyelid,  and  sometimes  less  perfectly  developed  in  the  lower 
as  well,  a  secondary  tarsal  arch  is  formed  by  a  branch  of  the  superior  pal- 
pebral, the  superior  marginal  artery,  which  runs  along  the  convex  border 
of  the  tarsal  plate  between  the  lamellae  of  the  tendon  of  the  levator  pal- 
pebral Numerous  small  twigs  join  the  tarsal  arches,  and  establish  an 
elaborate  anastomosis  in  which  the  infraorbital  and  facial  arteries  also  take 
part.  Branches  of  distribution  pass  forward  from  the  tarsal  arches  for  the 
supply  of  the  integument  and  orbicularis,  and  backward,  by  means  of  per- 
forating and  encircling  twigs,  to  supply  the  tarsus  and  Meibomian  glands  and 
the  palpebral  conjunctiva.  The  supply  of  the  tarsus  is  maintained  especially 
bv  the  superior  tarsal  arch,  while  the  inferior  arch  is  devoted  to  the  nutrition 
of  the  margin  of  the  eyelid.  Just  before  the  internal  palpebral  artery 
reaches  the  lid  numerous  twigs  are  distributed  to  the  lachrymal  caruncle, 
tear-sac,  and  the  tissues  surrounding  the  latter  and  the  canaliculi.  The  naso- 
lachrymal  canal  receives  its  supply  from  a  branch  formed  by  the  anastomosis 
of  the  infraorbital  with  the  inferior  internal  palpebral  artery. 

The  veins  of  the  eyelids  do  not  accurately  follow  the  course  of  the  arteries, 
but  are  arranged  in  two  series,  the  post-tarsal  and  pre-tarsal.  The  former 
collects  the  blood  from  the  conjunctival  surface  and  a  part  of  the  Meibomian 
glands,  and  is  tributary  to  the  ophthalmic  vein  ;  the  latter  receives  radicles 
from  the  integument,  muscular  structure,  and  the  Meibomian  glands,  and 
forms  a  subcutaneous  network  which  passes  into  the  superficial  temporal  and 
facial  veins. 

The  lymphatics  of  the  eyelids  are  disposed  as  a  pre-tarsal  and  a  post-tarsal 
network,  the  former  of  which  receives  the  tissue-juices  from  the  integument 
and  muscle,  the  latter  from  the  conjunctiva  and  Meibomian  glands.  Per- 
forating branches  establish  communication  between  the  two  networks.  The 
submaxillary  and  parotid  lymph-glands  receive  the  larger  lymph-vessels  from 
the  palpebral  networks. 

The  sensory  nerves  of  the  eyelids  are  derived  from  the  ophthalmic  and 
superior  maxillary  divisions  of  the  trifacial.  The  upper  eyelid  is  supplied 
principally  by  branches  from  the  frontal  and  supraorbital  nerves,  which  freely 
join  and  form  a  superior  marginal  plexus  along  the  edge  of  the  eyelid.  The 
chief  supply  of  the  lower  lid  is  derived  from  the  branches  of  the  infraorbital 
nerve,  which  ascend  to  the  border  of  the  lower  lid,  where  they  form  the 
inferior  marginal  plescus.  These  nerves  are  supplemented  by  twigs  from  the 
supra-  and  infratrochlear  branches,  which  are  distributed  to  the  area  around 
the  mesial  canthus.  An  especial  lower  branch  from  the  infratrochlear  nerve 
supplies  the  mucous  membrane  of  the  lachrymal  sac  The  terminal  branches 
of  the  lachrymal  nerve  become  subcutaneous  a  short  distance  beyond  and 
above  the  external  canthus,  contributing  a  few  twigs  to  the  eyelids,  but  end- 
ing chiefly  in  the  integument  to  the  outer  side  of  the  orbit. 

The  motor  nerves  distributed  to  the  muscular  structures  of  the  eyelids 
include  branches  from  the  oculo-motor  to  the  levator  palpebral,  and  from  the 
facial  to  the  orbicularis  palpebrarum  ;  additional  sympathetic  libers  are  dis- 
tributed t<>  the  involuntary  muscle  of  the  lid-.  The  ramifications  of  the 
motor  and  sensory  nerves  freely  intermingle,  and  constitute  a  network  ol 
considerable  complexity  within  the  superficial  structures  of  the  eyelids. 

The  Contents  of  the  Orbit. — The  orbital  contents,  including  the  visual 
apparatus,  consisting  of  the  eyeball  and  it-  associated  nerves,  muscles,  and 

glands  and  the  incidental  structures,  a-  branches  of  the  ophthalmic  U I- 

vessels  and  the  trifacial  nerve,  which  pas-  through  the  orbit  •  u  r<<"l'    to  more 
remote  parts,  are  supported  by  the  general   fibro-adipose  intraorbital  tissue. 


38      EMBRYOLOGY,   ANATOMY,   AND   HISTOLOGY  OF  EYE. 

This  periocular  cushion  of  fat  occupies  the  interspaces  between  the  various 
connective-tissue  partitions  and  bands  constituting  the  fibrous  framework, 
which  separates,  as  well  as  holds  together,  the  various  constituents  of  the 
orbital  contents.  Variations  in  the  amount  of  the  intraorbital  fat  affect  the 
relations  of  the  eyeball  to  the  orbital  opening,  a  conspicuous  example  of  such 
change  being  familiar  in  the  sunken  or  '•hollow-eyed"  appearance  following 
illness  or  conditions  favorable  to  the  absorption  of  adipose  tissue. 

Since  the  majority  of  the  structures  within  the  orbit  are  grouped  around 
the  eyeball  as  parts  subservient  and  accessory  to  the  visual  organ,  the  position 
of  the  ocular  bulb  with  relation  to  the  orbit  is  of  importance,  inasmuch  as  this 


Fro.  iv    oniiar  muscles  of  rfghl  Bide,  viewed  from  above,  after  removal  of  roof  of  <irl>it  (Testut) 

/:.  section  of  greal  \vinj,r  of  sphenoid  ;  C,  section  of  malar  bone  ;  /',  anterior  clinoid  pro 

/.'■i'ii'-  nerve;  1,  superior  rectus ;  2,  superior  oblique  muscle  with  its  pulley  (2')  and  its  insertion 

into  tin  ej  •  !,  internal  rectus ;  I,  external  rectus  :  ■">.  common  <u'i.L'in  (ligament  of  Zinnl  of  mus 

eles;  6,  cul  tendon  of  levator  palpebrse;  7,  7'.  7",  palpebral  expansion  of  same;  8,  insertion  of  Inferior 

oblique;  a,  intraorbital  cushion  or  fat ;  10,  orbicularis  palpebrarum. 

primary  relation  largely  determines  the  secondary  arrangement  of  the  asso- 
ciated structures.  Theeyeball  corresponds  with  the  orbit  neither  in  the  direc- 
tion of  it-  axis  nor  in  the  position  of  iis  center,  since  the  bulbar  axis  subtends 
with  that  of  the  orbit  an  angle  of  from  42  to  i:,  ,  while  the  eyeball  itself 
lies  1  or  *_!  mm.  nearer  the  lateral  than  the  mesial  wall,  and  probably  also 
slightly  nearer  the  roof  than  the  floor.  Owing  to  the  eccentric  position  of 
the  eyeball,  together  with  the  receding  plane  and  the  slight  projection  of  the 
lower  and  outer  segment  of  the  orbital  margin,  the  position  most  favorable  to 
reach  the  bull,  b  the  vicinity  of  the  inferior  and  external  angle.  The  ball 
occupies  the  anterior  half  of  the  orbit,  ii-  position  being  such  that  n  line  join- 
ing the  upper  and  lower  margins  of  the  orbit  opposite  the  anterior  pole  comes 
in  contact  with  the  anterior  cornea]  surface. 


'/'///;   OCULAR    M(  sci.l.s.  39 

The  Ocular  Muscles. — The  eyeball  is  rotated  around  its  three  principal 
axes  by  the  individual  or  combined  action  of  six  muscles — the  four  straight 
and  the  two  oblique;  an  additional  seventh  muscle,  the  levator  palpebral,  is 
attached  to  the  upper  eyelid,  which  it  raises. 

( )f  the  six  muscle's  inserted  into  the  eyeball,  all  except  the  inferior  oblique, 
which  occupies  the  anterior  part  of  the  orbit,  take  their  origin  from  the  apex 
of  the  orbit  and  pass  forward  to  their  insertion.  The  elevator  of  the  eyelid 
has  a  similar  course,  since  its  origin  is  closely  associated  with  the  straight 
muscles  of  the  ball  (Fig.  18). 

The  four  straight  or  recti  muscles  may  be  considered  as  having  a  common 
tendinous  origin  from  the  fibrous  ring  which  is  attached  to  the  apex  of  the 
orbit.  This  fibrous  oval  ring,  the  liyament  of  Zinn,  passes  down  the  inner 
side  of  the  optic  foramen  as  far  as  its  lower  margin,  then  extends  transversely 
across  the  inner  part  of  the  sphenoidal  fissure,  to  the  lower  border  of  which 
it  is  attached,  again  bridges  the  sphenoidal  fissure  about  the  middle,  and 
finally  gains  the  upper  margin  of  the  optic  foramen.  The  tendinous  origins 
of  the  straight  muscles  from  the  ligament  lie  so  closely  placed  that  at  first 
they  are  continuous,  and  form  a  somewhat  flattened  tube  which  extends  be- 
tween 2  and  3  mm.  before  separating  into  the  individual  tendons  of  the  recti 
muscles.  The  tendinous  tube  is  particularly  strong  above  and  below,  the 
thickened  bands  developed  within  the  ring  at  these  points  being  sometimes 
described  as  the  common  tendons.  The  origins  of  the  levator  palpebral  and 
superior  oblique  form  a  second  imperfect  concentric  layer  to  the  inner  side  of 
the  optic  foramen,  where  they  constitute  a  crescentic  zone  in  close  relation  to 
the  origin  of  the  superior  and  internal  rectus. 

The  superior  rectus  arises  from  the  upper  border  of  the  optic  foramen 
and  beneath  the  levator  palpebrse ;  the  internal  rectus  occupies  the  mesial  or 
inner  and  part  of  the  lower  margin  of  the  foramen  ;  the  inferior  reef  us 
springs  from  its  lower  border;  while  the  external  rectus  possesses  two  heads. 
The  lower  and  larger  head  is  attached  to  the  inferior  and  inner  border  of  the 
sphenoidal  fissure  and  that  part  of  the  tendinous  ring  which  stretches  across 
the  fissure  ;  the  upper  and  outer,  or  accessory,  head  springs  from  the  outer 
wall  of  the  sphenoidal  fissure,  being  separated  from  the  main  part  of  the 
muscle  by  a  narrow  interval  occupied  by  a  small  amount  of  connective  tissue  and 
the  third  and  sixth  nerves  and  the  nasal  branch  of  the  fifth,  together  with 
the  ophthalmic  veins.  The  four  recti  muscles  proceed  forward  toward  the 
eyeball,  the  posterior  half  of  which  they  embrace  above,  below,  and  at  the 
sides,  and  are  inserted  into  the  sclera  by  short,  thin,  and  slightly  broadened 
tendon-  a  short   distance   behind   the  corneal    margin   (Fig.   19). 

The  straight  muscles  differ  considerably,  when  compared  with  one  another, 
in  their  general  development,  length,  breadth,  and  exact  place  of  insertion. 
A-  i-  to  be  expected  from  its  unusual  work  in  converging  the  eyes,  the 
internal  rectus  leads  in  its  general  development,  being  the  broadest  and 
strongest,  a>  well  as  possessing  the  longest  tendon  and  mosl  anteriorly 
situated  place  of  insertion.  The  superior  rectus  is  the  smallest  and  weakest 
of  the  straight  muscles,  and  has  its  insertion  farthest  from  the  cornea,  but 
possesses   the    broadest    line  of  attachment  ;     the    inferior  and   external    recti 

exceed     tin-     utile]-     ill     their     length. 

Shortly  before  reaching  the  eyeball  the  muscular  liber-  of  the  recti  ter- 
minate in  thin  membranous  and  somewhat  expanded  tendons  of  insertion,  the 
fibers  of  which  not  only  blend,  but  become  intimately  interwoven,  with  the 
tissue  of  the  sclerotic  coat.  The  line-  of  attachment,  the  slight  convexities 
of  which  are  directed  toward  the  cornea,  vary  in  their  relation  to  the  corneal 


10      EMBRYOLOGY,    ANATOMY,    AND    HISTOLOGY   OF  EYE. 


margin,  that  of  the  internal   rectus  being  Dearest,  and   that   of  the  superior 
rectus  farthest   removed.     The  length  of    the  tendons  of    insertion  of    the 


Mm  , 

wr 

Fig.  19.— Ocular  muscles  viewed  after  removal  of  lateral  wall  of  orbil  (Testut):  a,  eyeball;  b,  optic 
nerve;  ''.'•'.  eyelids:  d,  maxillary  sinus;  '.  pterygoid  plate;/,  foramen  rotundum;  g,  roof  of  orbit ;  h, 
frontal  sinus ;  i,  supraorbital  nerve ;  fc,  septum  orbitale  ;  l.  levator  palpebra  superioris;  2,  3,  superior  and 
inferior  recti ;  i,  I,  portions  of  the  cut  external  rectus;  5,  internal  rectus;  6,  inferior  oblique ;  7,  inser 
tion  of  superior  oblique;  8,  annular  ligament  or  tendon  of  Zinn. 

ncti  and  the  distance  from  the  cornea,  determined  by  the  accurate  measure- 
ments of  Merkel   and  of  Fuchs,  are  as  follows: 

Length  of  Distance  of  insertion 

ti  ndon.  from  cornea. 

Internal  rectus 8.8  nun.  5.5  nun. 

Inferior  rectus 5.5     "  6.5     " 

External  rectus 3.7     "  6.9     " 

Superior  rectus 5.8     "  7.7     " 

The  insertion-lines,  therefore,  progressively  recede  from  the  corneal  margin 

from  the  insertion  of  the   internal   rectus  to  that  of  the  superior,  with  a  cor- 

st  B  C  D 


■  •i  the  positions  ol  the  Insertions  of  the  oculai  muscles    Fuchs-Testut)     Right  eye  : 
vecl_  from  above;  ft,  from  no*  from  below;  0,  from  temporal  side ;  x,  x,  antcro-posterior 

E>,  c,  tf,  superior,  inferior,  internal,  and  externa]  rectus;  e, 
oblique. 

responding   diminution  in  the  effectiveness  of  the  pull  of  the  several   mus- 
cles.      As   suggested   by   Tillaux,   the  distance  of  the   insertions   from   the 


THE  OCULAR   MUSCLES. 


II 


Fn;.  21.— The  eyeball  in  situ  with  its  muscles 
after  removal  of  surrounding  parts  of  orbital  con- 
tents (Testut) :  l.  eyeball;  l',  superior  rectus;  3, 
levator  palpebral    1,  inferior    rectus;    •"■,    internal 

rectus:  fi,  external  rectus:  7.  inferior  oblique;  x. 
superior  oblique  ;  8',  pulley  and  reflected  tendi  Q  of 
same. 


cornea  may  be  taken,  for  practical  purposes,  respectively  a-  ~>,  (J,  7,  and  8 
mm.  (  Fig.  20). 

The  superior  oblique,  or  trochlearis,  arises  aboul  2  mm.  in  front  of  the 
inner  margin  of  the  optic  foramen  :  it  proceeds  forward  and  upward  in  close 

relation  to  the  orbital  wall,  as  far  as  the  trochlear  fossa,  where  its  rounded 
irndoii  traverses  the  short  fibrous 
tube  of  the  trochlea,  and,  at  the 
anterior  extremity  of  the  canal, 
changes  its  direction  at  an  angle  of 
about  50°,  the  muscle  passing  back- 
ward and  outward  between  the  eye- 
ball and  the  anterior  end  of  the 
superior  rectus,  to  find  its  inser- 
tion into  the  sclerotic  beneath  the 
latter  muscle,  about  midway  between 
the  corneal  margin  and  the  optic 
nerve. 

The  inferior  oblique,  situated 
within  the  anterior  part  of  the  orbit, 
arises  from  the  mesial  wall  of  the 
orbit,  close  to  it<  anterior  margin, 
from  a  slight  depression  in  the 
orbital  plate  of  the  maxilla  over  the 
outer  wall  of  the  naso-lachrymal 
duct.  Starting  in  short  tendinous 
fibers,  the  muscle  leaves  the  orbital 
wall  and  sweeps   in  a  gentle  curve 

outward,  backward,  and  upward,  passing  between  the  inferior  rectus  and 
the  floor  of  the  orbit,  and  terminates  in  a  tendon  which  is  inserted  into  the 
sclerotic  at  the  posterior  and  outer  part  beneath  the  rectus  externus  f  Fig.  21  |. 

The  levator  palpebral  superioris,  as  indicated  by  its  name,  is  related  to  the 
upper  eyelid,  and  claims  attention  in  this  place  only  on  account  of  its  inci- 
dental association  with  the  ocular  muscles.  In  it-  origin  it  is  closely  related 
to  the  superior  rectus,  arising  by  a  pointed  tendon  above  and  in  front  of  the 
optic  foramen.  The  muscle  broadens  in  its  course  along  the  roof  of  the 
orbit,  close  to  the  periosteum  for  the  greater  part  of  its  length,  and  covers 
the  posterior  half  of  the  superior  rectus;  on  reaching  the  anterior  part  of 
the  orbital  cavity,  a  little  behind  its  superior  margin,  it  descends  through  the 
adipo-e  tissue  as  a  membranous  expansion  which  is  attached  to  the  root  of 
the  upper  eyelid.  Its  insertion  i-  peculiar,  and  consists  of  two  distincl  layers: 
tin-  upper  anterior  of  these  i-  fibrous  and  passes  in  front  of  the  tarsal  plate, 
blending  with  the  fibers  of  the  orbicularis,  while  the  lower  posterior  layer 
contain-  non-striped  muscular  tissue,  and  is  inserted  into  the  upper  border 
of  the  tarsus,  constituting  what  is  often  described  as  the  supe)"ior  palpebral 
muscle  of  MuUa  r  |  Fig.  23  . 

Closely  associated  with  the  action- of'  the  superior  and  inferior  recti  are 
the  oblique  muscles,  by  mean-  of  which  the  obliquity  of  the  pull  of  these 
straighl  muscles  i-  neutralized.  The  action  of  the  superior  oblique,  from  the 
location  of  the  insertion  and  direction  of  its  liber-,  when  the  eyeball  is  in  the 
primary  position,  is  to  move  the  cornea  downward  and  outward  ;  that  of  the 
inferior  oblique  is  to  cause  the  cornea  to  move  upward  and  outward.  The 
slight  outward  rotation  thus  effected  takes  place,  however,  in  opposite  direc- 
tions, since  when  caused  by  the  superior  oblique  the  movement  of  the  cornea 


12      EMBRYOLOGY,   ANATOMY,   AND   HISTOLOGY  OF  EYE. 

is  from  within  outward,  while  when  produced  by  the  inferior  oblique  the 
upper  halt' <>t'  the  vertical  diameter  i>  displaced  outward,  the  lower  half  at 
the  same  time  being  deflected  inward.  The  obliquity  of  the  pull  of  the 
oblique  muscles  is,  therefore,  well  adapted  to  neutralize  the  obliquity  attending 
the  contraction  of  the  superior  and  inferior  recti,  and,  in  point  of  fact,  simple 
elevation  and  depression  of  the  cornea  arc  effected  by  the  combined  action 
of  the  superior  straight  and  the  inferior  oblique  and  the  interior  straight  and 
the  superior  oblique,  respectively. 

Oblique  movements  arc  also  the  results  of*  the  associated  efforts  of  the 
recti  and  oblique  muscles,  as  instanced  in  the  common  action  of  the  superior 
and  internal  recti  and  the  inferior  oblique  in  movements  by  which  the  cornea 
is  carried  upward  and  inward  ;  the  inferior  and  external  recti  and  the  superior 
oblique  arc  similarly  associated  in  moving  the  cornea  downward  and  outward. 


Fig  22.    Semi-diagrammatic  view  of  the  relations  of  the  orbital  fascia  with  the  superior  muscles 

tut  i :  a,  frontal  bone,  with  ii>  periosteum  [a')\  b,  sclerotic;  c,  cornea;  </.  ciliary  process  .  e,  anterior 

bi  i     /,  superior  fornix  of  the  conjunctiva  ;  g,  superior  tarsus;  //,  orbicularis  palpebrarum  ;  <,  Beptum 

orbitale    I,  capsule  of' Tei ,  consisting  of  its  inner  (2)  and  external  (3)  wall  and  the  enclosed  lymph 

spaci  i  p,  5*,  6.  respectively  the  belly,  tendon,  and  sheath  of  the  superior  rectus ;  7,  orbital  prolonga 
tfon ;  B,  levator  palpebra,  with  is  sheath  (9)  and  Its  conjunctival  (10)  and  muscular  ill)  insertions;  12  its 
prolongation  and  insertion  into  the  fornix  conjunctivae. 


In  all  other  oblique  movements  of  the  cornea,  likewise,  the  straight  muscles 
are  supplemented  by  the  oblique,  the  desired  motion  representing  the  resultant 
of  the  forces  exerted,     Abduction  and  adduction  further  influence  the  action 

of  the  superior  ami  inferior  recti  in  consequence  of  the  alterations  in  the 
direction  of  the  pull  ;  thus,  when  the  eyeball  is  strongly  abducted  the  trans- 
verse axis  coincide-  with  the  axis  around  which  elevation  and  depression 
occur,  in  which  case  the  superior  and  inferior  recti  exert  a  simple  action  with- 
out their  accustomed  tendency  toward  oblique  or  rotary  movement.  (See  also 
page  I'M). )  The  actions  of  ocular  muscles  are  further  described  on  pp.  11*7.  198. 
The  Orbital  Fascia. — The  periosteum  of  the  orbit,  directly  continuous 
with  the  intracranial  dura  through  the  sphenoidal  fissure,  forms  a  funnel- 
shaped  investment,  which  encloses  the  orbital  contents  and  becomes  blended 

with    the   external    periosteum    around    the    margins  of  the  orbit.       Numerous 


TUB   ORBITAL    FASCIA. 


43 


septa  of  fibrous  tissue  arc  intimately  connected  with  the  inner  surface  of  the 
periosteum  on  the  one  hand,  and  extend  between  the  various  structures 
lodged  within  the  orbit,  to  which  they  afford  support  and  protection  on  the 
other;  the  framework  thus  formed  is  largely  occupied  by  the  cushion  of 
periocular  fat  which  fills  the  interspaces  between  the  eyeball,  blood-vessels, 
nerves,  and   muscles. 

In  the  immediate  vicinity  of  the  eyeball  the  intraorbital  fibrous  tissue  be- 
comes condensed  to  form  a  fascial  investment  which  surrounds  the  greater 
part  of  the  organ  ;  this  fibrous  envelope  is  known  as  the  tunica  vaginalis  oculi, 
or  capsule  of  Tenon.  This  consists  of  a  tunic  of  fascia  of  considerable  strength 
which  surrounds  the  posterior  two-thirds  of  the  eyeball,  from  which  it  is 
separated  by  a  narrow  lymph-cleft,  the  space  of  Tenon;  the  interval  between 


Fig.  23.— Semi-diagrammatic  view  of  the  orbital  fascia  of  right  side,  seen  after  horizontal  section  of  the 

eyeball  and  orbit,  the  lower  half  of  the  eyeball  being  represented  (Testut) :  a,  optic  nerve;  6,  vitr< s 

body  ;  c,  lens;  d,  cornea  ;  <.  sect  inn  of  lachrymal  sac;/,  ethmoid  cells  :  g,  malar  bone;  h,  floor  of  orbit;  1,  2, 
internal  and  external  rectus,  with  their  tendons  (1', '/);  '.'.  capsule  of  Tenon  :  I,  sheath  of  internal  rectus 
with  its  orbital  prolongation  (5)-;  6,  sheath  of  external  rectus,  with  its  orbital  prolongation  (7);  8,  inferior 
oblique,  with  its  sheath  ;  9,  conjunctiva. 

the  eyeball  and  capsule  is  bridged  by  numerous  delicate  bundles  of  fibrous 
tissue  which  pass  from  the  fibrous  tunic  to  the  adjacent  sclera,  thus  subdi- 
viding the  general  cavity  into  a  great  number  of  imperfectly  separated,  freely 
intercommunicating  spaces.  The  inner  surface  of  the  capsule,  as  well  as  the 
outer  surface  of  the  sclera  and  the  trabecula,  is  clothed  with  endothelial 
plates,  the  entire  space  of  Tenon  strongly  recalling  the  intracranial  sub- 
arachnoidean  lymph-space,  which  it  closely  resembles.  The  loose  attachment 
of  the  capsule  to  the  eyeball  facilitates  the  free  play  of  the  visual  organ 
in  the  fossa  thus  formed  within  the  peribulbar  adipose  cushion,  the  eyeball 
moving  in  the  capsule  in  a  maimer  somewhat  resembling  an  articulation. 
The  relations  of  Tenon's  capsule  are  so  complicated  by  its  prolongations 
and  attachments  to  surrounding  structures  that  special  reference  to  these  is 
desirable.  Posteriorly,  the  capsule  extends  as  far  as  the  point  at  which  the 
optic  nerve  pierces  the  sclerotic  coat,  where  it  fuses  with  the  sclera  and  outer 
sheath  of  the  nerve  as  the  hitter  blend-  with  the  fibrous  tunic  of  the  eyeball  ; 
likewise  the  ciliary  arteries  and  aerves  are  excluded  from  the -pace.     Ann- 


II      EMBRYOLOGY,   ANATOMY,   AND   HISTOLOGY  OF  EYE. 

riorlv.  the  capsule  lies  beneath  the  ocular  conjunctiva,  with  which  it  blends 
close  t<>  the  margin  of  the  cornea.  II'  the  conjunctiva  is  divided  by  a  circu- 
lar incision  just  posterior  to  the  corneal  margin,  the  capsule  of  Tenon  will  he 
found  so  closely  united  with  the  conjunctiva  that  reflection  of  the  latter 
structure  will  open  Tenon's  space  and  expose  the  capsule  at  its  anterior  limit 
(Fig.  23). 

The  tendon-  of  the  various  ocular  muscles  pierce  the  capsule  of  Tenon  in 
order  to  gain  their  insertions  into  the  sclera,  which  may  thus  he  regarded  as 
lying  within  the  -pace  of  Tenon,  although  the  tendons  are  separated  from 
actual  contact  with  the  lymph-stream  by  means  of  an  endothelial  covering. 
The  slit-like  openings  in  the  capsule  made  by  the  passage  of  the  tendons  are 
strengthened  by  local  thickenings  of  the  fibrous  tunic,  from  which  tubular 


extensions  of  the  capsule  are  prolonged  backward  upon  the  muscles  lor  ;i 
variable  distance, approximately  for  half  their  length.  The  fascial  sheaths 
thus  obtained  become  gradually  more  and  more  attenuated  in  their  course 
toward  the  origin  of  the  muscles,  until  finally  they  fade  away  by  blending 
with  the  perimysium,  [n  the  case  of  the  superior  oblique  the  tubular  pro- 
longation of  tin ■  capsule  extends  only  over  the  reflected  tendon  of  the  muscle, 
and  terminates  at  the  trochlea,  where  it  ends  by  becoming  attached  to  the 
margin  of  the  pulley.      The  -heath  investing  the  inferior  oblique  extends  as 

fat-  a-  the  Ihioi-  <<\'  the  orbit,  and  there  fuses  with  that  accompanying  the 
inferior   rectus. 

The    inner  or   ocular  border  of  the  vertical  slit-like  openings  through 
which  the  tendons  of  the  straight   muscles,  particularly  of  the  external  ami 


THE  LAI  ll I: ) 'M AL  APPABA  7V s.  I :, 

internal,  pass,  is  especially  strengthened  by  thickenings  "I"  the  fascia,  which 
are  further  reflected  outwardly  along  the  adjacent  sides  of  the  tendon-sheaths, 
forming  additional  connections  between  the  muscles  and  the  capsule  of  Tenon. 

In  view  of  the  fad  that  the  latter  structure  at  certain  points  is  firmly  con- 
nected with  the  bony  walls  of  the  orbit,  these  supplementary  hand-  in  a 
measure  act  as  pulleys  and  effect  the  important  object  of  preventing  undue 
pressure  on  the  eyeball  during  muscular  contraction. 

In  addition  to  the  foregoing  conjunctival  and  muscular  relations,  the 
capsule  of  Tenon  is  connected  with  the  orbital  walls  by  means  of  fascial  hands, 
the  most  important  of  which  are  the  suspensory  and  check  ligaments  (  Fig.  24). 
The  suspensory  ligament  consists  of  a  hand  of  orbital  fascia  in  the  anterior 
part  of  the  orbit,  where  it  forms  a  hammock-like  hand  of  considerable  breadth 
and  density  ;  the  suspensory  ligament  is  attached  mesially  to  the  lachrymal 
and  externally  to  the  malar  hone,  while  its  broader  central  part  blends  with 
the  capsule  of  Tenon  below  the  eyeball,  to  the  support  and  position  of  which 
it  materially  contributes.  A  somewhat  similar  hut  less  well-developed  hand 
lies  above  the  eyeball  and  blends  witli  the  sheath  of  the  superior  rectus  and 
the  levator  palpebral,  its  extension  forward  coming  into  close  relations  with  the 
upper  lid.  Other  fibrous  bands  stretch  across  the  orbit  above  the  levator 
palpebral  from  the  trochlea  to  the  fronto-zygomatic  juncture,  and  thereby 
form  a  fascial  arch  of  importance  to  the  support  of  the  upper  division  of  the 
lachrymal  gland. 

The  cheek  ligaments  are  robust  bands  which  extend  from  the  fascial 
sheaths  surrounding  the  external  and  internal  recti  muscles  laterally  as  far  as 
the  malar  and  lachrymal  bones  respectively,  where  they  blend  with  the  ex- 
tremities of  the  suspensory  ligament  already  described.  Their  action  in 
limiting  the  contraction  of  the  outer  and  inner  straight  muscles  and  in  pre- 
venting excessive  rotation  of  the  eyeball  is  appropriately  suggested  by  their 
name  of  "  check  ligaments."  A  somewhat  similar,  but  less  complete,  arrange- 
ment exists  in  connection  with  the  superior  rectus,  the  contraction  of  which 
muscle  is  still  further  limited  by  close  association  with  the  levator  palpebral 
The  fascial  extension  from  the  sheaths  of  the  inferior  rectus  is  joined  by  a 
process  from  that  of  the  inferior  oblique,  the  two  constituting  a  fibrous  hand 
of  considerable  strength  which  is  attached  to  the  floor  of  the  orbit  on  the  one 
hand,  and  blends  with  the  suspensory  ligament  of  the  eyeball  on  the  other. 

The  I/achrymal  Apparatus. — The  lachrymal  apparatus  consists  of  the 
tear-gland,  lodged  in  the  anterior  part  of  the  upper  and  outer  orbital  wall, 
and  the  system  of  canals  by  which  the  tears  are  conveyed  from  the  inner  side 
of  the  conjunctival  sac  to  the  inferior  nasal  meatus. 

The  lachrymal  <//<ni<l,  resembling  in  shape  and  size  a  -mall  almond,  con- 
sists of  two  fairly  distinct  parts — the  superior  orbital  portion  ami  the  inferior 
palpebral  or  accessory  portion.  The  former,  occupying  the  fossa  lacri- 
malis,  is  distinctly  larger,  and  measures  about  20  mm.  in  length,  12  nun.  in 
breadth,  and  5  nun.  in  thickness,  just  reaching  the  orbital  margin  at  the  point 
where  the  roof  of  the  orbit  joins  the  outer  wall.  The  upper  convex  surface 
i-  attached  to  the  periosteum  of  the  depression  in  which  it  i-  Lodged.  BeloM 
the  gland  i-  supported  by  the  fascial  arch,  which  extend-  from  the  trochlea 
to  the  fronto-malar  suture. 

The  lower  or  palpebral  />t>r/i<>ii  of  the  gland,  sometimes  described  as  a 
distinct  <il<iit<lnl<i  lacrimalis  inferior,  i-  somewhat  -mailer  than  the  upper, 
from  which  it  is  partially  separated  by  the  fascial  expansion  already  men- 
tioned. It-  lower  concave  surface  rests  upon  the  fornix  of  the  conjunctiva 
and  extends  laterally  almost  to  the  outer  canthus. 


4G      EMBRYOLOGY,    ANATOMY,    A\/>   HISTOLOGY  OF  IV 11. 


Fig.  25. — Section  exposing  the  lachrymal  chan 
nels  and  pari  of  the  lachrymal  sac  (Testut):  I 
plica  semilunaris;  2,  lachrymal  caruncle;  3,  3' 
lachrymal  puncta;  4, 4',  vertical  portions  of  lach- 
rymal canaliculi;  5,  ■■'.  horizontal  portions;  »'> 
fused  portion ;  7,  opening  into  lachrymal  sac  18). 


Iii  structure  the  lachrymal  gland  corresponds  to  a  tubulo-raceraose  gland 
df  the  serous  type,  it-  acini  being  drained  by  a  number  of  small  ducts  which 
in  the  orbital  portion  of  the  gland  unite  to  form  from  three  to  six  larger 
canals  :  these  receive  as  tributaries  the  ducts  (Venn  the  lower  portion  <>f  the 

gland,  the  canals  so  formed  opening  by 
distinct  orifices  arranged  with  consid- 
erable regularity  in  a  line  in  the  fornix. 
In  addition  to  the  chief  duets,  which 
open  with  definite  regularity,  a  vari- 
able number  of  smaller,  independent 
canals  terminate  in  irregular  groups 
about  the  apertures  of  the  larger 
ducts. 

The  lachrymal  passages  (Fig.  25), 
including  segments  of  very  varying 
lumen  and  course,  begin  at  the  small 
crater-like  lachrymal  puncta  which 
surmount  the  conical  lachrymal  papillce.  The  latter  elevations  occupy  the 
sharply  defined  margins  of  the  lids  just  where  the  mesial  end  of  the  arched 
palpebral  borders  passes  over  into  the  approximately  horizontal  and  more 
nearly  parallel  boundaries  of  the  lachrymal  lake.  The  upper  punctum  lies  l> 
mm.  from  the  mesial  canthus,  the  lower  one  being  slightly  farther  removed. 
The  apex  of  each  papilla  is  directed  toward  the  conjunctival  surface,  over 
which  it  glides  during  the  changes  of  position  of  the  bulbar  conjunctiva  occa- 
sioned by  the  excursions  of  the  eyeball.  The  lachrymal  puncta  are  immersed 
in  the  collection  of  tears  occupying  the  inner  angle  of  t  he  conjunctival  sac,  and 
continually  carry  off  the  secretion  of  the  tear-gland  l>\  capillary  attraction. 
When  closely  examined  the  upper  and  lower  papilla?  and  puncta  are  seen  to 
vary  slightly,  the  upper  papilla?  being  more  slender,  higher,  and  pierced  by  a 
punctum  about  0.05  mm.  less  in  diameter  than  that  of  the  lower  lid. 

In  structure  the  papilla?  resemble  the  adjacent  tarsal  hands,  being 
largely  composed  of  closely-felted  bundles  of  fibrous  tissue,  meagerly  sup- 
plied with  blood-vessels,  well  calculated  to  resist  the  action  of  the  orbic- 
ular muscle. 

The  lachrymal  canaliculi,  into  which  the  puncta  open,  have  at  first  a 
vertical  course;  very  soon,  however,  they  bend  sharply,  and  continue  their 
converging  course  generally  parallel  to  the  margins  of  the  lachrymal  lake  as 
far  as  the  inner  canthus,  where  the  canaliculi  usually  unite  in  a  common 
canal  which  almost  at  once  terminates  by  opening  into  the  lateral  and  slightly 
posterior  wall  of  the  lachrymal  sac.  In  exceptional  cases  the  canaliculi 
maintain  an  independent  course,  and  terminate  by  separate  orifices  which 
open  into  n  diverticulum  of  the  lachrymal  sac,  the  sinus  <>/  Maier.  The  entire 
length  of  each  canaliculus  measures  from  8  10  mm.,  the  upper  canaliculus 
being  longer,  more  curved,  and  steeper  in  its  descending  course  than  the 
lower.  The  lumen  of  the  canal  varies  at  different  poini>:  beginning  af  the 
narrow  orifice  of  the  punctum.  which  marks  the  mosl  constricted  point  and 
measuring  only  ".I  mm.  in  ilia  meter,  the  canal  soon  widens  into  a  spindle-form 
dilatation,  which  is  followed  by  a  diverticulum  occupying  the  bend  of  the 
canaliculus.  The  horizontal  portion  of  the  canal  measures  a  lit  tic  over  0.6  mm. 
in  diameter. 

The  walls  of  the  canaliculi  consisf  of  ;i  lining  of  stratified  squamous 
epithelium  supported  l»\  a  delicate  tunica  propria  rich  in  elastic  fibers  ;  out- 
Bide,  the  muscular  bundles  of  the  lachrymal  portion  <»f   the  orbicularis  palpe- 


THE  LA  CI  111 )  rMu  I  L  A  PPA  BA  Tl  rS.  47 

brarum  contribute  an  additional  stratum,  and  by  their  sling-like  fibers 
constitute  a  sphincter  around  the  vertical  portion  of  the  canaliculi. 

The  lachrymal  sac,  into  which  the  canaliculi  open,  may  be  regarded  as 
the  upper  dilated  orbital  segment  of  the  naso-lachrymal  duet,  the  lower  part 
of  which,  or  the  duet  propel1,  traverses  the  bony  canal  and  opens  into  the 
inferior  nasal  meatus.  The  length  of  the  sac  approximates  12  mm.,  when 
distended   measuring  between   G  and    7   mm.   in   diameter. 

The  sac  is  situated  at  the  side  of  the  nose,  near  the  inner  eanthus,  and 
lies  within  the  deep  lachrymal  groove  between  the  superior  maxillary  and  the 
lachrymal  bone;  its  upper  part  is  embraced  externally  by  the  mesial  tarsal 
ligament  and  some  of  the  inner  fibers  of  the  orbicularis  palpebrarum,  while 
the  orbital  surface  of  the  sac  is  covered  by  the  fibers  which  spring  from  the 
lachrymal  bone  and  constitute  the  tensor  tarsi,  or  Horner's  muscle.  The 
upper  blind  end  of  the  sac,  or  fundus,  usually  reaches  to  the  level  of  the 
upper  margin  of  the  tarsal  ligament,  sometimes  a  little  higher.  The  lower 
portion  of  the  sac,  between  the  inferior  margin  of  the  tarsal  ligament  and  the 
commencement  of  the  bony  canal,  differs  materially  from  the  upper  in  being 
covered  in  by  comparatively  thin  and  weak  structures,  the  anterior  wall  of 
this  portion  of  the  sac  having  the  attenuated  orbicular  fascia  alone  interposed 
between  the  integuments.  In  consequence  of  this  weakness  this  point  is 
frequently  the  seat  of  dilatations,  both  normal  and  pathological  ;  the  con- 
spicuous bulging  often  seen  in  connection  with  impeded  escape  of  the  tears 
corresponds  to  the  lower  part  of  the  sac,  which  is  unprotected  by  the  dense 
fibromuscular  covering  which  lies  in  front  of  its  upper  half.  The  wall  of 
the  sac,  as  well  as  that  of  the  duct,  is  composed  of  fibro-elastic  tissue,  strength- 
ened by  fibrous  processes  derived  from  the  tarsal  ligament.  Externally  the 
wall  of  the  sac  is  loosely  connected  with  the  periosteum  by  fibrous  tissue,  and 
therefore  capable  of  distention  ;  internally  it  is  lined  by  mucous  membrane 
directly  continuous  with  that  of  the  nasal  duct.  The  epithelium  covering  the 
mucous  membrane  of  the  sac,  as  well  as  of  the  duct,  is  columnar  in  type  and 
possesses  areas  in  which  cilia  are  present. 

The  nasolachrymal  duct,  which  constitutes  the  last  segment  of  the  tear- 
passage,  lies  within  the  bony  canal  formed  by  the  apposition  of  the  superior 
maxillary,  lachrymal,  and  inferior  turbinated  bones.  The  length  of  the  nasal 
duct  is  very  variable,  at  times  being  little  over  11  or  12  mm.,  at  others 
measuring  twice  as  much,  the  difference  being  largely  due  to  the  manner  in 
which  the  duct  terminates  in  relation  to  the  nasal  mucous  membrane,  since  as 
much  as  from  6—8  mm.  of  its  length  may  be  included  in  the  oblique  passage 
through  the  mucous  membrane.  The  diameter  of  the  nasal  duct  is  from  3- 
4  mm.  ;  it  is  not  uniform,  however,  since  slight  constrictions  at  its  beginning 
from  the  sac  ami  about  the  middle  of  its  course  are  very  frequent.  The 
position  of  the  lower  end  of  the  nasal  duct  also  varies,  but  it  is  usually  about 
•'!')  mm.  behind  the  posterior  margin  of  the  anterior  nasal  opening,  and  about 
I"  mm.  Prom  the  front  of  the  inferior  turbinal.  The  direction  of  this  canal, 
a-  indicated  by  the  position  of  probes,  varies  considerably  with  regard  to  the 
degree  of  inclination  of  the  course  of  the  canal  in  relation  to  both  the  frontal 
and  sagittal  planes.  In  determining  on  the  living  subjeel  the  inclination  of 
the  canal  with  the  sagittal  plane,  both  Arlt  and  Merkel  regard  :i-  trustworthy 
a  comparison  of  the  distance  between  the  middle  of  the  tarsal  ligaments  of 
the  two  sides  with  the  distance  between  the  points  where  the  nasal  alaj  join 
the  cheek.  When  these  measurements  coincide  the  nasolachrymal  canal 
descends  vertically;  when,  as  usually,  a  difference  is  noted,  the  deviation 
from  the  perpendicular  will  be  equal  t<>  half  the  difference.     The  direction  of 


48      EMBRYOLOGY,   ANATOMY,   AND   HISTOLOGY  OF  EYE. 

the  duel  with  regard  to  the  frontal  plane  is  best  determined,  according  to 
Merkel,  by  a  line  drawn  from  the  inner  canthus  to  the  interval  between  the 
second  premolar  and  first  molar  tooth  of  the  upper  jaw.  The  course  of  the 
nasolachrymal  duct  in  general  may,  therefore,  be  described  as  deviating 
slightly  backward  from  the  vertical  (Fig.  26). 

The  mucous  membrane  of  the  duct  is  connected  by  areolar  tissue  with  the 
periosteum  lining  the  bony  canal,  the  mucosa,  however,  being  separated  from 
the  periosteum  by  a  venous  plexus.  The  exact  manner  in  which  the  duct 
opens  into  the  interior  nasal  meatus  varies:  it  may  terminate  as  a  simple 
round  or  elliptical  orifice  or  by  an  inconspicuous  slit-like  opening  leading 
obliquely  into  the  mucous  membrane.  The  latter  arrangement  is  sometimes 
described  as  forming  the  so-called  ra/rc  of  Homer,  but  the  presence  of  a 
distinct  occluding  fold  must  be  questioned.  The  valves  described  in  other 
parts  of  the  nasal  duct  consist  merely  of  imperfect,  irregular,  and  inconstant 
folds  of  the  mucosa,  the  most  constant  and  best-marked  of  which  lies  at  the 


Maxillary 


Internal  palpebral  ligament. 
Opening  of canaliculus  into  sac. 
Constriction    marking    begin- 
ning of  bony  canal. 
Middle  concha. 


Int:-r;:r    it'ln: :  itel :    M    5/    11OS0- 

lachrymal  duct. 


Inferior  concha. 


Fig  26— Section  showing  the  course  and  relations  of  the  lachrymal  sac  ami   nasolachrymal  duct 

(Merkel) 

junction  of  the  lachrymal  sac  and  the  duct,  which  corresponds  to  the  nar- 
rowest   point    of  the  entire   lachrymal   canal. 

The  blood-vessels  supplying  the  lachrymal  duct  consist  of  the  arterial 
branches  from  the  nasal  and  inferior  palpebral  ;  the  relatively  large  and 
numerous  veins  mostly  join  the  nasal  plexus  and  become  indirect  tributaries 
to  the  ophthalmic  and  facial. 

The  nerves  distributed  to  the  tear-passages  are  derived  from  the  infra- 
trochlear  branch  of  the  nasal  division  of  the  ophthalmic. 

MACROSCOPICAL  AND  MICROSCOPICAL  ANATOMY  OF  THE  EYEBALL. 
The  general  form  of  the  eyeball,  as  represented  by  the  outline-  ot  its 
outer  fibrous  coat,  is  spherical:  when  critically  examined,  however,  the 
anterior  segment  of  the  globe  presents  deviation  from  the  typical  form,  due 
to  flattening  within  a  /one  lying  in  front  of  the  equator,  corresponding  to  the 
attachment  of  the  recti  muscles,  and  consequent  apparent  undue  prominence 
of  the  corneal  segment.      In   sagittal   section  the  eyeball   ie  aeemingl)  made 


ANATOMY  OF  THE   EYEBALL. 


19 


up  of  the  segments  of  two  spheres — a  larger  posterior  sclerotic  segment, 
embracing  approximately  four-fifths  of  the  globe,  and  a  smaller  anterior 
corneal  segment,  which  contributes  the  remaining  portion  of  the  bulb.  The 
junction  of  these  segments  is  marked  by  an  external  broad  annular  groove, 
the  sulcus  sclerce,   which  surrounds  the  corneal   periphery. 

The  eyeball  presents  further  deviations  from  the  globular  form  in  tho 
inequality  of  its  three  principal  diameters,  the  anteroposterior  diameter 
being  the  longest,  the  vertical  the  shortest,  and  the  transverse  intermediate. 
The  exact  determination  of  these  measurements  is  by  no  means  a  matter  of 


9 

Y" 

i        i      *. 

10  2  i 

Fig.  2".— Diagram  of  horizontal  section  of  human  eye  (Merkel  Rauber)  :   I,  optic  nerve ;   J.  dura) 
shoatli;  3,  sclera;  4,  conjunctiva ;  5,  cornea;  6,  choroid;  7,  ciliary  body  and  processes;  8  iris;  •.'.  n 
i",  fossa  centralis;    n,  ora  serrata;    12,  lens;  [3,  vitreous  body;   W,  anterior  chamber;   15,  posterior 
chamber;  16,  /■•<w  oi  /inn;  17.  intrazonular cleft. 

ease,  as  is  evidenced  by  the  discrepancies  in  the  figures  obtained  by  a  number 
of  competenl  investigators,  since  variations  in  the  ten-ion,  and  consequently 
in  the  dimensions,  of*  the  eyeball  are  quickly  produced  by  the  changes  which 
begin  very  soon  after  death.  Additional  variations  are  also  referable  to  the 
deviations  in  the  antero-posterior  diameter  associated  with  refractive  errors. 
The  principal  diameters  of  the  eyeball  in  millimeters,  based  upon  the 
careful  and  elaborate  -eric-  of  measurements  of  Sappey,  are  as  follows  : 

Male.  Female.  Av<  ra 

Antero-posterior  diameter 24.6                      23.9  24.2 

Vertical  diameter 23.5                      23.0  23.2 

Transverse  diameter 23.9                     23.4  28.6 

i 


50      EMBRYOLOGY,    ANATOMY,    AXJ)    HISTOLOGY   OF   EYE. 

Approximately,  these  diameters  may  be  considered  for  practical  purposes  as 
antero-posterior,  24  nun.;  vertical,  '_'.">;  transverse,  23.5.  The  eyeball  may 
therefore  be  regarded  as  a  sphere  slightly  flattened  from  above  downward 
and  from  side  to  side.  When  directed  toward  distant  objects  or  in  a  condi- 
tion of  accommodative  vest  the  axes  of  the  eyes  are  very  nearly  parallel  ;  the 
axes  of  the  optic  nerves,  on  the  contrary,  are  divergent,  their  entrance  lying 
between  2  and  •">  nun.  to  the  inner  or  nasal  side  of  the  point  at  which  the  axis 
of  the  eyeball  meets  the  posterior  wall  (Fig.  27). 
The  eyeball  consists  of  three  coats  or  tunics  : 

1.  The  external  fibrous  tunic,  of  which  the  sclerotic  forms  the  posterior 
four-fifths  and  the  cornea  the  anterior  fifth,  upon  which  depend  the  protec- 
tion of  the  more  delicate  parts  within  and,  to  a  limited  degree,  the  main- 
tenance of  the  general   form  of  the  organ. 

2.  The  middle  vascular  tunic,  embracing  the  parts  to  which  the  chief 
blood-supply  of  the  eyeball  is  distributed,  including  the  choroid,  the  ciliary 
body,  and  the  iris. 

•"'..  The  inner  nervous  tunic,  which  contains  the  specialized  neuro-epithelium 
for  the  reception  of  visual  stimulus,  the  nerve-cells,  and  the  nerve-processes, 
which,  as  the  nerve-fibers,  converge  to  form  the  optic  nerve. 

The  refractive  media,  the  crystalline  lens,  the  aqueous  humor,  and  the 
vitreous  body,  are  enclosed  within  these  coats,  which  the  media,  in  turn, 
materially  aid   in  supporting. 

The  Fibrous  Tunic. — The  Cornea. — The  anterior  fifth  of  the  eyeball 
i-  occupied  by  the  cornea,  which  structure,  although  principally  composed  of 
closely-felted  bundles  of  dense  fihrous  tissue,  presents  a  remarkable  glass-like 
transparency,  so  important  in  admitting  the  rays  of  light  to  the  interior  of  the 
ocular  bull).  The  refractive  index  of  the  cornea  is  about  1.37,  or  a  little  above 
that  of  water  and  the  aqueous  fluid.  The  transparency  of  the  cornea  is  pre- 
served only  when  the  close  normal  apposition  of  its  elements  is  maintained, 
any  disturbance  of  the  normal  arrangement,  as  by  compression,  resulting  in 
impaired   transparency. 

The  form  of  the  cornea,  when  examined  from  in  front,  is  not  quite 
circular,  but  elliptical,  the  greater  transverse  diameter  measuring  11.6  mm., 
the  smaller  vertical  only  11  mm.  The  apparent  projection  of  the  cornea 
beyond  the  sclera  depends  on  a  slight  flattening  of  the  latter  near  the  equator, 
rather  than  on  an  actual  projection  of  the  corneal  pole  beyond  the  general 
sphere  of  the  eyeball. 

The  curvature  of  the  anterior  corneal  surface  does  not  accurately  corre- 
spond to  a  sphere,  since  the  radius  of  curvature  in  the  transverse  direction 
(7.8  nun.)  is  slightly  greater  than  the  vertical  radius  (7.7  mm.);  while  slight 
asymmetry  of  the  corneal  curvature  is  probably  always  present,  marked 
variation-  are  also  of  frequency  and   then  constitute  astigmatism. 

The  form  of  the  inner  surface  of  the  cornea,  on  the  contrary,  corresponds 
to  :i  Bphere,  the  radii  of  curvature  being  equal  in  all  meridians,  and  measur- 
ing about  <;  mm.  The  discrepancy  in  the  curvatures  of  the  outer  and 
inner  corneal  surfaces  shows  that  the  thickness  of  the  cornea  necessarily  varies  : 
the  cornea  i-  slightly  thicker  al  the  periphery,  where  it  measures  from  0.9  to 
1.1    iiim..    being    from    0.8    to  0.9    mm.    thick    at    the   centre. 

The  cornea?  of  persons  advanced  in  age  usually  present  the  arcus  senilis, 
which  appears  a-  a  narrow  gray  or  yellowish-white  crescentic  border  extend- 
ing beyond  the  periphery  to  ward  the  pupil.  Not  infrequently  a  complete 
ring  encircle-  the  corneal  limbus,  formed  by  the  fusion  of  the  upper  and 
lower   crescents.       The    appearance    is   due    to    the    infiltration    of  the   corneal 


THE  CORXKA. 


5] 


stroma  by  particle-  which  arc  usually  assumed  to  he  of  a  Tatty  nature, 
although  this  is  questioned  by  Fuchs,  who  regards  the  change  as  due  to  a 
limited  hyaline  degeneration  of  the  corneal   fibers.     (See  also  p.  .*52b\) 

The  cornea  differs  from  ordinary  fibrous  tissue  in  not  yielding  gelatin  on 
boiling,  hut  a  modified  form  of  chondrin. 

The  structure  of  the  cornea,  a-  seen  in  vertical  section,  includes  five  well- 
marked  layers  :  these  are,  from  without  in  — 

1.  The  anterior  epithelium  ; 

2.  The  anterior  limiting  membrane; 

3.  Thi'  substantia  propria  ; 

4.  The  posterior  limiting  membrane; 

5.  The  posterior  endothelium. 

The  (interior  epithelium  of  the  cornea  is  a  direct  continuation  of  the  ecto- 
dermic  covering  of  the  adjacent  conjunctiva,  and  represents  one  of  the  few- 
parts  of  the  eve  derived  from  the  outer  embryonic  layer.  The  epithelium  is 
stratified  squamous  in  type,  and  thinnest  over  the  central  part  of  the  cornea, 
the  six  to  eight  layers  in  this  position  together  measuring  about  <>.04o  mm.;  at 
the  periphery  the  epithelium  is  almost  twice  as  thick.  The  deepest  cells 
approach  the  columnar  form,  their  bases,  often  somewhat  extended,  resting 
upon  the  anterior  limiting  membrane,  while  the  outwardly-directed  rounded 
ends  are  received  between  the  cells  of  the  more  superficial  strata.  The  ele- 
ments composing  the  middle  layers  are  polyhedral  in  form,  and  often  present 
the  appearance  of  prickle-cells.  The 
cells  of  the  superficial  strata  and  free 
surface  are  greatly  flattened  and  lie  par- 
allel to  the  free  surface  (Fig.  28). 

The  anterior  limiting  membrane, 
mt  mbrane  of  Bowman,  or  lamina  elastica 
anterior,  is  conspicuous  in  the  human 
cornea  and  represents  a  highly  devel- 
oped basement-membrane.  This  layer 
appears  as  a  homogeneous  glassy  band, 
about  0.002  mm.  in  thickness,  imme- 
diately beneath  the  epithelium  ;  it  is 
thickest  at  the  center  and  thinnest  at 
the  corneal  periphery.  The  membrane 
is  resolvable  into  the  fibrous  fibrillae 
upon  the  application  of  suitable  reagents, 
thus  demonstrating  its  true  nature  as  a 
localized  condensation  of  the  fibrous 
corneal  stroma,  of  which  it  is  a  special- 
ization. 

The  substance  proper  constitute-  the 
chief  bulk  of  the  cornea,  and  is  com- 
posed of  the  fibrous  stroma,  which  is 
built  up  of  innumerable  interlacing  bun- 
file-  of  fibrous  tissue.  The  interlacing 
fibrous  bundles  are  disposed  with  some 
regularity  as  lamella;,  although  the  exacl 
number  and  arrangement  of  these  are 
variable.  The  fibrillae  of  fibrous  tis- 
sue, a-  well  ;i-  the  bundle-,  are  held  together  by  the  interfibrillar  cement 
substance,  which  likewise  aid-  in  joining  the  lamellae.     The  fibrous  bundles 


Pig.  28. — Section  of  cornea  Piersol  a,  an- 
terior epithelium;  <■.  anterior  limiting  mem- 
brane :  '■. '<.  fibrous  stroma  of  substantia  propria, 
containing  corneal  corpuscles  (/)  lying  within 
Hi.-  corneal  spaces  ;  </.  i»>st.-rior  limiting  mem- 
braue;  < .  endothelium  lining  anterior  chamber. 


52     EMBMYQLOGY,  ANATOMY,   AND   HISTOLOGY  OF  EYE. 

cross  one  another  at  various  angles,  and  are  often  united  by  bands  which  pass 
between  the  adjacent  bundles;  these  fibres  arcuatce  are  especially  conspicuous 
in  the  anterior  lamella1.  The  peculiarity  of  the  substantia  propria  in  yielding 
after  boiling  a  modified  form  of  chondrin,  instead  of  the  usual  gelatin,  has 
already  been  mentioned. 

The  cellular  elements,  the  corneal  eorpuscles,  are  flattened,  plate-like 
connective-tissue  cells  which  lie  between  the  lainelhe  of  the  fibrous  stroma 
within  the  intercommunicating  lymph-spaces  hollowed  out  within  the  cement 
substance.  The  corneal  cells  are  irregularly  branched,  and  form,  by  means 
of  their  united  processes,  a  protoplasmic  network  throughout  the  corneal 
stroma.  The  corneal  spaces  in  which  the  cells  lie  are  larger  than  the  cells, 
and  are  therefore  only  partially  filled  by  the  protoplasmic  elements,  the  unoc- 
cupied space  affording  channels  for  the  circulation  of  the  nutrient  tissue-juices 
upon  which  the  investment  of  the  non-vascular  cornea  depends.  Communi- 
cation between  the  corneal  spaces  i-  established  by  the  canaliculi  which  pass 
from  one  space  to  the  other.  The  corneal  cells  usually  are  applied  to  one 
wall  of  the  space-,  and,  in  principle,  resemble  the  endothelial  plates  which 
line  other  and  larger  lymphatic  cavities.  Occasional  migratory  leukocytes,  or 
wandering  cells,  are  also  found  within  the  system  of  corneal  juice-channels. 

The  posterior  limiting  membrane,  membrane  of  Descemet,  membrane  <>j 
I),  mows,  or  posterior  clastic  nu  mbrane,  appears  as  a  sharply-defined  homogene- 
ous hand  from  0.010  to  0.012  mm.  in  its  thickest  peripheral  portion,  at  the  inner 
boundary  of  the  substantia  propria.  It  differs  from  the  anterior  limiting 
membrane  in  its  marked  resistance  to  acids,  alkalies,  boiling  water,  and  other 
reagents  ;  it  resembles,  but  is  by  no  means  identical  with,  elastic  tissue.  It 
is  capable  of  complete  separation  from  the  substantia  propria  after  prolonged 
maceration  in  a  1<>  per  cent,  solution  of  sodium  chlorid.  The  layer  in  ques- 
tion contains  no  cells,  and  ordinarily  presents  no  indication  of  being  composed 
of  secondary  lamellae,  although  sometimes  after  reagents  it  show-  traces  of 
such  structure. 

The  relations  of  the  posterior  limiting  membrane  at  the  corneal  periphery 
are  of  interest,  since  in  this  position  it  breaks  up  into  numerous  bands  which 
are  continued  into  the  trabecules  forming  the  pectinate  ligament  of  the  iris. 

The  posterior  endothelium  covers  the  inner  surface  of  the  membrane  of 
Descemet  and  forms  part  of  the  lining  of  the  anterior  chamber  of  the  eye. 
This  innermo-t  stratum  of  the  cornea  is  composed  of  a  single  layer  of  poly- 
hedral plate-,  the  outline-  of  which  constitute  a  mosaic  of  considerable  regu- 
larity. The  cells  closely  resemble  ordinary  endothelial  plates,  possessing 
oval,  sometimes  reniform,  nuclei  which  are  usually  of  greater  thickness  than 
the  surrounding  cell-body.  The  endothelium  and  the  membrane  of  Descemel 
are  of  importance  as  constituting  almost  impassable  barriers  to  the  escape  of 
the  aqueous  humor  into  the  lymph-channels  of  the  cornea. 

The  blood-vessels  of  the  normal  fully-developed  cornea  are  limited  to  an 
extremely  narrow  peripheral  /one,  about  1  mm.  in  width,  the  remaining 
portions  of  the  cornea  being  entirely  devoid  of  blood-channels.  The  vascu- 
lar /one  contain- tin'  terminal  loops  of  the  episcleral  branches  derived  from 
the  anterior  ciliary  arteries.  The  venous  radicles  become  tributaries  of  the 
anterior  ciliary   veins. 

The  /"  roes  of  the  cornea  constitute  a  rich  supply  arranged  in  the  form  of 
numerous  plexuses.  The  corneal  nerves  are  derived  from  the  ciliary  plexus, 
contributed  by  the  long  and  short  ciliary  nerves,  and  form  an  annular  plexus 
in  the  vicinity  of  the  corneal  margin.  The  twigs  from  the  annular  plexus 
pass  either  directly  or  indirectly  to  the  corneal  tissue,  those  destined  for  the 


THE  SCLERA. 

.•interior  layers  first  having  joined  the  conjunctival  nerves  before  proceeding 
to  the  cornea.  The  more  numerous  branches  winch  pass  directly  to  the 
corneal  stroma  from  the  annular  plexus  enter  the  substantia  propria  near  the 
posterior  Limiting  membrane,  the  far  greater  number,  however,  passing  to  the 

anterior  lamella,  only  about  one-third  of  the  nerves  which  enter  the  cornea 
being  distributed  to  the  posterior  layers.  The  nerve-bundles,  on  penetrating 
into  the  corneal  stroma,  are  invested  for  a  short  distance,  from  0.75— 1  nun.. 
by  perineural  lymph-sheaths,  the  individual  nerve-fibers  losing  their  medul- 
lary sheaths  at  about  the  same  time. 

After  entering  the  substantia  propria  the  nerves  form  the  fundamental 
plexus  within  the  corneal  stroma,  from  which  numerous  lateral  branches  are 
given  off  at  various  levels;  these  are  composed  of  non-medullated  fibers 
which  soon  break  up  into  the  component  varicose  fibrilke.  In  addition  to 
the  lateral  twig-,  perforating  branches  ascend  through  the  anterior  lamellae  as 
far  as  the  epithelium,  beneath  which  they  form  the  subepithelial  plexus.  The 
terminal  tibers  of  this  plexus  in  many  instances  enter  the  epithelium  to  end 
either  in  special  end-bulbs  or  between  the  cells  as  the  intraepithelial  plexus. 
The  plexuses  within  the  substantia  propria  formed  by  the  twigs  given  off  at 
various  levels  spread  out  between  the  lamellae  of  fibrous  tissue ;  the  nodal 
points  or  place-  of  meeting  of  the  fibers  are  often  marked  by  angular  areas 
outlined  by  the  interlacing  fibers ;  nuclei,  belonging  to  the  delicate  nerve- 
sheaths,  are  sometimes  present.  The  terminal  fibers  of  the  corneal  nerves 
are  related  to  various  forms  of  end-organs,  among  which  are  intricate  convo- 
lutions, less-contorted  loops  and  hooks,  and  irregular  quadrate  plates. 

The  Sclera. — The  sclerotic  coat  forms  the  posterior  four-fifths  of  the 
fibrous  tunic  of  the  eyeball,  contributing  largely  to  the  protection  and  sup- 
port of  the  more  delicate  structures  within,  as  well  as  affording  the  point-  of 
attachment  of  the  ocular  muscles.  Although  composed  of  practically  the 
same  histological  elements  as  the  cornea,  the  disposition  of  these  is  such  that 
the  dead-white  opacity  is  produced  which  so  conspicuously  contrasts  with  the 
beautifully  transparent  cornea. 

The  sclera  is  thickest  over  the  posterior  third  of  the  ball,  where  the 
maintenance  of  a  uniform  curvature  for  the  support  of  the  retina  is  of  great 
importance  :  in  the  vicinity  of  the  optic  nerve  the  sclerotic  coat  measures 
nearly  1  mm.  in  thickness,  graduallv  becoming  thinner  toward  the  anterior 
boundary,  until  beneath,  or  just  posterior  to,  the  zone  of  attachment  of  the 
recti  muscles  the  sclera  is  reduced  to  about  0.4  mm.  Anterior  to  the  tendon- 
zone  the  thickness  of  the  fibrous  tunic  is  augmented  by  the  expansion  of  the 
muscle  insertions  until  it  reaches  about  <U!  mm.  In  individuals  possessing 
thin  sclera  and  deeply  pigmented  eye-  the  sclerotic  coat  presents  a  bluish  or 
skimmed-milk  tint,  due  to  the  deeply-colored  tissue  beneath  the  fibrous  coal  ; 
tin-  bluish  appearance  is  well  marked  in  the  eyes  of  young  children. 

In  its  structure  the  sclera  closely  resembles  the  cornea,  being  composed 
of  interlacing  bundles  of  fibrous  tissue  disposed  with  much  greater  irregu- 
larity, however,  than  those  of  the  cornea.  The  cleft-  between  the  fibrous 
bundles  correspond  to  the  corneal  spaces  and  contain  irregularly  stellate 
connective-tissue  cells— the  scleral  corpuscles.  The  scleral  -pace-  are  less 
regularly  arranged  and  possess  a  less  elaborate  system  of  connecting  canal- 
iculi.  The  scleral  bundle-  further  differ  from  those  of  the  cornea  in  contain- 
ing numerous  elastic  liber-  and  in  yielding  gelatin  on  boiling:  their  general 
disposition  i-  equatorial  and  meridional,  although  the  bundles  interlace  with 
one  another  at  all  angles. 

In  addition  to  the  usual   branched  scleral  corpuscles,  those  occupy  ing  the 


54      EMBRYOLOGY,   ANATOMY,   AND   HISTOLOGY  OF  EYE. 

innermost  stratum  are  deeply  pigmented,  in  consequence  of  which  the  inner 

surface  of  the  sclerotic  coal  presents  a  dark  color  and  is  known  as  the  lamina 
fusca:  this  layer  constitutes  the  outer  wall  of  the  subscleral  lymph-space, 
and  is  attached  to  the  subjacent  choroid  by  numerous  trabecular,  which, 
together  with  the  limiting  walls  of  the  space,  are  covered  with  endothelial 
plates.  The  greater  extent  of  the  outer  surface  of  the  sclera,  from  the 
-heath  of  the  optic  nerve  to  the  insertion  of  the  ocular  muscles,  is  also 
clothed  with  endothelium,  which  forms  part  of  the  lining  of  the  episcleral 
space  of    Tenon. 

The  blood-vesseh  of  the  sclera,  in  addition  to  the  perforating  vessels, 
which  include  anterior  branches  from  the  anterior  ciliary  vessels,  the  large 
equatorially  situated  vena?  vorticosse,  and  posterior  branches  from  the  posterior 
ciliary  vessels,  are  represented  by  the  meager  twigs  within  the  superficial 
strata  of  the  fibrous  tunic  derived  from  the  wide-meshed  episcleral  network 
formed  by  branches  derived  from  the  anterior  and  posterior  ciliary  arteries. 
The  sclera  receives  additional  branches  from  the  short  ciliary  arteries  in  the 
vicinity  of  the  optic  entrance  :  these  small  vessels  are  of  interest,  since  from 
the  circidus  Zinnii,  which  they  form  within  the  fibrous  coat  around  the  optic 
nerve,  minute  twigs  extend  into  the  dural  nerve-sheath  and  anastomose  with 
the  arterioles  supplying  the  sheath  derived  from  the  central  artery  of 
the  retina,  thus  establishing  a  communication  between'  the  retinal  and  cho- 
roidal  circulation. 

The  veins  which  drain  the  scleral  coat  are  tributary  to  three  sets  of 
vessels:  those  from  the  anterior  tract,  emptying  into  the  anterior  ciliary 
veins  ;  those  from  the  equatorial  zone,  joining  the  vena?  vorticosaB ;  and  those 
from  the  posterior  part,  pouring  their  blood   into  the  posterior  ciliary  veins. 

The  lymphatics  of  the  sclera  are  represented  by  the  system  of  intercom- 
municating scleral  spaces,  those  in  the  vicinity  of  the  sclero-corneal  juncture 
being  in  close  relation  with  the  spaces  of  Fontana  at  the  angle  of  the  anterior 
chamber,  which  they  indirectly  aid  in  draining. 

The  nerves  distributed  to  the  sclerotic  coat  consist  of  a  lew  twigs  derived 
from  the  ciliary  nerves  as  these  pass  between  the  sclera  and  choroid,  which 
terminate  between  the  fibrous  bundles  of  the  superficial  layers  as  tortuous 
and   intricately  coursing  ultimate  fibrillar. 

The  relations  of  the  scleral  tissue  to  the  sheaths  surrounding  the  optic 
nerve  will  he  considered  with  the  description  of  the  Optic  Entrance. 

The  Sclero-corneal  Juncture. — The  position  at  which  the  sclera  and 
corneal  segments  of  the  fibrous  coat  meet  is  one  of  the  most  important 
regions  of  the  eye,  since  in  the  immediate  vicinity  of  this  junction  lie 
important  channels  through  which  escapes  the  aqueous  humor  as  well  as  the 
fibers  giving  origin  to  the  ciliary  muscle. 

The  conspicuous  line  <»l  union  between  cornea  and  sclera  depends  far  more 
upon  the  physical  differences  of  the  two  portions  of  the  fibrous  coat  than 
upon  actual  structural  variation,  since  the  elements  are  not  only  almost 
identical,  bui  directly  continuous.  When  seen  in  section  the  scleral  tissue 
extend-  along  both  margins  farther  forward  than  docs  the  corneal  substance, 
the  effect  of  this  arrangemenl  being  to  receive  the  cornea  with  an  apparent 
annular  groove  bounded  l>\  the  outer  and  inner  scleral  processes :  of  these  the 
inner  i-  -holler  and  doe-  not  reach  a-  far  toward  the  anterior  pole  as  the 
outer. 

The  connection-  of  the  inner  scleral  process  are  of  especial  importance 
on  account   of  the   relation-   to  the  structures    marking  the  meeting  <»l   the 

Cornea,  the    iii-,    and    the    ciliary   muscle.      Jusl    anterior   and    external  to  the 


THE  VASCULAR   TUNIC.  55 

inner  scleral  process  a  distinct,  usually  somewhat  irregularly  elliptical,  open- 
ing indicates  the  position  of  the  annular  venous  sinus,  the  tut  mil  of  Srltlniun 
(Fig.  29).  This  channel,  also  called  the  circulus  venosus  ciliaris,  as  seen  in 
meridional  sections,  elliptical  or  pyrii'orm  in  its  transverse  figure,  measures 
about  0.3  and  0.045  mm.  in  the  longest  and  shortest  diameters  respectively. 
The  walls  of  the  canal  of  Schlemm  differ  greatly  in  character,  the  outer 
boundary  being  dense,  while  the  inner  is  composed  of  a  spongy  reticulated 
layer,  apparently  the  continuation  of  the  inner  scleral  process.  The  inner 
wall  is  closely  united  with  the  posterior  limiting  membrane  of  the  cornea 
anteriorly,  and  internally  with  the  pectinate  ligament  of  the  iris  and  merid- 
ional fibers  of  the  ciliary  muscle. 

The  character  of  Schlemm's  canal,  whether  a  venous  or  lymphatic  chan- 
nel, was  long  a  subject  of  active  controversy  :  the  recent  investigations  of 
Leber,  however,  have  brought  the  formerly  opposed  views  into  harmony  by 
showing  that  the  conflicting  evidence,  based  upon  carefully  conducted  ob- 
servations, was  due  to  conditions  of  intraocular  tension  under  which  the 
experiments  were  carried  out.  It  may  be  regarded  as  definitely  established 
that  the  canal  of  Schlemm  is  an  annular  venous  sinus  which  by  means  of  the 
spaces  of  Fontana  stands  in  close  relation  to  the  anterior  chamber  on  the  one 
hand,  and  directly  communicates  with  the  anterior  ciliary  veins  on  the  other. 
Under  usual  conditions  Schlemm's  canal  contains  but  little  blood — a  fact 
which  is  explained  by  Schwalbe  upon  the  supposition  that  the  sinus  is  an 
annular  reserve  diverticulum  for  the  reception  and  storage  of  blood  when  for 
any  reason  there  is  a  temporary  retardation  to  the  escape  of  the  blood  passing 
through  the  anterior  ciliary  veins  ;  the  narrowness  of  the  communicating 
branches  between  Schlemm's  canal  and  the  scleral  veins  under  ordinary  con- 
ditions favoring  the  more  direct  passage  of  the  contents  of  the  scleral  veins 
into  the  anterior  ciliary  vessels,  rather  than  its  entrance  into  the  canal. 

The  tissue  forming  the  wall  of  the  anterior  chamber  at  its  angle,  occupy- 
ing the  space  between  it  and  the  canal  of  Schlemm,  is  peculiar  in  character. 
being  composed  of  an  aggregation  of  interlacing  trabecuhe  composing  a 
spongy  mass  containing  interfascicular  clefts,  the  spaces  of  Fontana.  These 
spaces  constitute  a  system  of  intercommunicating  lymph-channels  which 
are  imperfectly  lined  with  endothelial  plates  and  freely  communicate  with 
the  anterior  chamber,  the  aqueous  humor  filling  the  spaces. 

The  spongy  tissue  containing  the  spaces  of  Fontana  collectively  constitutes 
an  annular  prismoidal  mass,  the  apex  of  which  begins  at  the  corneal  margin, 
where  the  membrane  of  Descemet  splits  up  into  delicate  bands  :  these  bands 
mark  the  origin  of  the  trabecuhe  which  pass  toward  the  iris  and  constitute 
the  ligamentum  pectinabum  iridis,  a  rudimentary  structure  in  man  representing 
the  much  more  conspicuous  scries  of  conical  processes  extending  from  the  iris 
toward  the  cornea  in  ruminants.  The  imperfect  character  of  the  endothelial 
lining  of  the  spaces  of  Fontana  allows  the  ready  entrance  of  the  lymph  con- 
tained within    the  anterior  chamber,  so  that  the  clefts   between   the  t  rabecuhc 

are  filled  with  the  escaped  aqueous  humor;  the  loose  nature  of  the  septum 
forming  the  inner  wall  of  Schlemm's  canal  is  also  favorable  to  the  passage  of 
fluid-,  in  consequence  of  which  arrangement  the  aqueous  humor  i-  continu- 
ally passing,  under  normal  conditions  of  intraocular  tension,  through  the 
spaces  of  Fontana  into  the  canal  of  Schlemm,  ami  thence  into  the  communi- 
cating venous  radicles.  This  exit  for  the  intraocular  lymph  IS  of  the  utmost 
importance  in  maintaining  an  equilibrium  of  tension  within  the  eyeball. 

The  Vascular  Tunic. — The  middle  <»r  choroidal  coat  of  the  eyeball,  dis- 
tinguished by  its  dark  color,  and  therefore  often  called  the  uveal  tract,  is  essen- 


56     EMBRYOLOGY,   ANATOMY,  AND  HISTOLOGY  OF  EYE. 


X 

Fig.  29.    Section  through  cilia  part  of  cornea  and  sclera,  the  Iris,  ciliarj  p 

and  muscli  clera;    )/,  ciliarj    muscle ;  r,  radiating  fibers;   Mm,  circular  fibers  of 

Midler ;  //< ,  /.. .  pi  ci,  anterior  ciliary  artery  ;  8, 

canal  of  Schlemn  ti  of  ciliary  muscle;  cc,ff,  folds  of  anterior  surface  oi 

in  iris :  gp,  sphincter  pupilue;  />.  pupillary  border  of  iris  ;  A,  pigmenl  partly  detached  from  Iris;  P,  ciliary 
i  lliarj  i in"  .  "  ora  sei rata. 

tially  a  Bheel  "I"  vascular  connective  tissue.     1 1  includes  I  liree  distincl  | >< n-i i< >n- 
the  choroid,  thecilian  region,  and  the  iris  —and  extends  from  the  optic  nerve 


77//;  ciio n<> m. 


57 


U)  the  pupil.  The  character  of  its  component  structures  renders  the  nutritive 
e*»at  soft,  friable,  and  extensible,  and,  owing  to  the  presence  of  muscular  tissue 
within  its  ciliary  and  iridial  segments,  it  is  subjected  to  constant  variations  in 

its  tension.  The  blood-vessels  of  this  tunic  constitute  the  chief  nutritive  appa- 
ratus of  the  eye,  since  the  functionally  most  active  portions  of  the  organ,  as 
the  percipient  layers  of  the  retina  and  the  ciliary  muscle,  receive  their  nutri- 
tion from  this  source. 

The  choroid  constitutes  the  posterior  two-thirds  of  the  vascular  tunic, 
extending  from  the  optic-nerve  entrance  to  the  anterior  limit  of  the  visual 
portion  of  the  retina,  or  ora  serrata,  lying  closely  united  to  the  functionating 
segment  of  the  nervous  tunic,  to  the  nutrition  of  which  it  ministers.  The 
thickness  of  the  choroid  gradually  diminishes  toward  the  ora  serrata,  being 
about  0.1  mm.  near  the  nerve  and  0.00  mm.  at  the  ora  serrata.  While  ap- 
plied to  the  inner  surface  of  the  sclera  the  union  between  the  two  coats  is  not 
firm,  since  the  opposed  surfaces,  covered  with  endothelium,  are  separated 
by  the  intervening  suprachoroida!  lymph-space ;  irregular  trabecular  extend 
across  this  space,  and,  in  addition  to  attaching  the  sclera  and  choroid  imper- 
fectly, subdivide  the  cleft  into  numerous  secondary  compartments.  When 
separated  from  the  fibrous  coat  the  outer  surface  of  the  choroid  appears  rough 


Fin.  no.— Section  <>f  human  choroid  (Picrsoli :  <t,  retinal  pigment  adhering  to  vitreous  membrane  *h\ ; 
c,  capillary  layer,  or  chorio-eapillaris  ;  d,  c,  large  blood-vessels  of  stroma  layer  ;  g,  lamina  suprachoroidea  ; 
It,  tissue  of  sclera. 


and  ragged,  owing  to  the  adherent  torn  trabecular.  The  supraehoroidal 
.-pace  is  also  occupied  by  the  large  vascular  and  nervous  trunks  which 
traverse  the  cleft  in  their  course  to  other  parts  of  the  eyeball  ;  those  which 
pierce  the  sclera,  as  the  venae  vorticosae,  aid  in  further  uniting  the  vascular 
and  fibrous  tunics.  The  inner  surface  of  the  choroid,  on  the  contrary,  i>  very 
intimately  united  with  the  adjacent  pigmented  layer  of  the  retina,  so  that  the 
latter  often  adheres  to  the  choroid  when  the  middle  coat  is  removed. 

The  choroid  consists  of  a  more  or  less  compact  connective-tissue  stroma, 
which  supports  numerous  blood-channels  of  very  varying  size;  the  arrange- 
ment of  these  vessels  largely  determines  the  peculiarities  of  the  layers  into 
which    the   choroid    is   divided    (Fig.  30),      These   are    three: 

1.  The  layer  of  choroidal  stroma  containing  blood-vessels  of  large  size ; 
'1.  The  layer  of  dense  capillary  networks — the  chorio-capillaris  : 
3.  The  homogeneous  glassy  lamina  or  membrana  vitrea. 

The  loose  layer  of  trabecular  bands  connecting  the  outer  surface  of  the 
choroid  and  the  inner  surface  of  the  sclera  constitutes  the  lamina  supra- 
choroidea,  sometimes  described  as  an  additional  layer  oi  the  choroid.  The 
membrane-like   trabecular  consist  of  interlacing   fibro-elastic    bundles,  upon 


58      EMBRYOLOGY,    ANATOMY,   AND   HISTOLOGY  OF  EYE. 

the  surface  of  which  lie  the  flattened,  irregularly-branched  pigmented  con- 
nective-tissue cells,  the  deeply-pigmented  protoplasm  rendering  them  con- 
spicuous  elements. 

The  choroidal  stroma  consists  of  a  ground-substance  of  closely  interwoven 
connective-tissue  lamella?,  which  supporl  the  blood-vessels.  The  structural 
elements  include  the  usual  bundles  <»!'  white  fibrous  tissue,  numerous  elastic 
fibers,  and  stellate  pigmented  cells;  the  stroma  is  especially  dense  in  the  im- 
mediate vicinity  of  the  Mood-channels. 

The  layer  containing  the  large  blood-vessels  constitutes  the  larger  part  of 
the  choroid,  the  vascular  canals  appearing  as  apertures  and  lighter  channels 
within  the  darker  choroidal  stroma.  The  largest  vessels  occupy  the  most 
superficial  or  outer  stratum  of  the  choroidal  stroma,  those  of  medium  size  the 

C    F 


I  -Diagrammatic  view  of  principal  blood-vessels  and  nervesofthe  eyeball  (Testut):  A,  optic 
/:   sclera     /.".   viewed  in  section;  C,  section  of  cornea;   /',  ciliary  muscle ;  I.  ins:  f,  anterior 
chamber  i  I,  Bhort  postei  ior  ciliarj  arteries  ;  2,  long  posterior  ciliary  arteries;  :'..  anterior  ciliary  arteries 
i  ,.,  -  ,  ...  one  "t  tin-  large  venae  vorticosse;  6,  vena  vorticosa  after  piercing  the  sclera  ;  7,  vasa 
\  orl  Icosa  i  ■!  i  he  choroidal  i  unic. 

middle  layer,  while  the  innermost  layer  i-  devoted    to  the  capillary  network, 
t  he  chorio-capfflarix. 

The  mosl  conspicuous  of  the  large  superficial  blood-channels  are  the  four 
venous  trunks,  the  /•-  na  vorticosa  :  these  pierce  the  choroid  within  the  equa- 
torial zone  :it  points  aboul  equidistant  and  establish  foci  toward  which  the 
-mailer  veins  within  each  quad  rani  converge;  these  tributaries  form  peculiar 
venous  whorl-  within  the  superficial  layers  of  the  choroidal  stroma  (  Fig.  •">  I  l. 
The  vense  vorticosse  traverse  the  Buprachoroidal  -pace,  invested  by  a  partial 
envelope  contributed  by  the  lamina  Biiprachoridea,  and  pierce  the  sclera. 
running  obliquely  backward.     Perivascular  lymph-sheaths  usually  invesl  the 

Venous  trunk-  within  the  choroid.      The   arteries  within  the  choroidal   stroma 


THE  CILIARY  /:<)/> )'.  59 

possess  longitudinally  disposed  muscle-bundles  in  addition  to  the  customary 
circular  fibers. 

A  narrow  boundary-zone  separates  the  layer  containing  the  large  veins 
from  the  capillary  stratum:  it  consists  of  closely  felted  fibro-elastic  fibers 
intermingled  with  sparingly  distributed  connective-tissue  cells  devoid  of  pig- 
ment. In  many  animals,  as  the  horse,  cow,  or  sheep,  the  boundary-zone 
contains  many  bundles  of  dense  connective  tissue,  which  arrangement  pro- 
duces the  peculiar  metallic  reflex  sometimes  seen  in  such  eyes;  this  shining 
layer  constitutes  the  tapetum  fibrosum,  as  distinguished  from  the  tapetum 
cellulosum  of  the  carnivora,  which  structure  depends  upon  the  presence  of 
several   layers  of  cells  containing  minute  crystals. 

The  inner  capillary  zone  of  the  choroid,  the  chorio-capUlarifi  or  membrane 
of  Rwysehj  occupies  the  inner  portion  of  the  vascular  tunic  lying  next  the 
vitreous  membrane,  which  alone  separates  the  rich  vascular  layer  from  the 
nervous  coat,  to  the  nutrition  of  which  it  so  largely  ministers.  The  capil- 
laries are  unusually  uniform  in  size,  measuring  about  0.009  mm.  in  diameter; 
the  meshes  of  the  network  are  very  small,  even  surpassing  in  closeness  those 
of  the  lungs,  being  only  0.01  to  0.02  mm.  in  the  macular  region,  and  about 
0.02  to  0.03  mm.  toward  the  ora  serrata.  The  red  reflex  seen  in  the  eye  when 
viewed  with  the  ophthalmoscope  is  due  to  the  reddish  color  of  this  vascular 
layer  showing  through  the  retina. 

The  vitreous  membrane,  lamina  basilaris,  'membrane  of  Brueh,  or  lamina 
vitrea,  constitutes  the  inner  boundary  of  the  choroid,  lying  next  the  nervous 
tunic,  which  it  separates  from  the  chorio-capillaris.  The  membrane  repre- 
sents a  specialized  condensation  of  the  choroidal  stroma,  and  appears  as  a 
homogeneous  zone  which  measures  only  0.002  mm.   in  thickness. 

The  nerves  of  the  choroid  are  derived  from  branches  given  oft'  from  the 
long  and  short  ciliary  nerves  during  their  course  between  the  vascular  and 
fibrous  tunics.  The  choroidal  nerves,  which  are  both  medullated  and  non- 
medullated,  form  a  wide-meshed  plexus  within  the  lamina  suprachoroidea 
containing  groups  of  ganglion-cells.  From  this  plexus  numerous  slender, 
non-medullated  fibers  proceed  to  the  arteries,  the  muscular  tissue  of  which 
they  especially  supply  ;  isolated  or  very  limited  groups  of  ganglion-cells  are 
found  along  the  blood-vessels.  / 

The  lymphatics  of  the  choroid  are  probably  represented  by  distinct  cap- 
illary vessels  which  communicate!  with  the  lymph-spaces  between  the  channels 
of  the  chorio-capillaris  on  the  one  hand,  and  the  perivascular  sheaths  tribu- 
tary to  the  larger  lymph-canals  on  the  other. 

The  ciliary  body  includes  the  middle  segment  of  the  vascular  tunic, 
extending  from  the  ora  serrata  behind  to  the  sclero-corneal  juncture  in  front. 
A-  seen  in  meridional  sections,  this  region  appears  as  a  triangle,  the  longer 
and  outer  side  of  which  lies  next  the  sclera  and  sclero-corneal  juncture,  the 
short  anterior  side  against  the  pectinate  ligament,  and  the  inner  margin  in 
apposition  with  the  irregular,  deeply  pigmented  extension  of  the  retinal 
tunic. 

The  ciliary  body  presents  three  subdivisions— the  ciliary  ring,  the  ciliary 
processes,  and  the  ciliary  muscle. 

The  ciliary  ring,  or  orbiculus  ciliai'w,  includes  the  smooth  annular  tract 
lying  between  the  sinuous  border  of  the  ura  -errata  behind  and  the  ciliary 
proceases  in  front,  constituting  a  band  about  I  mm.  in  width.  This  zone 
differs  in  its  structure  from  the  choroid  proper,  chiefly  in  the  absence  ol  the 
rich  vascular  supply,  since  the  capillary  layer  ceases  ai  the  ora  serrata,  oral 
the  point  where  the  percipienl  element- of  the  nervous  tunic  end  for  whose 


60      EMBRYOLOGY,   ANATOMY,  AXD  HISTOLOGY  OF  EYE. 

nutrition  the  chorio-capillaris  is  especially  designed.  The  larger  blood- 
vessels of  the  choroid  are  here  represented  by  the  venous  trunks  which 
return  the  blood  from  the  iris  and  ciliary  processes  and  proceed  as  tributaries 
to  the  vena'  vorticosae.  When  viewed  from  the  posterior  surface  the  ciliary 
rinir  presents  numerous  delicate  radial  striations :  these  are  due  partly  to  the 
blood-vessels  and  partly  to  minute  plications  of  the  surface,  best  marked 
toward   the  anterior  boundary  of  the  ring. 

The  ciliary  processes  appear  on  the  posterior  surface  of  the  ciliary  region 
as  an  annular  series  of  pyramidal  folds,  about  seventy  in  number,  the  con- 
spicuous projecting  bases  of  which  encircle  the  attached  border  of  the  iris, 
while  their  apices  gradually  lade  away  in  the  orbiculus  ciliaris.  The  delicate 
radial  striations  seen  on  the  surface  of  the  latter  are  so  related  to  the  ciliary 
processes  that  each  projection  seemingly  begins  by  the  fusion  of  several 
striations,  and  rapidly  increases  in  breadth  and  height  to  a  point  opposite  the 
margin  of  the  crystalline  lens,  and  then  abruptly  diminishes  to  the  level  of 
the  iris.  The  elevations  measure  between  2  and  •">  mm.  in  length,  0.12  to  0.15 
mm.  in  breadth,  and  in  their  boldest  part  from  0.8  to  1  mm.  in  height.  The 
processes  consist  chiefly  of  convoluted  blood-vessels  supported  by  delicate 
connective-tissue  stroma,  and  covered  by  the  pigmented  extension  of  the 
retinal  tunic,  thenars  eUiaris  retince.  It  is  probable  that  the  particular  func- 
tion of  the  ciliary  processes,  in  addition  to  aflbrding  attachment  lor  the  libers 
of  the  suspensory  ligament  of  the  lens,  is  the  secretion  of  the  aqueous  humor, 
to  which  end  their  peculiar  formation  and  unusual  vascularity  are  especially 
adapted. 

When  seen  in  meridional  sections  each  process  is  observed  to  be  composed 
of  a  number  of  irregular  projections,  varying  greatly  in  size  and  arrange- 
ment (  Fig.  29)  ;  in  general,  the  maximum  elevation  marks  the  inner  angle  next 
the  iris,  from  which  point  they  gradually  diminish  toward  the  orbicular  ring, 
where  they  fade  away.  In  addition  to  the  connective-tissue  stroma  contain- 
in-  the  rich  convolution  of  blood-vessels,  the  inner  surlaee  of  the  ciliary 
processes,  a-  well  as  that  of  the  orbiculus  ciliaris,  is  covered  b\  a  continuation 
of  the  vitreous  membrane  of  the  choroid,  which  in  this  region  is  somewhat 
thickened,  measuring  from  0.003  to  (U*<)4  mm.;  this  limiting  membrane  sepa- 
rates the  stroma  of  the  ciliary  process  from  the  retinal  layer  represented  by 
the  double  stratum  of  epithelial  cells  which  covers  the  inner  surface  of  the 
projections. 

Tin'  ciliary  muscle  \<  very  conspicuous  in  meridional  sections  of  the  eye- 
ball, then  appearing  a-  a  triangular  fold  of  involuntary  muscle  and  connec- 
tive tissue  which  lie-  between  the  sclera  and  the  proper  tissue  of  the  ciliary 
processes.  In  its  entirety  the  ciliary  muscle  forms  a  prismoidal  annular 
band  which  surrounds  the  angle  of  the  anterior  chamber  and  attached  mar- 
gin of  the  iris. 

The  muscular  area  consists  of  three  sets  of  bundle-  of  involuntary 
muscle,  intermingled  with  connective  tissue,  arranged  as  meridional,  radial, 
and  circular  fibers.  The  meridional  bundles  are  closely  grouped  and  con- 
stitute a  compact  muscular  layer  next  the  sclera,  to  which  the)  are  loosely 
connected  by  liber-  of  the  lamina  suprachoroidea.  These  muscular  bundles 
take  origin  from  the  inner  scleral  process  and  tissue,  forming  the  inner  wall 
of  Schlemm's  canal  ;  posteriorly,  the  meridional  bundle-  arc  attached  to  the 
choroidal  tract,  into  which  they  are  inserted  by  delicate  tapering  processes; 
from  their  relation  to  the  vascular  tunic  the  meridional  muscular  bundles 
are  often  called  the  tensor  choroidea.  The  typical  meridional  fibers  lie  next 
the  Bclera;  those  more  internally  situated   gradually  assume  a   more  radial 


THE  IRIS.  61 

disposition,  and  insensibly  blend  with  those  whose  course  is  such  thai  they 
constitute  the  radial  group  (see   Fig.  29). 

The  radial  fibers  of  the  ciliary  muscle  arc  less  closely  placed  than  the 
meridional,  and  form  a  reticulum  in  which  the  muscular  bundles  are  -evi- 
rated by  a  considerable  amount  of  intervening  connective  tissue.  The  fan- 
shaped  mass  of  radial  fibers  diverges  from  their  point  of  origin  from  the 
membrane  of  Descemet  and  inner  wall  of  Schlemm's  canal,  the  innermost 
tihers  passing  toward  the  ciliary  processes  and  the  outer  to  the  anterior 
border  of  the  orbiculus  ciliaris. 

In  addition  to  the  meridional  and  radial  bundles  an  isolated  group  of 
circularly  disposed  muscular  libers  occupies  the  inner  angle  of  the  triangular 
field  formed  by  the  ciliary  muscle  at  the  base  of  the  iris;  these  fibers  consti- 
tute the  circular  or  ring  museh  of  Waller. 

The  general  form  of  the  ciliary  muscle  in  the  emmetropic  eye  approxi- 
mates a  right-angled  triangle,  the  hypothenuse  corresponding  to  the  long 
scleral  margin  :  in  the  markedly  abnormal  refractive  conditions  of  myopia 
and  hypermetropia  the  circular  fibers  are  respectively  atrophic  or  over-devel- 
oped, which  results  in  the  obtusely-angled  myopic  muscle  and  the  unusually 
acute-angled  muscle  of  the  hypermetropic  eye. 

The  blood-vessels  of  the  ciliary  body  are  derived  from  the  anterior  and 
long  ciliary  arteries,  which  form  around  the  root  of  the  iris  the  anastomotic 
ring,  the  eireulus  ii-i<Hs  major.  In  their  course  through  the  ciliary  muscle  to 
gain  the  periphery  of  the  iris  these  vessels  give  off  twigs  which  pass  directly 
to  the  muscle-substance;  the  arteries  supplying  the  ciliary  processes  pass 
backward  from  the  eireulus  iridis  major,  piercing  the  inner  part  of  the  muscle 
to  reach  the  anterior  extremities  of  the  elevations. 

The  veins  returning  the  blood  from  the  ciliary  muscle  pass  principally 
into  the  anterior  ciliary  trunks  :  additional  venous  radicles,  however,  convey 
a  part  of  the  blood  in  the  opposite  direction  to  join  that  returned  from  the 
ciliary  processes  by  the  posteriorly  coursing  vessels,  which  finally  become 
tributary  to  the  great  equatorial   veins. 

The  nerves  of  the  ciliary  body  include  sensory,  motor,  and  sympathetic 
fibers  derived  from  the  anterior  branches  of  the  long  and  short  ciliary  trunks; 
these  nerves  form  an  annular  plexus,  the  orbiculus  gangliosus,  within  the 
ciliary  muscle.  Four  sets  of  fibers  probably  exist  within  the  ciliary  body  : 
1.  sensory  libers,  largely  subscleral  in  distribution;  2,  vaso-motor  fibers  dis- 
tributed to  the  walls  of  the  blood-vessels ;  3,  motor  fibers  ending  within  the 
muscular  tissue  of  the  ciliary  body  ;  4,  fibers  terminating  within  the  inter- 
fascicular tissue  of  the  ciliary  muscle. 

The  iris  constitutes  the  anterior  segment  of  the  vascular  tunic,  and  i- 
visible,  on  looking  through  the  clear  cornea,  as  the  delicate,  contractile, 
variously  tinted  septum  which  contains  the  central  aperture  or  pupil.  The 
plane  of  the  iris  is  not  quite  vertical,  as  its  pupillary  margin  rests  upon  the 
anterior  surface  of  the  lens,  which  causes  slight  convexity  of  its  plane.  The 
thickness  of  the  curtain  is  about  *U>1  mm.  in  the  quiescenl  condition,  in  a 
widely  dilated  state  being  nearly  doubled.  The  diameter  of  the  iris  i-  about 
1  I  mm.,  of  which  the  pupil  appropriates  from  .'>-<)  nun.  when  at  rest 
also  p.  1  17). 

I'he  attached  or  ciliary  border  of  the  iris  joins  the  ciliary  body  behind, 
ami  j-  continuous  with  the  membrane  of  Descemet  through  the  pectinate 
ligament  in  front  ;  it-  zone  of  attachmenl  lies  aboul  •">  mm.  behind  the  ap- 
parent corneal  margin  :i-  viewed  from  before.  The  exact  outline  of  the 
thin  pupillary  border  i-  difficult  to  see,  owing  to  it>  intense  black  color  due  to 


62      EMBRYOLOGY,   ANATOMY,  AND  HISTOLOGY  OF  EYE. 

the  deeply  pigmented  tissue  which  forms  the  immediate  boundary  of  the  open- 
ing :  critically  examined,  it  presents  a  slightly  irregular  or  dentated  contour. 

The  color  of  the  iris,  as  viewed  from  the  anterior  surface,  varies  greatly, 
and  depends  for  its  production  upon  two  factors — the  deeply  pigmented  cells 
covering  the  posterior  surface  of  the  iris  as  well  as  lining  the  pupillary  open- 
ing, and  the  amount  of  pigment  contained  within  the  iridial  stroma.  When 
the  pigmented  stroma-cells  are  very  few  or  absent  the  dark  color  of  the  pos- 
terior layer  shines  through  the  thin  stroma,  and  the  iris  appears  blue;  when 
the  stroma  is  thicker  the  tint  becomes  modified  to  gray.  With  the  presence 
of  additional  pigment  within  the  stroma  varying  deeper  shades,  as  green, 
hazel,  brown,  are  produced;  finally,  when  the  stroma  is  laden  with  pig- 
mented cells,  the  darkest  tints  of  brown  appear — the  so-called  "black  eyes" 
(see  also  page  147). 

The  color  is  not  uniform,  but  is  distributed  in  irregular  spots  and  patches, 
sometimes  of  fanciful  form,  of  lighter  and  darker  tints,  so  that  a  definite  tint 
is  produced  only  on  viewing  the  iris  at  a  distance  sufficient  to  blend  the 
variously  tinged  areas,  ('lose  examination  shows  a  further  disposition  of  the 
color  in  two  /ones  concentric  with  the  pupil — the  pupillary,  from  1-2  nun. 
wide,  which  is  lighter  in  dark  eyes  and  darker  in  light  eyes,  and  an  outer  or 
ciliary,  from  3—4  mm.  in  width,  which  is  darker  in  dark  eyes  and  lighter  in 
light  eyes.  The  boundary-zone  between  the  two  is  often  marked  by  a  series 
of  festoon-like  ridges,  the  circulus  minor  iridic. 

The  (interior  surface  of  the  iris,  when  viewed  from  before,  exhibits  a  dis- 
tinct sculpturing  consisting  in  numerous  radial  striate  ridges  ;  these  are  par- 
ticularly line  and  closely  approximated  within  the  pupillary  zone,  where  they 
unite  toward  the  inner  margin,  leaving  deep  intervening  clefts.  The  broader 
ciliary  portion  is  subdivided  into  three  secondary  zones  concentric  with  the 
pupil — an  inner  smooth  ring,  not  plicated  during  dilatation  of  the  pupil  ;  a 
middle  fwrowed  band  ;  and  an  outer  irregularly  pitted  marginal  or  cribriform 
zone.  The  first  two  are  visible  in  the  living  eye,  the  third  is  covered  by  the 
scleral  border. 

The  posterior  surface  of  the  iris  presents  numerous  radially  arranged 
ridges  separated  by  intervening  furrows,  which  are  intersected  by  concentric 
lines;  within  the  pupillary  zone  the  concentric  markings  almost  disappear, 
while  the  radial  are  more  numerous  than  elsewhere,  resulting  in  the  apparent 
plication  of  the  inner  zone  of  the  iris. 

flic  form  of  the  human  pupil  is  normally  circular  under  all  conditions  of 
contraction  ;  in  marked  contrast  are  the  elliptical  or  slit-like  pupils  of  many 
mammals,  in  some  of  which,  as  the  horse  and  ox,  the  long  axis  of  the  con- 
tracted pupil   is  horizontal;  in  others,  as  the  cut  and  tiger,  vertical. 

The  structure  of  the  iris,  ;i-  -ecu  in  radial  sections,  presents  two  chief 
layers — the  iridial  stroma  proper  and  the  pigment  layer;  these  include  five 
sub-layers  (  Fig.  .">'-^) : 

I .   A  nterior  endot  helium  ; 
■_'.    A  nterior  boundary  layer  ; 
.'!.   Vascular  stroma  layer  ; 
I.    I  '"-tenor  limiting  layer  ; 
5.   Pigment  layer. 

Reference  to  the  development  <>l  the  iris  shows  thai  the  pigment  layer  is 
the  contribution  of  the  nervous  tunic,  and  morphologically  represents  the 
anterior  edge  of  the  secondary  optic  vesicle,  derived  from  the  ectoderm,  while 
the  remaining  parts  of  the  iris  are  mesodermic  in  origin. 

The  anterior  endothelium  forms  part  of  the  lining  of  the  anterior  cham- 


THE   IRIS. 


63 


her,  and  consists  of  a  single  layer  of  irregular  polygonal  plates,  directly  con- 
tinuous with  those  covering  the  posterior  surface  of  the  cornea. 

The  (inferior  limiting  membrane  does  not  exist  as  a  distinct  layer,  being 
simply  the  modified  and  condensed  subendothelial  stratum  of  the  general 
stroma  into  which  it  blends.  The  connective-tissue  cells  are  here  unusually 
closely  placed,  with  a  corresponding  meagerness  of  the  intercellular  fibrous 
tissue;  minute  interfascicular  clefts  represent  a  system  of  intercommunicating 
lymph-spaces.     Blood-vessels  are  wanting  within  this  part  of  the  iris. 

The  vascular  stroma  layer,  forming  the  hulk  (if  the  iris,  consists  of  a  loose 
connective  tissue  supporting  the  numerous  blood-vessels  and  nerves  which 
occupy  this  stratum,  and  enclosing  interfascicular  lymph-spaces,  as  well  as 


Fig.  32.  Sections  of  the  human  iris :  A,  radial  section;  B,  section  across  the  radii  (Retzius) :  6,  ante- 
rior condensed  zone  and  endothelium;  str,  stroma-layer ;  s,  bundles  of  muscular  libers  composing  the 
sphincter  pupil  he ;  '/,  muscle-cells  constituting  the  dilat  at'  >r  papillae;  r,  pigment  layer  of  iris  belonging 

to  retinal  tract. 


the  groups  of  involuntary  muscle-bundles  which  constitute  the  sphincter  and 
dilatator  pupillae  muscles.  The  radially  disposed  blood-vessels  and  nerve- 
trunks  are  invested  by  local  condensations  of  the  iridial  stroma,  the  peri- 
vascular sheaths  so  formed  representing  the  most  robust  portions  of  the 
stroma  layer,  the  intervening  areas  being  occupied  by  a  comparatively  loos< 
connective-tissue  reticulum. 

flic  variable  and  often  large  amount  of  pigment  contained  within  the  stroma 
layer  in  dark  irides  occur-  a-  irregular  accumulations  of  pigment-cells,  the 
anterior  layer  and  the  pupillary  zone  usually  containing  the  greatesl  number 
of  the  colored  elements.  In  very  dark  irides  the  distribution  of  the  pigment 
i-  very  general,  all  portions  of  the  stroma  layer  being  tilled  with  tin  colored 
particles. 


64      EMBRYOLOGY,    ANATOMY,    AND   HISTOLOGY  OF  EYE. 

The  muscular  tissue  within  the  iris  occurs  within  the  vascular  stroma 
layer,  and  includes  the  well-marked  circular  filters  surrounding  the  inner 
margin  of  the  iris  and  constituting  the  sphincter  pupillce,  and  the  much  less 
evident  and  often  disputed  radially  disposed  fibers  which  form  the  dilatator 
pupilla . 

The  sphincter  pupillce  consists  of  an  annular  hand  of  involuntary  muscle, 
varying  in  width  between  0.7  and  1.0  mm.,  according  to  the  condition  of  con- 
traction, and  from  0.07  to  0.10  mm.  in  thickness.  The  immediate  edge  of  the 
pupil  is  not  formed  by  the  muscular  tissue,  since  the  pigmented  retinal  sheet 
intervenes.  The  muscle  occupies  the  posterior  plane  of  the  stroma  layer, 
behind  the  blood-vessels;  the  bundles  composing  its  outer  border  are  loosely 
disposed,  certain  fibers  often  assuming  an  arched  course  and  fading-  away  in 
radial  offshoots. 

While  the  presence  of  a  sphincter  muscle  is  universally  admitted,  the 
existence  of  a  radially  disposed  dilatator  pupillce  is  by  no  means  undisputed. 
The  demonstration  of  a  distinct  layer  of  radiating  libers  is  very  unsatis- 
factory, so  much  so  that  many  competent  observers  have  concluded  that  such 
fillers  do  not  exist,  and  that  a  true  dilatator  is  absent,  although  the  presence 
of  radially  disposed  delicate  spindle-cells  is  indisputable.  Without  entering 
upon  a  rimme"  of  the  various  views  relating  to  the  nature  of  these  spindle- 
cells  lying  in  close  relation  with  the  posterior  limiting  lamella,  it  may  be 
stated  that  the  most  recent  and  trustworthy  investigations,  both  from  the 
morphological  and  the  physiological  standpoint,  as  those  by  Retzius  and  by 
Langley  and  Anderson,  tend  to  uphold  the  existence  of  dilatator  libers — if  not 
as  a  continuous  sheet,  at  least  as  groups  of  radiating  libers  which  collectively 
constitute  the  dilatator  pupillse,  the  presence  of  which  as  a  distinct  dilatator 
muscle  may  be  regarded  as  definitely  established. 

The  posterior  limiting  lamella  has  likewise  been  the  subject  of  much  dis- 
CUSsion,  due  largely  to  the  uncertain  relations  of  the  layer  of  delicate  spindle- 
cells  occupying  the  iridial  stroma  in  the  immediate  vicinity  of  the  posterior 
pigment.  The  limiting  lamella,  or  basal  membrane,  appear-  as  a  clear  layer 
of  greal  delicacy,  its  maximum  thickness  not  exceeding  0.002  nun.,  which 
closely  adheres  to  the  deeply  pigmented  retinal  zone,  with  which  it  is  often 
inseparably  united.  The  lamella  in  question  may  be  regarded  as  the  atten- 
uated anterior  continuation  of  the  membrane  of  Bruch,  which  extend-  for- 
ward from   the  choroid  over  the  orbiculns  ciliaris  and  ciliary  processes. 

The  pigment  layer  covering  the  posterior  surface  of  the  iris  as  far  as  the 
anterior  margin  of  the  pupil,  although  a  conspicuous  anatomical  portion  of 
tiie  iris,  morphologically  represents  the  anterior  segment  of  the  atrophic  por- 
tion of  the  nervous  tunic — thenars  retinae  iridica.  The  deeply  colored 
layer,  although  ordinarily  appearing  as  a  uniform  stratum  of  pigment- 
particles,  in  reality  consists,  as  seen  in  suitable  preparations,  of  two  distinct 
layers — an  outer,  made  up  of  low  irregular  fusiform  elements,  and  an  inner, 
composed  of  short  polygonal  cells ;  these  layers  arc  continuous  as  the  anterior 
margin  of  the  pupil  and  represent  the  double-layered  anterior  lip  of  the  optic 
cup.  On  approaching  the  ciliary  processes  the  amounl  of  pigrnenl  gradually 
lessens,  firsl  in  the  inner  layer,  mid  subsequently  likewise  in  the  cells  of  the 
outer  layer  ;  finally,  at  the  base  of  the  ciliary  elevations  the  outer  layer  alone 
contains  pigment-particles.  The  inner  cells  are  covered  on  their  \'vct'  surfaces 
l>v  .in  extremely  delicate  cuticular  membrane,  the  limitans  iridis,  which  is 
probably  the  continuation  of  the  cuticle  investing  the  ciliary  portion  of  the 
retinal  sheet. 

fhe  l,li,nil-n  ss<  Is  of  the  iris  include  the   ;i  it  <ii:il  stems   given  off  from  the 


THE  NERVOUS  TUNIC.  65 

anterior  border  of  the  drculus  arteriosus  iridis  major,  situated  around  the 
periphery  of  the  iris,  from  which  the  radially  disposed  arterioles  proceed 
through  the  stroma  layer  as  far  as  the  sphincter  zone.  At  this  point  they 
freely  join  to  form  a  second  anastomotic  circuit,  the  drculus  arteriosus  iridis 
minor,  which  surrounds  the  pupillary  opening  and  gives  off  three  sets  of 
twigs — an  internal,  for  the  supply  of  the  sphincter  muscle,  and  anterior  and 
posterior  groups  to  the  corresponding  layers  of  the  iris  stroma. 

The  capillary  networks  derived  from  these  sources  join  to  form  venous 
radicles  which  take  a  generally  radial  course,  the  veins  uniting  at  acute  angles 
to  form  the  larger  venous  trunks  which  accompany  those  from  the  ciliary 
processes  along  the  inner  border  of  the  ciliary  muscle  and  terminate  by  join- 
ing the  large  vena?  vorticosse.  The  vessels  of  the  iris  are  provided  with  peri- 
vascular lymph-sheaths  within  the  thickened  adventitious  coat. 

The  lymphatics  of  the  iris  are  represented  by  the  interfascicular  tissue- 
spaces  which  constitute  an  intercommunicating  system  of  clefts  within  the 
stroma,  and  at  the  periphery  communicate  with  the  spaces  within  the  ciliary 
body  and   with  the  spaces  of  Fontana. 

The  nerves  of  the  iris  are  derived  from  the  orbiculus  gangliosus,  which, 
as  already  noted,  is  formed  within  the  accommodative  muscle  by  the  branches 
of  the  ciliary  nerves.  The  trunks  destined  for  the  iris  pursue  a  spiral  course 
toward  the  periphery,  and  upon  entering  the  stroma  break  up  into  branches 
which  soon  become  reunited,  after  undergoing  new  combinations,  to  form 
plexuses  within  the  stroma-layer. 

The  nerves  of  the  iris  possess  three  varieties  of  terminal  fibers  :  1,  motor 
endings  within  the  muscular  tissue;  2,  sensory  endings  within  the  superficial 
layers  of  the  stroma;  3,  vaso-motor  endings  within  the  walls  of  the  arteries 
and  capillaries. 

The  presence  of  ganglion  nerve-cells  within  the  iris  is  doubtful.  At 
best,  they  occur  as  small,  sparingly  distributed  elements,  usually  of  irregular 
multipolar  form,  the  nervous  nature  of  which  is  not  beyond  dispute. 

The  Nervous  Tunic. — The  Retina. — Mewed  in  the  light  of  the  more 
modern  conceptions,  the  nervous  coat  can  no  longer  be  regarded  as  of  the  same 
limited  morphological  value  as  the  other  tunics  of  the  eyeball,  but  must  be  con- 
sidered as  a  true  nervous  center,  consisting  of  a  peripherally  situated  portion 
of  the  nervous  system,  and  not  merely  as  a  complex  apparatus  for  the  percep- 
tion of  light-stimulus. 

The  entire  nervous  tunic,  as  representing  the  structures  derived  from  the 
optic  vesicle,  extends  from  the  optic-nerve  entrance  to  the  anterior  pupillary 
margin.  The  modifications  which  take  place  within  this  extensive  tract  suffice 
to  differentiate  two  sharply-defined  segments — the  posterior,  embracing  the 
hindermost  part  of  the  tunic  from  the  optic  entrance  to  the  ora  serrata,  and 
constituting  the  functionating  pars  optica  retime,-  and  the  anterior,  which 
include-  the  atrophic  segment  covering  the  posterior  surface  of  the  ciliary 
body  and  the  iris,  and  hence  appropriately  designated  a-  the  pars  ciliaris  and 
pars  iridica  retinas,  respectively. 

The  visual  portion  of  the  nervous  tunic,  or  retina  proper,  is  closely  ap- 
plied to  the  choroid,  and  extends  from  the  optic  entrance  over  the  posterior 
two-thirds  of  the  eyeball,  ending  abruptly  at  the  ciliary  region  in  a  sinuous 
border,  the  ora  serrata,  where  it  passes  over  into  the  greatly  attenuated  ante- 
rior non-visual  segment  of  the  coat. 

The  retina  during   life   mid  in  health  i-  perfectly  smooth  and  transparent, 
its  blood-vessels  alone  being  distinguishable  :  owing  to  this  transparency  of 
it-  inner  division  the  dark  color  of  the  deeply  pigmented  outer  retinal  layer 

5 


66      EMBRYOLOGY,    ANATOMY,   AND   HISTOLOGY  OF  EYE. 

becomes  an  important  factor  in  absorbing  reflected  light-rays  and  thus  pre- 
venting interference.  During  life  the  retina  possesses  a  purplish-red  tint, 
due  to  the  presence  of  the  so-called  visual  purple  within  certain  ol*  its  ele- 
ments.    After  death  the  retina  s i  becomes  cloudy,  later  appearing  as  a  thin 

gray  veil.  In  thickness  the  retina  decreases  from  aboul  0.4  nun.  at  the  pos- 
terior pole  to  little  over  0.2  mm.  in  the  vicinity  of  the  ora  serrata. 

On  examining  the  eye-ground  (see  also  page  184)  a  conspicuous  circular 
whitish  area  marks  the  position  of  the  optic-nerve  entrance,  lying  a  little  to 
the  nasal  or  inner  side  of  the  posterior  pole  of  the  eyeball.  The  optic  disk, 
optic  jxijiillit.  optic  entrance,  or  porus  opticus,  is  not  quite  circular,  but  is  ellip- 
tical in  form,  its  longest  diameter  being  vertical  and  measuring  about  1.7  mm. 
as  against  1.5  mm.  in  the  horizontal  direction.  The  surface1  of  the  optic  disk 
often  presents  a  distinct  funnel-like  depression,  the  physiological  excavation, 
which  results  from  the  mode  of  development ;  the  excavation  is  usually 
eccentrically  placed,  being  somewhat  toward  the  nasal  side,  where  the  de- 
pression is  steepest  and  occupied  by  the  retinal  vessels.  Remains  of  the  fetal 
hyaloid  artery  may  be  seen  as  a  filament  of  connective  tissue  extending  into 
the  vitreous  body  from  the  optic  disk.  The  white  appearance  of  the  area  is 
due  to  the  scleral  connective  tissue  of  the  lamina  cribrosa  and  the  medullated 
nerve-fibers  shining  through  the  semi-transparent  layer  of  axis-cylinders 
which   occupy   the    disk. 

Critically  examined  through  the  ophthalmoscope,  the  margin  of  the  optic 
nerve  appears  as  a  faint  reddish  outline  ;  next  the  nerve  the  optic  disk  pre- 
sents a  narrow  white  annular  v(\^t\  the  scleral  ring,  which  is  the  vd^c  of  the 
aperture  in  the  fibrous  tunic;  outside  of  the  scleral  border  a  second  circle, 
often  quite  dark,  and  not  infrequently  broken,  appears  as  an  irregular  pig- 
mented zone,  the  choroidal  ring,  the  presence  of  which  is  due  to  the  deeply 
colored  choroid.  The  optic  entrance  corresponds  with  the  "blind  spot/5  the 
explanation  of  which  is  found  in  the  absence  of  the  perceptive  elements 
within    this  area. 

The  macula  Infra,  or  yellow  spot,  is  an  area  of  slightly  oval  form  distin- 
guished  by  it-  peculiar  reddish-brown  tint,  which  is  due  to  the  presence  of 
diffused  pigment-particles.  Th<  macula  corresponds  closely  with  the  axis  of 
the  eyeball,  and  lie-  about  I  mm.  to  the  temporal  side  of  the  centre  of  the 
optic  entrance  and  aboul  0.75  nun.  below  the  horizontal  meridian.  The  limits 
of  the  yellow  spot  are  not  sharply  defined,  since  it  blends  into  the  surround- 
ing retina,  1  nit  it-  form,  when  accurately  studied,  is  usually  almost  circular 
or  Inn  slightly  elliptical,  since  the  oval  form  frequently  described  depends, 
probably,  more  upon  ophthalmoscopic  appearances  than  upon  anatomical 
arrangement.  The  greatest  diameter  of  the  yellow  spot  measures  a  little 
over  "_'  nun.,  and  often  does  no1  quite  correspond  with  the  horizontal  me- 
ridian. 

About  the  center  of  the  macular  area  a  dark-brown,  apparent ly  deeply 
pigmented  spol  mark-  the  position  of  the  fovea  centralis,  a  depression  in 
which  the  retina  becomes  greatly  thinned,  ami  thus  allows  the  deeply-tinted 
subjacenl  pigment  to  become  exceptionally  conspicuous.  The  fovea  corre- 
sponds to  the  point  of  highest  acuity  of  vision,  and  anatomically  is  distin- 
guished  l>v  profound  modifications  in  the  arrangemenl  of  the  histological 
elements  of  i  he  ret  ina. 

'fhi'  size  of  the  fovea  as  usually  given,  between  0.2  and  <*. !  nun.,  is 
to.,  Bmall,  the  recenl  investigations  of  Dimmer,  Golding-Bird,  and  Schafer 
indicating  a  diameter  exceeding  1  nun.,  and,  exceptionally,  approximating 
nearly  -  nun.     Owing  'o  the  absence  of  the  rod-  within  the  fovea,  and  there- 


THE  RETINA. 


67 


fore,  likewise,  of  the  visual  purple,  this  region  possesses  an  inherently  lighter 
tint  than  the  surrounding  retina,  sometimes  appearing  as  a  faintly  tinted  spot 
when  examined  with  the  ophthalmoscope.  The  foveal  reflex  seen  with  the 
mirror  is  due  t<>  the  direction  and  slope  of  the  sides  of  the  depression,  the 
variations  in  these  resulting  in  the  differences  observed  in  the  ophthalmoscopic 
image  (compare  with  page  188). 

The  retina  morphologically  consists  of  two  distinct  layer — an  outer  and 
inner  lamella,  which  correspond  to  the  external  and  the  internal  layers  of  the 
optic  vesicle;  the  outer  lamella  is  represented  by  the  pigment  layer,  while  the 
inner  lamella  includes  the  remaining  retinal  strata.  The  inner  lamella  may 
be  further  subdivided  into  the  neuro-epithelial  and  the  cerebral  layers. 

Sections  of  the  nervous  tunic,  when  perpendicular  to  the  surface  of  the 
membrane,  show  numerous  strata,  the  outermost  of  which  i-  distinguished  by 
its  dark  color,  and  constitutes  the  retinal  pigment;  the  succeeding  layer- 
differ  widely  in  the  amount  of  protoplasmic  elements  which  they  contain, 
and  hence  vary  in  the  intensity  with  which  they  stain,  so  that  the  retina  pre- 
sents lighter  and  darker  strata  when  seen  in  usual  carmine  or  hematoxylin 
preparations.  The  designation  of  the  retinal  layers  (Fig.  33),  as  well  as  their 
morphological  relations  from  without  inward,  is  as  follows  : 


I.  Outer   layer  of    ( 
optic   vesicle,   \ 


II.  Inner   layer    of 

optic   vesicle, 


J  Pi 


grnent  laver. 


Neuro-epithelial  layer. 


Cerebral  layer. 


Retinal  Layers. 

Pigment  layer, 

Layer  of  rods  and  cones, 

Layer  of  bodies  of  visual  cells  i 

or  outer  nuclear  layer. 
External    plexiform    layer    or 

outer  reticular  layer, 
Layer  of  bipolar  cells  or  inner 

nuclear  layer. 
Internal     plexiform     layer    or 

inner  reticular  layer, 
Layer  of  ganglion-cells, 
Layer  of  nerve-fibers,  J 

The  retina  may  be  regarded  as  an  isolated  portion  of  the  central  nerv- 
ous system  immediately  connected  with  a  highly  specialized  perceptive  sense- 
apparatus:  a-  other  parts  of  the  nervous  axis,  so  the  retina  i<  composed 
of  two  varieties  of  elements,  the  nervous  and  the  sustentacular,  the  latter 
being  represented  by  the  modified  neuroglial-  reticulum  and  columns,  the 
fibers  of  Miiller.  The  nervous  elements  constitute  collectively  the  ganglion 
retinas,  and  represent  the  cortical  cells  of  the  brain.  In  principle,  therefore, 
the  retina  consists  of  the  percipient  elements,  closely  applied  to  the  pigment 
layer,  the  ganglion  retinae  and  the  ganglion-cells  with  their  liber.-,  which 
establish  communication   with  the  brain-centers. 

Tin  Pignu  nf  Layer. — The  conspicuous  deeply-colored  stratum  of  pigment- 
cell-  which  forms  the  most  external  layer  of  the  retina  is  the  direct  repre- 
sentative of  the  attenuated  outer  lamella  of  the  optic  vesicle.  It  is  composed 
of  hexagonal  element-,  about  0.015  mm.  in  diameter,  although  subject  t<> 
marked  individual  variation,  smaller  cells  often  surrounding  larger  ones. 
Close  examination  of  the  pigment-cells  in  section  shows  that  the  colored  par- 
ticle- d< t  invade  the  entire  protoplasm,  but  that  an  outer  zone,  containing 

the  nucleus,  is  clear,  the  pigment  being  confined  to  the  middle  and  inner 
rnent-  of  the  cell-.     The  inner  margin  of  the  pigment-cells  is  irregular,  in 
contrast  to  the  smooth  external  border  and  in  close  relation  to  the  outer  ends 
of  the  rod  and  cone  segments  of  the  visual  cell-  |  Fig.  :;i). 


6S      EMBRYOLOGY,  ANATOMY,    AND   HISTOLOGY  OF  EYE. 

The  pigment-cells  are  profoundly  affected  by  light  stimulus,  since  under 
the  influence  of  light  the  colored  particles  migrate  toward  the  rods  and  cones, 
between  which  the  protoplasm  of  the  pigment-cells  extends  (Fig.  35).     After 


Layer  of  pigment-cells. 
Layer  of  rods  and  cone*. 
External  limiting  membrane. 


6.        Outer  nuclear  layer  (layer  of 

/indies  of  visual  eells  I. 


Outer  plexiform  layer  (outer 
reticular  layer  i. 

Inner  nuclear  layer  (layer  of 
bipolar s). 


Inner  plexiform  layer  [inner 
reticular  layer). 


Layer  of  ganglion-cells. 

1.   Layer  of  nervt  -fibers. 

Internal  limiting  membrane. 
Fig.  33.     Diagrammatic  section  of  the  human  retina  (Max  Schultze). 

being  subjected  to  darkness,  on  the  contrary,  the  pigment  particles  arc  retracted 
and  collected  within  the  middle  or  so-called  basal  zone  (Fig.  36).  The  relation 
between  the  pigment-cells  and  the  rods  and  cones  explains  the  variation-  in  the 


;  Pigmented  epithelium  from  human  r<  tina  (Max  Schultze) :  a,  surface  \  i«  -\\  of  cells,  showing 
clear  nuclei  and  intercellular  lines;  b,  cells  seen  in  profile, with  protoplasm  extended  between  per 
cipienl  elements;  c,  cell  Mill  connected  with  rods. 

degree  of  attachment  between  the  colored  and  remaining  portions  of  the  retina  : 
after  exposure  to  lighl  the  intimate  relation  between  the  pigmenl  and  percipient 
elements  renders  the  attachment  between  the  two  originally  distinct  lamellae 


THE   RETINA. 


69 


much  stronger  than  that  existing  after  seclusion  in  darkness,  under  which 
conditions  the  tendency  to  the  natural  separation  of  the  embryologically  dis- 
tinct lamella1  becomes  pronounced,  the  pignienl   then   remaining  attached  to 

the  choroid   when   the  retina  is  removed. 

The  Layer  of  Neuro-epithelium. —  Under  this  heading  are  included  two 

strata,  which  are  usually  described  as  the  layer  of  rods  and  cones  and  the 
external  nuclear  layer,  the  former  being  the  specialized  outer  parts,  and  the 
latter  the  extended   and  attenuated   nucleated    bodies  of  the   visual   cells. 

The  layer  of  rods  and  cones  represents  the  highly  differentiated  outer 
extremities  of  two  forms  of  light-perceptive  elements,  the  rod-  and  the  cone- 
visual  eell.  Under  high  amplification,  as  seen  in  section,  rods  of  the  human 
retina  appear  as  elongated  cylindrical  forms,  about  0.060  mm.  in  length  and 
0.002  mm.  in  thickness,  each  consisting  of  an  outer  and  inner  segment  of  about 


Fig.  35. — Section  of  frog's  retina,  showing  the 
action  of  light  upon  the  pigment-cells  and  upon 
the  rods  and  cones  (v. Genderen-Stort).  The  retina 
had  been  exposed  to  li<_dit  for  some  time  before 
killing;  the  pigment-cells  have  extended  their 
protoplasm  between  the  rods  and  cones  nearly  to 
their  bases  :  the  cones  have  retracted. 


Fig.  36. — Section  of  frog's  retina,  showing  action 
of  darkness  upon  the  pigment-cells  and  upon  the 
rodsand  cones  (v.  Genderen-Stort).  The  retina  had 
been  kepi  in  the  dark  tor  some  hours  before  death, 
in  consequence  of  which  the  pigmenl  is  retracted 
toward  the  nucleated  part  of  the  cells  and  from 
between  the  rods.     The  cones  are  elongated. 


equal  length.  The  outer  segment  possesses  a  uniform  diameter  and  presents 
a  homogeneous  structure,  being  probably  of  the  nature  of  a  cuticular  appen- 
dage. The  external  segments  of  the  rods  are  of  interest  as  being  the  chief, 
if  not  the  sole,  possessor  of  the  visual  purple  or  rhodopsin,  the  color  being 
uniformly  distributed  throughout  this  part  of  the  rod.  The  inner  rod  seg- 
ment, with  slightly  increased  diameter,  is  of  feebly  marked,  ellipsoidal  form, 
and  exhibits  more  or  less  clearly  a  differentiation  into  an  external  faintly 
striated  subdivision,  the  rod-ellipsoid,  and  an  internal  granular  area,  the  li  ntic- 
uhir  body  (  Fig.  '■)!). 

The  body  of  the  rod-visual  cell  lies  within  the  external  nuclear  zone  and 
consists  of  the  attenuated  column  of  protoplasm,  the  rodrfiber,  and  the  more 
conspicuous  nucleus,  the  rod-grcmule.  The  rod-liber  is  directly  continuous 
with  the  inner  part  of  the  rod  at  the  outer  end,  and  extends  into  the  externa] 
plexiform  layer,  within  which  it  ends  iii  a  minute  knob-like  expansion  in  close 
relation  with  the  terminal  arborization-  of  the  bipolar  nerve-cells  (  Fig.  38). 


70     EMBRYOLOGY,   ANATOMY,  AND  HISTOLOGY  OF  EYE. 


The  nuclei  of  the  rod-cells,  which  usually  present  transverse  dark  and 
li*dit  stripes,  are  of  much  greater  thickness  than  the  rod-fiber,  in  consequence  of 
which  the  position  of  the  nucleus  in  each  visual  cell  is  indicated  by  a  marked 
enlargement  consisting  of  the  nucleus  surrounded  by  a  thin  envelope  of  pro- 
toplasm. The  nuclei,  or  rod-granules,  are  situated  at  all  layers,  and  con- 
tribute far  the  larger  share  of  the  deeply  staining  bodies  which  constitute 
the  chief  elements  <>t'  the  outer  granule-layer. 

The  cone-visual  rills  are  made  up  of  the  same  general  divisions  as  the 
associated  rod-elements,  including-  the  specialized   outer  part,  the  cone,  and 


p„;  p,7._.\  rod  and  a  cone  from  the  human  retina 
(Max  Schultze).  The  line,  I,  I,  indicates  the  position 
of  the  external  limiting  membrane;  the  portion  of 
the  figure  unshaded  represents  parts  of  the  \  isual  cells 
Contained  Within  the  outer  nuclear  layer. 


Fig.  38  -Diagram  of  the  neuro-epithelial  ele- 
ments of  the  retina  (Quain-Sehwalbe) :  i,  bipolar 
nerve  cells,  related  t"  the  rod-  and  cone  \  isual 
cells  in  the  outer  plexlform  layer  (5);  6,  the 
nucleated  bodies  "!'  the  rod- and  cone-visual 
cells,  containing  the  rod-  and  cone-granules 
(nuclei)  and  the  rod- and  cone-fibers  these 
parts  of  the  visual  cells  constitute  the  outer 
nuclear  layer) ;  ~.  the  layer  of  rods  and  cones 
which  represents  the  cuter  highly  specialized 
ends  of  the  visual  cells :  each  rod  and  cone  is 
composed  of  ti iter  and  inner  segment. 


the  cone-cell  body  within  the  external  nuclear  layer.  Each  cone  comprises 
.in  outer  ami  an  inner  Begment,  which  differ  both  in  length  and  in  thickness. 
In  contrast  to  the  almost  uniform  diameter  and  length  of  the  two  parte  of 
the  rods,  the  outer  Begmenl  of  the  cone-  i-  shorter  and  ihiuiier  than  the  inner 

segment,  which  i-  conical,  or,  more  accurately  regarded,  ellipsoidal,  and  rnea- 
auree  about  0.006  mm.  where  it  i-  broadest.  The  com-  do  not  extend  a-  far 
into  the  pigmenl   layer  ;i-  the   rods,  terminating  as  blunted  cone-  at  a  point 

al t  opposite  the  middle  of  the  outer  segments  of  the  adjacent  rod-.     The 

cones  do  not  contain  the  visual  purple,  bul  possess  a  somewhat  higher  refrac- 


77//:   RETINA.  71 

tive  index  than  the  r<xl>.  While  the  outer  cone  segment  displays  a  tendency 
to  break  up  into  transverse  disks,  the  inner  segment  exhibits  a  faint  1  < n i ^ i - 
tudinal  striation. 

The  body  of  the  eone-visual  cell  contributes  to  form  the  external  nuclear 
layer,  and  consists  of  the  attenuated  cell-body,  the  cone-fiber,  and  broader 
conspicuous  nucleus,  the  cone-granule.  The  latter,  instead  of  occupying  all 
levels  of  the  nuclear  layer,  as  do  the  nuclei  of  the  rod-cell.-,  are  limited  to 
the  zone  immediately  below  the  external  limiting  membrane,  being  continu- 
ous with  the  bases  of  the  inner  cone-segments  :  additional  characteristics  of 
the  cone-granules  are  their  large  size,  lack  of  cross-stripes,  and  possession  of 
nucleoli.  The  cone-fibers  terminate  within  the  outer  plexiform  layer  in 
expanded  bases  or  feet,  which  stand  in  close  relation  with  the  arborizations 
formed  by  the  terminal  expansions  of  the  cone-bipolars. 

The  entire  number  of  rods  within  the  human  retina  has  been  estimated 
by  Krause  at  130,000,000;  that  of  the  cones,  by  Salzer  at  3,360,000;  the 
number  of  rods,  therefore  in  the  man  is  greatly 
in  excess  of  the  cones  throughout  most  parts  of 
the  retina — in  the  fovea,  however,  the  cones  are 
alone  present.  The  numerical  proportion  between 
the  two  varieties  of  percipient  elements  varies 
in  different  parts  of  the  nervous  tunic,  as  shown 
by  the  variation  in  the  pattern  seen  on  inspecting 
the  surface  of  the  retina  where  the  cones  appear 
as  larger  circles  surrounded   by  areas  of  smaller  FlG  sg.-surface  view  of  the 

rinova  ■  the  eones  are  usnallv  spnaratod  l>v  an  rods  and  cones,  showing  the  rela- 
imgb,     uit    com*    aie     usiuuiN     .-epauiixu    u\      ui       tive  distribution  of  these  elements 

interval  occupied  l>v  three  or  tour  rods.      In  the      (Koitiker):  a,  from  macula  lutea, 

...  n    ,'  '   l      ,i  ■  ,i  where  only  cones  are  present;  b, 

Vicinity  OI   the  macula  the    COnes  increase  SO  that        from    near  macula,  where  only  a 

only  a  single  row  of  rods  intervene,  while  in  the  contVTfrom  r^dwaPyahefweeo 
fovea  the  cones  alone  are  present  (Fig.  39).  p^pondlrateraserrata'where  r"'ls 

The  External  Plexiform,  or  Outer  Reticular 
Layer. — This  stratum  lies  next  the  layer  of  visual  cells  or  neuro-epithelium, 
and  is  the  first  of  the  lamella?  which  constitute  the  cerebral  division  of  the 
retina.  The  layer  appears  as  a  light,  faintly  staining  zone,  about  0.01  mm. 
in  breadth,  the  apparent  granular  structure  of  which,  as  seen  under  moderate 
amplification,  giving  place  to  an  intricate  reticulum  when  examined  with 
higher  magnification.  The  true  nature  of  this  reticulum  was  demonstrated 
only  after  the  introduction  of  the  more  recent  improved  methods  of  staining 
by  the  Golgi  silver  and  methylene-blue  processes:  recent  investigations  have 
shown  that  the  major  part  of  the  plexiform  layer  consists  of  the  delicate 
ramifications  and  intricate  interfacings  of  the  processes  of  the  nerve-cells 
constituting  the  ganglion  retime  and  occupying  the  inner  nuclear  zone,  held 
together  by  the  delicate  framework  of  sustentacular  tissue. 

The  exact  relations  between  the  central  extremities  of  the  cone-  and  rod- 
visua]  cells  ami  the  endings  of  the  nerve-cell  processes  have  long  keen  the 
subject  of  discussion.  The  direct  connection  formerly  supposed  t"  exisl 
between  the  nerve-cells  and  the  visual  cell-   i-  no  longer  tenable    in  the  light 

of  our  i lern  conceptions  regarding  the  ultimate  endings  of  nerve-processes, 

since  the  best  authorities  are  agreed  that  each  nerve-cell  exists  a-  an  inde- 
pendent element,  whose  relation  to  other  cells  is  one  of  contiguity  and  not 
of  anatomical  continuity.  The  nervous  elements  in  close  relation  with  the 
visual  cell-  are  the  ••rod"  and  "cone"  hipolars,  the  nucleated  bodies  of 
which  form  the  conspicuous  "granules"  of  the  inner  nuclear  layer.  I  lie 
peripherally  directed  processes  of  these  nerve-cells  extend  within  the  external 


72     EMBRYOLOGY,  ANATOMY,  AND  HISTOLOGY  OF  EYE. 

plexiform  layer  and  terminate  in  end-arborizations  surrounding  the  inner 
extremities  of  the  visual  cells,  which  also  penetrate  into  the  reticular  zone. 

Additional  nervous  elements,  the  horizontal,  basal,  or  stellate  cells,  are 
found  within  the  external  plexiform  layer ;  they  exist  in  two  forms,  the 
smaller  outer  and  the  larger  inner  cells.  The  former  are  flattened  stellate 
elements  which  lie  within  the  outer  pact  of  the  plexiform  layer,  through 
which  their  Long  axis-cylinder  processes  extend  for  considerable  distances  to 
terminate  in  arborizations  surrounding  the  ends  of  the  visual  cells,  thus 
establishing  indirect  conduction  between  the  elements  lodged  within  the 
plexiform  stratum.  The  larger  inner  horizontal  cells  occupy  the  deeper 
portions  of  the  layer,  some  possessing  descending  processes  which  penetrate 
centrally  as  far  as  the  inner  plexiform  layer,  in  which  they  terminate  in 
arborizations. 

The  Layer  of  Bipolar  Nerve-cells,  or  the  Inner  Nuclear  Layer. — This 
stratum,  as  usually  seen,  closely  resembles  the  outer  nuclear  layer,  being 
apparently  composed  of  large  numbers  of  deeply  staining  granules.  The 
layer  measures  from  0.035  nun.  in  the  vicinity  of  the  optic  disk  to  0.018 
mm.  at  the  ora  serrata. 

The  ganglion-cells  of  the  layer  consist  of  two  chief  varieties — those 
especially  related  to  the  rod-visual  cells,  and  hence  appropriately  called  rod- 
bipolars  ;  and  those  associated  with  the  cone-cells,  known  as  the  cone-bipolars. 
The  particular  purpose  of  the  bipolars  is  to  supply  the  connecting  link  be- 
tween the  visual  cells,  around  which  they  terminate  on  the  one  hand,  and 
the  large  ganglion  elements  giving  off  the  nerve-fibers  to  the  brain,  in  rela- 
tion to  which  their  centrally  directed  processes  expand,  on  the  other.  Refer- 
ence to  Fig.  40  shows  thai  the  arrangement  of  the  processes  of  the  cone- 
bipolars  diners  from  that  of  the  processes  of  the  rod-bipolars :  the  latter 
extend  through  the  entire  thickness  of  the  inner  plexiform  layer  to  the 
bodies  of  the  ganglion-cells,  which  they  enclose  with  their  arborizations. 
The  descending'  processes  of  the  cone-bipolars,  on  the  contrary,  are  limited  to 
the  inner  plexiform  layer,  meeting  with  the  expansions  of  the  ascending 
dendrites  of  the  large  ganglion-cells  at  various  levels,  where  the  interlacing 


Fig.  in.  Elements  of  the  mammalian  retina  after  treatment  with  the  Golgi  silver  method  (Cajal): 
i.  Section  of  the  dog's  retina:  a,  cone-fiber ;  b,  rod-fiber  and  nucleus;  c,  d,  Dipolar  cells  (inner  gran- 
ales)  \\  i t 1 1  vertical  ramification  of  outer  processes  destined  to  receive  the  enlarged  ends  of  rod-fibers  .  i , 
bipolars  with  flattened  ramification  for  ends  of  cone-fibers  :./',  giant  bipolar  with  Battened  ramification  ;  </, 
cell  sending  a  neuron  >>r  nerve-fiber  process  to  the  outer  molecular  layer;  ft,  amacrine  cell  with  diffuse 
arborization  in  inner  molecular  layer:  i,  nerve-fibrils  passing  to  outer  molecular  layer ;  j,  centrifugal 
fibers  passing  from  nerve-fiber  layer  to  inner  molecular  layer ;  m,  nerve-fibril  passing  into  inner  molecu 
lar  layer  :  /»,  ganglionic  cells. 

II.  Horizontal  or   basal  ceils  of  the  outer  molecular  layer  of  the  dog's  retina.     A.  small   cell  with 

dense  arborization;   B,  large  cell,  lying  in  inner  nuclear  layer,  hut  with  its  processes  branching  in  the 
outer  molecular :  a,  its  horizontal  Qeuroo  :  C,  medium  sized  cell  of  the  same  character. 

III.  Cells  from  the-  retina  of  the  ox:  n.  roil  hi[.olars  with  vertical  arborization:  b,  r,  </.  i.  cone- 
bipolare  with  horizontal  ramification  :  /,  </.  bipolars  with  very  extensive  horizontal  ramification  of  enter 
process .  /'.  cells  lying  on  the  outer  surface  of  the  outer  molecular  layer,  ami  ramifying  within  it ;  i,j,m, 
amacrim  thin  the  substance  of  the  inner  molecular  layer. 

IV.  Neurons  or  axis  cylinder  proceE  ■  -  bi  longing  i<  i  horizontal  cells  of  t lie  outer  molecular  layer,  one 
of  them. '.,  ending  in  a  close  ramification  at  a. 

v.  Nervous  elements  connected  with  the  Inner  molecular  layer  of  the  ox's  retina  :  A.,  amacrine  cell, 
with  Long  proceE  ag  In  the  outermosl  Btratum;  It.  large  amacrine  with  thick  processes  ramify- 

ing in  Becond  stratum;  C,  flattened  amacrine  with  long  and  fine  processes  ramifying  mainly  in  the  Brst 
ami  nith  Btrata;  D,  amacrine  with  radiating  tufl  of  fibrils  destined  for  third  stratum;  E,  large  ama- 
crine, with  i  Bfth  stratum;  F,  small  amacrine,  branching  in  second  stratum ;  G,  H, 
amacrines  destined  For  fourth  stratum;  ".  small  ganglion-cell  sending  its  processes  t"  fourth 
stratum  :  b,  a  small  ganglion-cell  with  ramifications  in  three  Btrata;  c,  a  small  ceil  ramifying  ultimately 
t stratum ;  d  a-sized  ganglion-cell  ramifying  in  fourth  si  ratum  ;  < .  giant  cell,  branching  in 
third  stratum  :  /.  a  bistratified  ceil  ramifying  in  second  ami  fourth  Btrata 

VI,    Amacrines  and  ganglion-cells  from  the  dog :  A,  amacrine  with  radiating  tuft;  B,  large  amacrine 

-■  to  third  stratum ;   C  and  <•,  small  amacrines   with   radiations  in  Becond  Btratum:    l''.  Bmall 

tratum;  D,  amacrine  with  diffuse  arborization:    E,  amacrine  belonging  in 

fourth  -tratum:  a,  </.-.</,  small  ganglion-cell  in  various  strata:  b, /,   large  ganglion-cells, 

rig  two  diffet  n  :  /,  bisl rat Ifled  cell. 

vii.    \  from  Me  dog     \.  B,  C,  -mail  amacrinef  ramifying  In  middle  of 

layer;  '■,  </.  </.  ft,  i  q-i  '  irious  Minis  of  arborization ;  /.  a  larger 

cei  i,  similar  in  characti  r  to  </,  but  with  longer  branch  ;  ".  c,  e,  giant  cells  with  thick  branches  ramifj  tng 

In  the  first,  second,  and  third  layers ;  L,  L,  endsot  bipolars  branchini  'Us. 


74     EMBRYOLOGY,   ANATOMY,   AND   HISTOLOGY  OF  EYE. 

arborizations  of  the  two  elements  form  plexuses  <>t'  considerable  extent.  The 
peripheral  arborizations  of  the  cone-bipolars  expand  beneath  the  broad  bases 
of  the  cone-visua]  cells,  forming  horizontally-extended,  terminal  plate-like 
groups  of  ultimate  fibril  he. 

In  addition  to  the  bipolar  cells  the  inner  zone  of  the  inner  nuclear  layer 
contains  nervous  elements  which  were  long  ago  described  by  Miiller  under 
the  name  of  "spongioblasts,"  under  the  impression  that  the  cells  in  question 
were  concerned  in  the  production  of  the  sustentacular  framework  of  the 
layer:  these  elements  arc  now  regarded  as  nervous  in  character,  and,  from 
their  peculiarity  of  seemingly  being  without  axis-cylinder  processes,  have 
been  named  by  Cajal  amaerine  cells.  The  richly  branching  dendrites  of  these 
elements  extend  into  the  inner  plexiform  layer,  in  which  they  end  either  in 
the  expanded  brush-like  arborizations  of  the  diffuse  amacrines,or  in  the  hori- 
zontally extending  arborizations  of  the  stratiform  type.  A  few  oval  nuclei 
within  this  stratum  belong  to  the  long  columnar  supporting  fibers  of  Miiller, 
which  usually  possess  irregular  nucleated  expansions  within  the  zone. 

The  Internal  Plexifoivn,  <</•  Inner  Reticular  Layer. — This  has  been  already 
largely  described  incidentally  to  the  consideration  of  the  bipolar  cells,  since  the 
expansions  of  the  processes  of  these  elements  contribute  largely  to  the  formation 
of  this  layer.  The  inner  plexiform  stratum,  about  0.04  mm.  in  width,  resem- 
bles closely  the  similar  outer  zone,  being  really  an  intricate  reticulum  formed 
by  the  interlacement  of  the  processes  of  nerve-cells  situated  in  the  adjacent 
laminae.  In  addition  to  the  delicate  supporting  framework  of  neuroglia,  the 
principal  constituents  of  the  layer  are  the  descending  processes  of  the  rod- 
and  cone-bipolars  and  the  horizontal  cells  of  the  inner  nuclear  layer,  and  the 
ascending  dendrites  from  the  subjacent  large  ganglion-cells,  augmented  by 
the  processes  derived  from  the  amaerine  cells.  The  supporting  libers  of 
Miiller  are  also  conspicuous  as  vertically  coursing  striae  within  this  stratum. 

The  Layer  of  Gfanglion-cells. — This  layer,  as  indicated  by  the  name,  is 
characterized  by  the  large  nervous  elements  which  form  its  chief  constituent. 
The  conspicuous  ganglion-cells  are  disposed  as  a  closely-placed  single  row 
throughout  the  greater  part  of  the  retina  :  toward  the  macular  region,  how- 
ever, they  become  more  numerous,  and  in  the  immediate  vicinity  of  the  yellow 
spot  are  arranged  as  a  double  layer,  increasing  in  number  within  that  area  until, 
at  the  margin  of  the  fovea,  they  are  superimposed  to  such  an  extent  that  they 
lie  from  six  to  eighl  deep.  Toward  the  ora  serrata,  on  the  contrary,  they 
are  sparingly  distributed,  lying  isolated  and  widely  separated.  The  ganglion- 
cells  resemble  other  typical  nervous  elements  in  the  possession  of  richly 
branched  dendrites,  which  pass  into  the  inner  plexiform  layer  to  end  in 
arborizations  in  relation  with  the  descending  processes  of  the  bipolars,  and 
axis-cylinder  processes,  or  neurites,  which  become  the  axis-cylinders  of  the 

nerve-fibers    < verging  toward    the  optic    entrance,    and    thence,   as    optic 

fiber-,  brainward.  The  detail-  of  the  distribution  of  the  dendrites  within  the 
inner  plexiform  layer  have  supplied  a  basis  for  the  division  of  the  ganglion- 
cells  into  two  groups — those  which  terminate  in  horizontal  ramifications 
limited  to  definite  strata,  and  those  which  terminate  in  diffuse  ramifications 
distributed  to  the  entire  layer.  Additional  distinction-,  depending  on  the 
-i/<    of  the  cells,  as  large,  medium,  and  small,  are  also  recognized. 

Tin  Layer  "f  Nerve-fibers. — This  is  largely  the  direct  contribution  of  the 
preceding  stratum,  since  the  nerve-fibers  composing  this  zone  are  the  extended 
i  nil  lite-  of  the  ganglion-cells.  After  arising  from  the  presiding  cells  the  libers 
alnio-t  at  once  a--iiniea  horizontal  course  and   form  larger  or  -mailer  bundles, 

which,  after  traversing  a  distance  varying  with  t  he  position  of  their  origin,  con- 


THE   SUSTENTACULAB    TISSUE. 


75 


m.l.e. 


verge  to  the  optic  entrance  and  contribute  t«»  the  formation  of  the  visual 
nerve.  The  size  of  the  aerve-fibers  is  generally  small,  bul  a  limited  number 
of  very  large  fibers  also  exist  :  these,  it  is  supposed,  arc  connected  with  gan- 
glion-cells of  exceptional  magnitude. 

In  addition  to  the  centrally  coursing  filters  the  presence  of  fine  periph- 
erally directed,  or  " centrifugal,"  aerve-fibers  lias  been  established.  The 
central  connections  of  such  fibers  are  at  present  uncertain  ;  their  peripheral 
terminations  lie  within  the  inner  plexiform  layer,  and  apparently  have  no 
discoverable  connection  with  the  cells  of  the  ganglion  layer. 

The  bundles  of  nerve-fibers,  while  pursuing  a  general  radial  course  to- 
ward the  optic  entrance,  freely  intermingle  and  form  a  reticulum.  The 
presence  of  the  macula  lutea  disturbs  the  strictly  radial  course  of  the  bundles 
on  the  temporal  side  of  the  optic  disk,  the  space  separating  the  latter  from 
the  yellow  spot  being  traversed  by  from  twenty-five  to  thirty  delicate  fasciculi 
which  possess  an  almost  straight  course  from 
the  macula  to  the  disk;  these  fibers  collec- 
tively constitute  the  macular  bundle  described 
by  Michel.  The  bundles  adjacent  to  the  macu- 
lar group  suffer  deflection  from  the  typical  rad- 
ial course  and  arch  above  and  below  the  macu- 
lar area;  beyond  the  yellow  spot  the  arching 
bundles  possess  the  typical  radial  arrangement. 

The  Sustentacular  Tissue. — The  sus- 
tentacular  tissue,  or  neuroglia,  of  the  retina 
exists  in  two  forms — as  the  conspicuous  rad- 
ial fibers  of  Midler  and  as  the  spider-cells 
(Fig.  41). 

The  Jibe  is  of  Mutter  constitute  a  sustaining 
framework  which  supports  the  nervous  elements 
as  well  as  the  neuro-epithelium,  coming  into  inti- 
mate relations  with  all  parts  of  the  retina.  The 
Mullerian  fibers  are  modified  neuroglia-cells, 
derived  originally  from  the  ectodermal  tissue 
of  the  wall  of  the  neural  tube,  which  extend 
through  almost  the  entire  thickness  of  the 
retina,  reaching  from  the  rods  and  cones,  be- 
tween which  they  contribute  delicate  septa,  to 
the  inner  surface  of  the  nervous  tunic,  where 
their  expanded  bases  unite  to  form  a  seem- 
ingly continuous  sheet,  the  mevibrana  limitans 
interna.  The  fibers  are  slender  nucleated  col- 
umn- which  contribute  lateral  offshoots  at 
various  levels  to  the  several  retinal  layers, 
among  the  elements  of  which  the  processes 
break  up  into  delicate  sustaining  fibrillar  and 
reticula.  The  broadesl  expansion  along  the 
course  of  the  fibers  usually  occupies  the  inner 
nuclear  layer,  and  also  contains  the  oval  nucleus. 
At  a  level  corresponding  to  the  position  of 
the  inner  end-  of  the  rod-  ami  cone-  the  -11-- 
tentacular     fiber-    come    into    apposition    and 

form  an  apparent  fenestrated  partition,  the  membrana  limitans  externa,  from 
the  outer  surface  of  which  minute  septa  projeci  between  the  rods  and  cone-. 


Pig.  ii.— a 


771. 1. 1. 

supporting    fiber 


of 


Miiller  after  staining  byGblgi's  Bilver 
method  (Ramon  y  Cajal  .  The  exten- 
sions of  a  single  fiber  are  shown  in 

relation  to  the  several  retinal  layers: 
l.  layer  of  nerve-fibers;  2,  ganglion- 
cells;  ::.  inner  plexiform  layer:  1.  inner 
nuclear  layer;  5,  outer  plexiform  layer; 
6,  outer  nuclear  layer :  m.  I. »..  m.  I.  i.,  re- 
ly, the  external  ami  internal 
limiting  membrane  ;  b,  nucleus  of  fiber  ; 
./.  process  extending  into  internal 
plexiform  layer. 


76      EMBRYOLOGY,    ANATOMY,   AND   HISTOLOGY  OF  EYE. 

probably  acting  as  an  insulation  <>f  the  individual  percipient  elements.  A.s 
already  noted,  the  inner  end.-  of  the  fibers  of  Mullei  are  greatly  enlarged, 
the  bases  of  the  conspicuous  pyramidal  or  conical  expansions  coming  into 
close contacl  and  producing  the  appearance,  when  treated  with  silver  nitrate, 
of  a  continuous  layer  of  endothelial  plates:  the  bundles  of  retinal  nerve- 
fibers  pass  between  the  diverging  fibers  to  continue  their  radial  course. 
Within  the  fiber  layer  additional  sustentacular  elements  exist  as  the  spider- 
cells,  neurogliar  element-  whose  characteristic  appearance  is  due  to  the  long, 
delicate  processes  which  extend  from  the  cell-body  between  the  aerve-fibers 
in   various  direction-. 

The  Macula  I<Utea. — The  structure  of*  the  retina  undergoes  important 
modifications  within  two  areas — at  the  macula  lutea  and  the  ora  serrata  (Fig. 
12).  (  >n  approaching  the  macula  the  ganglion-cells  become  so  numerous  that 
a  single  layer  do  longer  suffices  for  their  accommodation,  and  consequently  they 
lie  two  deep  ;  within  the  macular  area  the  number  further  increases,  so  that  they 
constitute  a  stratum  which  includes  from  six  to  eight  rows  of  the  nervous  ele- 
ments. On  reaching  the  fovea  centralis,  however,  the  greatly  thickened  gan- 
glion-layer rapidly  decreases  in  thickness  toward  the  center  of  the  depression, 
becoming  scattered  and  do  longer  sufficient  to  constitute  a  complete  stratum, 
until  at  the  bottom  of  the  pit  the  ganglion-cells  are  altogether  absent.  The 
fiber-layer  consequently  suffers  a  corresponding  diminution,  and  disappears  as 
a  distinct  stratum  at  the  point  where  the  ganglion-cells  end.  The  bipolar  cells 
continue  to  the  center  of  the  fovea  as  an  irregular  row  of  small  elements  sup- 
ported within  the  finely  reticular  tissue  which  represents  the  U\mh\  outer  and 
inner  plexiform  layers,  and  fills  the  space  between  the  visual  cells  and  the 
inner  surface  of  the   retina. 

The  most  prominent  stratum  within  the  fovea  is  that  formed  by  the  visual 
cells,  here  composed  entirely  of  the  cone-cells,  which  present  a  depth  about 
three  times  that  of  all  the  more  internally  placed  strata  combined.  The 
cones  gradually  lengthen  on  approaching  the  foveal  center  until,  over  the 
middle  of  the  depression,  they  measure  more  than  double  the  length  of  the 
corresponding  element-  at  the  margins  of  the  pit  :  associated  with  the 
increased  length,  the  cones  become  greatly  attenuated,  appearing  as  long, 
delicate,  -lender  liber-  of  which  the  outer  segment  contributes  by  far  the 
greater  part  (  Fig.  42). 

fhe  external  limiting  membrane  exhibits  a  slight  inward  deflection  over 
the  area  included  within  the  outward  curve  of  the  inner  membrane:  this 
outer  depression,  the  so-called  fovea  externa,  produces,  however,  but  slight 
dipping  inward  of  the  outer  surface  of  the  retina,  as  the  increased  length  of 
the  cones  in  a  measure  compensates  for  the  sinking  of  the  limiting  membrane. 
It  i-  probable  that  the  position  oi  the  external  fovea  corresponds  to  an  asso- 
ciated thickening  of  the  choroidal  tissue.  In  recapitulation,  therefore,  the 
layer-  occupying  the  center  of  the  fovea  are  the  cone  visual  cells,  constituting 
the  layer  of  cone-  ami  the  external  nuclear  layer  ami  the  fused  outer  and 
inner  plexiform  strata,  with  the  included  bipolar  cell-.  The  ganglion-cells 
and  their  derivative  oerve-fibers  are  absent   in   the  center  of  the  fovea. 

The  Ora  Serrata. — -The  extreme  anterior  limit  of  the  visual  portion 
of  the  retina  i-  distinguished  by  :i  sudden  diminution  in  the  thickness  oi  the 
aervous  tunic,  dependent    upon   the  abrupt    termination  of    the    percipient 

element-,  .i-  well    :i-    t  ho-e    layers   <•(  n  icer  i  ie<  I    in    t  he  t  ra  u  -i  n  i  --ion  01    the  light 

stimuli  centrally,  the  layer  oi  retinal  pigment  alone  retaining  its  identity  in 
the  further  extension  of  the  oervous  coat. 

The  characteristic  series  of  aboul  forty  well-marked  dentations  observed 


THE  OPTIC  ENTRANCE. 


77 


in  the  adult  retina  are  closely  associated  with  the  accommodative  function, 
since  in  early  life,  before  accommodation  is  fully  exercised,  the  typical  ser- 
rated border  i>  wanting,  the  termination  of  the  visual  part  of  the  retinal 
sheet  being  marked  by  a  comparatively  smooth  line,  the  "transition  border" 
of  Schon,  beset  with  numerous  minute  projection-  which  afford  attachment 
to  certain  of  the  delicate  zonular  fibers. 

The  sudden  reduction  of  the  retina  depends  especially  upon  the  disap- 
pearance of  the  plexiform  strata,  the  layer  of  rods  and  cone-,  however,  hav- 
ing previously  lost  its  integrity  as  a  distinct  zone.  The  inner  nuclear  layer 
is  continued  farthest,  at  the  anterior  limit  of  the  ora  passing  into  the  single 
layer  of  columnar  elements,  which,  in  conjunction  with  the  pigmented  cells, 
are  continued  over  the  ciliary  zone  and  processes  as  the  pars  ciliaris  retinae. 


m.l.e 


Fig.4'2.— Iiiagrammatif  section  through  the  fovea  centralis  of  the  human  retina  (Golding-Bird  and 
Schafer) :  2,  ganglion-cell  layer;  i.  inner  nuclear  layer;  6,  miter  nuclear  layer,  the  cone-fibers  forming 
the  so-called  external  fibrous  layer  of  Henle;  7,  cones;  m.l.e.,  external  limiting  membrane;  m.l.i.,  in- 
ternal limiting  membrane:  o.g.,  i.g.,  outer  and  inner  granules  (cone-nuclei  and  bipolars). 

The  radial  fibers  of  Miiller  are  especially  well  developed  in  the  vicinity  of 
the  ora  serrata,  being  of  large  size  and  numerous.  So  close  is  tin-  relation 
between  the  sustentacula!'  tissue  and  the  ora  that  it  has  been  suggested  that 
the  supporting  fibers  are  continued  beyond  the  limits  of  the  serrated  border 
and   become  connected   with   the  zonular  fibers. 

The  Optic  Entrance. — The  point  toward  which  the  centrally  directed 
axis-cylinders  of  the  fiber-layer  converge  to  escape  from  the  interior  of  the 
eyeball  and  to  form  the  optic  nerve  is  marked  by  a  light-colored  circulai 
area,  varying  from  1.5  to  1.7  nun.  in  diameter,  the  optic  entrance,  <>/>fic  disk, 
or  optic  papilla.  The  surface  of  the  yellowish-  or  bluish-white  di-!<  i-  broken 
by  the  central  retinal  vessels  which  pierce  the  area  eccentrically,  lying  usually 
somewhat  nearer  the  nasal  side,  and  pass  over  the  margins  of  the  disk  to 
train  the  surrounding  fiber-layer. 

On  examining  a  vertical  section  through  the  optic  entrance    Fig.   13)  it 


78     EMBRYOLOGY,    ANATOMY,    AND   HISTOLOGY  or  EYE. 


will  be  seen  that  the  thick  bundles  of  the  optic  fibers  which  arch  over  the 
margins  of  the  interrupted  retinal  and  choroidal  layers  to  gain  the  disk  pro- 
duce a  slight  elevation,  the  /><i/>i//<i  opUd :  in  consequence  of  the  rapid  arching 
of  the  fibers  the  center  of  the  disk  is  lower  than  the  margin  ;  hence  the  pro- 
duction of  the  so-called  physiological  excavation  (see  also  page  66).  The 
remaining  retinal  layers  terminate  abruptly  in  the  vicinity  of  the  nerve- 
entrance,  a  narrow  maze  of  reticulated  intermediate  tissui'  separating  them 
from  the  arched  bundles  of  nerve-fibers.  The  ganglion-cells  are  the  first  to 
disappear,  while  the  visual  cells  continue  farthest  toward  the  nerve,  the  rod- 
and  cone-fibers  assuming  an  oblique  position. 

The  blood-vessels  of  the  retina  first  appear  on  the  optic  disk  as  they 
emerge  from  the  bundles  of  nerve-fibers,  between  and  parallel  to  which  they 
run  from  the  point  at  which  they  obliquely  enter  the  optic  nerve  some  15  to 
20  mm.  beyond  the  eyeball.  The  retinal  vessels,  of  which  the  arteria  centra/is 
retina  ami  the  accompanying  vein  are  the  chief  trunks,  form  a  closed  system 
which  only   indirectly,  in  the  vicinity   of  the  optic  entrance,  communicates 


i    y  « 

Fir;.  43.— Longitudinal  sect  inn  of  optic  entrance  of  human  eye  (Piersol) :  a,  a,  bundles  of  optic  fibers, 
which  spread  out  over  retina  ata',a';  b,  layers  of  retina ;  c,  choroid;  '/.sclera,  continued  across  optic 
nerve  as  the  lamina  cribrosa  ;  < .  g,  i.  respect  ively  the  pial,  arachnoid,  and  dura!  sheaths  of  optic  nerve, 
enclosing  subdural  and  subarachnoidal  Lymph-spaces ;  I,  I',  retinal  blood-vessels  cut  longitudinally. 

with  the  vessels  distributed  to  the  remaining  coats  of  the  eyeball.  <  hi  attain- 
ing thr  optic  disk  the  central  artery  divides  into  two  main  stems,  the  superior 
and  inferior  pupillary  branches,  directed  almost  vertically  upward  and  down- 
ward. These  subdivide  into  smaller  branches,  the  superior  and  inferior  nasal 
and  temporal  arteries,  which  run  mesiallyand  laterally;  additional  twigs  pass 
directly  outward  ;is  the  superior  and  inferior  macular  arteries  to  supply  the 
important  area  of  the  yellow  spot.  While  the  greater  pari  of  the  macular 
area  is  richly  supplied  with  blood-vessels,  the  fovea  centralis  is  without  them. 
On  examining  the  details  of  the  vascular  distribution  of  the  retina  it  is 
found  thai  the  vessels  of  larger  size  are  contained  within  the  fiber-layer, 
dividing  into  branches  which  do  not  anastomose,  being  "end-arteries.'"  The 
arterioles  break  up  into  rich  capillary  networks,  which  arc  distributed  :is  the 
inner  and  outer  plexuses,  t  he  former  lying  :it  t  he  junction  of  the  fiber-  and  the 
ganglion-layer,  while  the  latter  is  si  tun  ted  within  t  he  inner  nuclear  zone,  being 
especially  destined  for  the  nutrition  of  the  functionally  active  bipolar  nerve- 
cells.      A.8  already  noted,  the    nutrition  of  the    percipient  clement-,  the  visual 

cell-,  i-  mainly  maintained   by   the  dense  vascular  network  of  the  chorio- 

eapillaris   of  the    middle   tunic 


THE  OPTIC  NERVE.  79 

The  lymphatics  of  the  retina  arc  represented  chiefly  by  the  perivascular 
lymph-channels  which  enclose  all  the  veins  and  capillary  blood-vessels,  and 
communicate  with  the  subpial  lymph-space  of  the  optic  nerve.  Between  the 
larger  nerve-bundles,  in  the  vicinity  of  the  optic  papilla,  the  interfascicular 
lymph-clefts  may  be  regarded  as  additional  lymphatic  channels.  The  fad 
that  injections  from  the  subpial  space  pass  between  the  pigment  layer  and  the 
rods  and  cones,  and  again  between  the  inner  surface  of  the  retina  and  the 
adjacent  hyaloid  membrane,  has  been  regarded  as  proof  of  the  existence  of 
lymph-spaces  in  these  situations. 

The  Optic  Nerve. — The  nerve  of  sight,  about  5  cm.  in  length,  is  divisible 
into  three  segments — the  intracranial,  the  intraorbital,  and  the  intraocular. 
The  first  of  these,  the  intracranial,  extends  from  the  optic  commissure  to  the 
optic  foramen,  a  distance  of  about  1  cm.,  and  contains  the  extensions  of  the 
fibers  which  eventually  pass  to  end  in  terminal  arborizations  associated  with 
the  nerve-cells  of  the  cerebral  centers  within  the  pulvinar  of  the  optic 
thalamus,  the  external  geniculate  bodies,  and  the  anterior  corpora  quadri- 
gemina.  The  cortical  areas  connected  with  sight  have  been  definitely  located 
within  the  occipital  lobe,  and  probably  include  the  cunens.  The  intraorbital 
portion  of  the  nerve  presents  a  series  of  slight  curves  which  render  the 
nerve  sigmoid  rather  than   straight. 

Transverse  sections  of  the  optic  nerve  show  it  to  be  composed  of  a  large 
number,  about  eight  hundred,  of  distinct  bundles  of  medullated  fibers  sepa- 
rated from  one  another  by  connective-tissue  septa,  which  are  derived  as 
offshoots  from  the  pial  sheath  investing  the  nerve.  The  entire  number  of 
fibers  contained  within  the  optic  nerve  probably  approaches  a  million,  the 
measurable  fibers  having  been  estimated  at  about  half  that  number  by  Salzer. 
In  its  arrangement  and  composition  the  optic  nerve  resembles  a  gigantic 
funiculus,  the  endoneurium  being  in  the  present  instance  represented  by  the 
penetrating  pial  tissue,  while  the  sheath  itself  corresponds  to  the  perineurium. 
The  nerve-fibers  vary  in  diameter  from  a  delicacy  which  defies  measurement 
to  a  thickness  of  0.01  mm.  In  addition  to  the  connective-tissue  fibers  form- 
ing the  coarser  trabecula  and  septa,  the  sustentacular  tissue  proper  consists  of 
neuroglia  in  which  numerous  spider-cells  are  prominent :  these  elements  are 
supplemented  by  the  deeply-staining  connective-tissue  cells  belonging  to  the 
fibrous  septa. 

The  intraorbital  portion  of  the  optic  nerve  is  invested  by  extensions  of' 
the  brain-membranes  which  form  the  corresponding  dural,  arachnoidal,  and 
]>i<t/  sheaths.  The  general  character  of  these  envelopes  is  similar  to  that  of 
the  meninges,  the  tough  dural  sheath  lying  outside  and  the  pial  sheath  closely 
applied  to  the  nerve,  with  the  arachnoidal  sheath  between.  Between  the 
dural  and  arachnoidal  envelopes  lies  the  subdural  lymph-space  ;  between  the 
arachnoidal  and  the  pial  sheaths,  the  subarachnoidal  space.  <  >n  reaching  the 
fibrous  tunic  of  the  eyeball  all  these  sheaths,  together  with  the  included 
spaces,  terminate  by  blending  with  the  fibro-elastic  stroma  of  the  sclera,  tin 
lymph-spaces  extending  sometimes  for  a  short  distance  between  the  filmm- 
bundles  of  the  outer  tunic. 

The  external  limit  of  the  intraocular  segment  of  the  optic  nerve  is  dis- 
tinguished by  the  position  at  which  the  nerve-fibers  acquire  a  medullary 
sheath  on  emerging  from  the  sclerotic  tissue  which  they  traverse.  I  hi' 
scleral  bundles  separate  to  allow  the  passage  of  the  groups  of  optic  fibers, 
and  interlace  with  one  another  to  form  a  sieve-like  structure,  the  l<tuiiit<< 
cribro8a  (Fig.  4:5).  The  bridging  fibers  arc  contributed  particularly  by 
the  inner  third  of  the  scleral  coat,  but  are  supported  by  additional   bundles 


80     EMBRYOLOGY,  ANATOMY,  AND  HISTOLOGY  OF  EYE. 

of  fibrous  tissue  derived  from  the  connective-tissue  septa  of  the  optic 
nerve. 

The  Crystalline  I^ens. — The  most  important  part  of  the  refractive 
apparatus  of  the  eye  consists  of  a  transparent  lenticular  body,  the  crystalline 
lens,  of  circular  outline  and  biconvex  section,  which  supports  the  pupillary 
margin  of  the  iris  in  front  and  rests  within  a  depression,  the  patellar  fossa,  on 
the  anterior  surface  of  the  vitreous  body  behind  ;  laterally,  the  lens  is  con- 
nected with  the  supporting  fibers  which  collectively  form  the  suspensory  liga- 
ment, or  zone  of  Zinn.  The  lens  substance  consists  of  a  soft,  compressible 
material  of  such  transparency  during  youth  as  to  possess  no  color;  later,  with 
the  advent  of  senile  changes,  it  assumes  a  yellowish  tint  and  slight  opalescence, 
which  first  affects  the  central  portion  of  the  lens  and  gradually  extends  toward 
the  periphery.  Early  in  life  the  lens  substance  is  of  the  same  consistency 
throughout  ;  gradually,  however,  the  central  portion  becomes  harder,  until 
in  advanced  age  considerable  difference  in  condensation  distinguishes  the 
"nucleus"  from  the  cortical  layers.  The  lens  being  non-vascular,  its  nutri- 
tion is  maintained  entirely  by  the  intercellular  transmission  of  nutritive 
fluids:  the  differentiation  of  the  central  and  peripheral  portions  is  due  to 
the  loss  of  water  of  the  favorably  situated  central  portion  of  the  lens.  The 
hardening  which  thus  gradually  takes  place  results  in  loss  of  elasticity  of  the 
lens  substance,  which  change  is  manifested  in  the  defective  accommodation 
which  characterizes  the  eyes  of  persons  after  middle  life.  Owing  to  the 
increased  density  of  the  nucleus,  the  central  portion  of  the  lens  of  advanced 
years  reflects  more  light,  and  the  pupil  consequently  lacks  the  jet  black  of 
young  eyes  and  appears  slightly  dimmed. 

The  soft  lens  substance  is  enclosed  within  a  delicate  elastic  but  strong 
membrane,  the  lens  <-<ij>su/c .-  the  latter  is  resistant  to  reagents,  such  as  alco- 
hol and  acids,  a-  well  as  to  putrefactive  changes.  While  possessed  of 
considerable  strength,  it  is  brittle  and  readily  torn  by  sharp  instruments; 
when  incised  it>  cut  edges  roll  in  a  characteristic  manner,  with  the  outer 
surface  inward.  When  viewed  in  section  that  portion  of  the  enveloping 
membrane  covering  the  front  surface  of  the  lens  is  seen  to  be  distinctly 
thicker  than  the  corresponding  part  behind  :  these  differences  have  given  rise 
to  the  designation  of  these  portions  of  the  membrane  as  the  (interior  and  jms- 
terior  capsule,  although  both  are  but  parts  of  the  same  general  envelope. 

Invested  by  its  capsule,  the  lens  measures  from  9—10  mm.  in  its  trans- 
verse diameter,  being  larger  in  old  and  large  subjects  ;  its  average  thickness 
i-  about  4  nun.,  but  this  dimension  necessarily  varies  with  the  condition  of 
accommodation,  being  somewhat  greater  when  the  eye  i-  fixed  on  near  objects 
and  less  when  accommodated  for  distance.  The  radius  of  curvature  of  the 
-in  face-  also  varies  under  such  changing  conditions,  that  of  the  anterior  sur- 
face, however,  manifesting  greater  change  under  the  extremes  of  accommoda- 
tion than  that  of  the  posterior ;  thus,  while  the  radii  of  the  anterior  surface 
for  distant  and  near  vision  are  respectively  1<>  and  <i  mm.,  those  of  the  pos- 
terior surface  for  the  same  condition-  are  respectively  t>  and  5  mm.  These 
figures  establish  the  fact  that  the  curvature  of  the  anterior  surface  of  the 
lens  is  much  more  affected  in  accommodation  than  that  of  the  posterior, 
which  remains  almost  unchanged.  (See  also  page  135.)  The  length  of 
a  meridian  of  the  lens  measures  about  12  mm.  The  average  weight  of 
the  lens  is  about  0.22  gin.,  and  the  specific  gravity  1121.  The  anterior 
pole  of  the  lens  lie-  about  *_!..'!  nun.  behind  the  cornea  under  passive  con- 
dition- of  accommodation  ;  it-  posterior  pole,  about  15.5  mm.,  in  front  of  the 
macula  lutea.     Critical  examination  ha-  demonstrated  a  slight  outward  devi- 


77/  /•;  <  'it )  -s  r.  \uj  .  v  /•;  l  ENS. 


81 


ation,  of  from  three  to  seven  degrees,  of  the  antero-posterior  Lens-axis  from 
that  of  the  eye  ;  an  additional,  but  smaller,  vertical  deviation  has  also  been 

noted. 

The  structure  of  the  crystalline  lens  can  best  be  appreciated  alter  recall- 
ing what  has  already  been  stated  in  connection  with  its  mode  of  formation. 
The   lens  develops  by  the  elongation  and  modification  of  the  original  ecto- 

dermic  epithelial  cells,  which  become  converted  into  the  lens-fibers,  those 
constituting  the  posterior  wall  of  the  primary  lens-sac  at  first  composing 
the  entire  lens  substance.  Subsequently  additional  layers  of  lens-fibers  arc 
produced  by  the  elongation  and  specializa- 
tion of  the  cells  constituting  the  anterior 
wall  of  the  lens-sac,  which  later  are  known 
as  the  epithelium  of  the  (inferior  capsule. 
The  region  in  which  the  transformation 
of  the  epithelial  cells  into  lens-fibers  takes 
place  corresponds  to  the  equatorial  area, 
and  is  known  as  the  transitional  zone; 
throughout  the  entire  period  of  growth 
this  region  exhibits  the  conversion  of  the 
columnar  epithelial  elements  of  the  anterior 
capsule  into  the  elongated  meridionally 
arranged  lens-fibers.  The  lens  substance, 
therefore,  is  composed  of  modified  epi- 
thelial tissue. 

The  capsule  of  the  lens  is  of  entirely 
different  origin,  since  its  development  is 
due  to  mesodermic  tissues,  and  is  distinct 
from  that  of  the  lens  substance. 

The  capsule  of  the  lens  envelops  the 
lens  substance  on  all  sides  with  a  delicate, 
highly  elastic  membrane,  which,  in  addi- 
tion to  supporting  the  soft  material  con- 
stituting the  bulk  of  the  lens,  affords 
attachment  for  the  fibers  of  the  suspensory 
ligament.  The  capsule  varies  in  thick- 
ness, being  most  robust  in  the  central  area 
of  its  anterior  surface,  where  it  measures  from  0.010  to  0.015  mm.  in  thickness, 
and  thinner  at  the  periphery  ;  its  most  attenuated  part  is  the  central  area  of 
its  posterior  portion,  where  it  measures  from  0.005  to  0.007  mm.  The  capsule 
does  not  exhibit  any  details  of  structure,  and  in  chemical  composition  and 
reactions  differs  from   both   fibrous  and   elastic   tissue. 

The  <j)/t/i</iinn  of  the  lens-capsule  lies  beneath  the  anterior  capsule  alone, 
consisting  of  a  single  layer  of  polyhedral  flattened  cells,  about  0.020  nun.  in 
diameter.  These  elements  morphologically  represent  the  anterior  wall  of  the 
original  lens-sac.  On  approaching  the  margin  of  the  lens  the  cells  of  the 
anterior  capsule  become  more  elongated,  until  finally,  in  the  transition  /one, 
the  epithelial  elements  become  converted  into  the  young  lens-tibers.  As  a 
result  of  these  changes  being  confined  to  a  limited  area,  the  nuclear  zone, 
a  peculiar  spiral  figure,  is  produced  by  the  elongating  cells  and  their  nuclei, 
to  which  the  term   lens-whorl  has  been  applied, 

The  substance  of  the  lens,  constituting  it-  entire  bulk,  is  composed  of 
layers  of  elongated  ami  modified    epithelial    cell-,  the  l< ns-jihcrs,  united  by  an 
extremely   thin    layer  of  cement   substance.     The   individual    lens-fibers,  as 
r, 


Fig.  44.— Meridional  section  through 
human  crystalline  lens  (Babuchin) :  .1, 
anterior,  B,  posterior  surface;  C,  C,  equa- 
torial region;  1,1',  anterior  and  posterior 
capsule;  2,  epithelium  beneath  anterior 
lens-capsule;  3,  lens  substance  composed 
of  fibers;  4,  transition  /.one  where  cells  of 
anterior  epithelium  are  converted  into  lens- 
fibers  ;  a,  nucleus. 


82      EMBRYOLOGY,    ANATOMY,    AND  HISTOLOGY  OF  EYE. 

seen  after  isolation  by  boiling,  maceration  in  dilute  acids,  and  other  methods, 
are  long,  ribbon-like  fibers  which,  on  transverse  view,  present  a  compressed 
hexagonal  outline.  'The  lens-fibers  vary  in  length,  those  forming  the  outer 
layers  of  the  lens  being  distinctly  longer  than  those  found  within  the  nucleus: 
the  former  extend  about  two-thirds  of  the  meridional  distance  from  pole  to 
pole,  while  the  latter  correspond  to  the  length  of  the  lens-axis.  Additional 
differences  in  the  breadth  and  thickness  exist  between  the  fibers  from  the 
periphery  and  central  layer-,  the  dimensions  of  the  more  superficially  situated 
fibers  being  the  greater.  The  fibers  also  exhibit  variations  in  consistency, 
depending  upon  the  relatively  greater  amount  of  tissue-juices  in  the  cortical 
layer-. 

The  lines  of  apposition  of  the  meridionally  arranged  lens-fibers,  joined 
by  the  cement  substance,  produce  definite  figures  of  a  stellate  form,  the  so- 
called  Uns-stars,  which  are  especially  well  marked  in  the  young  or  in  the 
cortical  portion  of  the  older  lens.     (See  page  23.) 

The  growth  of  the  lens  after  its  primary  development  is  due  entirely  to 
the  addition  of  layers  of  new  lens-fibers  derived  exclusively  from  the  cells 
of  the  anterior  epithelium,  the  transformation  being  limited  to  the  equatorial 
/one.  There  is  no  evidence  of  the  direct  multiplication  of  the  lens-fibers 
themselves,  since  these  elements  represent  cells  which  have  become  specialized 
beyond  the  limit-  of  reproduction. 

The  Vitreous  Body. — The  extensive  space  bounded  by  the  crystalline 
lens  and  its  suspensory  ligament  in  front,  and  by  the  retina  behind,  is  filled 
by  the  vitreous  body  or  humor  vitreus.  The  fresh  vitreous  body  appears  as 
a  semi-fluid  mass,  perfectly  transparent,  whose  general  form  resemble-  a 
flattened  sphere,  the  anterior  pole  of  which  is  further  modified  by  the  pres- 
ence of  the  patellar  fossa  for  the  reception  of  the  posterior  surface  of  the 
crystalline  lens.  The  function  of  the  vitreous  is  to  support  the  nervous 
tunic,  rather  than  to  act  as  a  refractive  medium,  since  its  index  of  refraction 
(1.336)  is  almost  identical  with  that  of  the  aqueous  humor,  and  but  slightly 
in  excess  of  that   of  water. 

When  the  fresh  vitreous  i-  thrown  upon  a  filter,  by  far  the  greater  part 
of  the  tissue  passes  through  as  a  watery  fluid,  a  very  slight  proportion  of  the 
entire  structure  remaining  as  morphological  constituents:  this  observation 
establishes  the  fact  that  the  vitreous  body  anatomically  consists  of  two  por- 
tion-, the  supporting  framework  and  the  fluid  tissue.  (  liemically,  the  vitreous 
consists  of  about  98.5  percent,  water,  the  remaining  small  proportion  of  the 
whole,  composed  of  -olid-,  include-  salts,  extractive-,  and  minute  quantities 
of  proteids  and   Qucleo-albumin. 

The  semi-fluid,  gelatinous  vitreous  substance  proper  is  enclosed  within  a 
delicate  envelope,  the  hyaloid  membrane,  from  which  a  delicate  supporting 
reticulum  extends  throughout  the  mass  of  the  vitreous  body.  Without  con- 
sidering in  detail  the  conflicting  views  a-  to  the  structure  of  the  vitreous 
body  which  from  time  to  time  have  been  advanced,  it  may  be  regarded  as 
established  that  the  vitreous  substance  represents  an  embryonal  form  ofcon- 
uective  tissue  modified  by  an  unusual  infiltration  of  water,  so  thai  it-  original 
condition  .-i-  ;i  connective  tissue  bec< •-  masked. 

The  true  nature  of  the  tissue  in  question  can  only  be  determined  by  ex- 
amination of  the  fetal  vitreous  before  the  infiltration  of  the  watery  constit- 
uents has  taken  place.  The  young  tissue  presents  a  delicate  reticulation 
of  connective-tissue  elements,  the  interlacing  fibrillar  forming  a  delicate 
mesh  work  containing  numerous  nucleated  areas,  With  the  advance  of 
development    the  connective-tissue  element-  of   the  vitreous  tissue  become 


THE  SUSPENSORY  APPARATUS  OF  THE  LENS. 


83 


less  and  less  conspicuous,  until  the  adult  tissue  contains  only  suggestions  of 
the  stellate  cells  which  at  one  time  were  prominent  morphological  elements. 
In  suitably  prepared  specimens  a  delicate  supporting  framework  composed 
of  exceedingly  fine  fibrillae  can  be  demonstrated  in  all  parts  of  the  vitreous  : 
at  the  peripheral  parts  of  the  vitreous  local  condensations  exist  which 
in  places,  as  within  the  patellar  fossa,  suffice  to  form  the  external  limiting 
envelope.  Membranous  septa,  concentrically  or  otherwise  disposed,  as 
described  by  various  author.-,  must  be  regarded  as  artificial  products  if  :it 
all  present. 

The  cellular  elements  of  the  adult  vitreous  (Fig.  45)  are  very  meager,  and 
consist  in  a  few  sparingly  distributed  atrophic  connective-tissue  cells;  in 
addition  to  these  elements,  which  belong  to  the  vitreous  tissue,  migratory 
leukocytes,  or  wandering  cells,  also  occur,  especially  immediately  beneath  the 
hyaloid  membrane,  where  they  all  constitute  the  subhyaloid  cells.  These 
cells  are  derived  probably  from  the  blood-vessels  in  the  vicinity  of  the  optic 
entrance  and  the  ora  serrata. 

The  central  portion  of  the  vitreous  is  penetrated  by  a  channel,  the  hyaloid 
canal,  canal  of  Stilling,  canal  of  Cloquet,  or   central  canal,  which   extends 


Fig.  45.— Morphological  elements  found  within  the  vitreous  body  (Schwalbe) :  a,  g,  <t,  cells  without  vac- 
uoles :  b,  c,  e,f,  g,  vacuolated  forms. 

from  the  optic  entrance  toward  the  lens  as  far  as  the  patellar  fossa  :  this  canal 
surrounds  the  atrophic  remains  of  the  fetal  hyaloid  vessels,  which  traversed 
the  vitreous  and  supplied  the  vascular  lens  envelope.  The  channel  begins  as 
a  slight  enlargement,  the  area  Martegiani,  of  a  diameter  equal  to  that  of  the 
optic  disk,  and  end-  in  the  neighborhood  of  the  posterior  lens  surface  in  a 
blind,  not   infrequently  somewhat   dilated,  extremity. 

The  hyaloid  membram  encloses  the  greater  part  of  the  vitreous  body  a-  a 
transparent  envelope  of  great  delicacy  which  closely  adhere-  to  the  retina. 
In  eyes  which  have  been  kepi  for  several  days  in  dilute  alcohol  the  hyaloid 
membrane  can  be  demonstrated  on  the  vitreous  body,  since  in  such  specimens 
it  can  be  separated  from  the  retina  without  mutilation.  The  hyaloid  mem 
brane  i-  wanting  over  that  part  of  the  vitreous  body  which  surrounds  the 
patellar  fossa  :  within  tin-  depression  the  peripheral  condensation  of  the  sup- 
porting tissue  of  the  vitreous  body  alone  constitutes  the  limiting  envelope  of 
the  soft  gelatinous  tissue  within. 

The  Suspensory  Apparatus  of  the  I,ens. —  The  position  of  the  crys- 
talline lens  i-  maintained  by  mean-  of  a  series  of  delicate  bands,  which  pass 
IV the  vicinity  of  the  pra  serrata  over  the  ciliary  processes  to  be  attached 


$4      EMBRYOLOGY,   ANATOMY,    AND   HISTOLOGY  OF  EYE. 


Fig.  16.  -Diagrammatic  view,  from 
posterior  surface,  of  the  insertion  of  the 
zone  of  /.inn  into  the  capsule  of  the 
lens  I  .--tut  i :  l,  posterior  tens  surface  : 
2,  its  equator ;  3,  zonula  ;  i.  5,  the  anterior 
ami  posterior  bands,  inserted  into  the 
corresponding  surfaces  of  the  lens-cap- 
sule;6,  the  interfascicular  spaces,  for- 
merly regarded  a>  the  canal  <>f  Petit. 


to  the  periphery  of  the  lens.     These  fibers  collectively  constitute  the  suspen- 
sory ligament,  or  zone  of  Zinn,  a  structure  of  greal   importance  not  only  for 

the  support  <>t"  thr  leu-,  hut  also  in  effecting  the  changes  in  the  curvature  of 

the  lens  surface  associated  with  accommoda- 
tion |  Figs.  16  and  47). 

Viewed  from  the  posterior  surface,  the 
suspensory  ligament  appears  as  a  delicate 
annular  structure,  about  <i  mm.  in  width, 
which  blends  with  the  periphery  of  the  lens 
on  the  <»ne  hand,  and  with  the  hyaloid  mem- 
brane in  the  vicinity  of  the  ora  -errata  on  the 
other.  When  examined  under  low  magnifi- 
cation  in  meridional  sections  of  the  ciliary 
region  the  suspensory  ligamenl  i-  seen  to  be 
not  a  continuous  membrane,  hut  an  interla- 
cing series  of  delicate  fibers  which  bridgeat 
various  angles  the  space  between  the  lens  and 
the  ciliary  processes. 

The  older  view,  whereby  the  zone  of 
Zinn  was  regarded  as  a  direct  continuation 
of  the  inner  leaflet  of  the  hyaloid  membrane,  formed  by  means  of  the 
cleavage  which  was  supposed  to  take  place  in  the  vicinity  of  the  ora 
serrata,  has  been  now  generally  displaced  by  the  newer  teachings  founded 
upon  the  more  accurate  studies  of  the  developmental  relations  of  the  parts  in 
question  :  according  to  these  observations  the  hyaloid  membrane  does  not 
undergo  cleavage,  hut  continues  closely  applied  to  the  ciliary  body,  over 
which  its  attenuated  extension  stretches  as  far  as  the  processes  before  fading 
away.  The  suspensory  fibers  constituting  the  zone  of  Zinn  originate  as  inde- 
pendent structures,  and  genetically  arc  closely  related  to  the  primitive  vitreous 
body.  Subsequently  the  zonular  libers  become  closely  attached  to  the  ora 
-errata  as  well  as  the  hyaloid  membrane,  and  seemingly  take  partial  origin 
from  these  structures  (Fig.  47). 

The  zonular  fibers  of  the  adult  may  be  divided  into  chief  and  accessory. 
The  chief  zonular  fibers,  which  constitute  the  principal  union  between  the 
leu-  and  the  surrounding  ciliary  body,  may  be  subdivided  into  orbiculo- 
capsular  and  cilio-capsular  according  to  the  position  of  their  attachment  to 
the  ciliary  body,  whether  to  the  orbiculus  eiliaris  or  the  ciliary  processes. 
When  traced  to  their  attachment  to  the  lens  the  libers  are  found  to  vary  in 
the  position  of  their  insertion  into  the  capsule,  some  being  fused  in  advance, 
others  behind  the  lens  periphery:  these  variations  of  attachment  affeel  es- 
pecially the  orbicular  group  of  zonular  fibers,  ami  hence  their  classification 
into  the  orbiculo-antero-capsular  and  the  orbiculo-postero-capsular  libers, 
which  pass  from  the  ciliary  ring  to  the  anterior  and  posterior  surfaces  of  the 
lens-capsule  respectively.  The  liber-  springing  from  the  summits  and  sides 
of  the  ciliary  processes  join  the  lens-capsule  either  on  the  posterior  surface  or 
at  the  periphery,  and  are  hence  designated  the  cilio-postero-capsular  or  the 
cilio-i  quatorial  fibers. 

The  accessory  libers  are  important  additions  to  the  strength  of  the  -us- 
pensory  ligament,  since  they  comprise  numerous  shorter  bands  which  act  as 
brace-  ana  binders  to  the  longer  chief  trabecules.  The  accessor)  fibers  are 
principally  of  two  kinds — those  which  pa—  from  the  ciliary  processes  to  the 
long  zonular  fibres,  and  those  which  extend  from  point  to  point  within  the 
ciliary  zone.      The  lir-t  group  includes  numerous  short  bands  which  unite  the 


THE  AQUEOUS  HUMOR. 


85 


orbiculo-capsular  fibers  with  the  ciliary  processes  and  ciliary  ring;  the  second 
comprises  especially  the  Wands  which  have  the  fixation  of  the  ciliary  processes 
as  their  especial  purpose,  and  constitute  two  principal  groups — the  orbiculo- 
cfUiary  and  the  iniracUiary  fibers. 

The  /one  of  Zinn,  or  the  suspensory  ligament,  i>  evidently  not  a  contin- 
uous membrane,  but  a  .-erics  of  interlacing  hands  between  which  numerous 
apertures  and  clefts  occur.  The  insertion  of  the  zonular  fibers  into  the  lens 
is  so  regular  and  the  fibers  hound  together  so  intimately  that  it  is  possible  to 
inject  air  between  the  constituents  of  the  zone,  so  that  the  lens  is  surrounded 


Fir,.  -47.— Meridional  section  through  ciliary  region,  including  part  of  the  lens  (Fuchs):  C,  cornea; 
pe,pc,  pigmented  and  non-pigmented  cells  of  the  pars  ciliaris  retina-:  L,  lens ;  M,  ciliary  muscle;  r,  h< 
radiating,  .'/»,  its  circular  fibers:  d,  anterior  ciliary  artery;  s,  canal  of  Schlemm;  z,  origin  of  ciliary 
muscle;  c,/,anterior  surface  of  iris;  break  at  er;  gp,  sphincter  pupillae;  /».  edge  of  pupil;  /',  ciliary 
process;  A,  pigment  lining  in-,  partly  separated  at  v;  ".blood-vessel;  z,  zone  of  Zinn:  zXtzx,  fibers  of 
suspensory  ligament,  enclosing  spaces  i,  i;  k,  lens-capsule. 

by  an  annular  scries  of  headed  dilatations.  This  appearance  was  long  ac- 
cepted as  demonstrating  the  existence  of  a  delicate  channel,  the  en  mil  <<j 
/'(/if,  encircling  the  periphery  of  the  lens.  With  the  more  accurate  under- 
standing of  the  composition  of  the  supporting  apparatus  of  the  lens  the  exist- 
ence of  the  canal  of  Petit  has  become  doubtful,  and  in  the  former  sense  of  a 
closed  annular  channel  altogether  denied  by  mosl  authorities.  The  inter- 
communicating space-  between  the  zonular  fibers  establishes  a  passageway  for 
fluids  from  the  posterior  chamber  into  the  vitreous  chamber. 

The  Aqueous  Humor. — The  aqueous  humor,  the  transparent  lymph 

derived    from    the    blood-vessels   surrounding   the   spaces    in  which    it    i-   con- 


86       EMBRYOLOGY,   ANATOMY,   AND  HISTOLOGY  OF  EYE. 

tained,  fills  both  the  anterior  and  posterior  chamber,  as  well  as  the  extensions 
of  the  latter  represented  by  the  intrazonular  spaces. 

The  production  of  the  aqueous  humor  takes  place  in  the  posterior  cham- 
ber, and  is  effected  chiefly  by  the  blood-vessels  of  the  ciliary  processes,  and 
possibly  also  by  those  of  the  vascular  ridges  which  extend  to  the  posterior 
surface  of  the  iris.  The  recesses  between  the  ciliary  processes  have  been 
regarded  by  some  as  representing  special  secreting  tissue,  the  so-called  "  ciliary 
glands,"  but  there  is  little  evidence  to  sustain  the  view  that  in  the  secretion 
of  the  aqueous  humor  the  entire  ciliary  processes  do  not  take  part. 

The  quantity  of  aqueous  humor  usually  presenl  is  about  '11')  cub.  mm.,  its 
weight  about  0.275  gm.,  and  its  specific  gravity  L.0053.  Its  index  of  refrac- 
tion is  1.337,  but  slightly  in  excess  of  that  of  water  (1.334),  and  nearly  that 
of  the  cornea  (1.360):  compared  with  the  refracting  index  of  the  vitreous 
(1.336),  it  is  found  to  be  almost  identical.  The  quantity  of  aqueous  humor 
present  is  an  important  factor  in  determining  the  intraocular  tension,  and 
hence  the  maintenance  of  the  free  escape  of  the  lymph,  as  provided  for  in  the 
spaces  of  Fontana  and  the  canal  of  Sehlemm,  is  of  great  importance.  In  it.> 
chemical  composition  the  aqueous  humor  consists  chiefly  of  water  :  in  addition 
to  the  98.6  parts  of  this  constituent,  small  quantities  of  solids,  extractives, 
and  proteids  are  present.  The  aqueous  humor  possesses  the  property  of 
absorbing  certain  organic  substances  with  which  it  comes  in  contact,  such  as 
Mood  and  the  lens  substance;  it  also  possesses  solvent  properties  to  an  extra- 
ordinary degree  for  many  drugs.  With  the  exception  of  a  few  migratory 
leukocytes,  the  aqueous  humor  is  without   morphological  elements. 

Trie  Blood-vessels  of  the  Eyeball. — The  terminal  arrangement  and 
distribution  of  the  blood-vessels  of  the  various  parts  of  the  eye  have  already 
been  described  in  connection  with  the  consideration  of  the  various  structures: 
a  brief  description  of  the  general  arrangement  of  the  vessels  supplying  the 
visual  organ  is  here  added. 

All  the  arteries  supplying  the  eyeball  are  derived  from  the  ophthalmic 
artery  as  two  sets  of  branches,  the  retinal  and  the  ciliary.  These  form  two 
separate  systems,  which  communicate  only  in  the  vicinity  of  the  optic  en- 
trance  by   means  of  minute  anastomotic   twigs. 

The  retinal  system  is  based  upon  the  distribution  of  the  central  artery  <>/ 
flu  retina,  a  small  branch  which  arises  from  the  ophthalmic  close  to  the  optic 
foramen,  usually  in  common  with  the  internal  ciliary,  seldom  as  an  inde- 
pendent trunk.  On  gaining  the  interior  of  the  eyeball  th<  central  stem 
divides  into  the  retinal  arteries,  and  during  the  fetal  stages  continues,  forward 
to  the  posterior  lens  surface  a-  the  hyaloid  artery,  a  vessel  which  later  dis- 
appears. 

The  ciliary  system  supplies  the  remaining  parts  of  the  eyeball,  and  con- 
sists of  two  sets  of  vessels,  the  posterior  and  anterior  ciliary  arteries.  The 
posterior  arise  by  two  chief  trunks,  an  inner  and  an  outer,  which  are  given 
off  from  the  ophthalmic  artery  while  it  lies  below  the  optic  nerve.  These 
stems  each  divide  into  from  four  to  ten  branches,  which  surround  the  optic 
nerve,  and  on  reaching  the  eyeball  pierce  the  sclerotic  coat  in  the  vicinity  of 
the  point  of  entrance  of  the  nerve.  The  posterior  ciliary  arteries  then  form 
two  group — the  short,  which  pass  at  once  to  the  choroidal  tract  to  take  pari 
in  forming  the  rich  vascular  network  of  the  middle  tunic;  and  the  long, 
which     pass    forward,    one   mi    each    side   of    the   eye,  between    the   sclera    and 

choroid,  to  the  ciliary  region,  where, after  giving  direct  branches  to  the  ciliary 
muscle,  they  join  the  anterior  ciliary  arteries  to  form  the  vascular  plexuses 

from    which    the   adjacent    parts   are   supplied. 


THE  LYMPHATICS  OF  THE  EYEBALL.  87 

The  anterior  eiliary  arteries,  usually  from  -i.\  to  eight  in  number,  arc 
derived  from  the  muscular  and  lachrymal  branches  of  the  ophthalmic  :  in  the 
vicinity  of  the  corneal  margin  they  penetrate  the  scleral  coat,  and  finally  join 
the  long  posterior  ciliary  vessels  to  form  the  circulus  arteriosus  iridis  major. 
Before  passing-  through  the  sclerotic  these  arteries  give  off  anterior  and  pos- 
terior branches  which  supply  the  conjunctiva  and  anterior  |>art~  of  the  fibrous 
tunic.  After  piercing  the  sclera  twigs  are  given  off  which  pa—  to  the  ciliary 
muscle,  as  well  as  other-  which  as  recurrent  branches,  together  with  similar 
branches  from  the  long  posterior  ciliary  arteries,  anastomose  with  the  choroidal 
vessels  derived  from  the  short  ciliary  trunk-.  An  important  anastomotic 
communication  is  thus  established  between  the  blood-vessels  supplying  the 
choroid   proper  and   those  distributed  to  the  ciliary   region. 

The  branches  of  the  long  posterior  and  the  anterior  ciliary  arteries  inos- 
culate within  the  ciliary  region  to  form  in  the  vicinity  of  the  root  of  the  iris 
an  arterial  circuit,  the  circuit's  arteriosus  iridis  major,  from  which  vessel-  are 
given  off  to  the  ciliary  processes  and  the  iris,  as  well  as  recurrent  anastomotic 
twigs  to  the  choroid. 

The  venous  fruit/:*  draining  the  eyeball  in  general  correspond  in  their 
arrangement  to  that  of  the  arteries,  the  chief  groups  being  the  retinal,  posterior, 
and  anterior  ciliary  veins.  The  retinal  veins  receive  the  blood  from  the 
closed  retinal  system  and  follow  closely  the  corresponding  arteries.  The 
posterior  ciliary  veins,  or,  more  familiarly,  the  vena  vorticosa?,  collect  the 
blood  from  the  iris,  the  ciliary  processes,  part  of  the  ciliary  muscle,  the 
orbiculus  ciliaris,  and  the  choroid,  and  pierce  the  sclerotic  coat  within  the 
equatorial  region  as  four  large  trunks,  which  converge  at  points  about  equi- 
distant from  one  another  :  after  penetrating  the  fibrous  tunic  they  additionally 
receive  the  episcleral  veins.  The  anterior  ciliary  veins  drain  a  much  more 
limited  area  than  that  supplied  by  the  corresponding  arteries,  since  within 
the  eyeball  they  receive  only  the  blood  returned  from  the  ciliary  muscle, 
taking  up  the  small  radicles  communicating  with  Schlemm's  canal  :  after 
emerging  from  the  sclerotic  coat  the  anterior  ciliary  veins  receive  a-  tributa- 
ries the  episcleral  and  the  anterior  conjunctival   vessels. 

The  Lymphatics  of  the  Eyeball. — The  lymph-channels  of  the  eye- 
ball comprise  two  systems,  the  anterior  and  the  post*  rim-. 

The  anterior  lymph-tract  embraces  i  1  )  the  chambers  occupied  by  the  mosl 
important  intraocular  collection  of  lymph,  the  aqueous  humor,  together  with 
the  system  of -pace-  by  which  this  fluid  is  normally  carried  off,  a-  represented 
by  the  -pace-  of  Fontana  and  canal  of  Schlemm  :  and  ( '1)  the  elaborate  system 
of  juice-channels  within  the  cornea  and  adjacent  part  of  the  sclera.  The 
posterior  lymph-tract  includes  two  separate  systems,  that  of  the  choroid  and 
of  the  retina.  The  lymphatic  fluid  of  the  choroid  is  collected  within  the 
perichoroidal  lymph-space,  between  the  choroid  and  the  sclera,  from  which 
cleft  the  lymph  escapes  chiefly  into  the  -pace  of  Tenon,  or  episcleral  lymph- 
space,  by  means  of  the  perivascular  lymphatic  canals  accompanying  the  venae 
vorticose  :  additional  perivascular  channels  may  also  exist  in  connection  with 
the  posterior  ciliary  arteries.  The  accumulated  lymph  within  the  space  of 
Tenon  find-  its  way  into  the  large  intracranial  lymph-spaces,  probably  by 
mean- of  tin-  supravaginal  space  which  surrounds  the  exterior  of'  the  optic 
nerve.  The  retinal  system  of  lymphatics  is  represented  bythe  perivascular 
lymph-sheaths  surrounding  the  retinal  vessels,  a-  well  a-  by  the  hyaloid 
canal  within  the  vitreous.  These  channel-  communicate  with  the  lymph- 
cleft-  within  the  optic  nerve,  which  are  connected  with  the  greal  intracranial 
lymph-spaces  by  mean-  of  the  subarachnoidal  spaces  of  the  optic  nerve. 


GENERAL    PHYSIOLOGY   OF  VISION. 

By  ALBERT  P.  BRUBAKER,  M.  D., 

OF    PHILADELPHIA. 


Introduction. — The  visual  apparatus  in  its  entirety  constitutes  a 
mechanism  the  excitation  of  which  gives  rise  (1)  to  the  sensation  of  light  and 
its  different  qualities — colors;  (2)  to  the  perception  of  light  and  color  under 
the  form  of  pictures  of  external  objects;  (3)  to  the  production  of  muscular 
sensations  by  which  we  judge  of  the  size,  distance,  and  direction  of  objects. 
The  specific  physiological  stimulus  to  the  terminal  apparatus  of  the  optic 
nerve  is  the  impact  of  the  undulations  of  a  perfectly  elastic  medium,  the 
ether.  The  transfer  of  the  energy  of  the  ether-vibrations  into  that  form  of 
energy  known  as  a  nerve-impulse  takes  place  in  the  pigment  of  the  neuro- 
epithelial layer  of  the  retina.  The  nerve-impulses  so  generated  are  trans- 
mitted by  the  fibers  of  the  optic  nerve  to  the  cells  of  the  cerebral  cortex,  in 
which  some  molecular  process  takes  place  out  of  which  the  mind  forms  the 
sensations  of  light  and  color.  In  general,  it  may  be  said  that,  at  least  for 
the  same  color,  the  intensity  of  the  objective  vibrations  determines  the  inten- 
sity of  the  sensations. 

The  optic  nerve,  obeying  the  same  general  laws  of  nerve-stimulation, 
reacts  also  to  the  electric  current  and  to  mechanical  agencies,  as  shown  by 
Hashes  of  light  with   varying   shades  of  color. 

The  formation  of  images  on  the  percipient  elements  of  the  retina,  which 
by  their  forms  and  associated  colors  give  rise  to  the  perception  of  objects,  is 
made  possible  by  the  introduction  of  a  complex  refracting  apparatus  consist- 
ing of  the  cornea,  aqueous  humor,  crystalline  lens,  and  vitreous  humor. 
Without  these  agencies  ether-vibrations  would  only  give  rise  to  a  sensation 
of  diffused  luminosity.  The  movements  of  the  eyeball  occasioned  by  the 
contractions  of  the  ocular  muscles  are  attended  by  muscular  sensations,  out 
of  which  the  mind  draws  its  conclusions  as  to  the  size,  distance,  and  direction 
of  objects. 

The  Bye  a  laving  Camera. — En  its  construction,  in  the  arrangement 
of  its  various  parts,  ami  in  their  mode  of  action  the  eve  may  be  com- 
pared to  a  camera  obscura.  Though  the  comparison  may  not  be  absolutely 
exact,  yet  in  a  general  way  it  is  true  that  there  are  many  striking  points  of 
similarity  between  them — e.g.  the  sclera  and  choroid  maybe  compared  to 
the  walls  of  the  camera  ;  the  combined  refractive  media  to  the  single  lens,  the 
action  of  which  results  in  the  focussing  of  the  light-rays ;  the  retina  to  the  sen- 
sitive plate  receiving  the  image  formed  ;it  the  focal  point;  the  iris  to  the 
diaphragm  lor  the  regulation  of  the  amount  of  lighl  to  he  admitted,  and  for 
the  partial  exclusion  of  those  marginal  rays  which  give  rise  to  spherical  aber- 
ration; the  ciliary  muscle  to  the  adjusting  screw,  by  means  of  which  the 
image  is  broughl  t"  m  focus  on  the  sensitive  plate,  notwithstanding  the  varying 
distances  of  the  objeel  from   the  lens.     The  presence  of  the  visual  j>nr/)/<    in 


THE  DIOPTRIC  APPARATUS.  89 

the  rods  of  the  retina  capable  of  being  altered  by  light  makes  the  comparison 
still  more  striking. 

The  Retinal  Image.  -The  existence  of  an  image  on  the  retina  can  be 
readily  seen  in  the  excised  eye  of  an  albino  rabbit,  the  coats  of  which  are 
quite  transparent  from  the  absence  <>t'  pigment.  Its  presence  in  the  human 
eye  can  be  demonstrated  with  the  ophthalmoscope.  It  is  this  image,  com- 
posed of  focal  points  of  luminous  rays,  which  is  the  basis  of  our  sight- 
perceptions,  and  which  stimulates  the  rods  and  cones,  and  out  of  •  which  the 
mind  constructs  space-relations  of  external  objects.  In  only  two  essential 
respects  does  the  image  on  the  retina  differ  from  the  object,  aside  from  the 
fact  that  the  object  has  usually  three,  the  image  only  two,  dimensions — viz. 
in  size  and  relative  arrangement  of  its  parts.  Whatever  the  distance,  the 
image  is  generally  smaller  than  the  object:  it  is  also  reversed,  the  upper 
part  of  the  object  becoming  the  lower  part  of  the  image,  and  the  right  side 
of  the  object  the  left  of  the  image,  and  the  reverse. 

The  Dioptric  Apparatus. — The  media  by  which  rays  of  light  entering 
the  eye  are  refracted  and  brought  to  a  focus  with  the  production  of  an  image 
consist  of  the  cornea,  aqueous  humor,  lens,  and  vitreous  body.  As  the  two 
surfaees  of  the  cornea  are  practically  parallel,  and  as  the  index  of  refraction 
of  the  aqueous  humor  is  the  same  as  that  of  the  cornea,  they  may  be  regarded 
as  but  one  medium.  The  refracting  surfaees  may  therefore  be  reduced  to 
the  anterior  surface  of  the  cornea,  the  anterior  surface  of  the  lens,  and  the 
posterior  surface  of  the  lens. 

Rays  of  light  emanating  from  one  point — that  is,  Jwmocentric  ray* — 
entering  the  eye  must  traverse  successively  the  different  refractive  media. 
In  their  passage  from  one  to  the  other  they  undergo  at  their  surfaees  changes 
in  direction  before  they  are  converged  to  a  focal  point.  In  order  to  mathe- 
matically follow  the  rays  in  all  their  deviations  through  the  media,  to 
determine  their  focal  point,  and  to  construct  the  image,  a  knowledge  of  the 
form  of  the  refracting  surfaces,  the  refractive  index  of  the  different  media, 
and  the  distance  of  the  surfaces  from  each  other,  must  be  obtained. 

The  following  constants  are  now  accepted:  The  radii  of  curvature  of 
that  portion  of  each  refracting  surface  used  for  distinct  vision  are  for  the 
cornea  7.829  mm.,  for  the  anterior  and  posterior  surfaces  of  the  lens  10  and 
6  mm.,  respectively.  The  indices  of  refraction  of  the  different  media  are  as 
follows:  cornea  and  aqueous  humor,  1.3365;  lens,  1.4871;  vitreous  body, 
1.3365.  The  distance  from  the  vertex  of  the  cornea  to  the  lens  is  3.6  mm. ; 
the  thickness  of  the  lens,  3.6  mm. ;  the  distance  from  the  posterior  surface  "I 
the  lens  to  the  retina,   15  mm. 

Homocentric  rays  of  light  entering  the  eye  pass  from  air  with  a  refractive 
index  of  1.00025  into  the  cornea  with  an  index  of  1.3365.  In  passing 
from  the  rarer  into  the  denser  medium  they  undergo  refraction  and  are 
rendered  somewhat  convergent.  The  extent  of  this  firsl  refraction  and  con- 
vergence is  sufficiently  great  to  bring  parallel  rays,  if  continued,  to  a  focus 
about  10  mm.  behind  the  situation  of  the  retina.  On  entering  the  leu-  they 
are  for  the  same  reason  again  refracted  and  converged,  and  if  continued 
would  come  to  a  focus  about  6.5  mm.  behind  the  retina.  ( )u  passing  into  the 
vitreous  body  they  are  again  converged  to  an  extent  sufficient  t"  focalize 
them   on    the   retina   f  fig.  4<S). 

While  it  is  possible  thus  to  geometrically  follow  the  rays  through  these 
media  bv  mean-  of  the  above-mentioned  factors,  the  procedure  is  attended 
with  many  difficulties.  Moreover,  as  the  relation-  all  change  when  rays 
enter  the  eye  from  objects  situated   progressively  nearer  the  eye,  a  separate 


90 


GENERAL    PHYSIOLOGY  OF  VTSTOX. 


calculation  is  necessitated  for  each  distance  for  the  determination  of  the  size 
of  the  image. 

A  method  by  which  these  difficulties  are  much  reduced  was  suggested  by 
(Jauss  and  developed  by  Listing.  It  was  demonstrated  by  Gauss  that  in 
every  complicated  system  of  refracting  media  separated  by  spherical  centered 
surfaces  there  may  be  assumed  certain  ideal  or  cardinal  points,  to  which  the 
system  may  be  reduced,  and  which,  if  their  relative  position  and  properties 
be  known,  permit  of*  the  determination,  either  by  calculation  or  geometrical 
construction,  of  the  path  of  the  refracted  ray,  and  the  position  and  size  of 
the   image   in  the   last   medium   of  the  object   in   the   first. 

Every  dioptric  system  can  be  replaced,  as  (Jauss  showed,  by  a  single 
system  composed  of  six  cardinal   points  and  six  planes  perpendicular  to  the 


Fig.  48.— Refraction  of  homoeentric  rays  and  the  formation  of  images  on  the  retina. 


common  axis — e.g.  two  focal  points,  two  principal  points,  two  nodal  points, 
two   focal    planes,   two   principal   planes,  and   two   nodal   planes. 

Properties  of  the  Cardinal  Points.1— The  first  focal  point,  I-\  in 
Fig.  19,  ha-  the  property  that  every  ray  which  before  refraction  passes  through 
it  after  refraction  is  parallel  to  the  axis. 

The  second  focal  point,  F2,  has  the  property  that  every  ray  which  before 
refraction    is   parallel    to  the  axis   passes  after  refraction   through   it. 

The  second  principal  point,  II.,,  is  the  image  of  the  first,  II{  :  that  is,  rays  in 
the  first  medium  which  go  through  the  first  principal  point  pass  after  the  last 
refraction  through  the  second.  Planes  at  right  angles  to  the  axis  at  these 
point-  are  principal  planes.  The  second  principal  plane  is  the  image  of  the 
first.  Every  point  in  the  first  principal  plane  has  its  image  after  refraction 
at  a  corresponding  point  in  the  second  principal  plane  at  the  same  distance 
from  the  axis  and  on  the  same  side. 

The  second  nodal  //<>iitf,  \  ,,  is  the  image  of  the  first,  .V,  :  a  ray  which  in 
the   firsl    medium    is   directed    to  the  first    nodal  point    passes  after   refraction 

'In gh    the   second    lal    point,  and    the   direction-   of  the    rays  before   and 

after  refraction  an'  parallel  to  each  other.  In  Fig.  I!»  let  .1  />'  represent  the 
axis.  fhe  distance  of  the  first  focal  point,  /•',,  from  the  first  principal  plane, 
//,.  i-  the  anterior  focal  distance.  The  distance  of  the  posterior  focal  point, 
A  ,  from  the  second  principal  plane,  //,.  is  the  posterior  focal  distance.  The 
distance  of  the  first  nodal  point.  A',,  from  the  first  focal  point  is  equal  to  the 
9econd  focal  distance.  The  distance  of  the  second  nodal  point,  .Y_„  from 
the   posterior  focal  point   is  equal   to  the  anterior  focal   distance.     It   is  evi- 

1  For  additional  consideration  of  iliis  subject  sec  pajjes  lo'.i  ami  !•_!.">. 


properties  or  the  cardinal  points. 


91 


dent,  therefore,  that  the  distance  of  the  corresponding  principal  and  nodal 
points  from  cadi  other  is  equal  to  the  differences  between  the  two  focal  dis- 
tances. Also  the  distance  of  the  two  principal  points  from  each  other  is 
equal  to  the  distance  of  the  two  nodal  points  from  each  other.      Finally,  the 


A 


?, 


#, 


'  hA  V2 


/■:■ 


Fjq,  49.— Diagram  showing  the  position  and  relation  of  the  cardinal  points. 

focal  distances  are  proportional  to  the  refractive  indices  of  the  first  and  last 
media.  Planes  passing  through  the  focal  points  vertically  to  the  axis  are 
known  as  focal  planes. 

From  these  properties  of  the  cardinal  points  the  position  of  an  image  in 


Fig.  50—  Diagram  to  find  the  image  in  last  medium  of  a  luminous  point  in  the  first. 

the  last  medium  of  a  luminous  point  in  the  first  may  be  determined,  and  the 
course  of  a  refracted  ray  in  the  last  medium  be  constructed  if  its  direction 
in  the  first  be  given  according  to  the  following  rules : 

1.  To  find  the  image  in  the  last  medium  of  a  luminous  point  in  the  first : 
Let  A  (Fig.  50)  be  this  given  point.  Draw  A  B  parallel  to  the  axis  until  it  meets  the 
second  principal  plane  in  B ;  then  B  F2  will  be  this  ray  after  refraction.  Draw  a  second 
ray  from  A  to  the  first  nodal  point;  then  draw  another  ray,  D  E.  from  the  second  nodal 
point  parallel  to  A  C.  This  will  be  the  refracted  ray  in  the  last  medium.  Where  the 
two  refracted  ravs,  BF2  and  D  E,  intersect,  the  image  of  A  will  be  =  Av* 


If,   If. 


Fig.  51.— Diagram  to  find  the  refracted  ray  in  the  last  medium  of  a  given  ray  in  the  first  medium. 

■1.  To  find  the  refracted  ray  in  the  last   medium  of  a  given  ray  in  the  firsl  medium: 
Le1  .I  B    Fig.  51    be  the  given  ray.     Continue  this  ray  until  it  met-  the  first  prin- 

*  If  the  point  A  \-  infinitely  far  from  the  eye,  all  the  rays  Btriking  the  eye  will  be  parallel 
to  each  other.  The  nodal  rav  musl  therefore  be  drawn,  and  the  point  where  this  nodal  ray 
meets  the  Becond  focal  plane  will  be  the  image  of  A  .1 ,.  where  all  rays  parallel  to  the  nodal 
ray  will  meet. 


92 


<ii:.\i:n.\i.  riivsioLoay  or  visiox. 


cipal  plain'  in  C.  Draw  CD  parallel  to  tin'  axis.  Nmv  assume  any  point,  such  as  /.', 
in  tin'  given  ray.  ami  find  it-  image  Ex  by  the  Rule  1.  Then  />/•>',  becomes  the  course 
of  tlie  refracted  ray. 

The  Schematic  Bye. — A.ccepting  the  system  of  cardinal  points.  List- 
ing, Donders,  and  v.  Helmholtz  have  constructed  "schematic"  eves  to  be 
substituted    lor  the   refracting  system  of  the  natural   eye. 

For  this  purpose  it  is  necessary  to  deduce  from  the  various  estimates  of 
the  indices  of  refraction  of  the  different  media,  of  the  radii  of  curvatures 
of  the  differenl  refractive  surfaces,  and  of  the  distances  separating  them  an 
average  eye  as  a  basis  for  calculation.  The  most  recent  attempt  is  that  of 
v.  Helmholtz.  The  data  he  assumed  are  as  follows :  The  refractive  index 
of  air-  1  ;  of  the  cornea  and  aqueous  humor,  1.3365  ;  of  the  lens,  1.4371  ; 
of  the  vitreous  hmnor,  1.3365;  the  radius  of  curvature  of  the  cornea,  7.829 
rum.  ;  of  the  anterior  surface  of  the  lens,  10  mm. ;  of  the  posterior  surface, 
li  mm.  ;  the  distance  from  the  apex  of  the  cornea  to  the  anterior  surface  of  the 


Fig.  52.  Diagram  showing  the  position  of  tin'  cardinal  points  in  the  "schematic  eye."  The  con- 
tinuous lines  in  tlir  upper  halt  of  tin-  flgure  show  their  position  in  the  passive  emmetropic  eye.  The 
dotted  lines  indicate  the  change  in  their  position  in  an  eye  accommodated  for  the  objeel  .1  at  the  distance 

a  from  tin-  cornea,  or  152  nun.     The  lower  half  of  the  figure  shows  the  formation  of  a  distinct   image  on 
the  retina  of  an  eye  accommodated  tor  the  object  A  at  the  distance  a  from  the  cornea. 

lens,  -'I.';  mm.  ;  thickness  of  lens,  3. (J  nun.  From  these  data  v.  Helmholtz 
calculated  tli«'  position  of  the  cardinal  points  for  the  eye  as  follows  (see 
Fig.  52):  The  first  focal  point  is  situated  13.745  nun.  before  the  anterior 
surface  of  the  cornea;  the  posterior  focal  point  i-  situated  15.619  turn. 
behind  the  posterior  surface  of  the  lens;  the  first  principal  point,  1.753  mm. 
behind  the  cornea  ;  the  second  principal  point,  "2. KM!  mm.  behind  the  cornea  ; 
tin-  firsl  ami  -croud  n<,dal  point-.  6.968  and  7.321  mm.  behind  tin'  apes  of  the 
cornea,  respectively.  The  anterior  focal  distance  of  this  schematic  eye  there- 
fore amounts  to  15.498  mm.,  and  the  posterior  focal  distance  to  20.713  mm. 
\\  hen  the  eye,  however,  i-  accommodated  for  near  vision,  the  relations  of 
the  cardinal  point-  are  changed  a-  follow-,  if  the  point  accommodated  for 
lie-  [52  mm.  from  the  cornea  ;  Anterior  focal  distance,  L3.990  nun.  ;  posterior 
focal   distance,    L8.689   mm.;   distance   from  cornea  of  the  firsl  and  second 


THE   REDUCED    EVE. 


93 


principal  point-,  1.858  and  2.257  mm.  respectively  ;  distance  of  the  posterior 
focus,  20.955  nun.  from  cornea.  Given  this  schematic  eye  in  the  accommo- 
dated state,  the  course  of  the  rays  and  the  determination  of  the  position  of 
an  image  in  the  last  medium  of  a  luminous  point  in  the  first  can  easily  be 
determined  by  the  rules  above  given. 

The  Reduced  Bye. — As  suggested  by  Listing,  this  schematic  eye  may 
be  yet  further  simplified  or  reduced  to  a  single  refracting  surface  hounded 
anteriorly  by  air  and  posteriorly  by  aqueous  or  vitreous  humor.  Without 
introducing  any  noticeable  error  in  the  determination  of  the  size  of  the  retinal 
image,  the  anterior  principal  and  the  anterior  nodal  points  may  he  disregarded, 
owing  to  the  minuteness  of  the  distances  (0.39  mm.)  separating  the  two  sys- 
tem- of  points.  There  is  thus  obtained  one  principal  point  and  one  nodal 
point,  which  latter  becomes  the  center  of  curvature  of  the  single  refracting 
surface.     The  dimensions  of  this  "reduced"  eye  are  as  follows  (see  Fig.  53)  : 


Fig.  53.— DiagTam  showing  the  position  of  the  cardinal  points  in  the  "  reduced  eye."  The  continuous 
lines  in  the  upper  half  of  the  figure  show  their  position  in  the  passive  eye.  Tin-  dotted  lines  refer  to 
their  change  of  position  when  the  eye  is  accommodated  for  the  near  object,  .1.  Tin-  lower  half  of  the 
figure  shows  the  formation  of  an  image  in  the  reduced  eye  and  the  relation  between  the  size  < >f  the 
object  and  the  size  of  the  image. 

From  the  anterior  surface  of  the  cornea  to  the  principal  point.  2.106  mm.; 
to  the  nodal  point,  7.321  mm.  The  anterior  focal  distance  is  15.498  mm.; 
the  posterior  focal  distance,  20.713.  There  is  thus  substituted  for  the  nat- 
ural eye  a  single  refracting  surface  having  a  radius  of  curvature  of  5.215 
mm.  The  index  of  refraction  of  this  eye  i-  1.3365,  which  is  that  of  the 
vitreous  humor.  In  such  an  eye  luminous  rays  emanating  from  the  anterior 
focal  point  are  parallel  to  the  axis  niter  refraction  in  the  interior  of  the  eye. 
Also  rays  parallel  to  the  axis  before  refraction  unite  at  the  posterior  focal 
point.  By  means  of  this  reduced  eve  the  construction  of  the  refracted  ray, 
the  various  calculations  a-  to  the  size  of  the  image,  the  size  of  diffusion  cir- 
cles, etc.  are  much  facilitated. 

In  Fit:.  54  lot  .1  B  represenl  an  object.  From  .1  homocentric  rays  fall  on  tin-  sin- 
gle refracting  surface  //.  One  of  the  rays,  the  nodal  ray.  falling  en  the  surface  per- 
pendicularly, passes  unrefracted  through  the  single  nodal  point,  .V.  to  the  posterior  focal 
plane.  The  remaining  ray-,  falling  en  this  surface  under  varying  degrees  of  incidence, 
undergo  corresponding  degrees  of  refraction,  by  which  they  form  a  converging  con.- of 


94 


GENERAL    PHYSIOLOGY  OF  VISION. 


rays  which  unite  at  a  point  situated  on  the  nodal  ray.  These  two  points  arc  known 
as  conjugate  foci.  The  same  holds  true  for  homocentric  rays  emanating  from  B  or  any 
other  point  of  the  object. 

The  size  of  the  retinal  image,  /,  may  now  be  easily  calculated,  when  the  size  of 
the  object,  0,  and  its  distance,  J),  from  the  refracting  surface  with  radius  of  curvature, 
R,  are* known,  by  the  following  formula: 

( > :  1  =  D  +  R :  F,  -  R. 
For,  a>  the  triangles  .1  N  B  and  a  N  b  are  equal,  we  have 

A  B:  ab  =  f  N:  A  g,  or  a  b  = — — u. 


Fig.  54. — Diagram  to  illustrate  formation  of  images  in  reduced  eye. 

Accommodation.1 — In  a  normal  or  emmetropic  eye  homocentric  parallel 
rays  of  lighl  after  passing  through  the  optic  media  are  converged  and  brought 

to  a  focus  on  the  retina.  Hays,  however,  which  conic  from  a  luminous  point 
situated  near  the  eye,  and  which  are  therefore  divergent  and  passing  through 
the  optic  media  at  the  same  time,  arc  intercepted  by  the  retina  before  they  arc 
focussed,  and  give  rise  to  the  formation  of  diffusion-circles  and  indistinctness 
of  vision,  'flic  reverse  is  also  true.  When  the  eve  is  adjusted  for  the  refrac- 
tion and  focussing  of  divergent  rays,  parallel  rays  will  he  brought  to  a  focus 
before  reaching  the  retina,  and,  again  diverging,  will  form  diffusion-circles. 
It  is  evident,  therefore,  that  it  is  impossible  to  simultaneously  focus  both 
parallel  and  divergent  rays,  and  to  see  two  objects  distinctly  at  the  same 
time  which  are  situated  at  different  distances.  The  eye  must  be  alternately 
adjusted  first  to  one  object  and  then  to  another.  The  capability  which  the 
eye  possesses  of  adjusting  itself  to  vision  at  different  distances  is  termed 
accommodation. 

The    following   table  of   Listino-   shows   the   size  of  the   diffusion-circles 

for d   of  objects   situated   at   different  distances  when  the  accommodative 

power  i-  suspended  : 

i  listance  of  the  focal 
Distance  of  Luminous  point.  [mint  behind  the  posterior  Diameter  of  the  diffusion-circle. 


65 
25 
12 

>; 

3 

L.500 

0.750 

0.375 

0.188 

0.094 

0.08.8 


surface  of  the  retina. 
o.        mm. 
o.i  lor.     " 
0.012     '• 
0.025     " 
0.050     " 
0.100     " 
0.20 
0.40 

o.so       •■ 
1.60 
3.20 
3.42 


0. 

0.0011 

0.0027 

0.0056 

0.0112 

0.0222 

0.0443 

0.0825 

0.1616 

0.3122 

0.5768 

or,  hi 


Iditional  consideration  of  this  subject  consult  page  134  and  page  155. 


OPTICA  I.    DEFECTS.  95 

The  normal  eve  when  adjusted  f'<»r  distant  vision  is  in  a  passive  condition 
and  unattended  with  fatigue.  I  n  the  act  of  adjustment,  however,  lor  near  vision 
the  eye  passes  into  an  active  state,  the  result  of  a  muscular  effort,  the  energy 
of  which  is  proportional  to  the  nearness  of  the  object  toward  which  the  eye  is 
directed.  From  the  above  table  it  is  evident  that  ray-  of  light  coming  from 
infinity  or  from  any  object  even  but  <>  m.  distant  are  so  nearly  parallel  and 
the  diffusion  circles  so  very  small  that  the  indistinctness  of  the  image  is 
scarcely  perceived,  and  hence  no  perceptible  accommodative  effort  is  required. 
Rays  coming  from  objects  situated  progressively  nearer  the  eye  require  for 
their  localization  a  constantly  increasing  effort  of  accommodation.  During 
accommodation  the  lens  undergoes  a  change  of  shape,  becoming  more  convex, 
especially  on  its  anterior  surface.  The  greater  the  degrees  of  divergence  of 
tiie  rays  the  greater  must  be  the  increase  in  lens  convexity,  in  order  that  they 
may  be  sufficiently  converged  and  focalized  on  the  retinal  surface.  Changes 
in  the  curvatures  of  the  lens,  either  of  increase  or  decrease,  are  attended  with 
corresponding  changes  in  the  distinctness  of  the  image. 

Mechanism  of  Accommodation. — Though  it  is  generally  admitted  that 
the  increase  in  the  convexity  of  the  lens  is  caused  by  the  contraction  of  the 
ciliary  muscle  and  the  subsequent  relaxation  of  the  suspensory  ligament,  the 
exact  manner  in  which  this  is  brought  about  is  not  well  understood.  When 
the  eye  is  in  repose  and  adjusted  for  distant  vision  the  lens  is  somewhat  flat- 
tened from  the  traction  of  the  suspensory  ligament.  When  the  eye  requires 
adjustment  for  near  vision  the  ciliary  muscle  contracts,  the  suspensory  liga- 
ment relaxes,  and  the  lens,  in  consequence  of  its  inherent  elasticity,  bulges 
forward  and  becomes  more  convex.  Its  antero-posterior  diameter  is  thus 
increased  and  its  refractive  power  is  proportionally  greater. 

It  is  generally  admitted  that  during  accommodation  the  meridional  fibers 
of  the  ciliary  muscle  draw  forward  the  ciliary  processes  and  relax  the  liga- 
ment. At  the  same  time  the  outer  border  of  the  iris  is  drawn  somewhat 
backward.  In  extreme  efforts  of  accommodation  it  is  also  believed  by  some 
observers  that  the  circular  fibers,  the  so-called  "annular  muscle,"  contract 
and  exert  a  pressure  on  the  periphery  of  the  lens,  and  thus  aid  other  mechan- 
isms in  increasing  the  convexity.  This  view  appears  to  be  supported  by  the 
fact  that  in  hyperopia,  where  there  is  a  constant  effort  required  for  distinct 
vision  even  of  distant  objects,  the  annular  muscle  becomes  very  much  hyper- 
trophied,  thus  serving  to  reinforce  the  action  of  the  meridional  fibers.  In 
myopia,  on  the  contrary,  where  the  accommodative  effort  is  at  a  minimum, 
the  entire  muscle  possesses  less  than  its  average  size  and  development  (com- 
pare with  page  135). 

Optical  Defects.1 — From  a  purely  physical  point  of  view  the  eye  i-  not 
a  perfect  instrument.  It  is  not  quite  achromatic,  is  not  free  from  spherical 
aberration,  and  is  not  exactly  centered.  Moreover,  its  area  of  distinct  vision 
i-  quite  limited,  and  does  not  correspond  with  the  field  of  projection,  the 
retina.  In  first-class  optical  instruments  the  lenses  are  centered — that  is, 
their    exact   centers  are   situated  on    the   same  axis.      In    viewing  an  object 

through  such  a  system  the  visual  line  corresp Is  with  the  axis  of  the  lens- 

system.     This  is  not  the  case  with  the  lens-system  of  the  eye. 

A    line  passing  through   the  Center  of  the  cornea  and   the  center  of  the  eye, 

the  optic  cuxi&  ' >  .1  in  hig.  oo,  does  not  pass  exactly  through  the  center  of  the 
lens,  and  does  not  fall  into  the  point  of  most  distinct  vision,  the  fovea.     'I  his 

1  For  a  lull  consideration  of  the  optical  defects  of  the  eye,  see  sections  devoted  t"  <  >|>ii<s  and 
Refraction. 


96 


GENERAL    PHYSIOLOGY  OF  VISION. 


has  led  to  the  recognition  of  other  lines,  the  relations  of  which  must  be  borne 
in  mind  in  all  optical  discussions. 

1.  The  visual  axis,  or  line  of  vision  V L,  is  the  line  connecting  the  point 
viewed,  the   nodal   point,  and   the  fovea   centralis. 

2.  The  line  of  fixation,  or  line  of  regard  V  C,  is  the  line  connecting  the  point 
viewed  with  the  &  nt(  r  of  rotation,  the  latter  being  situated  (5  mm.  behind  the 
nodal  point  of  the  eye  and  9  before  the  retina.  The  relations  of  these  lines 
and  certain  angles  in  connection  with  them  are  shown  in  the  following  figure  : 


TemporrzLSide 


Tftzsal  Stele.. 


Fig.  55.— Diagram  showing  the  corneal  axis  D  A  the  optic  axis  0  A,  the  visual  axis  V L,  and  the  line  of 
fixation  V  r ;  also  the  three  angles  a,  /3,  y, 

The  angle  included  between  the  line  I)  D  (the  major  axis  of  the  corneal 
ellipse)  and  the  visual  line  is  the  (inf/lc  alpha,  amounting,  on  the  average,  to 
about  5°.  The  angle  included  between  the  optic  axis  and  the  line  of  regard 
is  known  as  the  angle  gamma,  while  the  angle  between  the  optic  axis  and  the 
line  of  vision  is  known  as  the  angle  beta  (see  also  page  129). 

Functions  of  the  Iris. — The  iris,  in  virtue  of  the  capability  it  pos- 
sesses of  alternately  enlarging  and  diminishing  the  size  of  its  central  opening, 
the  pupil,  forms  in  several  respects  an  important  corrective  apparatus  of  the 
eye  it  servesas  a  diaphragm  by  which  the  rays  of  light  which  would  other- 
wise pass  through  the  margin  of  the  lens  are  cut  off,  so  that  spherical  aberra- 
tion is  in  a  great  measure  overcome.  It  also  serves,  through  the  contrac- 
tion of  its  muscular  fibers,  to  form  a  fixed  point  of  support  for  the  ciliary 
muscle  during  the  period  of  active  accommodation.  Owing  t<>  the  fact  that 
the  circular  fibers  of  the  iris  alternately  contract  and  relax  with  increasing 
and  decreasing  intensities  of  light,  it  serves  to  regulate  the  amount  of  light 
entering  the  eye  accessary  for  distinct  vision.  In  the  absence  of  light  the 
sphincter  pupiUa  relaxes  and  the  pupil  enlarges.  As  the  light  increases  in 
intensity  the  muscle  contracts  and  the  pupil  becomes  smaller.  The  contrac- 
tion of  tin'  sphincter  nni-ele  i-  with  a  given  intensity  of  light  greater  when 
the  lighl  fill-  directly  into  the  fovea.  Contraction  of  this  muscle  also  occurs 
a-  :m  associated  movement  in  the  act  of  convergence  of  the  optic  axes  in 
accommodative  efforts  and  in  consensus  with  the  other  eye. 

The  movements  of  the  iris  by  which  the  size  of  the  pupil  is  determined 
from  moment  to  moment  are  caused  by  the  contractions  of  the  sphincter 
pupilla  and  dilatator  /itij>i//<i  muscles.  The  contraction  of  the  sphincter  is 
entirely  reflex  and  involve-  for  it-  action  the  pint-  necessary  to  the  perform- 
ance of  any  reflex  act — viz.  a  sentient  surface,  the  retina  ;  an  afferent  nerve, 
the  optic;  a  central   center   situated    in   the  gray   matter  of  the  aqueduct  of 


FUNCTIONS  OF   THE  RETINA.  97 

Sylvius;  and  an  efferent  nerve,  the  motor  oculi.  The  stimulus  requisite  for 
the  calling  forth  of  a  contraction  is  the  impact  of  ether-vibrations  on  the  ends 
of  the  rods  and  cones.  According  to  the  intensity  of  the  lighl  or  ether-vibra- 
tion- will  he  the  energy  of  the  contraction.  The  contraction  of  the  dilatator 
pupilla  i-  determined  by  the  activity  of  a  continuously  active  nerve-center 
situated  in  the  medulla  oblongata,  which  transmits  its  regulative  nerve- 
impulses  to  the  iris  through  libers  in  the  sympathetic. 

The  exact  course  of  these  fibers,  however,  in  man  is  not  satisfactorily 
determined.  From  their  origin  they  pass  successively  through  the  cervical 
cord,  the  anterior  roots  of  the  first  and  second  dorsal  nerves,  the  upper 
thoracic  ganglion,  the  cervical  sympathetic,  the  upper  cervical  ganglion 
through  fibers  to  the  ophthalmic  division  of  the  fifth  nerve,  the  nasal  nerve, 
and  long  ciliary  nerve  to  the  iris. 

A.s  to  the  action  of  the  two  sets  of  muscles,  they  appear  to  bear  an  antago- 
nistic relation  to  each  other,  for  section  of  the  motor  oculi  is  followed  by 
relaxation  of  the  circular  fibers  and  dilatation  of  the  pupil.  Stimulation  of 
the  sympathetic  in  the  neck  is  followed  by  a  much  larger  dilatation  of  the 
pupil.  The  normal  physiological  stimulus  to  the  dilator  center  is  probably 
dyspneic  blood,  though  it  is  excited  by  muscular  activity  and  stimulation  of 
various  sensory  nerves. 

Function's  of  the  Retina. — Of  all  the  layers  of  the  retina,  the  rods 
and  cones  appear  to  be  the  most  essential  to  vision.  It  is  only  this  layer 
which  is  capable  of  receiving  the  light-stimulus  and  of  transforming  it  into 
some  specific  form  of  energy,  which  in  turn  arouses  in  the  fibers  of  the  optic 
nerve  the  characteristic  nerve-impulses.  The  nerve-fibers  themselves  are 
insensible  to  the  impact  of  the  ether-vibrations,  and  require  for  their  excita- 
tion some  intermediate  form  of  energy.  That  this  is  the  case  was  shown  by 
Donders,  who  reflected  a  beam  of  light  on  the  optic  nerve  at  its  entrance 
without  the  individual  experiencing  any  sensation  of  light.  This  region, 
occupied  only  by  the  optic-nerve  fibers  and  devoid  of  any  special  retinal 
elements,  is  therefore  an  insensitive  or  blind  spot.  The  diameter  of  this 
spot  is  about  1.5  mm.,  and  occupies  in  the  field  of  vision  a  space  of  about 
6°.  It  is  situated  about  3.5  mm.  to  the  nasal  side  of  the  visual  axis.  Its 
existence  can  be  demonstrated  by  the  familiar  experiment  of  Mariotte — e.g. 
if  the  right  eye  be  directed  to  the  cross  in   the  following  figure  (56)  and  the 


PlG.  ">6.— To  demonstrate  the  blind  spot. 

left  eye  closed,  and  the  paper  be  held  at  a  distance  of  10  inches,  the  circle 
will  entirely  disappear.  This  occurs  when  the  image  fill-  on  the  optic  oerve 
at  it-  entrance.  (See  also  page  470.)  The  experiment  of  Purkinje  demon- 
strates the  same  fact. 

It  is  well  known  that  the  blood-vessels  of  the  retina  are  situated   in  its 
innermost  layers  a  short  distance  behind  the  optic-nerve  fibers.     Owing  to 
this  anatomical  arrangement,  a  portion  of  the  light  coming  through  the  pupil 
will  be   intercepted    by  the  vessels  and  a  shadow  projected  <>n  the  layer  of 
rods  and  cones.     Ordinarily,  these  shadows  are  not  perceived,  for  the  reason 

7 


GENERAL   PHYSIOLOGY  OF  VISION. 

that  the  shaded  part-  arc  more  sensitive  and  their  excitability  less  readily 
exhausted,  and  perhaps  because  the  mind  has  Leaned  to  disregard  them. 
Bui  if  light  be  made  to  enter  the  eye  obliquely,  the  position  of  the  shadows 
will  l«c  changed,  when  at  once  they  become  apparent.  This  can  be  shown  in 
the  following  way  : 

It'  in  a  darkened  room  a  lighted  candle  be  held  several  inches  to  the  side 
and  to  the  f'mnt  of  the  eve,  and  then  moved  ii|>  and  down,  there  will  be 
perceived,  apparently  in  the  field  of  vision,  an  arborescent  figure  correspond- 
ing to  the  retinal  blood-vessels.  This  i-  due  to  the  falling  of  the  shadows 
on  unusual  portions  of  the  layer  of  rods  and  cones  (see  also  page   141). 

Excitability  of  the  Retina. — The  retina  is  not  equally  excitable  in  all 
parts  of  it-  extent.  The  maximum  degree  of  sensibility  is  found  in  the 
macula  lutea,  ami  especially  in  it-  central  portion,  the  fovea.  In  this  region 
the  layers  of  the  retina  almost  entirely  disappear,  the  layer  of  rods  and  cones 
only  remaining,  and  in  the  fovea  only  the  latter  are  present.  That  this  area 
is  the  point  of  mosl  distinct  vision  is  shown  by  the  observation  that  when 
the  eye  i-  directed  to  any  given  point  of  light,  its  image  always  falls  in  the 
fovea.  Anv  pathological  change  in  the  fovea  i-  attended  by  marked  indis- 
tinctness <>f  vision.  The  sensibility  of  the  retina  gradually  but  irregularly 
diminishes  from  the  macula  toward  the  periphery.  This  diminution  in 
sensibility  hold-  true   for  monochromatic  as  well  as  white  light. 

A-  stated  above,  the  nature  of  the  molecular  processes  which  take  place 
in  the  retinal  tissue,  and  which  arc  caused  on  one  hand  by  the  light-vibra- 
tions, and  on  the  other  hand  develop  ncrve-inipnlses,  is  entirely  unknown. 
The  discovery  of  the  visual  purple  in  the  outer  segment  of  the  rods  gave 
promise  of  some  explanation  of  the  process,  especially  when  it  was  shown  to 
mdergo  changes  when  exposed  to  the  action  of  light.  Ki'ihne  even  succeeded 
in  obtaining  an  optogram,  or  a  fixed  image,  of  an  external  object  in  a  manner 
similar  to  that  by  which  an  image  i-  fixed  on  the  sensitive  plate  of  a  camera. 
But  a-  tin-  pigmenl  i-  wanting  in  the  cones,  and  especially  in  the  fovea,  it 
cannot  be  considered  essential  to  distinct  vision,  although  that  it  plays  some 
important  role  in  the  visual  process  is  highly  probable.  The  visual  purple 
disappears  when  the  eye  is  exposed  to  light,  but  is  restored  when  light  is 
excluded.      It     ha-    also    been    observed    that    under    the    influence    of    light- 

-timnlation    the   «• -    become   shorter,  and    in    the   darkness   again  become 

longer  (see  page  'i'.'i. 

Color-perception. — A  beam  of  sunlight  passed  through  a  glass  prism 
is  decomposed  into  a  series  of  colors — red,  orange,  yellow,  green,  blue,  indigo, 
and  violet — the  so-called  spectral  colors,  so  well  exemplified  in  the  rainbow. 
The  spectral  color-  are  termed  simple  colors,  because  they  cannot  be  any 
further  decomposed  by  a  prism.  Objectively,  the  spectral  color-  consist  of 
very  rapid  transverse  vibrations  of  the  ether,  from  about  l<><>  millions  of 
million-  per  second  for  red  to  about  760  million-  of  million-  for  violet,  but 
subjectively  they  are  sensations  caused  l>\  the  impact  of  the  ether-waves  on 
tin-  percipient   layer  of  t he  retina. 

It  i-  possible  to  mix  "i-  Mend  these  spectral  color-sensations  in  the  eye  by 
stimulating  the  same  area  of  the  retina  by  differenl   spectral  color-,  either  at 

the  -ami'  time  or  in    rapid  succession.        The  following   table  -how-  the  results 

of  -ml,  experiments  as  performed  by  v.  rlelmholtz  (Dk.  dark;  Wh.  = 
whitish  I. 


THEORIES  OF  COLOR-PERI  EPTION. 


99 


Violet. 


Indigo.        Cyan-blue. 


Bluish- 
green. 


'•rr>  II. 


yellow. 


Yellow. 


Purple         Dk.-rose       Wh.-rose     White  Wh.-yellow  Gold-yellow  |Orange 

Dk.-rose       Wh.-rose     White  Wh.-yellow  Yellow         Yellow 

Wh.-rose      White  Wh.-green  Wh.-yellow  Gr.-yellow  .    . 

White  Wh.-green    Wh.-green  Gn 

White-blue  Water-blue  Bl.-green 

Bluish-green  Water-blue  Water-blue 

('van-blue       Indigo  .    . 


Red 

<  >  ramie 
Yellow 
( rr.-yellow 

Green 


These  are  the  mixed  colors.  But  it  is  to  1"-  observed  that  only  two  new 
color-sensations  can  be  produced,  white  and  purple,  the  remaining  mixed 
colors  already  finding  their  equivalent  in  the  spectrum.     White  ami  purple, 

therefore,  are  color-sensations,  which  have  do  objective  equivalent  in  a  simple 
number  of  ether-vibrations  like  the  spectral  colors. 

Two  spectral  colors  which  by  their  mixture  produce  the  sensation  of 
white  are  called  complementary  colors.  Such  are  red  and  green-blue,  golden 
yellow  and  blue,  green  and  purple.  The  mixture  of  all  the  spectral  colors 
produces  white  again.  This  is  the  result  of  adding  two  or  more  color-sensa- 
tions. Different  results  are  obtained,  however,  by  adding  colored  pigments. 
Yellow  and  blue,  for  example,  produce  in  the  eye  white,  but  on  the  painter's 
palette  green.  For  the  explanation  of  such  facts  reference  must  be  made  to 
larger  treatises.  The  colors  of  nature  are  usually  mixture-  of  simple  colors, 
as  can  be  shown  by  spectroscopic  analysis  or  by  a  synthesis  of  spectral  colors. 

In  all  color-sensations  we  must  distinguish  three  primary  qualities :  (1) 
hue  ;  (2)  purity  or  tint ;  (3)  brightness  or  luminosity.  The  first  quality  <rives 
the  main  name  to  the  color — e.g.  red  or  blue — this  depending  on  the  spectral 
color  or  the  mixture  of  two  spectral  colors  with  which  it  can  be  matched. 
The  second  quality,  the  tint,  depends  on  the  admixture  of  white  to  the 
groundcolor;  and  the  third  quality,  brightness,  depends  on  the  objective 
intensity  of  the  light  and  the  subjective  sensitiveness  of  the  retina.  Color- 
perception  thus  far  refers  only  to  the  most  sensitive  part  of  the  retina.  At 
the  more  peripheral  parts  of  the  retina  the  colors  are  seen  somewhat  differ- 
ently, as  is  shown  by  the  following  table  giving  the  limits  up  to  which  the 
colors  are  recognized  : l 

White.  Blue.  Red.  Green. 

Externally 90°  80°  65°  50° 

Internallv 60°  55°  50°  I' 

Superiorly 45°  40°  35°  30° 

Inferiorlv 70°  60° 


45 


35° 


Theories  of  Color-perception. — The  theory  <>f  r.  Helmholtz,  originated 
by  Thomas  Young  (1807),  assumes  in  it-  latest  form  the  existence  in  the 
human  retina  of  three  different  kind-  of  end  organs,  each  of  which  i<  loaded 
with  its  own  photo-chemical  substance  capable  of  being  decomposed  by  a 
certain  color,  and  thus  exciting  the  fiber  of  the  optic   nerve. 

In  the  first  group  these  end  organs  are  loaded  with  a  red-sensitive  sub- 
stance, which  is  affected  mainly  by  the  red  part  of  the  spectrum  ;  the  second 
group  has  it-  end  organ-  provided  with  a  green-sensitive  substance,  which  i- 
mainly  excited  by  the  green  color;  while  the  third  group  i-  provided  with  a 
blue-sensitive  substance,  thi-  latter  being  mainly  affected  and  decomposed  by 
the  blue-violet  portion  of  the  spectrum.  AH  these  three  differenl  end  organs 
are  present  in  every  part  of  the  most  sensitive  area  of  the  retina,  and  are 
connected  by  separate  nerve-fibers  with  special  parts  of  the  brain,  in  the  cells 
of  which  each  call-  up  it-  separate  sensation  of  red  or  green  or  blue. 
1  For  further  discussion  of  thi-  subjeel  see  page  167. 


tOO  GENERAL    PHYSIOLOGY  OF  VISION. 

Out  of  these  three  primary  color-sensations  all  other  color-sensations 
arise,  [fa  Light  mainly  excites  the  red- or  green- or  blue-sensitive  substance 
of  a  retinal  area,  we  term  it  red,  green,  or  blue,  respectively.  But  if  two  of 
these  photo-chemical  substances  arc  stimulated  simultaneously,  quite  different 
sensations  arise,  'rim-  simultaneous  stimulation  of  the  red  ami  green  sub- 
stances  gives  rise  to  the  sensation  of  yellow,  that  of  red  ami  blue  to  the 
sensation  of  purple,  and  that  of  Wine  ami  green  to  the  sensation  of  blue-green. 
Simultaneous  stimulation  of  all   three  ssbstances  of  a  certain  area  produces 

thesensati f  white.      According  to  this  theory,  complementary  colors  are 

all  those  which  together  excite  all  the  three  substances.  Color-blindness  is 
explained  by  this  theory,  on  the  assumption  that  two  of  the  photo-chemical 
substances  have  become  similar  or  equal  in  composition  to  each  other. 

fhe  theory  of  Hering,  brought  forward  in  1874,  has  the  underlying  as- 
sumption that  the  process  of  restitution  in  a  nerve-element  is  capable  of 
exciting  a  sensation.  This  theory  asserts  that  there  are  three  visual  sub- 
stance- in  the  retina— a  white-black,  a  red-green,  and  a  yellow-blue  visual 
substance.  A  destructive  process  in  the  white-Mack  substance,  such  as  is 
induced  not  only  by  white  fight,  but  also  by  any  other  simple  or  mixed  color, 
produces  the  sensation  of  white,  while  the  process  of  restitution  or  assimila- 
tion m  this  substance  produce-  the  sensation  of  black.  Similarly,  red  Light 
produce-  di-a— imitation  or  decomposition  in  the  red-green  substance,  and 
this,  again,  the  sensation  of  red.  Green  Light,  however,  favors  the  process  of 
restitution  or  assimilation  in  the  red-green  substances,  and  thus  gives  rise  to 
the  sensation  of  green,  [n  the  same  way  the  sensation  of  yellow  has  its  cause 
in  the  decomposition  of  the  yellow-blue  substance  induced  by  yellow  Light, 
while  the  sensation  of  blue  i-  produced  by  an  assimilative  process  in  the 
same  substance.  Simultaneous  processes  of  disassimilation  and  assimilation 
in  the  same  visual  substance  antagonize  each  other,  and  consequently  produce 
no  color-sensation  by  mean-  of  this  substance,  but  only  the  sensation  of  white, 
by  reason  of  decomposition,  by  both  color-,  in  the  white-black  substance. 
Thus,  yellow  and  fine,  impinging  on  the  same  retinal  area,  have  no  effect  on 
the  yellow-blue  substance,  because  they  are  antagonistic  in  their  action  on 
this  substance,  but  only  produce  the  sensation  of  white,  as  both  yellow  and 
blue  decompose  the  white-black  material.  Color-blindness  is  explained  by 
tin  assumption  of  the  absence  of  either  the  red-green  or  the  yellow-blue 
visual  substance  in  the  retina. 

Movements  of  the  Eyeball. — The  almost  spherical  eyeball  lies  in  a 
correspondingly  shaped  cavity  of  the  orbit,  like  a  ball  placed  in  a  socket,  and 
i-  capable  of  being  moved  to  a  considerable  extent  by  the  six  ocular  muscles 
which  are  attached  to  it.  'fhe  movements  of  each  eye  are  referred  to  three 
fixed  line-  or  axes  which  have  their  origin  at  the  point  of  rotation  of  the  eye- 
ball, this  point  lying  about  1.7  mm.  behind  the  center  of  the  globe.  If  the 
eve  looks  straight  forward  in  the  horizontal  plane  (the  head  being  erect),  the 
Line  joining  the  center  of  rotation  with  the  object  looked  at  i-  the  visual  line 
or  visual  axis.  Around  this  antero-posterior  axis  the  eye  may  be  regarded  as 
performing  it-  circular  rotation  or  torsion.  At  right  angles  to  this  line,  and 
joining  the  center  of  rotation  of  both  eye-,  i-  the  horizontal  or  transverse  axis 
around  which  the  movements  of  elevation  (up  to  34   land  depression  (down 

to  57     i  lake   pi;  ice.         \|    right   angles   to  both  of  tlie-e  line-  there  is  the  m Ileal 

axis,  around  which  the  movements  of  adduction  (toward  the  nose  up  to  45°) 
and  abduction  (toward  the  temple  up  to  L2  i  occur.  The  six  muscles  may  be 
divided  into  three  pairs,  each  of  which  has  a  common  axis  around  which  it 
tend-  to  move  the  eyeball.     Km  only  the  common  axis  of  the  internal  and 


MOVEMENTS  OF  THE  EYEBALL: 


101 


external  recti  coincides  with  one  of  three  axes  before  mentioned — namely, 
with  the  vertical  axis — thus  moving  the  hall   only   inwardly  or  outwardly, 

respectively.  The  other  two  pairs,  however,  have  their  own  axes  of  action, 
and  their  movements  of  the  hall  must  he  therefore  analyzed  with  regard  to 
all  the  three  axes,  each  of  these  four  muscles  producing  rotation,  elevation, 
and  depression,  and  abduction  or  adduction.  The  superior  and  inferior  recti 
muscles,  forming  one  pair,  move  the  eye  around,  a  horizontal  axis  which 
intersects  the  median  plane  of  the  body  in  front  of  the  eyes  at  an  angle  of 
63°,  and  the  superior  and  inferior  oblique  muscles  forming  the  third  pair 
rotate  the  globe  around  a  horizontal  axis  which  cuts  the  median  plane  of  the 
body  behind  the  eyes  at  an  angle  of  39°.  Thus  it  is  that  each  muscle  moves 
the  eye  as  follows,  the  movement  for  practical  purposes  being  referred  to  the 
cornea  :  The  rectus  externus  draws  the  cornea  simply  to  the  temporal  side, 
the  rectus  interims  simply  to  the  nose  ;  the  superior  rectus  displaces  the  cornea 
upward,  slightly  inward,  and  turns  the  upper  part  toward  the  nose  (medial 
torsion);  the  inferior  rectus  moves  the  cornea  downward,  slightly  inward,  and 
twists  the  upper  part  away  from  the  nose  (lateral  torsion)  ;  the  superior 
oblique  displaces  the  cornea  downward,  slightly  outward,  and  produces  medial 
torsion  ;  while  the  inferior  oblique  moves  the  cornea  upward,  slightly  out- 
ward, and  produces  lateral  torsion.  These  facts  show  that  for  certain  move- 
ments of  the  eye  at  least  three  muscles  are  necessary  (see  following  table) : 


Intra  nl. 
Outward, 

Upward, 

Doivnward, 

Inward  and 
upward, 


Rectus  interims. 

Rectus  externus. 
(  Rectus  superior. 
{  Obliquus  inferior, 
f  Rectus  inferior. 
{  Obliquus  superior. 
(  Rectus  interims. 
<  Rectus  superior. 
I  Obliquus  inferior. 


Inward  and 

downward, 

Outward  and 
upward, 

Outward  and 

downward. 


Rectus  internus. 

Rectus  inferior. 

Obliquus  superior. 

Rectus  externus. 

Rectus  superior. 

Obliquus  inferior. 
( Rectus  externus. 
■<  Rectus  inferior. 
(  ( >bliquus  superior. 


If  both  eyes  have  their  line  of  vision  in  the  horizontal  plane  parallel  with 
each  other  and  with  the  median  plane  of  the  body,  they  are  said  to  be  in  the 
primary  'position.  All  other  positions  are  called  secondary.  Both  eyes  always 
move  simultaneously,  which  is  called  the  associated  movement  of  the  ci/cs. 
There  are  three  forms  of  associated  movements  :  (1)  movement  of  both  eye-  in 
the  same  direction  ;  (2)  movements  of  convergence  by  which  the  visual  lines 
are  converged  on  a  point  in  the  middle  line  of  the  body;  (3)  movements  of 
divergence,  by  which  the  eyes  are  brought  back  from  convergence  to  paral- 
lelism, or  even  to  divergence,  as  in  certain  stereoscopic  exercises.  A  combi- 
nation of  (1 )  and  (_!)  or  of  ( 1  )  and  (3)  takes  place  for  certain  positions  of  the 
object  looked  at.1 

1  For  further  and  similar  consideration  of  the  physiological  action  of  the  ocular  muscles  see 
pages  41,  42,  497,  and  498. 


GENERAL  OPTICAL  PRINCIPLES: 

KATOPTRICS,  DIOPTRICS,  PHYSIOLOGICAL  OPTICS. 
liv  WILLIAM  S.  DENNF/IT.  M.  lb.  andCOLMAN  WARD  CUTLER,  M.  D., 

OF   NETS     JTOBK    CITY. 


Light  from  its  source  spreads  from  center  to  circumference — not  as  the 
arrow  flies,  bul  as  the  wave  passes.  The  continually  repeated  cycle  at  the 
origin  is  imitated  in  all  it>  essentials  at  each  surrounding  particle,  which, 
being  thus  made  luminous,  transmits  in  turn  what  it  has  received  to  others 
next   removed. 

This  is  not  the  place  to  discuss  al  length  the  wave  theory  of  light,  but  let  it  be 
remembered  t lint  the  image  on  the  retina  is  the  result  of  purely  mechanical  processes 
into  which  the  time  element  necessarily  enters.  Whatever  the  nature  of  the  cycle  at 
the  origin,  it  has  to  do  with  a  mass  of  matter  controlled  by  elastic  forces,  hence  its 
period  is  constant.  The  conditions  at  balf-cycle  periods  are  such  as  may  be  represented 
by  algebraic  equals  and  opposites,  compounding  into  zero  if  both  are  impressed  on  the 
same  body  at  the  same  time. 

The  passage  of  light  through  space  is  the  transference  of  motion  from  one  body  to 
another,  or  to  many  others  whose  reactions  bring  or  tend  to  bring  the  first  to  rest,  and 
which  are  broughl  to  resl  in  turn  by  those  on  whom  they  act. 

The  time  element  in  this  process  of  light  propagation  is  also  determined  strictly  in 

irdance  with  mechanical  laws,  and  hence  the  spherical  shell  of  a  wave-surface  is 
deformed  or  distorted  by  any  change  in  the  density  or  structure  of  the  medium  through 
which  it  passes 

At  the  outset,  in  a  homogeneous  medium,  the  wave-surfaces  are  spherical,  and  the 
light  received  by  any  body  to  which  the  wave  has  reached  is  measured  by  the  area  of 
wave-surface  which  it  intercepts.  This  mean-  that  the  body  is,  as  it  were,  a  buffer  to 
the  moving  masses  of  which  the  medium  is  composed. 

If  the  recipient  is  at  an  equal  distance  from  two  such  sources  of  light  whose  phases 
and  cycles  are  similar,  it  will  of  course  receive  twice  the  light  that  it  would  from  one. 
Now.  the  whole  theory  of  transmission  by  waves  implies  that  every  separate  point  of  u 
wave-front  is  itself,  while  the  wave  is  passing,  nothing  other  than  an  instantaneous 
source  of  light,  and  may  he  treated  a-  such,  and  that  the  results  traceable  to  any  one  lumi- 
nous element  i  Fig.  57,  I)  are  the  same  as  may  be  obtained  by  the  summation  of  results 


i  rate  the  fact  that  h  hen  the  center  of  a  wave-surface  Is  behind  the  wave,  it  is  a 
radiant  ;  when  In  front  "t  the  u 

due  to  Bimilar  condition-  as  they  exist  al  -one-  later  period  in  every  separate  element, 
a,  >>.  c,  d,  etc.,  along  the  whole  wave-surface.    Thus  it  happens  that  any  point.  //,  equally 

distant   from  tin-  point-,  I,  and  C,  receives  double  the  amount  of  lighl  or  energy  from  both 

theee  point-  that  it  doc-  from  either. 


REFRACTION  AND   REFLECTION.  103 

A  change  in  the  form  of  the  wave-fronl  so  that,  as  at  a',  </',  it  curves  in  a  circle  about 
the  point  p  toward  which  it  i-  advancing,  makes  that  point  the  recipient  of  all  the  energy 
which  was  distributed  along  its  arc 

Tmage-forming  optical  instruments  arc  devices  by  which  each  light-wave 
that  comes  from  one  of  a  configuration  of  points,  the  object,  is  made  to  curve 
around  the  corresponding  one  of  another  configuration  of  points,  the  imagi . 

Fig.  58  delineates  this  process  in  its  simplicity,  where  a  lens  is  made  of  such  medium 
as  will  delay  by  its  density  the  progress  of  the  wave,  and  is  so  shaped  that  it  will  give 


/■  )  mm  i  i  •/ 


Fig.  58.— Showing  the  physical  relation  of  a  lens  to  its  conjugate  foci :/',  radiant ;/",  focus  conjugate  to/. 


to  the  wave-front  a  circular  section.  The  ray,  as  indicative  of  the  direction  toward 
which  the  wave  at  any  point  is  moving,  is  identical  with  the  radius  of  the  curved  wave- 
surface  at  that  point,  and  the  radius  of  a  circle  measures  its  straightness  of  are.  just  as 
the  reciprocal  of  the  radius  measures  its  curvature. 

Thus  it  will  be  seen  that  the  study  of  the  propagation  and  distribution  of 
light  is  very  much,  at  bottom,  the  study  of  curves,  and,  as  curves  arc  deter- 
mined by  the  properties  of  their  normals  or  radii,  it  is  possible  for  Geometrical 
Optics  to  be  cultivated  as  a  degenerate  form  of  Physical  Optics,  dealing  prin- 
cipally with  the  positions  of  points  and  the  lengths  of  line-segments. 

The  accessibility  of  certain  truths  when  sought  by  geometrical  methods, 
and  the  accessibility  of  the  methods  themselves  as  instruments  of  research, 
are  their  all-sufficient  but  not  their  only  recommendation.  In  the  pages  that 
follow  only  occasional  reference  will  be  made  to  the  physical  aspects  of  the 
case,  but  attention  is  here  invited  to  the  fact  that  not  only  as  a  figure  of  speech, 
luit  in  the  accurate  mathematical  sense,  rarity  is  the  reciprocal  of  density, 
straightness  of  curvature,  and  slowness  of  velocity.  From  these  hints  it  will 
be  found  that  the  formulae  used  in  the  study  of  refracting  and  reflecting  sur- 
faces and  centered  lens-systeins  give  abundant  evidence  of  their  physical 
origin,  and  a  recognition  of  this  relationship  will  be  an  easy  and  legitimate 
mnemonic  device. 

Thus  in  Equation  13,  page  L08,  one  may  read  each  term  as  the  value  in  diopters  of  a 
lens  or  a  pencil.  <  >ne  recognizes  the /'s  as  typical  of  focal  distances,  and  the  r  as  a 
radius,  but  f  and  f"  are  also  radii,  and  their  magnitudes  measure  the  flatness  of  the 

incident  and  refracted  waves;    -    is  the  curvature  of  a  wave-surface,  and   u//  is  the 

coefficient  of  slowness  for  wave-travel  in  the  medium  thus  indexed,  while  u"  —  ft'  is  the 
lag  of  the  wave  as  it  passes  from  one  medium  to  another;  and  so  OD  until  the  whole 
physical  theory  is  read  from  the  necessary  geometrical  relations. 

Refraction  and  Reflection. — With  SnelVslaw  for  a  stepping-stone  we 
now  pass  to  the  geometrical  consideration  of  refraction  and  reflection.     This 


104 


<;i\i:i;m.  optical  i>rix(ti>li:s. 


law  for  oearly  a  hundred  year-  was  the  expression  merely  of  the  results  of 
experience  in  the  observation  of  refracted  light.  It  is  now  generalized  and 
applied  to  both  reflection  and  refraction.  Its  consistency  with  the  irarc 
theory  of  light  may  be  seen  as  follows: 

When  a  wave-surface  whose  section  may  he  represented  by  a  l>  (Fig.  59) 
passes  through  d,  the  surface  separating  one  medium   from  another  in  which 


(;il 


(J"1 


|-,,-  59.— Showing  that  a  wave-surface  is  not  changed  in  its  direction  by  passing  through  (d)  an  optical 

surface  parallel  to  it.  however  the  character  of  the  medium  may  change  a1  that  surface,  but  that  when 
th.-  optica]  surface  [a')  is  inclined  to  the  wave-surface,  the  latter  must  experience  a  change  in  its  direc- 
tion dependent  on  its  change  of  velocity  in  passing  from  one  medium  into  the  other. 

for  any  reason  whatever  lighl  make-  its  way  at  a  different  rate  of  speed,  if 
the  wave-surface  immediately  before  its  passage  is  parallel  to  the  surface  sepa- 
rating the  two  media,  it  will  he  parallel  to  it  immediately  after  its  passage, 
because  at  no  time  have  the  circumstances  governing  its  speed  differed  along 
the  whole  line  of  the  wave-front,  the  change  having  taken  place  everywhere 
at  the  same  in-taut.  The  length  of  section  is  immaterial  so  that  it  be 
straight.  Its  straightness  as  a  measurable  quantity  is  the  arc  divided  by  the 
radius,  so  whatever  the  curve  for  a  section  as  small  as  you  please,  the  above 
statement  is  practically  true,  neither  end  of  the  wave  gains  on  the  other  and 
it  continues  to  advance  in  a  straight  line. 

If  the  wave  enter-  a  retarding  medium  whose  surface,  d',  is  not  parallel 
to  it-  own.  instead  of  making  its  way  as  it  otherwise  would  to  the  position 
a",  bl}  the  spread  of  the  light-disturbance  from  particle  to  particle  has  cov- 
ered, say,  a  -mailer  area  in  the  new  medium  than  in  the  old,  and  the  limit 
of  it-  advance  is  along  the  common  tangent  of  the  circles  whose  radii  are 
proportional  to  the  time  since  they  began  to  form  in  the  new  medium.  Since 
the  line  '■'  represents  the  velocity  of  propagation  in  the  medium  //  and  v"  in 
the  medium  fi",  the  desired  relation-,  are  easily  established.  Each  is  perpen- 
dicular to  it-  wave  front  and  is  consequently  a  radius  or  ray ;  a",  A,  shows 
the  place  to  which  the  wave  would  have  advanced  had  the  character  of  the 
medium  ii"t  changed  at  </'.  ami  a",  b"  -how-  the   place  to  which  it  really  has 

advanced  during  the  same  interval  of  ti Each  form-  the  side  of  a  right- 
angled  triangle  whose  hypothenuse  i-  the  separating  surface,  and  whose 
respective  bases  arc  corresponding  sections  of  wave-surface,  and  form  with 
the  surface  of  separation  the  angles  V  and  /".  One  of  these  angles  is  the 
angle  of  incidena  ;  the  other  i-  the  angle  of  refraction.  Hence  the  sine  of 
tin  angle  of  incidence  i-  to  the  sine  of  the  angle  of  refraction  as  the  velocity 
.•it  incidence  is  to  the  velocity  after  refraction,  or,  as  usually  stated, 


sin  i 
-in  /' 


(1) 


HFFliACTIOX  AX/)    REFLECTION.  L05 

In  practice  it  is  easy  t<>  Locate  the  centers  from  which  the  waves  come  and 
to  which  they  go,  and  easy  to  locate  the  center  of  the  optical  surface  ;  con- 
necting these  centers,  p'}  p"}  or  //"  and  n  with  the  point  of  incidence  a  I  Fig. 
<i(>),  gives  ns  the  three  radii,  each  of  course  perpendicular  to  the  surface  to 

which  it  belongs,  and  consequently  mutually  inclined  to  each  other  as  are 
those  surfaces. 

Through  the  relations  of  these  radii  the  law  was  discovered,  through  them 
it  is  most  easily  proved,  and  through  them  it  is  most  frequently  stated,  angles 
of  incidence,  reflection,  and  refraction  being  defined  as  angle-  made  by  the 
incident,  reflected,  or  refracted  ray  (perpendicular)  with  the  radius  of  the 
optical  surface. 

The  ability  to  transfer  the  attention  from  surfaces  to  rays,  and  to  replace 
velocities  by  their  reciprocals,  is  a  great  geometrical  advantage,  though  it 
gives  a  show  of  artificiality  to  the  whole  theory  of  optical  instruments  as  far 
as  we  have  occasion  to  pursue  it. 

If   u,  however  accented,  is  taken   to   represent     >  Equation   1    may  lie 

written 

sin  i//i/  =  sin  i//fJ-//,  (2) 

and  Equation  2  is  Snell's  law. 

As  here  used,  //,  //',  etc.  represent  the  time  needed  for  light  to  travel  unit 
distance  in  the  medium  with  which  each  is  connected  ;  they  might  be  called 
coefficients  of  slowness  or  coefficients  of  sine  magnitude  ;  they  are,  in  fact, 
called   indices  of  refraction. 

The  time  needed  for  light  to  spread  unit  distance  in  ether — or  in  air, 
which  is  very  nearly  the  same — is  the  standard  of  measurement,  and  is 
assumed  to  be  1.  The  actual  value  in  seconds  for  ether,  for  air,  or  for  other 
media  is  of  no  special  import  to  us  here;  we  need  only  the  relative  magni- 
tudes, which  are  known  or  easily  obtained,  and  are  represented  by  //  appro- 
priately accented.  When  //.  is  equal  to  1,  it  is  often  omitted  from  a  product 
as  a  matter  of  brevity  and  convenience.  In  all  the  formulae  here  used  it 
will  be  written  for  the  sake  of  symmetry  and  clearness. 

With  this  much  of  physical  explanation  and  the  law  of  sines  as  the  rule 
of  the  road,  we  may  proceed  to  speak  of  rays  and  foci  as  of  pencils  and  points, 
hoping  that  their  true  significance  will  not  be  forgotten,  and  believing  that  the 
little  effort  that  is  necessary  to  identify  physical  with  geometrical  relation- 
ships will  more  than  pay  for  itself  as  a  guard  against  error  and  as  a  mne- 
monic aid. 

Wc  shall  use  the  word  refraction  in  its  most  general  sense,  including 
refraction  and  reflection.  If  exceptions  to  this  usage  occur,  they  will  be 
noted. 

The  first  general  problem  that  presents  itself  in  the  study  of  image-form- 
ing optical  instruments  is  this :  Given  waves  of  circular  section,  what  will  be 
their  curve  in  either  medium  after  incidence  on  the  spherical  surface  which 
separates  it  from  another  of  different  index  '.' 

The  problem  may  be  solved  by  the  aid  of  Fig.  HO.  .1.  in  which  wave-  at 
ah  would  converge  upon  the  point  pf}  excepl  that  the  optical  surface  changes 
their  curvature,  giving  them  a  center  at  //'.  In  this  particular  case  //,  />.  /-', 
n',;i"  are  known,  ami  />"  \<  sought,  but  the  solution  desired  should  enable  us 
to  determine  the  position  of  any  one  of  the  quantities  when  the  others  are 
given,  h  being  the  point  where  the  optical  surface  meets  the  line  connecting 
it-  center  with  that  of  the  incident  wave. 


106 


GENERAL    OPTICAL    PRINCIPLES. 


At  //  the  incident  wave  and  the  optical  surface  have  a  common  tangent, 
and  there  is  no  change  in  the  direction  »>f  the  wave  or  of  its  radius;  conse- 
quently, the  center  of  the  two  waves  will  he  on  a  line  with  the  center  of  the 
optical  surface.  At  any  other  point  of  incidence  the  law  of  sines  applied  to 
the  two  kimwn  radii  will  indicate  the  third,  and  its  cross  witli  the  axis  at p" 
will  he  approximately  the  center  of  wave  curvature.  The  solution  is  as 
follow-  : 


of  refraction  and  reflection,  showing  the  relative  positions  as  expressed  by 

to  be  the  same  for  rays  and  normals  as  for  the  surfaces  i"  \\  hicb  they  belong.    At  ii  the  waves 

trallel  to  theoptii  a  \s  any  point  common  to  optical  and  wave-surfaces;  p'  is  the  en  hit 

i. i  the  Incident  wave,  p"  of  the  refracted,  and  /.'"  of  the  reflected  wave.    The  values  of  radii,  curvat 

and  focal  distances  are  ordinarily  considered  positive  when  the  centers  t"  which  thej  appertain  lit-  to  the 

righl  real!  positive. 

For  the  convenience  of  a  one-letter  notation  draw  Fig.  01  identical  with 
I'  ig.  60,  hut  represenl  the  radius  of  the  refracting  surface  by  r,  the  distance 
of  any  point  />  from  the  center  of  the  refracting  surface  by  g  appropriately 
accented,  the  distance  of  any  point  />  from  <i  by  e,  also  appropriately  accented, 
and  distances  from  A  by/.  Then  in  Fig.  <il  will  he  .-ecu  one  triangle  whose 
sides  are  >-.  < '.  and  gf,  and  whose  vertex  measures  the  angle  of  incidence,  and 
another  triangle  whose  sides  are  /■.  <".  and  g",  and  whose  vertex  i-  the  angle 
of  refraction.     The  angle  between  r  and  g  may  lie  called  <">. 


REFRACTION  A  .X I >    REFLECTION. 


107 


From  the  well-known  property  of  triangles  conic  these  two  equations 

(3) 


sin  ;         (/ 
sin   <5 


Dividing  3  by  4  to  eliminate  o, 


By  Snell's  law,  Eq.  "J, 


Therefore,  7      /,~,>    or    H-"g"e'= "'.'/'' ' 


sin  i 

2! 

sin  & 

e' 

sin  /' 
sin  i" 

g'e" 
e'g"' 

sin  /' 
sin  /" 

(5) 

(7) 


It  should  be  noticed  hen1  that  when  the  point  a  (Fig.  61)  is  placed  very  near 
to  li  the  pole  of  the  optical  surface,  e  is  nearly  equal  in  value  to/,  and  at  the 
limit,  when  a  and  h  become  identical,  any  e  is  exactly  equal  to  the  corresponding 
/.  The  value  of/ at  the  instant  when  a  and  A  coincide  is  the  value  thai  gives 
accurately  the  curvature  of  the  wave  at  h.  If  the  wave  is  circular  in  section, 
//'  determined  for  one  point  on  its  surface  is  determined  for  all.  When  the 
refracted  wave  has  not  a  circular  section,  it  is  usual  in  practice  cither  to  shut 


/" 


f 

Fig.  61.— A  one-letter  notation  for  case  (.4)  Fig.  60. 


off  that  portion  of  its  surface  which  departs  appreciably  from  a  uniform  curve, 
and  assumes  that  all  the  rays  cross  at  the  limiting  position  of  />".  or  to  name 
for  the  focal  point  that  position  of//'  which  is  nearest  to  the  greatest  number 
of  rays  at  once.  Some  information  may  be  obtained  concerning  the  curve  of 
the  wave  by  substituting  for  e'  and  e"  in  Eq.  8  the  value  which  each  pos- 
sesses by  virtue  of  its  being  opposite  to  the  angle  d  in  the  triangle  to  which 
it  belongs  ;   thus  : 

e/2  =  ^  +  ;-2_2.7//-cosJ.  (8) 

e/n  =  y>n  +  r2  _  2g//r  cos  (j_  (9) 

Squaring  7  and  substituting  the  value  <■  from  {), 

" ' f2g"2\ a''2  ^  r8     -I'/r  cos  '5)  =fi/2g'2(g"2  +  r- -  '!</' 7  i :i 

It   is  not   necessary  to  ask   here  the  full  significance  of  tin-  formula,  but 
only  to  remark  that  when  g'  is  equal  fco/^-7  )   .'/"<    ''    disappears    from    the 

equation,  ami  consequently  the  refracted  wave  ha-  a  circular  section.    <  me  such 

position   may  be   found   for  p'  on   either  side  of  /•.     The  distance   fr any 

position  of  j,"  to  the  limiting  position  when  <i  h      <>  i-  the  aberration  for  the 


108  GENERAL   OPTICAL   PRINCIPLES. 

angled  (longitudinal  spherical  aberration),  and  there  is  no  aberration  tor  such 
values  of  g'  or  g"  as  cause  d  to  disappear. 

A-  will  be  readily  appreciated,  any  irregularity  in  the  curvature  of  the 
refracted  wave  interferes  with  the  point-to-point  correspondence  of  the  image 
t,,  it-  object.  The  optical  surfaces  of  most  instruments  arc  spherical,  and 
many  circumstances  conspire  to  limit  our  use  of  these  surfaces  to  that  part 
which  is  so  near  the  axis  as  to  be  practically  without  aberration,  or  to  have 
only  so  much  aberration  as  may  be  ignored  or  eliminated  by  compensatory 
error-:  so  in  all  first  approximations  p"  in  its  limiting  position  is  taken  as 
the  focus  conjugate  to  />'  ;  and  since  the  e's  and  the  /'s  are  in  this  position 
identical,  Eq.  7  may  be  written  thus: 

(^  =  9'f-,    or     ^=/^C  (11) 

?  g"r       "'    r   g' 

Designating  these  segments  by  their  terminal  points,  as  in  Fig.  60,  the  nature 
of  the  relation  sought  becomes  apparent  : 

f^J>l>\:l>l>'\  (12) 

ft'      p'n     p" 'a 

In  (li  a  /''i>")  we  have  an  anharmonic  range  in  which  the  two  foci  are  con- 
jugate to  the  center  and  tiie  pole  of  the  optical  surface,  and  the  cross  ratio  is; 
the  ratio  of  wave  velocity  in  the  two  media.  It  is  worth  while  to  study  into 
this  a  little  if  necessary,  for,  besides  furnishing  the  easiest  possible  method 
of  remembering  the  relations  of  the  foci  to  their  surface,  it  shows  that  the 
relation-  are  reciprocal,  and  that  the  two  foci,  being  given  a  surface  of  any 
curve,  may  be  placed,  or  a  curve  corresponding  to  any  place  may  he  deter- 
mined in  precisely  the  same  way. 

Anv  combination  of  lenses  and  mirrors  may  he  replaced  by  an  equiv- 
alent surface:  this  is  of  very  general  utility,  and,  moreover,  in  the  theory  of 
thin  pencils  the  circle  of  least  confusion  is  located  between  the  first  and 
second  focus  of  the  pencil  by  the  harmonic  variety  of  this  relation,  the  ratio 
being,  as  in  the  case  of  the  mirror,  equal  to  — 1.      (See  p.  127.) 

Again,  when  g  in  Eq.  11  is  replaced  by  it-  equal  (/ — r),  we  have  the 
following  : 

n"      I  ff  —  r\  f ft 

,      f„_.'f,  '  which,  when  reduced, as  it  easily 
can  be,  gives  the  most  important  formula  in  this  part  of  the  hook  : 


(13) 


In  as  brief  a  treatise  on  geometrical  optics  as  this  mu<t  be,  Eq.  13  may  be  considered 
:ui  epitome  of  all  that  has  -one  before  ami  a  key  to  all  that  follows.  It  should  be  com- 
mitted to  imim.ry  ami  associated  with  Fig.  60,  .1.  until  each  i>  a  "word-sign"  for  the 
other.  Et  should  never  be  written  in  any  other  form  until  it  has  become  so  familiar  to 
the  eye  thai  from  anj  aide  an  error  of  transcription  would  be  discovered  at  a  glance. 
It  i-  general  in  it-  application  for  the  local  distances  of  axial  pencils  for  a  surface  of 
:  1 1 1  \  circular  curvature,  plus  or  minus,  between  any  media  of  whatever  index.  It  mighl 
ju-t  as  well  have  been  deduced  from  anj  of  the  special  cases  pictured  in  Fig.  60, 
and  the  preceding  applies  and  may  be  read  equally  well  in  connection  with  anyone 
ol  these  cases,  p"'  is  used  in  this  figure  to  indicate  the  position  which  p"  assumes 
when  fi"  //';  that  is,  in  all  cases  of  reflection.  Fig.  60,  A,  was  chosen  as  the  type 
by  which  all  may  be  classed  and  remembered,  because  in  it  all  the  curvatures,  all  the 
local  distances,  and  other  magnitudes  are  positive  quantities;  and  if  Eq.  \''>  is  remem- 
bered as  belonging  to  the  case  where  all  the  quantities  are  plus,  no  confusion  need  atise 


CARDINAL    POINTS. 


109 


in  interpreting  apparent  anomalies  of  sign  when  a  numerical  equation  of  this  form 
presents  itself. 

The  discussion  of  Eq.  13  is  much  more  simple  than  its  derivation.  It  tin- optical 
surface  is  a  plain-,  r  becomes  infinite  and  the  last  member  vanishes,  and  consequently 

—  =£-     or       —  =  ■*— .    which  must   be  construed   t<>  mean  that  the  conjugate  foci  of  a 

f  "  f  '  ll"  f  •>      & 

plane  refracting  surface  are  on  the  same  side  of  the  surface  and  at  distances  whose  ratio 
is  the  same  as  the  indices  for  the  two  media.  If  any  value  represented  by/',/",  or  r 
has  a  minus  sign,  it  of  course  represents  a  distance  to  the  Left  of  h.  If/'  or/"  repre- 
sents an  infinite  value,  the  inference  is  that  the  wave  surface  is  perfectly  flat,  that  the 

rays  are  parallel. 

Only  in  one  case  can  /*'  and  p."  be  replaced  by  quantities  having  different  ~i_rn-. 

That  //'should  equal  -(/'would  indicate  a  position  of  the  wave  that  physical  condi- 
tion.-, can  only  account  for  by  the  supposition  that  it  is  a  reflected  wave— that  is,  turned 
back  into  the  medium  whence  it  came — and  consequently  travelling  with  the  same 
velocity  as  before.  Therefore  the  numerical  value  of  fi"  must  be  the  same  as  «'.  And 
it  can  be  stated  in  this  connection  that  when  the  indices  differ  in  sign  their  numerical 

values  do  not  differ,  and  (  ,  I  =  — 1.     This  only  happens  in  cases  of  reflection. 

It  is  not  only  unnecessary,  but  it  is  confusing,  to  make  any  distinction 
between  problems  of  reflection  and  refraction  other  than  what  i-  indicated  by 
the  signs  of  the  refractive  indices. 

The  simplicity  and  generality  of  the  conditions  is  such  that  the  laws,  the 
methods,  the  formulae,  and  their  interpretations  are  the  same  for  katoptrics  as 
for  dioptrics. 

Katoptrics  is  that  part  of  the  science  of  optics  that  deal-  with  the  phe- 
nomena of  reflection,  especially   from   regular  surfaces  like  mirrors. 

Dioptrics  treats  of  the  phenomena  of  refraction,  and  with  the  definitions 
we  dismiss  the  distinction,  except  in  such  degree  as  it  is  shown  by  the  signs 
of  the  indices.  Eq.  13  is  the  open  sesame  to  all  of  Optics  that  we  require. 
When  the  quantities  that  are  represented  by  //.'  and  //."  are  of  unlike  sign, 
they  are  equal  and  we  are  dealing  with  reflection.  All  other  cases  are 
refractive. 

The  inverse  situation  is  covered  by  the  rule  which  tells  us  to  treat  all 
mirrors  as  optical   surfaces   between   media   whose  indices  are   1    and   —  1. 

Cardinal  Points,  four  in  number,  may  be  named  in  connection  with  a 
single  optical  surface  (Fig.  62).     They  are  //,  the  center  of  the  surface,  A.  the 


Flo.  02.— Above,  the  first  principal  focus  i>  a  radiant,  and  rays  become  parallel  in  (V1.     Below,  rays  par- 
allel in  >/j.'  converge  in  u".  to  the  second  principal 

principal  j»>i,tf.  F7,  the  first  principal  focus,  and  /-'".the  second  principal 
focus. 

The  Center. — Since  concentric  circles  are  parallel,  the  wave  whose  center 
of  curvature  before  incidence  i-  ,/  will  have  /'  for  a  center  after  incidence  — 
i.e.  the  ray  that  passes  through  /<  i-  un  refracted. 

It  will  be  seen  hereafter  that  the  relative  size  of  object  ami  image  is  the  ral 
their  respective  distances  from  »  :  that  they  approach  »  together;  that  each  i>  inverted 
in  passing  through  // ;  and  that  when  they  meet  at  »  the  size  of  one,  in  term-  of  the 
other,  i-  numerically  equal  to  the  ratio  of  the  velocities  of  the  light  wave-  by  which 


lid  GENERAL   OPTICAL   PRINCIPLES. 

the  respective  images  arc  formed.    It  will  be  seen  also  that  the  center  n  is  to  the  optical 
surface  what  the  two  Qodal  points  n'  and  n"  are  to  the  lens  or  the  optical  system. 

The  principal  point  h  is  the  point  where  the  optical  surface  is  pierced  by 
the  line  connecting  it-  center  with  the  radiant. 

Object  and  image  approach  A  together.  At  //  they  are  equal  and  congruent  (see 
page  L12),  and  to  h  of  the  optical  surface  correspond  the  two  principal  points,  h'  and 
fi".  of  the  system. 

The  principal  loci.  F'  and  F" .  are  the  same  for  the  surface  as  for  the  system. 

The  first  principal  focus,  /•".  is  the  center  of  those  waves  which  after 
incidence  become  plane.  In  other  word-,  V  is  the  cross  of  rays  that  are 
made    parallel    by    incidence   on    the   optical    surface. 

The  second  principal  focus  is  the  center  of  those  waves  that  before  tnci- 

denc i  the  surface  were  parallel  ;  or  it  may  be  stated  thus:  Rays  previously 

parallel  cross  after  incidence  at  the  last  principal  focus. 

These  foci  are  found  by  giving  to  the  variables  of  Eq.  13  such  values  as 
will  impose  the  required  conditions. 

To  find  /•",  substitute  x  for  /"  in  Eq.  13  and  solve  for  /.  This  is 
because  the  center  of  a  plane  wave  or  the  focus  of  a  parallel  pencil  is  at  infin- 
ity.     If/"  =  3o,  —  =0,  and  so  disappears  from  the  expression,  and  we  have 

r— £-,-*>  (14) 

the  necessary  result  of  the  condition  imposed. 

The  second  principal  focus,  F",  is  found   in  the  same  way,  for   when 

J       v..         0,  and 

S"=JPL-rF"-  t15) 

To  apply  this,  suppose  light  from  air  is  incident  on  a  convex  glass  surface  whose 
radius  is  one-fifth  meter  (.20  M  i.  Replacing  </  by  1.  the  index  for  air,  yf'  by  1.54,  the 
index   for  glass,  and  r  by   .20,    Eq.  15  gives 

F„      1.54x.20     .308      -? 

1.54      1         .54 

[f  the  surface  had  been  concave,  as  in  Fig.  60  [C),r  would  have  been  equal  to  —.20, 
and  /'"  would  have  had  the  same  value,  with  a  contrary  sign  to  indicate  that  it  was  on 
the  left  of  h.  It'  the  surface  is  to  he  a  mirror,  the  same  equations  are  used,  and  //  is 
put  equal  to      u" ;  thus  from  Eq.  14 : 

/."     I      /.",      •_•«"       2 

For  /•"'  one  obtains  the  same  result,  showing  that  the  principal  focus  for  either  side 
of  a  reflecting  surface  is  halfway  between  the  center  and  the  surface. 

When  /•''  and  /•'",  the  principal  foci,  are  known,  a  very  simple  formula 
may  he  obtained  for  placing  the  conjugate  of  any  other  given  focal  point; 
thus,  multiplying  Eq.  i:l»\  r  and  then  dividing  each  numerator  by  fx"  —  //', 
it  becomes 

Replacing  each   numerator  by  the  values  obtained   from    Eqs.   II  and   15, 

we    have 

/•'"    /•" 

I.  L6 


CONJUGATE  IMAGES.  Ill 

Free  from  fractions  and  subtract  F'F"  from  cadi  side  : 

/•'"/'  t  F'f"     f'f"     F'F"      /•''/•''' *"* 
[F"   ■/")(/' -F')=      F'F". 
i  /•" '     i"    is  u"  I  Fig.  63)  and  (/- F')  is  «'. 

Changing  the  sign  convention  so  that  one  accented  quantity  measures  dis- 
tance- to  the  left  and  two  accented  quantities  are  measured  toward  the  right, 


F' 


F" 


/ 


FlG.  63.— Showing  the  relation  of  conjugate  foci  to  principal  foci.    Symmetrical  notation  about  F' 

and  F"  as  origins. 

we  gel  a  very  convenient  symmetrical  notation  for  the  relation  of  conjugate 

foci  to  principal  foci : 

u'u''-=F'F".  (17) 

For  the  relation  given  in  Eq.  16  there  is  a  very  simple  graphic  solution.     As  the 
line  /'  (Fig.  (34)  is  turned  on  the  point  p  whose  rectangular  co-ordinates  are  F'  and  /'". 


Fig.  64.— Graphic  solution  for  Eq.  16. 

the  parts  cut  off  from  the  axes  are  respectively  equal  to/'  and/",  due  regard  being  had 
to  sense. 

Conjugate  Images:  Object  and  image  are  corresponding  configurations 
of  points.  By  this  is  meant  that  to  each  point  in  one  configuration  there  cor- 
responds a  point  in  the  other  configuration  whose  relation  to  it  and  to  some 
optical  -urface  i>  that  by  which  in  the  preceding  paragraphs  //  has  been  con- 
nected with  p".  The  path  <>f  the  light-wave  being  reversible,  either  config- 
uration may  in  theory  play  the  part  of  object  to  the  other  as  image.  Their 
distances  from  each  other  and  from  the  cardinal  point-  of  the  surface  are 
determined  by  previous  considerations.  Their  relative  magnitudes  are  to  be 
determined. 

The  magnification  of  an  object  by  it-  image  i-  ordinarily  of  two  kind-, 
longitudmal  and  transverse.  With  the  longitudinal,  which  may  be  obtained, 
for  example,  by  comparing  (Fig.  65)  <{  %'  with  q"  s",  we  will  not  here  con- 
cern ourselves.     The  following  is  an  easy  ge strical  determination  oi   the 

transverse  dimensions  of  object  and   image:   Lei  the  line  pf q'  perpendicular 


112 


( ;  EN /•: h'AI.    OPTICAL    PBINCIPL  ES. 


to  the  axis  be  represented  by/,  its  conjugate  by  ./",  minus  because  it  is  on 
the  opposite  side  of  the  axis,  and  it  is  important  to  distinguish  an  inverted 
from  .in  uprighl  image.  From  the  point  p'  let  two  lines  be  drawn,  one  par- 
allel to  the  axis  and  one  through  F',  the  first  principal  focus,  and  let  them 
he  continued  till  they  meet  the  optical  surface.     As  these  lines  are  rays,  their 


i    *' 


Fig.  65.— Image  ami  objecl  :  magnification  determined  by  properties  of  the  principal  foci  (Eq.  18). 

course  after  meeting  the  surface  is  determinate.  That  parallel  to  the  axis  will 
pass  through  the  second  principal  i'oens  F",  and  that  from  the  first  principal 
focus  will  be  made  parallel  to  the  axis.  Where  these  two  refracted  rays  meet 
will  he  the  focus  conjugate  to  pf,  and  p"  q"  will  in  this  ease  be  —j". 

The  three  horizontal  lines  of  the  figure  are  parallel.  The  two  /'s  are 
-within  required  limits  perpendicular  to  them,  hence  the  triangles  on  the  left 
are  all  similar,  and  the  triangles  on  the  right  are  all  similar;  so  we  have  these 
two  equations  from  a  comparison  of  the  sides  of  similar  triangles: 

il  =  F'~f  =     F" 
F 


(18) 


y,  r,  F" -j" 

From  these  two  equations  we  may  learn  where  an  object  must  be  placed  in  order 

that   object   ami  image  may  be  equal  and  cosensal.      For  such  a  condition  -%-  must  lie 

equal  to  1.  This  can  only  be  the  case  in  (18),  where  /''  and  j"  are  both  equal  to 
nothing;  therefore  the  only  place  is  at  the  surface  itself,  and  there  object  and  image 
meet  and  arc  of  the  -a me  size.     To  find  where  object  and  image  are  equal  in  size  and 

opposite  iii  sense,  we  put   ■.,,     -1.    This  condition  is  imposed  upon  (18),  when // 

lF'  and  when./"      2  F".  ' 

By  replacing  /*"  and  /•"'  by  their  equals  from   Equations  14  and  15,  and  letting 

u"         V 

ly  and/"  each  equal  to  /•,  Equation  18  reduces  to  ^~=  'rr/    This  may  be  construed  to 

mean,  thai  when  the  two  images  meet,  as  they  must,  in  the  center  of  the  optical  surface, 
their  dimensions  arc  proportional  to  the  velocity  of  light  in  the  media  to  which  they 
respectively  correspond. 

For  refraction  it  will  he  seen,  r.  </.,  that  hnaire  and  object  arc  cosensal,  but  when,  as 

V 
in  reflection,//     —  fi//,  '.,,     - 1,  and  therefore  image  and  object  are  of  opposite  sense 

and  equal  in  size. 

In  practice  the  center  of  a  concave  mirror  may  he  found  by  placing  a  needle  in  it- 
vicinity  and  moving  il  until  it>  point  i-  coincident  with  the  point  of  its  image.  The 
cross-ratio  (see  page  108)  bj  which  tic-  cardinal  points  of  the  mirror  are  connected  with 

the  conjugate  foci  being  l .  I »  /'./"./")  is  an  harmonic  range,  and,  any  three  points  being 
given,  the  fourth  may  he  determined  by  the  well-known  formula: 


„  h   I'll   J"ll 


(19) 


'I'lc    graphic  solution  is  convenient,  as  it  may  he  done  with  a  pencil  and  straight- 
edge only.     It  three  consecutive  elements  are  given,  as  /".  /'../'  I  Fig.  66),  connect  these 

three  points  by  Straight   line-  with  any  other  point,  <i,  not   in  a  line  with  them.     Through 

any  point  "ii  the  middle  lim-  ilraw  two  diagonals,  as  in  the  figure,  and  complete  the 


HELMHOLTZ'S   FORMULA. 


1 1 3 


quadrilateral.  Its  fourth  side  will  cut  the  axis  at  n,  the  point  required.  If  one  of  the 
middle  points  of  the  range  is  sought,  as  h,  connect  the  two  contiguous  elements  with 
any  point,  a,  as  before.     Cross  the  triangle  thus  formed  by  any  line  n  c,  put  in  the  two 


Fig.  06. — Graphic  construction  by  which  the  following  questions  are  answered:  Given  the  surface 
of  a  mirror,  what  must  its  curvature  be,  or  where  must  its  center  be  in  order  to  produce  a  picture  of/  at 
/'  or  of/'  at/  ?  Given  the  center,  where  must  the  surface  be  ?  Given  the  mirror  and  the  object,  where 
will  the  image  be  ?  or  the  mirror  and  the  image,  where  must  the  object  be '.' 

diagonals,  and  draw  through  their  intersection  the  line  a  h  ;  h  is  the  fourth  harmonic 
sought. 

An  analogous  construction  serves  for  surface,  lens,  or  system.    Take  three  points,  c,  d, 
and  e  (Fig.  67),  equally  distant  from  the  line  an,  and  so  placed  that  the  distances  cd 


Fig  67.— Graphic  method  for  locating  any  one  of  the  four  cardinal  points  of  an  optical  surface  when 
the  other  three  are  known.  Any  axis  may  be  placed  across  the  pencil  (a  c  d  t  n),  so  that  any  three  points 
shall  ration  any  three  of  the  lines.  The  point  soughl  will  be  on  the  other  line.  It  is  only  necessary  in 
the  construction  to  make  c  d  :ce=p!  :  ij-'" ,  and  c  e  parallel  to  a  n. 

and  ce  are  proportional  to  the  indices  of  the  first  and  last  media.  From  a  through  each 
of  tin'  other  points  draw  a  line.  The  axis  of  any  optical  surface  may  be  placed  across 
this  pencil  of  four  lines,  so  that  three  of  the  lines  cross  it  at  any  three  cardinal  points. 
'flic  fourth  point  is  determined  by  the  cros>  of  the  axis  a  and  the  fourth  line.  Tins 
drawing  will  answer  too  tor  all  systems  whose  first  and   last  media  are  in   this   ratio. 

Before  proceeding  to  show  thai   other  systems  of  more  surfaces  than  one 


Fig  68.    Tan  a':  tan  a"     /' :/"  (relative  to  "  Helmholtz's  formula"). 

may,  if  their  centers  arc  colinear,  be  treated  much  in  the  same  way  as  single 
.surfaces,  it   i-  necessary  to  prove   Helmholtz's  formula  connecting  the   size 


114 


GENERAL   OPTICAL   PRINCIPLES. 


of  each  image  with  the  inclination  to  the  axis  of  any  ray  common  to  them 
all.  Let  /'  a  j"  (Fig.  68]  be  the  ray  between  two  images.  Assuming  the 
figure  t"  be  made  up  of  two  right-angle  triangles, 


therefore. 


ks  is  evident  from  Fig.  <>•'>, 


a  h 

a  It 
tan   «                  tan  « 

/" 

tan*'        f" 
tan*"        /'' 

> 

<L-JL 

•/'   j"' 

■Ju 


(21) 


Substituting  in  Eq.  11  the  values  obtained  from  Eqs.  20  and  21,  we  have  the 
relation  sought  : 

"','  tan  et'  =  [i"j"  tan  «".  (22) 

1  [ere  we  begin  the  study  of  centered  optical  systems  by  calling  attention 
to  the  fact  that  the  geometrical  relations  of  object  and  image  are  such  that  dis- 
tinction is  often  unnecessary  ;  that  an  object  and  its  n  images  are  frequently 
spoken  of  as(w  +  l)  images;  and  that  any  image  may  be  considered  object 
or  image  at  convenience. 

The  position  and  size  of  any  image  may  of  course  be  determined  for  any 
number  of  surfaces  by  proceeding  step  by  step  from  the  object  to  the  final 
image  through  as  many  refractions  and  reflections  as  are  necessary  to  attain 
it.  This  laborious  method  is  avoided  by  the  localization  of  cardinal  points, 
which  fulfil  the  same  function  for  the  system  as  do  those  previously  described 
for  the  single  surface. 

( )f  focal  points  for  the  system  this  must  be  said  :  They  are  measured  not 
from  the  first  and  last  surface  (  Fig.  69),  but  from  two  principal  points  the 


J,  n  +  l 

<V  0  +  1 


Fig.  69.— Foci  of  surfaces  are  measured  from  the  surfaces  as  i".u.    Foci  of  systems  are  measured  from 

tlic  principal  points  "i'  th.'  system,  as  F'h'. 

"first"  and  the  "last"  whose  function-  are  described  below,  and  whose  posi- 
tions and  distances  from  their  respective  surfaces  are  designated  by  h'  and  A"'1. 

The  "-><„„,/"  principal  point,  principal  focus,  principal  plane,  nodal  point,  ami  so 
on.  arc  properly  bo  named  tor  a  single  surface,  but  lor  a  system  of  surfaces  to  use  the 
ordinal  adjective  dm-  i-  sometimes  misleading.  Weshall  use  the  term  last  principal 
point  or  (n  l  th  principal  point,  and  so  on,  giving  if  the  ordinal  adjective  and  the  number 
of  primes  that  corresponds  to  the  medium  to  which  it  appertains.  This  is  not  so  much 
an  innovation  a-  a  conscientious  adhesion  lo  the  -pirit  ami  method  of  the  notation  ami 
nomenclature  in  detail.  Something  i-  gained  if  the  accents  on  letters  serve  to  locate 
the  phenomena  to  which  their  existence  is  due.  The  ability  to  locate  other  cardinal 
point-  a  -et.  in  fact,  lor  each  medium  reached  by  waves  that  were  parallel  at  incidence 
on  tie-  system  may  not  be  of  any  special  importance,  but  it  is  or  advantage  to  have 
characters  systematically  named  ami  accented.  It  enables  us  to  read  our  record-  aright 
and  to  locate  easily  the  processes  to  which  the  characters  refer. 

I'lc  removal  of  the  origin  for  tin-  estimation  of  focal  distances  accounts  for  the 
appearance  <,f  /,'  and  h///  in  the  denominators  of  Eqs.  23  ami  •_'  i  '  infra).    The  obscurity, 


CENTERED   OPTICAL   SYSTEMS. 


115 


if  any,  vanishes  when  it  is  remembered  thai  h  and  //"'  as  distances  are,  by  convention, 
counted  plus  when  measured  into  the  system  from  the  tirst  and  last  surface  respectively. 
/•"s  and  $'s,  the  surface  foci,  arc  measured  both  right  or  both  left,  each  from  its  surface 
while  the  3"'s,  the  foci  for  the  .system,  arc  measured  both  in  the  same  direction  as  the 
/•"s  and  *'.s.  This  is  the  reason  why  in  Eq.  23  /•"  has  been  replaced  by  (&'  -  h')  while 
in  Eq.  2i,  4>///  has  been  replaced  by  (©'"-A"') 

We  may  now  proceed  to  the  consideration  of  three  media  separated  bv 


f 

y 

<r^ 

^S^^f 

<$y 

y 

^  > 

f 

F' 

ti~~     ~^^^~^^ 

^L 

■"v 

<F 

f 

/' 


g" 


J" 


/" 


V 


Fig.  70.— Combined  systems  of  optical  surfaces. 

two  surfaces.  In  this  system  are  three  images  (Fig.  70), j',j",  and/'",  each 
corresponding  to  light  distribution  in  the  similarly  accented  medium,  j" 
serving  as  image  to  j'  by  the  first  surface,  and  as  object  to  the  image  j'"  by 
the  second  surface. 

The  first  principal  focus  of  the  system  is  the  focus  conjugate  by  the  F 
surface  (Fig.  71)  to  the  first  principal  focus  of  the  0  surface.     Changing  the 


Fi<;.  71.—"  The  first  principal  focus  of  the  system  is  the  focus  conjugate  by  the  F  surface  to  the  first  prin- 
cipal focus  of  the  <£  surface." 

surface  of  reference,  thus  from  one  surface  to  another,  demands,  of  course, 
that  <j>  be  replaced  by  {(j)—  d).  <1,  being  the  distance  between  the  two  surfaces 
(cK  //),  is  obtained  from  Eq.  13  by  the  following  substitution,  and,  being 
the  only  unknown  quantity,  its  value  is  immediately  forthcoming: 


By  the  same  method  is  obtained 


-E. 


d'"-h'"      F"-d 


(23) 


(24) 


116 


GENERAL    OPTICAL    PRINCIPLES. 


Principal  Planes. — There  are  definite  reasons  for  replacing  the  one  prin- 
cipal point  on  the  polo  of  the  single  surface  by  the  two  points,  h'  and  h'", 
not  necessarily  on  any  surface.  We  may  imagine  a  plane  through  each  car- 
dinal point  perpendicular  to  the  axis  and  designated  by  the  name  of  the 
point.  On  the  principal  plane,  which  is  tangent  to  and  within  required  limits 
is  coincident  with  the  single  surface  (Fig.  72), the  end  points  of  incident  rays 


Figs.  72  and  73.— Principal  points  and  planes  as  defined  for  the  surface  and  for  the  system. 

are  arranged  in  a  configuration  that  is  identical  with  the  beginning  points  of 
refracted  or  reflected  rays;  and  it  will  be  remembered  that  conjugate  images 

approach  this  plane  together  until  their  corresponding"  points  are  united  each 
to  each  and  the  two  images  become  identical.  No  such  single  plane  can  be 
placed  in  any  system  of  optical  surfaces,  hut  two  planes  perpendicular  to  the 
axis  may  always  be  found  such  that  the  configuration  of  end  points  a'  //  // 
I  Fig.  T-'li  of  incident  rays  on  one  surface  is  congruent  with  an+1,  6n+1,  and 
,  the  beginning  points  of  reflected  or  refracted  rays  in  the  last  or  (>i  +  l)th 
mod  in  ii  i,  such  also  that  when  the  first  image  moves  toward  one  of  these  planes 
ami  disappears  in  it,  the  final  image  moves  also  toward  the  second  plane  and 
disappears  in  it.  A  little  consideration  will  convince  the  student  that  if  ./, 
the  middle  image  of  the  three  index  system  (Fig.  74),  be  so  placed  that  it  as 


A 


//• 


A 


Fig.  74.— The  cardinal  points  ol  a  three-index  system  Above,  h and  ij,  Aral  an<i  last  surfaces ;  w  and 
//",  fir-t  and  la>t  principal  points  ;  •/,  middle  Image  Below  ,  r  and  n,  tir-t  and  last  centers ;  n'  anil  //'".  first 
and  lasl  nodal  points  ;  0,  optical  centi  i 

an  object  produces  two  images  (one  by  each  surface)  equal  in  size  and  cosensal, 
these  two  images  will  lie  in  planes  which  answer  the  above  description.     We 


THE  OPTICAL    CENTER.  117 

shall  call  this  middle  image  ./.  From  these  planes  along  the  axis  conjugate 
foci  of  the  system  arc  measured. 

Whatever  transformations  take  place  within  the  system  are  comparatively  unimport- 
ant if  only  we  may  receive  light  emergent  from  one  plane  apparently  unchanged  since 
its  entrance  at  the  other.  If  also  these  planes  arc  so  related  that  the  ohjecl  approaches 
one  as  its  image  approaches  the  other,  until  in  size  and  sense  alike  each  disappears  in 
its  plane,  then  the  two  principal  plains  are  quite  tit  to  replace  the  single  plane  of  the 
single  surface,  and  Fig.  ":!.  which  we  use  here  to  illustrate  the  system,  becomes  exactly 
what  Fig.  72  would  become  if  pulled  apart  and  separated  by  the  distance  between  h' 
and  //"': 

We  now  proceed  to  find  the  position  of  this  middle  image,  indicating 

principal  foci  as  nsnal  by  capital  letters,  other  focal  distances  by  -mall  let- 
ter-. Of  course  the  distance  of  the  middle  image  from  the  F surface  will  be 
indicated  by/",  its  distance  from  the  0  surface  by  "". 

y     f"      1 


From  Eg.  18,  J  = 

„•///         $// 


25 


Divide  25  bv  20,  and 


j"       $"-9>r      J 

y  _  F"$"  —  F 
y//~  F"4>"~<i)"f" 


Bv  condition,  3—  =  l:        therefore         F"6"=  (l>"i", 

.„, 

(It"       a" 

and  ?_=2_.  (26) 

jpV/  f" 

Tims  it  is  seen  that  the  middle  image  will  have  in  the  two  surfaces  con- 
jugates that  are  equal  and  cosensal  if  it  divides  the  middle  medium  into 
parts  proportional  to  the  principal  foci  appertaining  thereto.  If  d  represents 
the  distance  between  the  surfaces  and  ./the  place  of  the  middle  image,  Jh 

d  V" 
will  be  equal  to  /"  =  F„      ^„.     The  conjugate  focal  distance  Jh '  may  be 

found  by  substituting  this  value  for  /"  in  Eq.  13. 

In  like  manner  Eq.  13  applied  to  the  <1>  surface  will  give  the  value  of  (j)'" 
(1  (!>" 
for  h'"  from  that  of  <p"  =  (j)lr 

It  is  hardly  necessary  to  repeat  that  h'  and  //"'  used  as  magnitudes  define 
the  distances  of  the  principal  points  from  their  surfaces:  they  arc  usually 
considered  positive  when  in  the  middle  medium.  It  is  not  uncommon  to 
give  to  an  optical  system  a  symmetrical  notation,  so  that  the  direction  /"'  F 
h! h  are  considered  positive  when  each  is  measured  from  it-  own  principal 
plane  away  from  the  other. 

Optical  Center. — It  remain-  for  us  to  determine  what  point  or  point-. 
ifany,maybe  found  along  the  axis  of  the  system  having  properties  like  those 
of  the  centers  of  single  surfaces.  There  i-.  generally  speaking,  ii"  point 
through  which  a-  through  a  center  light  will  pa—  withoul  change  of  direc- 
tion. Only  in  the  special  case  where  the  center-  of  the  surfaces  are  coin- 
cident can  tin-  happen.  One  may  assume,  however,  that  somewhere  is  a 
point  -o  situated  that  light  passing  through  it  will  be  equally  and  oppositely 
refracted  at  the  two  surfaces.  In  this  case  the  first  and  final  path-,  though 
not   necessarily  identical,  must   !><'  parallel. 

The  optical  center  i-  the  name  by  which  tin-  point  i-  known,  and  to 
determine  it-  place  we  make  use  of  Equation  22.  By  it  the  linear  dimen- 
sion- of  0  ;ii'-  < nected  with  those  of  it-  first  and  lasl  image  ;  thus, 

it'j'  t:u.  «'      p"Otftn«"      i'"'j'"  tan  «'"• 


IIS 


GENERAL    OPTICAL    PRINCIPLES. 


We  may  drop  out  the  middle  term  of  this  equation,  and  as  the  condition 
imposed  is  thai  a'  is  equal  to  a'",  the  other  tangents  also  disappear,  giving 

„>y    u'-y\  (28) 

the  condition  to  which  we  must  conform  in  Locating  the  three  points.  By  the 
usual  notation  we  use  g  to  measure  distance-  from  the  first  center,  and  j  those 
from  the  second,  and  remember  that — 

-/'/•'"     ,/"/•",     and     fifl"$"=fi"$/";  (29) 

which  may  be  easily  proved. 

Referring  to  Fig.  70,  whore  the  distribution  along  the  axis  of  the  cardinal 
points  of  the  two  surfaces  is  shown  in  its  relation  to  0  and  its  two  images,  we 

have  two  expressions  for  the  relative  size  of  eaeh  pair  : 

./'    £_       '■'" 

0    g"     g"-F'' 


y,„  _ 


</'' 


0      ) "     y"  -  <P 


ff  —  rt>>" 


(30) 

(31) 


Dropping  out  the  middle  terms  and  multiplying  Eq.  30  by //' and  Eq.  31 

bv    «"', 

(t'y  _  n'F" 

O       g"-F' 


n"'<p' 


0 


r 


(j)'" 


(32) 


The  two  right-hand  members  are  equal  by  Eq.  28.  Expressing  the  equality 
of  the  two  left-hand  members  after  substituting  the  numerators  from  Eq.  29 
and  dividing  by  //', 

g"-F'      y"-Q'" 

By  composition  and  alternation, 

'     =2-.  (34) 

Calling  8  the  distance  between  /and/^,  we  find  here  again,  for  the  optical 
center  a-  for  the  middle  image,  we  must  divide  a  distance  into  parts  propor- 


i  i'..  .       l  Ji-   optical  center  of  a  lens.    The  cross  of  the  axis  with  a  line  connecting  the  surface  ends 
of  two  parallel  radii  i>  the  optical  center. 

tional  to  the  principal  foci  of  the  two  surface-,  but  this  time  we  must  use  the 

principal  foci  for  ray-  that  are  parallel  in  the  middle  medium,  whereas  before 
we  used  the  principal  foci  for  rays  that  wen  parallel  outside  the  middle 
medium. 


NODAL    POINTS. 


119 


In  a  three-index  system  the  optical  center,  and  in  the  lens,  where  the  first 
and  last  media  are  the  same,  both  middle  image  and  optical  center  can  be 
located  geometrically,  as  in  Fig.  75.  The  surface  ends  of  any  two  parallel 
radii  arc  connected  by  a  straight  lint' ;  its  cross  with  the  axis  is  the  optical 
center  of  the  lens.  . 

The  image  of  the  optical  center  in  each  surface  gives  the  nodal  point  cor- 
responding to  that  surface  ;  it  may  he  found  by  Eq.  13  as  above,  remembering 
that 

6F'  , 

=9' 


F'  +  ( 


and 


#0" 


and 


that 


F/  +  <p/// 


=r 


,:;.-,, 


g//+r=f//     and     y//+p  =  ^/ 


These  two  points  are  called  nodal  points,  and  transformations  of  waves  and 
ravs  incident  to  the  passage  of  light  from  one  of  these  points  to  the  other 
may  in  many  cases  be  ignored,  for  we  know  that  what  goes  into  the  system 
as  if  directed  to  n'  will  come  out  unchanged  in  direction  as  if  from  /;'".  So 
here,  again,  we  have,  as  in  the  case  of  the  principal  points,  lost  space,  and 
the  geometrical  constructions  which  give  graphic  solutions  with  single  snr- 


F.  h-  h»    »■»>>■         F- 

Fig.  7f>.— Construction  for  finding  the  conjugate  to  any  radiant  when  the  cardinal  points  arc  known. 
A  is  the  axis  of  an  optical  surface;  />',  the  axis  of  a  system  of  surfaces.  Cardinal  planes  are  indicated  by 
the  usual  letters,  cardinal  points  are  where  those  planes  intersect  the  axes.  To  find  the  conjugate  oi 
any  radiant/  in  the  surface  A,  draw  two  rays,  one  parallel  to  the  axis,  one  through  the  center  ol  the 
surface.  The  former  after  refraction  must  pas*  through  the  principal  focus:  therefore  its  path  is  deter- 
mined. The  direction  of  the  latter  is  unchanged  by  refraction.  Its  cross  with  the  first  ray  is  the  focus 
f"  conjugate  to  /'.  For  a  system  the  method  is  the  same,  except  that  for  incident  rays  the  surface  and 
center  are  replaced  bythe first  principal  plane  and  first  nodal  point.  Refracted  rays  are  drawn  from 
the  last  principal  plane  and  last  nodal  point.  It  will  be  noticed  thai  the  second  picture  is  identical  w  it li 
the  first,  except  thai  all  the  lines  have  parted  cither  at  the  surface  or  the  center,  and  the  diagram  has 
been  lengthened  by  the  break  an  amount  equal  to  n'  n'". 

faces  may  be  used  equally  well  for  systems;  but  every  picture  thus  formed 
will  be  broken  in  two,  some  of  its  lines  parting  at  the  principal  plane,  some 
at  the  center.  The  two  halves  being  separated  by  translation  parallel  to  the 
axis,  there  will  result  a  similar  construction,  except  that  the  surface  h  takes 
on  a  finite  thickness  equal  to  h'  h'",  and  the  center  n  instead  of  being  a  point 
is  stretched  out  into  a  line,  reaching  from  n'  to  n"',  and  equal  in  length 
to  h'  h"'. 

It  is  hardly  possible  in  an  article  as  short  as  this  musl  be  to  include  rigid 
demonstrations  of  everything  necessary  to  its  usefulness.  Little,  so  far,  has 
been  omitted  which  was  necessary  to  show  both  geometrical  and  functional 


120  GENERAL   OPTICAL   PBINCIPLES. 

relations  existing  between  the  cardinal  points  of  the  optical  system  and  the 
center,  the  pole,  and  the  two  foci  of  the  single  surface. 

The  student  who  desires  to  pursue  the  matter  in  the  same  thorough  manner 
must  be  referred  to  Helmholtz  for  whatever  of  proof  is  omitted  from  the 
remaining  pages. 

By  a  continuation  of  the  methods  used  above  it  can  be  proved  that  when 
the  principal  point-  are  located  for  any  system  of  two  surface-,  and  when  the 
principal  foci  of  the  system  are  measured  from  these  points;  that  when  the 
Qodal  points  are  placed,  and  §',  §'",  //',  and  ;/'"  he  usc-*l  as  above  to  indicate 
distances  from  them  ;  and  when,  as  in  Eq.  17,  //'  and  u"  are  used  to  measure 
distances  away  from  the  center,  with  the  principal  loci  as  origins, — then  not 
only  Eq.  13,  but  also  Eqs.  17  and  is,  apply  equally  well  to  the  system  as  to 
the  surface,  if  only  allowance  he  made  for  the  lost  space  between  the  prin- 
cipal  planes  and   between   nodal   points. 

This  fact  i-  of  great  practical  utility,  as  it  gives  no  restriction  at  all  in 
cases  where  the  thickness  of  the  lens  is  small  as  compared  with  its  focal 
length.  In  most  of  the  cases  where  spectacles  are  usvd  the  thickness  of  the 
glass  may  he  ignored.  When  we  add  to  this  statement  the  extension  which 
i-  warranted  by  fact  that  not  only  may  surfaces  he  compounded  into  systems 
without  change  of  properties,  but  these  systems  still  further  compounded,  the 
one  with  the  other,  it  will  appear  that  for  every  -el  of  surfaces,  however 
many  in  number,  an  equivalent  set  of  eight  points  may  he  determined  as 
follow-:  The  optical  center,  the  middle  image,  the  two  principal  points,  the 
two   no dal  points,  and   the   two  foci. 

The  following  formulae  give  the  places  of  the  cardinal  points  where  three 
media  are  concerned.  They  are  applicable  to  media  separated  either  by 
surfaces  or  systems,  if  only  it  he  remembered  to  measure  <l  from  the  last  prin- 
cipal point  of  the  fust  medium  to  the  first  principal  point  of  the  last  medium, 
and  to  measure  the  distance  between  nodal  points  of  the  component  systems 
in  like  manner. 

In  Fig.  7  I.  where  d  is  A  ft  and  d  is  n  v,  we  may  let  x'  and  x"  represent  the 
sections  of  d  by  •/,  and  //'  and  //"  the  sections  of  o  by  0.     (See  also  Fig-.  70.) 

77/-  middle  image  .1  divides  the  distance  d  into  x'  and  x"  : 


.III  X  , 


(36) 


The  optical  center  divides  the  distance  d  into  //'  and  //" 

On       y>  F'lS  "'r"'S       ,1 

J      /••"     iJj"     ,,",  /■"•      $»      I 

0      „,/        <l>'"*  u.'"9"i 

/■"    </'"     v."  /•'"  +  <t>")   J 


(37) 


From  Fig.  75  it  is  easily  proved  that  d  and  d  are  similarly  divided  by  0. 
We  may  therefore  substitute  d  for  o,  //  for  n,  and  35  for  v  in  Equations  o7, 
and  so  obtain  the  formula?  for  the  position  of  the  optical  center  as  measured 
from  the  two  surfaces. 

Principal  Points. — h'  and  //"  as  linear  magnitudes  are  positive  when 
measured  from /i  and  37,  the  extremes  of  </  toward  the  middle  medium: 

/  /    •    <!>■■     ,/' 


It'" 


/•'"    l/>"    ./' 


(38) 


PRINCIPAL   FOCI. 


121 


_  Principal  Foci. — &'  and  3*'"  arc  considered  positive  when  each  principal 
point  conies  between  it-  focus  and  the  other  principal  point: 


& 


F'W" 


*' 


(39) 


JP//Q/// 

F"     </,"-   ,f 

Nodal  points,  n'  and  n'"}  are  measured  inward  from  the  extremities  of  d 

F'd + F//0///  -  F'&' 


a '    ;/t3' 


■  &'  =  ■ 


,///_  ;,/// 


=  K' 


■  »z_gi///  = 


F"+$"-d 
$'"d  +  F'$" -  F"ii>" 


(40) 


From  these  last  equations,  by  the  substitution  of  the  values  of  the  F's 
and  the  $'»,  as  obtained  by  Eqs.  14  and  15,  are  deduced  the  simplest  expres- 
sions for  the  cardinal  points  of  any  system.  They  flow  from  the  above 
equations  without  complication  or  difficulty,  and  are  obtained  by  the  ordinary 
processes  of  elimination.  Expressed  in  terms  of  fi' ft" ft'" ,■  and  p,  they  reduce 
to  vulgar  fractions  having 

/i"(fi"'-ft")r+fi"(/i"-n')P-(fi'"-ii"W-p')d  =  N,  11 

for  a  common  denominator.  This  term,  being  constant  for  the  system,  may 
be  calculated  once  for  all,  and  so  is  abbreviated  to  N,  there  being  no  phys- 
ical significance  here  intended.  It  is  merely  an  abbreviation  borrowed  from 
Helmholtz. 

These  are  the  values  : 


&' 


fi'fi"rp 


,,_li"  u'"rp 


&'"  = 


N 


p'(p»-p'")rd 
N 


h,„ -?'"(/*' -I*")pd 
N 


=  p'(ji"-(i'")rd  +  li"iti'"-/i')rp 

N 
n,„  =  ?"'(?' -p")pd  +  fi"{,u'-p'")rPi 


H=d"-&'=  fiz_  szz  =  d-Az_^z//; 

W-p'){li»'-p''){r-P-d) 

N 


d-n'-i 


1-J 
(43) 

(44) 
(45) 


Eqs.  39  to  45  may  be  used  without  restriction. 

These  general  formulae  may  be  much  simplified  by  the  imposing  of  cer- 
tain conditions  which  often  occur  in  practice.  Thus,  if  the  middle  medium 
is  very  thin,  d  may  be  considered  equal  too.  In  t  hat  case  //  is  also  equal 
to  o,  and  h,  //, ./,  //",  and  rt  all  coincide  ;  so  the  hist  term  in  N  disappears,  and 
our  system  is  practically  described  by  the  two  values  of  3'  and  W.  The 
fir-t  two  terms  only  of  their  denominators  being  left,  we  write  in  full,  ;i> 
follows  : 

f-'r  p 


3«/ 


^///_yU//)r+(/U//_/,/)p' 


»"  =  . 


ir      r  n 


{fi'"-p")r+(fi"-fi')p 

If  both  radii  are  now  supposed  alike,  the  middle  medium  drops  out  of  the 
account, 


p'r 


3-" '  =  -' 


V 


17 


L22  GENERAL   OPTICA  I.   PRINCIPLES. 

and  we  have  a  single  optical  surface  between  the  firsl  and  third  medium — a 
condition  realized  in  the  passage  of  light  through  the  cornea  and  aqueous. 

A  -till  more  important  condition  that  may  he  imposed  on  a  system  of  two 
surfaces  is  thai  the  firsl  and  Last  media  shall  have  the  same  index.  This  gives 
the  leu-  proper. 

The  Lens.  —  It  would  seem  the  part  of  wisdom  to  confine  the  term  "lens" 
to  such  combinations,  and  to  use  the  word  "system"  lor  others.  In  this  way  a 
distinction  i-  made  which  is  in  keeping  with  the  derivation  of  the  word  and 
with  ordinary  mechanical  constructions,  and  which  is  continually  in  evidence 
through  the  simplicity  of  the  resulting  formulas,  while  a  lens  that  is  used  as 
a  window  between  two  different  media  is  such  only  in  name,  and  the  name  so 
used  i-  definitive  only  of  a  triviality.  We  shall  use  the  word  "lens"  only 
for  two-index  systems.  The  crystalline  lens  of  the  eye  is  not  excluded  from 
this  category,  as  the  aqueous  and  vitreous  are  of  the  same  refractive  power. 

Reducing  Kip  41  to  45  by  letting-  p"1  u.' y  we  have  the  formulae  charac- 
teristic of  lenses  : 

g,/=g,///  = p'li"rp (48) 


p-'dr 

(fi"-(i')d+fi"(p-r)' 
li'dp 


(fi"-tt')d  +  it"(p-r. 


(49) 


fl  =  d .  (p"-p')(d  +  p-r)  (5Q , 

{n"-p')d+pf'{p-r) 

Fig.  77.  illustrative  of  the  preceding  paragraphs,  shows  the  disposition  along  the 
a\i-  of  the  cardinal  points  of  several  optical  systems,  a  is  a  single  optical  surface,  and 
to  it  corresponds  the  aphakic  eve  and  the  schematic  eye  of  Listing,  b  is  the  general  case 
of  two  surfaces  separating  three  media,  all  of  different  indices.  In  this  the  nodal  points 
and  the  principal  points  are  not  identical,  c  is  a  true  lens  as  described  above,  in  form 
resembling  the  crystalline.  In  it,  as  in  defg,  other  lenses,  principal  points,  and  nodal 
points  coincide,  and  it  may  be  noted  that,  assuming  u"  >  »'  and  d  less  than  r  p,  positive 
lenses  are  thicker  in  the  middle. 

Double  convex  and  double  concave  lenses  have  their  principal  points  between  the 
curved  surfaces.      In   plano-convex  and  plano-concave  lenses  A,  A"7,  and  J  all  come 

ther  on  the  curved  surface.  In  the  meniscus  they  pass  out  of  the  substance  of  the 
lens  and  arrange  themselves  in  the  medium  farthest  from  the  centers  of  curvauire. 

/  corresponds  to  the  human  eye,  /•  to  the  eye  with  a  spectacle  lens  before  it. 

The  continuity  of  a  series  of  systems  is  seen  by  looking,  for  example,  at 
system  6,  and  poting  that  the  point  31'"  in  the  relevant  formulas  is  such  a 
function  of  /'"'  and  p  thai  one  may  be  increased  as  the  other  is  decreased 
without  altering  the  place  of  31"'  ;  so  thai  wherever  in  a  system  of  three 
media  3*'"  happen-  to  be  placed  by  making  the  compensatory  changes  in  p 
and  "  .  "'"  may  be  broughl  to  We  equal  to  y."  without  altering  the  places 
of  the  principal  foci.  In  this  way.  without  changing  the  disposition  of  the 
foci,  /<"'  may  be  varied  until  it  i-  equal  to  r,  in  which  case  h'  will  be  equal 
to  nothing.  In  other  word-,  the  single  surface  may  he  treated  as  a  system 
in   which   the  third   index  of  refraction  is  equal   to  the  second,  and  whose 

rod  surface  has  an  infinite  curvature,  and  whose  center  and  surface  are 
both  coincident  with  the  center  of  the   firsl    surface.     Such  a  substitution  of 

values  may  always  be  made  in  the  use  of  Eqs.  17  to  50,  where  oj f  the 

component   systems  is  a  single  surface. 

The  Diopter. — Consistent  with  any  scheme  thai  measures  the  direction 
of  light-propagation  as  positive,  the  curvature  of  the  wave  is  considered  posi- 
tive when  it-  center  i-  in  front  of  it,  for  it-  radiu-  inu-t  be  then  positive,  and  SO, 


THE  DIOPTER. 


L23 


whether  mirror,  refracting  surface,  or  sys- 
tem, it>  strength  as  an  optical  factor  is  esti- 
mated by  the  curve  of  the  wave,  the  con- 
vergence of  the  rays  that  may  be  produced 
by  it.  The  unit  which  is  now  universally 
and  almost  exclusively  used  iu  the  esti- 
mation of  the  strength  of  lenses  is  the 
diopter,  suggested  by  Xagel  and  named  by 
Monoyer.  It  is  to  the  credit  of  ophthal- 
mologists that  in  their  optical  work  inches 
are  being  fast  forgotten.  Lenses  are  thus 
described  by  giving  to  each  the  reciprocal 
of  its  focal  length  in  meters,  and  placing 
before  this  number  the  sign  -f-  or  -  to 
denote  whether  it  has  a  real  or  virtual 
focus  for  parallel  rays.  The  convenience 
of  this  method  is  its  chief  recommendation, 
as  combinations  of  lenses  are  subject  to 
computation  by  simple  addition  in  an  all 
but  universal  standard  of  measurement, 
instead  of  requiring  pencil  and  paper  com- 
putations in  terms  that  are  none  too  rapidly 
becoming  archaic. 

The  focal  length  of  a  lens  whose  dioptric 
number  is  given  is  of  course  the  reciprocal 
of  that  number  in  meters,  or  one  hundred 
times  that  reciprocal  in  centimeters. 

In  comparing  the  two  systems  it  may  be  said 
of  one  that  it  designates  the  lenses  by  their  f'oeal 
lengths  in  inches,  the  other  gives  to  a  lens  its 
additive  value  in  diopters.  To  reduce  accurately 
from  either  system  to  the  other,  one  divides  39.37 
by  the  number  of  the  lens.  A  sufficient  approx- 
imation for  all  test-case  examples  is  to  use  40  as 
the  dividend.  Thus  a  glass  of  8-inch  focus  is 
equal  to  ")  diopters.  A  three-diopter  lens  lias  a 
focal  distance  of  one-third  of  a  meter — that  is,  33 
cm. — or.  if  its  old  number  in  inches  is  desired, 
divide  40  by  3.  It  is  approximately  No.  13; 
accurately,  it  is  13.123,  unless  the  method  of 
calculation  has  proved  superior  to  the  method  of 
it>  original  manufacture  and  measurement,  which 
for  ordinary  spectacle  lenses  is  quite  likely  to  he 
tin-  case. 

For  all  thin  lenses  the  distance  between  the 

principal  planes  may  he  ignored,  and  the  equa- 
tions that  have  been  used  for  surfaces  may  he 
used  without  restriction;  and  in  their  use  they 
admit  of  such  simplification  as  comes  from  put- 
ting S/  &'"  §'  %'".  There  are  but  three 
cardinal  points  to  such  a  lens.  The  nii<l<llr 
image,  the  optical  center,  the  two  nodal  points,  and 
the  two  principal  points  are  all  united  in  a  single 
point    halfway  between  the  two  principal  foci. 

The  strength  or  'power  of  a  leu-  is  the 
convergence  that  it  can  produce  iii  parallel 
rays.  It  i<  also  the  curvature  it  can  give 
to  a  plane  wave   thai    passes  through    it  ;    it 


ihr 


4    b 


\ 


i 


i  re    77.    Showing  ill'-  relative  positions 
principal  point*  and  nodal  points 
for  diflfi  renl  systems  of  surfai 


124 


GENERAL    OPTICAL   /7, IXCIPLES. 


is  also   the   reciprocal  of  its   focal  distance.       Either   one  of   these   defin- 
itions   implies  the   other.       Whichever  way  it  is   defined,—    is   its  meas- 

ure.  This  definition  musl  1»«'  modified  for  a  single  surface  or  a  system 
other  than  a  lens.  The  dioptric  strength  of  such  a  system  is  consistently 
considered  to  be  the  measure  of  the  curvature  in  air  or  vacuum  which  it  will 
impress  on  a  wave  that  was  Hat  before  reaching  it.  Some  such  convention 
musl  be  adopted,  as  the  convergence  produced  is  greater  on  the  side  of  the 
Lesser  index,  though  the  system  is  the  same  (Fig.  78).     With  this  limitation 


Fig,  7S.— For  a  single  surface  the  convergence  produced  in  parallel  rays  is  greater  on  the  side  of  the 

loser  index. 

we  can  evaluate  systems  as  well  as  lenses  in  diopters,  and  the  value  will  he 
the  index  of  the  last  medium  divided  by  the  length  of  the  principal  focus  in 
that  medium.  With  this  convention  the  dioptric  value  of  a  system  is  the 
same   for   lighl    travelling  in   either  direction. 

It  is  hardly  necessary  to  define  further  the  word  " focus,"  or  the  word 
"conjugate,"  which  has  been  used  so  often  to  signify  that  two  points  or  two 
configurations  of  points  are  associated  as  object  and  image  through  the  agency 
of  some  surface  or  system. 

Virtual  and  Real  Images. — But  the  distinction  of  virtual  and  realh&s 
not  been  mentioned  thus  fir  in  relation  to  foci  and  images.  A  focus  or  image 
is  real  when  it  is  a  place  from  which  light  really  emanates  or  to  which  it 
actually  attain.-.  It  is  virtual  when  the  physical  conditions  that  it  repre- 
sents, though  having  no  real  existence,  are  such  that  they  would  account  for 
the  reactions  taking  place  at  some  other  point  if  there  were  no  break  in  the 
homogeneity  of  the  intervening  medium. 

Thus  uc  see  in  Fig.  79  light  from  any  point  of  j'  falls  on  the  screen  /■'  as  if  coming 
from  j"'y  though  no  light-waves  or  ray-  enter  the  medium  behind  the  reflecting  surface. 

Again,  were  the  surface  a  refracting  surface,  the 

light  would  fall  on  the  screen  /"  as  if  coming  from 

/'  ,/",  the  virtual  image  <»f ,/'.  though  none  of  the 

waves  that  are  disposed  as  if  coming  from  /'"are  in 

>       the  medium  in  which  j"  is  placed.     We  may  say, 

consistently  with  the  notation  of  this  article,  that 


Fig  v.*  — Virtinil  [magi       •  by  refrac-  Fig  -,|     Virtual  focus  of  concave  lens, 

tions,  /'"  by  refractions. 

when  the  image  i  finds  itself  in  a  medi whose  a nta  are  different  from  it-  own,  the 

image  is  virtual.     Examples  of  real  images  are  seen  in  Figs.  72,  73,  and  78.     Fig.  80 
show-  a  concave  lens  with  it-  virtual  focus  al   '•>///. 


(AFDLXAL    I'OIXTS   OF  THE  EYE. 


125 


We  take  note  here  that  the  general  forms  of  the  lenses  given  in  Fig.  77 
may  be  described  by  the  following  terms:  Double  convex,  double  concave, 
plano-convex,  plano-concave,  concavo-convex,  or  convexo-concave;  the  last 
variety  when  thinnest  on  the  edges  is  called  a  meniscus. 

Applying  Eqs.  48  to  oO  to  obtain  the  characteristic  properties  of  this 
group,  one  easily  proves  that  the  principal  points  of  the  double  convex  and 
the  double  concave1  variety  are  between  the  two  surfaces;  that  in  the  piano- 
lenses  they  are  both  united  on  the  curved  surface  ;  that  for  the  concavo-con- 
vex type  they  pass  out  of  the  substance  of  the  lens  on  the  side  of  the  greater 
curvature. 

It  will  be  found  also  that  when  radii,  surfaces,  and  indices  are  so  arranged 
that  the  strength  of  the  lens  is  negative — that  is,  when  the  lens  has  a  virtual 
focus  <*F"  falling  on  the  left  in  the  figure  and  31'  on  the  right — then  h'  and 
hi"  are  also  transposed,  each  being  found  between  the  other  and  its  own  prin- 
cipal focus.  With  one  exception  the  lenses  that  are  thickest  in  the  middle 
are  of  positive  focal  length,  and  all  positive  lenses  whose  index  is  greater 
than  that  of  the  surrounding  medium  are  thicker  in  the  middle  than  at  the 
edges.  The  one  exception  of  a  minus  lens  that  is  thinner  at  the  edges  occurs 
when  r  is  greater  than  p,  when  d  is  greater  than  the  distance  between  the 
centers,  and  when  //'  {p  —  r)  is  algebraically  less  than  (//'  —  fif)d.  Equation 
49  will  under  such  conditions  give  a  minus  value  for  "&'". 

The  human  eye,  as  has  been  said,  is  a  centered  system  of  optical  sur- 
faces like  that  given  in  Fig.  77  (j).  We  copy  here  from  Czapski's  table  of 
dimensions  and  constants,  given  for  reference  in  his 
book  on  optical  instruments,  where  figures  collected 
from  various  sources  by  Helmholtz  furnish  what 
might  be  called  a  composite  reproduction  of  the 
type,  and  where  also  are  tabulated  the  results  of  care- 
ful measurements  and  calculations  in  a  single  case  by 
Tscherning.  Along  the  vertical  line  of  Fig.  81  are 
the  cardinal  points  and  other  points  of  interest  as 
arranged  on  the  axis  of  the  eye.  Between  cornea 
and  retina  the  spaces  are  correctly  given  on  an 
enlarged  scale  of  2.5  to  1.  All  distances  are  in 
meters,  so  that  when  applied  to  use  in  the  above 
formulae  the  strength  of  a  lens  or  system  will  be 
expressed  in  the  diopter,  the  familiar  unit  of  the  test- 
case. 


.0*49Oo|_  Ml 
Afc. 
013700 1  Afe. 


~outoo_  _fi 


03IIOO. 
.  OSbiOi . 
OUSOCL. 


TTc 


The  cases  in  which  practice  suggests  or  renders  useful 
the  application  of  the  above  formulae  are  not  infrequent. 
We  mention  only  two:  One  a  case  of  axial  myopia  in  which 
a  supposition  that  the  dioptric  system  of  the  eye  has  remained 
the  same,  hut  the  retina  has  been  displaced  backward  an 
amount  which  is  easily  calculated  from  the  strength  of  the 
glass  needed  to  give  distinct  distant  vision.  Suppose  the 
size  of  the  retinal  image  is  required  for  the  corrected  eye. 
The  correcting  lens  is  usually  made  as  thin  as  possible; 
hence  its  optical  center  and  all  the  cardinal  points  except 
the  two  foci  are  at  its  geometrical  center.  F"  is  minus, 
and,  measured  along  the  axis,  F'  is  plus;  (/  is  the  distance 
of  the  correcting  lens  from  the  cornea  added  to  0.001 7oI>2, 
the  distance  of  the  cornea  in  front  of  //'  of  the  eye.  Both 
foci  of  the  emmetropic  eye  may  be  obtained  from  the  table, 
and  thus  the  figures  are  all  obtainable  for  getting  principal 

points  and  nodal  points  for  the  complete  system  through   the  application  of  formula 
36  to  41. 


4  Co. 

Cm. 


FIG.     81.— Tile     rar.lin.il 

points  of  the  human  eye, 
measured  from  the  cornea 
From  cornea  to  retina,  en 
larged  to  a  i- 


126  GENERAL    OPTICAL   PRINCIPLES. 

Another  interesting  case  occurs  when'  the  Lens  has  been  removed  and  a  strong  plus. 
glass  is  worn.  The  nodal  points  of  the  glass  may  be  calculated  without  difficulty,  <>r, 
it  used  for  reading,  a  plano-convex,  with  the  flat  side  in  front,  will  be  acceptable  to  the 
patient,  and  its  nodal  points  arc  on  the  convex  surface. 

The  surface  of  the  cornea  is  the  principal  poinl  of  the  eye,  and  its  curvature  read 
from  the  ophthalmometer  locates  its  center,  which  is  the  nodal  point  for  the  aphakic 
eye,  or  this  center  may  be  assumed  to  be  like  the  average  and  supplied  from  Fig.  81. 

It  can  be  hardly  thought  necessary  to  guide  the  student  farther,as  he  1ms 
now  all  the  points  of  the  component  systems  which  tire  required  to  give  the 
cardinal  points  of  the  equivalent  or  resultant  system,  and  these  being  found, 
the  magnification  is  forthcoming  by  Eq.  18  or  Eq.  2(>. 

Astigmatic  Surfaces  and  Pencils. — We  pass  now  to  a  very  brief 
consideration  of  astigmatic  surfaces  and  pencils.  We  have  thus  far  assumed 
that  the  optical  surfaces  were  spherical — that  is  to  say,  surfaces  of  revolution 
about  their  common  axis,  and  whose  principal  sections  were  circular. 

It  happens  that  such  is  not  always  the  case.  Imperfections  of  the  cornea 
or  lens  give  for  the  surfaces  of  the  eye  itself  imperfect  approaches  to  sphericity  ; 
and  even  if  that  were  not  so,  a  displacement  of  any  center  or  radiant  focus 
from  the  axis  of  the  system  produces  the  same  change  in  the  transmitted 
or  reflected  pencil  that  would  result  from  imperfect  curvature  of  the  sur- 
face. 

For  the  small  pencils  with  which  we  deal  there  is  only  one  form  of  astig- 
matism. It  is  that  which  would  be  given  to  a  pencil  of  light  by  the  optical 
action  of  a  toric  surface.  A  sphere  is  the  surface  developed  by  the  revolution 
of  a  circle  about  one  of  its  diameters.  A  torus  is  developed  by  the  revolution 
of  a  circle  about  any  line  that  is  in  the  same  plane,  but  not  a  diameter. 
Roughly  speaking,  when  the  axial  line  is  a  cord  the  torus  is  shaped  like  an 
apple  with  a  dimple  in  its  blossom  end  equal  to  that  in  its  stem  end.  When 
the  axial  line  is  not  a  cord,  the  torus  is  like  an  anchor  ring.  When  the  line 
is  at  an  infinite  distance  from  the  circle  the  toric  surface  is  a  cylinder. 

The  toric  lenses  in  use  are  supposed  to  be  such  as  might  be  sliced  from  a 
toric  surface  by  a  plane  parallel  to  its  axis  of  development.  Such  a  lens  is 
centered  optically  when  both  its  centers,  the  center  of  the  circle  and  the  cen- 
ter about  which  in  its  development  the  circle  revolves,  are  on  the  axis  of  the 
system. 

it  will  need  but  little  consideration  to  convince  the  reader  that  in  two 
different  sections  of  such  a  surface  the  problems  relative  to  the  transmission 
of  light  will  be  exactly  similar  to  those  which  we  have  just  considered  as  true 
for  any  plane  whatever  of  the  spherical  surface. 

A  plane  section  of  the  toric  surface  may  be  taken  perpendicular  to  the 
circumference  of  the  developing  circle,  or  coincident  with  that  circumference, 
and  in  either  ease  it  will  be  a  circular  section.  In  one  case  it  will  be  the  sec- 
tion of  least,  and  in  the  other  the  section  of  greatest,  curvature,  with  foci  cor- 
respondinglj  shorter  and  longer  than  in  other  sections  ;  and  in  each  case  may 
the  optical  c litions  be  described  and  determined  by  the  same  laws  and  for- 
mula? a-  those  previously  considered  lor  a  spherical  surface,  which  is  a  sur- 
face of  circular  section. 

The  sectii f  the  toric  surface  through  it-  two  centers,  both  of  which  we 

suppose  to  be  on  the  axis  of  our  optical  system,  may  take  place  through  a 
meridian  not  coincident  with  the  section  of  greatest  or  least  curvature,  and 
then  consecutive  ray-  from  any  axial  point  will  not  be  reunited  by  this  sur- 
face "ii  tin-  axis,  l>nt  near  it.  The  result  i-  that  an  axial  pencil  directly  inci- 
dent on  such  a  surface  ha-  the  characteristics  that  are  portrayed  by  Fig.  82, 
showing  the  general  form  of  the  pencil  from  A.ubert,  and  the  distribution  of 


ASTIGMATISM. 


127 


its  component    rays  as  in  a  diagram  by  Edward  Jackson   from    Norris  and 
Oliver's  System  of  Diseases  of  tJu    Eye. 

The  point  along  the  axis  that  can  be  mosi  satisfactorily  utilized  a-  a  focal 
point  i-  at  F0  in  the  figure.  It  is  the  place  where  the  rays  are  collected  into 
thf  smallest  bundle.  It  i-  called  "the  circle  of  least  confusion,"  and  its 
place  between  /*',  and  F,  divides  that  distance  in  such  ratio  that  it  is  a  fourth 


Fig.  82.— Showing  the  distribution  of  rays  and  focal  lines  in  an  astigmatic  pencil  i  h  FF '  F,  i  =  —  1. 

harmonic  to  Fx  and  Fr  Consequently,  it  is  determined  by  the  same  formulae 
and  constructions  that  arc  used  to  locate  the  conjugate  foci  in  a  spherical 
mirror  (see  pp.  108  and  113). 

Astigmatism  is  usually  an  anomaly  and  not  a  desideratum.  It  is  meas- 
ured and  discussed  in  terms  of  the  diopter,  which  have  proved  equally  use- 
ful whether  applied  to  pencils  or  lenses. 

The  amount  of  astigmatism  is  the  strength  of  a  lens  which  under  ordinary 
optical  conditions  would  change  the  convergence  of  the  meridian  of  lea>t  to 
that  of  greatest  curvature,  or  rive  eersa.  The  correcting  lens  must  be  essen- 
tially a  toric,  and  one  also  whose  focal  anomaly  is  exactly  equal  and  opposite 
to  that  of  the  pencil  to  be  corrected.  For  simplicity  the  cylinder  is  usually 
chosen,  and,  having  only  one  finite  focus,  it  is  designated  by  the  dioptric  value 
of  the  correction  required. 

In  correcting  the  anomalies  of  refraction  and  accommodation  it  is  not  in 
general  possible  to  use  a  simple  lens,  either  cylinder  or  sphere.  One  gives 
thi  cylinder  necessary  to  make  either  of  the  extreme  foci  coincident  with  the 
other,  and  then  adds  whatever  of  spherical  correction  is  required.  The  par- 
ticular combination  of  cylinder  and  sphere  that  is  used  is  more  a  matter  of 
commercial  than  of  physiological  interest. 

The  astigmatism  that  has  been  described  as  produced  by  a  toric  lens  is 
the  only  kind  that  has  been  successfully  and  systematically  corrected.  It  is 
for  "thin  pencils"  the  only  kind  that  exists,  and  tor  pencil-  as  large  as  may 
enter  the  pupil  it  is  the  only  kind  that  merits  attention,  aberration  being  so 
well  known  by  its  own  name  as  to  be  considered,  if  at  all,  under  a  separate 
head. 

The  classification  of  astigmatism  into  "simple"  "  compound"  "  myopic" 
"hyperopia"  and  so  on  may  have  it<  clinical  advantage-,  but  it  seems  ti- 
the writer  to  be  of  very  doubtful  propriety.  We  deal  only  with  one  kind  "f 
astigmatism.  It  may  have  its  existence  in  a  myopic  eye,  a  paper-weight,  or 
in  the  glass  door  of  a  Gothic  house,  but  a  nomenclature  that  takes  cognizance 
of  such  facts  i-  confusing  to  the  novice  unless  he  clearly  understands  that  the 
astigmatism  and  it-  method  of  correction  is  the  same  in  every  case. 

For  those  who  find  it  convenient  to  classify  astigmatism  by  it-  associated 
anomalies  it  may  be  stated  that  when  the  retina  of  the  eve  at  resl  fall-  behind 

the    posterior    focal    line,  the    condition    i-    what    i-   called   "  COW1 p0U nd   myopic 

astigmatism;"  when  it  falls  on  the  posterior  focal  line,  il  is  called  "simple 
myopic  astigmatism;"  when  it  fall- between  the  two  focal  lines,  il  is  called 
•■  mi. n<l  astigmatism." 


L28  GENERAL    OPTICAL    PRINCIPLES. 

"When  the  retina  passes  through  the  first  focal  line  it  is  called  "simple 
hyperopia  astigmatism"  and  when  in  front  of  both  focal  lines  the  anomaly 
is  said  to  be  " compound  hyperopia  astigmatism"  (set  also  p.  'I'll).  This 
cumbrous  and  useless  attempt  at  precision,  as  it  is  usually  taught,  merely 
serves  to  conceal  the  fact  that  there  is  a  point  on  the  axis  between  the  first 
and  second  focal  lines  through  which  the  retina  must  pass  to  obtain  the  best 
image  compatible  with  that  particular  degree  of  astigmatism. 

The  construction  for  finding  this  point  has  been  given  above.  The  dis- 
tribution   along    the   axis  of  the   four    letters    in    Fig.   82  is  hF2:hF1  = 

/;,/•',  :  /•;,/•',,  or.  briefly,  (A  F0  F,I-\)  -  1.  When  the  retina  of  the  eye  at 
resi  passes  through  this  point  |  /•],),  the  ease  should  be  considered  simply  as 
one  of  astigmatism.  If  the  retina  passes  behind  this  point,  there  is  myopia 
as  well  ;  if  in  front  of  it,  hypermetropia. 

The  glasses  found  in  most  trial  cases  for  the  correction  of  astigmatism 
are  cylinders  in  pairs,  both  plus  and  minus,  quarter  numbers  to  2.50,  and 
half  numbers  to  6.  The  spherical  lenses  are  usually  in  quarter  numbers  to 
2.50,  half  numbers  to  7,  whole  numbers  to  11,  and  then  increasing  two  diopters 
at  a  step  to  2<>  or  22,  a  pair  each  of  both  kinds,  plus  and  minus,  the  cylin- 
ders usually  piano-cylinders,  the  sphericals  double  convex  or  double  con- 
cave. 

Optic  Axis ;  I/ine  of  Vision  ;  I,me  of  Fixation ;  I/ine  of  Sight. — 
We  have  spoken  of  the  eye  as  a  centered  system,  and  such  it  is  in  type.  Its 
principal  points,  its  nodal  points,  its  center  of  motion,  as  well  as  the  cardinal 
points  of  the  lens,  are  usually  all  on  one  line  or  nearly  so.  This  line  is  called 
the  optic  axis.  It  is  approximately  the  axis  of  symmetry  for  the  whole 
organ.  It  is  sometimes  the  ease  that  the  macula,  the  center  of  the  most  acute.' 
perceptive  power,  is  directly  in  this  line,  but  oftener  it  is  not.  When  the 
optic  axis  passes  through  the  macula,  it  is  the  line  of  vision  as  well,  meaning 
by  the  line  of  vision  or  the  line  of  sight  the  line  on  which  the  object  must  be 
placed  in  order  that  the  visual  act  should  be  most  advantageously  performed. 
I  fader  these  circumstances  also  the  opl  i'#  axis  is  the  line  of  fixation,  for  it  is 
the  line  passing  through  the  center  of  motion  and  indicative  of  the  eye's 
position    or  aim. 

An  excentric  position  of  the  macula  lutea  is  so  common  as  to  be  the  ride 
rather  than  the  exception.  It  i-  usually  toward  the  outer  side  of  the  optic 
axis.  ( tonsequently,  the  line  of  vision  is  no  longer  coincident  with  that  axis, 
but  crosses  it  w  itli  a  -light  "  fault  "  at  the  nodal  points,  and  the  line  of  fixa- 
tion connecting  the  center  of  moti >f  the  eye  with  the  object  on  which  it  is 

trained  has  now  a  position  which  differs  from  the  optic  axis  almost  as  much 
as  the  line  of  vision. 

The  angle  OMA  (Fig.  83)  is  taken  as  the  measure  of  this  lack  of  sym- 
metry due  to  the  excentricity  of  the  macula.  It  is  called  the  angle  gamma,  y. 
It  is  reck d  as  plus  when  the  optic  axis  falls  outside  of  the  visual  axis. 

Another  peculiarity  <>\'  construction  musl  be  considered  in  connection 
with  the  form  and   position   of  the  cornea. 

It  i-  convenient,  and  in  some  measure  consistent  with  existing  conditions, 
to  look  upon  the  cornea  as  ellipsoidal  rather  than  spherical  in  its  contour.  Its 
horizontal  section  it  the  curve  were  completed  would  occupy  a  position  in  the 
average  emmetropic  eye  something  like  thai  pictured  in  Fig.  84.  Here  it  is 
seen  thai  the  corneal  major  axis  does  not  coincide  either  with  the  visual  axis 
or  the  optic  axis.  The  lack  of  symmetry  thus  pictured  is  usually  measured 
bv  tlic  angle  which  the  major  axis  of  the  cornea  make-  with  the  visual  axis. 
This  angle  is  known  a-  a,  th<    angh   alpha,  and   is  reckoned   plus  when  the 


MIRRORS. 


129 


vi-ual  :ixis  pierces  the  cornea  on  its  nasal  side.     In  high  myopia  the  angle  a 
is  often  negative  (see  also  p.  96). 


Fig.  83.— OMA  =  The  angle  gamma. 


Fig.  84.— The  angle  alpha. 


Mirrors. — In  the  eve  itself  are  no  plane  surfaces,  and  no  surfaces  whose 
chief  function  is  comparable  to  that  of  the  mirror;  but  such  surfaces  musl 
be  considered  as  being  intrinsic  parts  of  many  instruments.  The  mirror-like 
action  of  the  dioptric  surfaces  of  the  eye  is  made  use  of  in  various  methods 
of  investigation. 

A  mirror  being  only  a  special  ease  of  single  optical  surface  where  //  = —  u" y 
it  may  be  most  satisfactorily  discussed  in  connection  with  previous  studies  by 
making  the  substitution  of  //  for  — ft"  in  the  general  formula?  13  and  18. 

Substituting  and  reducing,  we  have 


i-+i-=2. 


(51) 


/"     f 

As  has  been  previously  mentioned,  this  formula  is  suggestive  of  the  harmonic 
relation  for  which  a  construction  lias  already  been  given  (Figs.  66  and  67). 
Whichever  side  of  the  surface  is  used,  the  principal  focus  is  halfway  between 
the  center  and  the  surface.      It  is  found  from  Eq.  13  in  the  usual  way. 

It  is  evident  from  the  formula  or  from  the  graphic  construction  that 
image  and  object  are  always  on  the  same  side  of  the  principal  focus  :  also  that 
they  are  always  separated  by  the  surface  or  the  center,  never  by  both;  also, 
wherever  the  object,  the  image  that  is  on  the  same  side  of  the  principal  focus 
a>  the  reflecting  surface  is  a  virtual  image. 

The  relation  between  the  size  of  object  and  image  is  precisely  the  same  as 
for  dioptric  surfaces,  and  may  be  determined  either  by  Eq.  18  or  21. 

We  have  but  one  more  presenl  application  for  Eq.  13,  and  thai  is  for  the 
special  case  where  the  surface,  either  dioptric  or  katoptric,  is  plane.  In  such 
case  /■  =  <»,  the  second  member  disappears,  and 

£/=£ 


L30  GENERAL   OPTICAL   PRINCIPLES. 

which  may  be  construed  as  saying  thai  the  foci  conjugate  to  a  plane  optical 
surface  vary  as  their  respective  indices.  Make  this  a  reflecting  surface  again 
by  putting  ,"-"  =  — f*',  and  we  find  thai  foci  conjugare  to  a  plane  mirror  arc 
of  equal   length  ami  of  opposite  sense j  thus: 

1       -  ]. 

Substituting  *  tor  /"  or  V"  in  Eq.  IS,  we  find  that  for  plane  surfaces, 
whether  katoptric  or  dioptric, 

4^=   ±1,  (54) 

showing  that  in  reflection  or  refraction  the  image  is  equal  in  size  to  the  object. 
The  ambiguity  of  sign  enter-  the  equation  on  account  of  the  double  interpre- 
tation which  may  he  given  to  the  expression  for  infinity. 

It  must  l>e  remembered  thai  the  conditions  to  which  these  formulae  have 
been  applied,  and  to  which  alone  tiny  are  considered  applicable,  are  such  as 
exist  for  centered  surfaces  and  pencils  of  light  whose  rays  make  very  small 
angles  with   each  other  and   with  the  axis  of  the  system. 

The  Prism. — The  prism  enter-  a  system  optically  through  the  decenter- 
ing  of  one  or  more  of  its  surfaces.  The  prismatic  lens  in  it-  simplicity  dif- 
fers from  the  ordinary  lens  in  no  other  way,  and  the  prismatic  element  in  the 
lens  i-  measured  by  the  angle  between  the  two  lines  that  contain  the  cardinal 
points  of  the  two  surfaces.  To  qualities  which  the  prismatic  glass  possesses 
by  virtue  of  it-  curved  surfaces  must  he  added  those  that  are  due  to  the  non- 
coincidence  of  the  two  axes,  and  these  are  best  studied  in  the  case  of  the 
plane  prism.  The  action  of  n  prismatic  lens  as  used  in  ophthalmology  is  the 
added  action  of  the  simple  lens  and  the  plane  prism.  The  plane  prism  is 
made  np  of  two  plane  optical  surfaces  inclined  to  each  other  at  an  angle  less 
than   180°.     'flic  firsl   and   third  media  are  usually  alike.     These  conditions 

cannot  he sidered  analogous  to  any  previously  discussed,  as  on  one  or  both 

planes  the  pencil  is  oblique ;  neither  is  it   possible  to  look  upon  both  planes 


l  !-.  35     Refraction  of  light  in  tin-  principal  section  of  a  plane  prism. 

:i-  centered  on  any  finite  axis.  Consequently,  we  have  to  begin  again  with 
tiie  law  ofSnell,  ami  we  confine  ourselves  to  refraction  in  a  principal  section. 
The  apex  or  edgt  of  the  prism  i-  the  intersection  of  the  two  planes  form- 
ing it-  sides  or  faces.  A  principal  section  is  a  section  of  the  prism  by  a  plane 
perpendicular  to  the  edge.  A  base-apex  line  is  the  line  of  intersection  of  either 
side  with  :i  principal  section,  from  Snell's  l:i\\  we  know  that  a  ray  of  lighl 
which   before  incidence  is  confined  to  a  plane  <>/  principal  section   will   pa-- 


PJRISMS. 


L31 


through  the  prism  without  passing  oul  of  thai  plane.  Such  plane  is  pictured 
in  Fig.  85,  where  angles  made  with  the  normals  to  the  first  surface  arc  desig- 
nated by  n,  those  made  with  the  second  surface  by  C\  and  where  the  primes 
show  in  what  medium  the  light-ray  making  the  angle  is  situated. 

[f  /.'  is  the  refracting  angle  of  the  prism  and  I>  the  total  angular  devia- 
tion caused  in  any  ray  passing  through  the  prism,  the  following  relations  are 
easily  established  : 

l>     <p'     <>"  I  ty'—y".  (55) 

M  =  <p"  +  ip".  (56) 

D  =  (t>  +  i>-R.  (57) 

Applying  Eq.  2  to  the  angles  in  question,  gives 

fi'  sin  $'=(i"  sin  <p",  (58) 

ip'  =  R+D-<l>',  (59) 

V»"=i2--0",  (60) 

and                          //'sin{(i?     D)     <>'[      u"smR-<l>'.  (61) 

Hence,  by  easy  trigonometry, 

sin  (R+D)  cos  <;/-  cos  i  II-  J><  sin  <./     "      '  sin  /.*  cos  o"-cos  R  sin  0" )  .  (62) 

When  the  prisms  are  thin,  as  in  most  spectacle  lenses,  the  angles  /.'  and 
M  +  D  may  be  substituted  for  their  sines,  and  1  for  their  cosines,  giving 

D  =  J2//^cosi^_1|.  (63) 

l   flf    cos  Of  > 

and  this  is  still  further  simplified  in 

D={ti"-fi')R,  (64) 

bv  limiting  the  angle  of  incidence  to  one  so  small  that 

COS  V  _-\ 

COS  I .-' 

When  the  light-ray  passes  symmetrically  through  the  prism,  as  in  Fig. 


86,  x  may  be  substituted  for  </>"  and  </>",  giving 


2 


D     ■ 
—  =sin 


t>!) 


/,' 


which  is  useful,  because  it  expresses  the  action  of  the  prism  on  light  which 


Fig.  86.— Refraction  a1  position  of  minimum  deviation 

passes  through  in  its  position  of  minimum  deviation,  a  term  which  defines 
itself. 


132 


GENERAL   OPTICAL  PRINCIPLES. 


The  deviation  at  position  of  perpendicular  incidence  or  perpendicular  exit 
is  given  by 

D  =  sin-1f        nii\-i2. 


A  simple  transposition  of  Go  gives 


.    iZ  +  D 
sin  — 
[iff  _  2 

2 


(66) 


(67) 


the  formula  for  getting  the  index  of  refraction  from  the  deviation  and  refract- 
ing angle. 

Total  Reflection. — There  is  one  special  condition  that  comes  to  our 
notice  gcnerallv  in  connection  with  reflection  and  refraction  at  plane  sur- 
faces.    We  may  take  as  illustration  Fig.  87,  and  ask  guidance  of  Snell's  law 


v 

r 

Fig.  87.— Concerning  total  reflection. 

when  the  wave  whose  normal  /•,  incident  from  the  denser  medium  (//"),  makes 

with  the  limiting  surface  an  angle  whose  sine,  multiplied  by      ,,  is  greater 

!'■ 
than  1.     The  path  that  Snell's  law  would  seem  to  indicate  for  the  refracted 

wave  would  he  an  impossible  path,  for  there  is  no  angle  whose  sine  is  greater 
than  1.      Under  such  conditions  refraction  does  not  take  place. 

There  is  do  break  in  the  continuity  of  the  phenomena,  for  when  the  angle 

a" 
i,"  i-  so  great  that  '   -  -in  <>>"       1  ;  then  sin  (j/  =  1,  and  the  refracted  ray,  r  , 

/ 
i-  parallel  t<>  the  surface.     The  wave-front,  in  other  words,  is  perpendicular 
to  the  optical  surface,  and  neither  recede-  nor  approaches  it. 

\  -till  greater  increase  of  the  angle  <>"  would  so  increase  <''  that  its  gen- 
eral direction  would  be  into,  instead  of  out  from,  (;>").  The  angle  would  have 
a  minus  -inc.  Imt  it-  numerical  value  could  he  nothing  other  than  /'",  since 
the  medium  is  {[*"))  and  this  is  the  relation  characteristic  of  reflection.  Under 
such  conditions  all  the  [ighl  that  is  not  destroyed  is  reflected,  and  the  phe- 
nomenon is  known  a-  total  reflection. 

The  prism  i-  of  use  in  ophthalmology  chiefly  on  account  of  its  causing  a 
deviation  in  tin-  path  of  light,  and  thus  furnishing  an  instrumenl  which  may 
he  w~c(\  either  a-  cause  of.  or  compensation  for,  slighi  anomalies  of  the  posi- 
tion of  the  eye  itself.      The   practical   application  to  Buch   purposes  i-  given 


THE  METER  ANGLE.  |:; 

elsewhere.  In  thai  application  it  is  accessary  to  take  cognizance  of  its 
value  as  used  to  cause  deviation  of  light,  and  thus  an  apparent  displacement 

of  any  object  through  it.  The  relation  between  the  refracting  angle  and 
the  deviation  produced  being  such,  prisms  have  until  recently  been  described 
by  their  refracting  angles  as  Pr.  1°,  Pr.  2°,  and  so  on.  By  Eq.  65  it 
will  be  seen  that  the  deviation  produced  by  any  prism  of  ordinary  glass, 
D  =  (1.54  —  1)  R,  is  very  nearly  one-half  the  refracting  angle  of  the 
prism  ;  and  since  one-half  a  degree  is  about  the  smallest  increment  which 
ophthalmologists  have  found  useful,  the  scale  is  a  very  convenient  one,  and 
in  spite  of  criticisms  is  still  much  in  use.  Its  only  fault  is  that  the  numbers 
on  the  glasses  do  not  correspond  to  the  values  for  which  they  are  used.  To 
remedy  this  defect  it  has  been  proposed  to  number  prisms  by  the  angular 
deviation  in  degrees,  replacing  the  degree-mark  by  a  small  <\  to  avoid  eon- 
fusion,  thus  Pr.  ld,  Pr.  2d.  This  is  the  Deviation-angle  System  of  Jackson. 
The  unit  in  this  system  is  about  double  the  value  of  the  unit  of  the  Refraet- 
ing-a  ngle  Si/stem . 

To  obviate  the  necessity  of  making  any  material  change  in  the  size  of  the 
working  unit,  it  was  proposed  to  give  to  each  prism  the  value  of  its  angular 
deviation  in  terms  of  the  radian,  the  only  unit  of  angle  that  is  recognized  in 
works  on  analysis  and  mathematical  philosophy.  One  one-hundredth  of 
this,  the  radian  angle,  which,  in  accordance  with  "C.  G.  S."  (Centimeter- 
Gramme-Second)  nomenclature,  is  a  cenirad,  is  so  near  the  unit  of  the  Refract- 
ing-angle  System  as  to  be  practically  indistinguishable  from  it.  This  is  the 
Centrad  System  of  Dennett.  The  Refracting-angle  System  and  the  Centrad 
System  so  nearly  coincide  that  for  glass 
of  any  ordinary  index  some  number  be- 
tween 0  and  35  will  be  identical  for  the 
two  systems,  and  the  others  of  the  scale 
will  be  so  near  as  to  admit  of  interchange 
under  ordinary  circumstances.  Centrads 
are  prescribed  thus:  Pr.  lv,  Pr.  2V. 

The   Prism-diopter  Scale  of  Prentice 
does  not  differ   much   from   the   Centrad 
Scale,  and  does  not  diner  appreciably  from     FlG-  ®-^™ ^\?^;{]  of >"'i— u">' 
it  in  the  numbers  that  are  most    used.      It 

gives  to  every  prism  the  value  of  the  tangent  of  the  deviation  in  hundredth-, 
of  the  radius.     Centrads  and  the  prism  diopters  are  compared  in  Fig.  88. 

The  same  fault  may  be  found  with  the  Prism-diopter  Scale  as  with  the  Refracting- 
angle  Scale — namely,  the  number  on  the  glass  is  ;i  transcendental  function  of  tin'  value 
for  which  the  ulass  is  used.  Within  the  Hunts  of  common  use  the  three  scales  .ire  alike, 
and  the  choice  is  one  of  symbol  and  sentiment  only.  Prism  diopters  are  described  thus  : 
Pr.  1^   Pr.  2A,  and  so  on. 

To  Pnntice  i-  due  also  the  suggested  change  of  the  °  to  d  for  the  degree  deviation. 
and  to  A  for  the  tangent  deviation.  The  author  has  extended  the  symbolism  to  the 
centrad  system  by  inverting  the  triangle  for  it. 

There  remains  only  the  Meter-angle  System,  it  having  been  suggested  that 

the  "Meter  Angle"  of  Xagel  be  adopted  as  a  unit  for  prism   nomenclature. 

The  Meter  Angle. — The  meter  <ni</l<  \<  the  angle  made  by  the  visual 

axis  and  the  median  plane  when  the  eye  i>  directed  to  a  point  in  that  plane 
one  meter's  distance  from  the  center  of  rotation.  The  value  of  this  angle 
depends,  of  course,  on  the  interocular  distance,  which  must  need-  be  conven- 
tionalized if  it  is  used  for  purposes  of  prism  notation.  An  interocular  dis- 
tance of  .06  makes  the  meter  angle  equal  to  •"»  .  Though  a  little  narrow  tor 
an  adult,  it  is  perhaps  a-  good  a  distance  as  any  to  assume.     The  advantage 


134 


GENERAL   OPTICAL   PRINCIPLES. 


of  this  unit  is  supposed  to  consisl  in  this,  thai  for  any  point  of  fixation  con- 
vergence and  accommodation  are  expressed  in  the  same  terms,  the  inclination 
of  the  axis  to  the  median  line  being  the  same  in  meter  angles  as  the  accom- 
modation in  diopter-.  The  writer  is  not  aware  that  the  meter  angle  is  in 
actual  use  as  a  prism  unit.  1 1 >  relation  to  convergence  may  be  seen  in  Fig. 
89,  and  the  following  notation  has  been  suggested  :    I'r.  Lm,  Pr.  '2'". 


Fig.  89.    The  meter  angle. 


Table  I.  gives  the  deviation  in  degrees  corresponding  to  all  the  different 
-\  stems  of  prism  notation  : 

Table  I. — Showing  the  Value  in  Degrees  of  Deviation  of  Prism  belonging  to 

the  Other  Systems? 


**                         • 

5  •                 - 

If                1 

~  " 

x                  P 

•6 

cS 
u 

G 

- 

Deviation. 

T    '— 
-    - 

7 

Deviation. 

Meter-an- 
gle. 

Deviation. 

Pr.  1°  =  0°  32'  20" 

1V 

e    34'  22" 

0°34'22+ 

lm  =  l°43'    6" 

1 

2°  =  1°    4' 50" 
3°=1°  37'  20" 
4°  =  2°    L'20" 

..V 

1°    8'  45" 
L°43'    7" 

2°  17'  30" 

3* 

lA 

1°    9' 
1°43' 

2°  17' 

2m  =  3°26'12// 
3m  =  5°    9' 18" 
4">  =  6°52'24" 

!  For  interocular 
distance  of  .06. 

5°  =  2°  4i"    8" 

:.v 

2°  51'  53" 

5A 

2°  52' 

5m  =  8o30/    5// 

J 

6°  =  3°  14'  50" 

6^ 

3    26'  IV 

6* 

3°  26' 

7       3     17' 20" 

:" 

4°    0'38" 

7^ 

4° 

go_^o  20'    2" 

8V  = 

4°  33'  in" 

>A 

4°  34' 

9°  =  4°51'  10" 

9V 

5°.  9'  23" 

9* 

5°  12' 

10°-  .v  23'  10" 

10^ 

5°  1 

inA 

5°  4:;' 

11°     5°  58'  20" 

I]1 

6°  L8'    8" 

11^ 

6°  17' 

1»=1°50' 

1 

12°  =  6°  32' 

l:;       7       V  50" 

14°  =  7°  38' 

12V 

i:;v 

6  52'  .".1" 

7  26'  53" 
8°    1'  16" 

12^ 

i:;A 

1IA 

6°  51' 

7°  24' 
1     >8' 

2*  =  3°  40' 43" 

3m  =  .-.°:;iK  11" 

I"1     70-Jl'"j:;" 

,  For  interocular 
distance  of  .064. 

15       8°  L1'32" 

I5N 

-    35' 39" 

l.-r 

8°  32' 

5m  =  9°12'   3" 

J 

Accomttiodation  i^  that  function  of  the  eye  that  makes  clear  vision 
possible  at  varying  distances. 

This  adjustment  for  all  distances  between  the  far  point,  punctwm  remotum, 
and  the  near  point,  punetum  proximum,  is  accomplished  by  the  action  of  the 
ciliary  muscle   in  changing  the   form   of  the  lens. 

The  theory  of  this  process,  which  has  been  generally  accepted,  is  that  of 
1  [elmholtz.  The  ciliary  muscle  may  be  considered  as  made  up  of  two  parts — 
an  outer,  formed  of  longitudinal  fibers  which  arise  at  the  junction  of  the 
cornea  and  sclera,  and  pass  backward  to  a  diffuse  attachment  in  the  outer 
layers  of  the  choroid,  called  the  tensor  choroidea  or  muscle  of  Briicke;  and  an 
inner  portion,  formed  of  fibers  which  have  an  approximately  circular  course, 
e:dled  compressor  lentisor  Mailer's  muscle.  When  the  ciliary  muscle  contracts, 
the  choroid  and  ciliary  processes  are  drawn  forward,  and  by  the  contraction 

1  This  table  is  taken  from  Dennett's  article  on  "  Prisms"  in  a  System  of  Diseases  of  tlu  Eye, 
edited  by  Norris  and  Oliver,  vol.  ii.  p.  I  I- 


ACCOMMODA  '//ox 


l:;: 


of  circular  fibers  the  circumference  of  the  ciliary  processes  is  narrowed,  the 
zonula  or  suspensory  ligament  of  the  lens  relaxed,  and  the  lens,  being  released 
from  the  tension  which  this  has  exerted  on  its  capsule,  tends  to  assume  a 
more  convex  shape.  This  hypothesis  has  no1  been  seriously  disputed  until 
Tscherning,  following  in  the  footsteps  of  Thomas  Young,  developed  a  theon 
which,  as  it  becomes  more  generally  understood,  may  in  pari  prove  a  danger- 
ous rival  to  that  of  Helmholtz. 

Briefly,  Tscherning  asserts  that  the  accommodation  does  not  depend  on  a 
relaxation  of  the  zonula  of  Zinn,  but  on  its  tension  through  the  agency  of  the 
ciliary  muscle,  whereby  the  peripheral  portion  of  the  lens  is  flattened  and 
the  curve  of  the  anterior  surface  from  an  approximately  spherical  approaches 
a  hyperboloid  form.  The  theories  of  Helmholtz  and  Tscherning  are  illustrated 
by  Fig.  90. 


Fn.. '.'ii.— a,  accommodation  according  to  Helmholtz.  The  dotted  line  represents  the  thicker  form 
assumed  by  the  lens  when  the  traction  of  the  zonula  is  diminished  by  the  contraction  of  the  ciliary 
muscle.  B,  accommodation  according  to  Tscherning.  The  unbroken  lines  show  the  lens  at  rest.  The 
dotted  lines  show  the  change  occurring  during  accommodation,  supposed  to  be  due  to  the  traction  of  the 
zonula  being  increased  by  the  contraction  of  the  ciliary  muscle.  Ii  will  be  seen  thai  the  increased 
dioptric  ]«ower«if  the  lens  viiav  in-  obtained  either  by  relaxation  of  the  zonula  or  by  contraction.  Tscher- 
ning believes  that  the  changes  which  he  has  observed  in  the  lens  during  accommodation  prove  that  the 
latter  theory  is  correct,  while  Hess  {Graefes  Arch.,  xlii.  1,  S.  288;  Ibid,  xliii.  3,  S.  17/ 1  opposes  it  strongly. 

As  regards  the  change  in  the  lens  itself,  Tscherning's  view  seems  abundantly  proven 
by  numerous  experiments.1  The  action  of  the  ciliary  muscle  is  still  undetermined.  The 
older  description,  as  given  above,  is  supported  by  the  diagrams  according  to  [wanoff, 
but  these  results  have  not  Keen  corroborated  in  recent  times,  although  they  appear  in 
some  of  the  besl  text-books.  Tscherning  believes  thai  the  inner  portion  of  the  muscle 
retracts,  having  its  more  fixed  attachment  posteriorly  in  the  choroid,  which  is  steadied  by 
the  tension  of  the  vitreous, this  being  increased  during  accommodation  by  the  backward 
traction  of  the  lens.  This  retraction  of  the  oblique  fibers  of  Midler's  muscle,  which  is 
probably  not  as  purely  a  circular  muscle  as  bas  heretofore  been  described,  makes  trac- 
tion on  the  zonula  and  produces  the  changes  in  the  lens.  The  iris  as  a  diaphragm 
cuts  off  the  peripheral  parts  of  the  lens.  SO  that  whichever  view  is  taken  ofthe  mechan- 
ism of  accommodation  the  optical  conditions  remain  practically  the  same. 

By  accommodation  is  meanl  the  muscular  effort,  the  change  in  the  shape 
of  the  lens,  .and  the  effect  produced  on  vision.  The  muscular  effort  is  -ell- 
evident.  The  change  in  the  pupillary  portion  of  the  lens  is  ~een  from  the 
changes  which  the  reflexes  called  the  images  of  Purkinjt  undergo  during 
accommodation.  These  images  are  catoptric — thai  is,  formed  by  reflection 
from  the  cornea,  the  anterior  and  the  posterior  surfaces  of  the  lens.     In  the 

1  Cr/ellit/.er :  "  Die  Tscherningsehe  Accommodationstheorie,"  A rchiv f.  Ophth.,  Bd.  xlii.,  iv. 
Abtheilung.  !  Graefe  and  Saemisch :   Handbuch  der  Augenheilkunde,  Bd.  i.  p.  276. 


136  GEXERAL    OPTICAL  PRINCIPLES. 

pupillary  space  pictured  in  Fig.  91  are  seen  the  reflections  of  two  bright 
squares,  one  above  another  :  a  is  reflected  from  the  surface  of  the  cornea,  b 
from  anterior  surface  of  lens,  c  from  posterior  surface  of  lens.     They  are  best 


a     b     (  , 

B 
Fig.  91. — A,  reflections  during  distant  vision;  7?,  during  near  vision;  a,  from  the  cornea ;  6,  from  the 

anterior  surfat f  lens;  c,  from  posterior  surface  < if  lens.    It  is  seen  that  the  reflections  from  the  anterior 

surface  of  the  lens  become  smaller,  showing  that  that  surface  becomes  more  convex  during  accommoda- 
tion. C,  reflection  of  a  candle  flame;  a,  from  cornea,  sharply  defined;  b,  from  anterior  surface  of  lens, 
large  and  blurred  ;  c,  from  posterior  surface  of  lens,  small  and  inverted. 

seen  in  a  dark  room  when  a  bright  light  is  thrown  on  the  eye  from  the  side 
opposite  the  observer. 

During  accommodation  the  reflex  of  the  anterior  surface  of  the  lens  be- 
comes smaller,  which  indicates  an  increase  in  convexity.  In  some  eyes  the 
image  changes  its  position  in  a  manner  to  indicate  a  slight  advancement  of 
the  surface  (Helmholtz),  but  this  is  not  constant  (Tscherning).  The  posterior 
surface  of  the  lens  becomes  slightly  more  convex,  but  does  not  change  its 
position.  The  pupil  contracts  during  accommodation.  According  to  Tscher- 
ning, the  portion  of  the  iris  between  the  pupillary  border  and  the  periphery 
retires  a  little,  corresponding  to  the  flattening  of  the  peripheral  portion  of  the 
lens  which  he  has  proven  takes  place.  It  has  been  stated  that  the  tension  of 
the  anterior  chamber  diminishes  during  accommodation.  Foerster  (1864) 
observed  that  in  patients  with  small  keratoceles  the  protrusion  diminished  or 
disappeared  during  accommodation,  to  reappear  when  this  was  relaxed. 

When  the  accommodation  is  relaxed  the  eve  is  adjusted  for  a  far  point. 
When  the  greatest  accommodative  effort  compatible  with  clear  vision  is  made, 
the  adjustment  is  for  the  near  point. 

Range  of  Accommodation. — Accommodation  is  measured  by  its  effect 
on  the  vision,  and  the  effect  may  be  described  either  in  terms  of  distance 
traversed  between  the  far  and  near  points,  as  measured  from  the  eye  (range 
of  accommodation),  or  in  diopters,  expressing  the  increase  of  the  refractive 
power  of  the  Lens  (amplitude  <>r  power  of  accommodation).  The  additional 
strength  which  the  lens  gains  may  be  considered  as  a  separate  lens  placed  in 
front  of  the  crystalline. 

The  focal   distance  of  such  a  lens   being  .1,  the  distance  of  the  far  point 

from  the  eye  R,  and  of  the  near  point  /',  the  range  of  accommodation  would 

be  A  =  P — B,  and,  as  tli<'  refractive  power  of  a  lens  is  the  inverse  of  its 

local  distance,  the  refractive  power  of  the  lens  which  we  assume  to  represent 

accommodation  would  be 

1=  1      ' 
A     P     /; 

The  application  of  this  to  emmetropia  is 

1111 

A      P      oc      /•' 

the  far  point  being  at  infinity. 


PRESBYOPIA.  137 

The  power  of  accommodation  is  measured  by  the  strength  of  a  lens  suf- 
ficient to  give  the  rays  leaving  the  near  point  the  direction  in  the  vitreous 
which  they  would  have  if  without  it  they  came  from  infinity,  or  in  emnie- 
tropia  the  accommodation  is  measured  by  the  dioptric  value  of  the  near 
point. 

For  example,  an  emmetrope  whose  near  point  was  at  10  cm.  would  have  10  diopters 
of  accommodation  ;  thus  ; 

i—L-l~L-ioj>. 

A      .10     cc      .10 

A  myope  with  a  far  point  at  50  cm.  (2  diopters  of  myopia)  would  have  an  accommoda- 
tive ability  of  8  diopters  ;  thus  : 

i-=- -  =  10  2)-2  D  =  8D. 

A     .10     .50 

In  hyperopia  only  convergent  rays  are  focussed  on  the  retina,  and  the 
far  point  is  a  virtual  focus  behind  the  eye.  It  has  therefore  a  negative 
value. 

We  may  best  not  alter  the  formula,  but  remember  that  a  negative  sign  in  its  last 
denominator  makes  that  fraction  additive,  as  seen  in  the  following  example,  where  a 
person  whose  hypermetropia  is  2  D,  and  whose  near  point  is  10.  cm.,  is  shown  to  have 
an  accommodative  power  of  12  D: 

\  =  —  -  (-^— ]  =  —  +  —  =  10  D  +  2  D  =  12  D. 
A      .10     V-.50/     .10     .50 

Practically,  the  accommodation  in  hyperopia  equals  the  sum  of  the 
iens  required  to  bring  vision  to  infinity  with  that  representing  the  dioptric 
value  of  the  near  distance.  It  will  be  seen  from  what  has  preceded  that  the 
measurement  of  the  far  point  is  equivalent  to  the  determination  of  the  static 
refraction  of  the  eye.  The  near  point  is  the  nearest  point  at  which  very  small 
type  can  be  seen  most  distinctly,  and  is  usually  measured  by  Jaeger's  test 
type. 

Relative  Accommodation. — Ordinarily,  accommodation  and  convergence 
are  exerted  together,  the  eyes  being  directed  to  the  point  for  which  vision  is 
adjusted,  but  a  considerable  latitude  or  independence  of  these  functions  in 
their  relations  to  each  other  is  possible.  If,  for  instance,  an  emmetrope  fixes 
at  a  point  3 •">  cm.  from  the  eye,  the  corresponding  accommodation  would  be 
3  D,  but  a  certain  amount  of  relaxation  of  accommodation  and  of  additional 
power  is  possible  with  the  same  convergence.  This  relative  accommodation 
varies  for  each  point  of  fixation.  The  normal  relations  have  been  tabulated 
by  Donders.1 

The  practical  applications  are  numerous.  A  lack  of  unity  between  accommodation 
and  convergence  is  seen  in  the  normal  eye  at  the  near  point.  The  function  of  converg- 
ence being  stronger  than  that  of  accommodation,  the  absolute  near  point  is  attained  at 
a  sacrifice  of  binocular  vision,  convergence  over-acting,  and  thus  reinforcing  accommo- 
dation. In  hyperopia  the  accommodation  required  is  greater  than  the  convergence, 
and  the  same  tendency  of  the  two  functions  to  reinforce  each  other  offers  a  stimulus  to 
the  latter  which  may  result  in  convergent  strabismus.  In  myopia  less  accommodation 
is  required;  accordingly  there  is  less  incentive  to  converge,  and  insufficiency  of  converg- 
ence or  even  divergence  may  occur. 

Presbyopia. — The  power  of  accommodation  diminishes  progressively 

from  the  earliest  youth.  As  a  result,  the  near  point  recedes  from  the  rye, 
until  at  about  the  age  of  forty  in  emmetropia  it  reaches  the  distance  <>i'  '-"-' 
cm.,  and  the  strength  of  accommodation   has  become  abouf    L5    /;.     Near 

1  Accommodation  mid  Refraction  of  the  Eye,  \>.  111. 


138 


G  ENEBA  L   OPTH  .  I  L    PBINi  7/7,  ES. 


vision  then  is  rendered  difficult,  and  from  this  time  on  convex  glasses  must 
be  used  to  bring  the  near  point  nearer  and  to  compensate  for  the  diminishing 
power  of  accommodation.  The  cause  of  this  change  is  a  physiological  sclero- 
sis of  the  crystalline  lens,  which  renders  it  less  elastic  in  response  to  the  force 
of  the  ciliary  muscle.     The  table  (Table  11.)  and  accompanying  curve,  de- 


- 

Distance 
of  Pin 

Distance  of  K 
in  meters. 

Ampli- 
tude of 

Presby- 
opia in 

< 

111 

meters. 

.1. 

0.07 

30 

14.  D 

15 

0.08 

00 

12. 

20 

0.10 

00 

10. 

25 

o.l  -1 

00 

8.5 

30 

el  1 

00 

7. 

35 

0.18 

00 

5.5 

40 

0.22 

' 

4..". 

0. 

4:. 

0.28 

30 

3.5 

1. 

r,o 

0.4 

X 

2.5 

2. 

:,:, 

0.66 

1.    H.0.25) 

1.75 

3. 

(in 

2 

2.(H.0.5) 

1. 

4. 

65 

4. 

L.33    1 1.  0.75) 

0.5 

4.75 

7«i 

-1. 

-0.8  (H.  1.25) 

0.25 

•>..> 

lb 

0.5 

-0.5  (H.  1.75) 

0. 

6.25 

80 

ii  1 

i>  1  i  II.  2.5) 

n. 

7. 

10       IS      2 

: 

s     So     jf      60      e 

r     70    ?f    & 

' 

II 

\P 

f 

8 

7 
6 

s 
« 

3 
2 

0 

r 

7*— 

/J 

-2 

-3 
J. 
-f 

Table  II..  with  the  accompanying  curve  <  Fig.  92),  show  s  the  relations  of  age  to  accommodation  and 
static  refractiou.  The  table  is  taken  from  Xagel,1  and  is  slightly  modified.  The  curve  is  modified  by 
Landolt  from  bonders. 

vised  by  Donders,  shows  the  decrease  in  the  amplitude  of  accommodation  as 
well  as  the  change  in  the  static  refraction,  beginning  at  about  the  age  of 
fifty-five,  by  which  an  acquired  hyperopia  takes  place;  the  curve,  y>  p,  repre- 
sents the  changes  in  the  near  point  ;  the  curve  r  r,  the  far  point. 

V-  has  been  said,  presbyopia  begins  at  the  time  when  near  vision  becomes 
difficult.  This  period  varies  with  the  refraction  of  the  eye,  for  the  reason 
that  the  strength  of  the  accommodation    required  to  bring  the  near  point  to  a 

comfortable  distance  depends  on  the    positi f   the    far    point.     Thus    in 

myopia  the  far  point  is  nearer  the  eye  than  in  hyperopia,  and  the  same 
strength  of  accommodation  will  continue  the  range  of  useful  vision  for  near 
work  at  it-  proper  distance  later  in  life  ;  that  is  to  say,  presbyopia  is  postponed 
in  myopia  ami  anticipated  in  hyperopia  as  <• pared  with  emmetropia. 

Ii    will   lie    -ecu   thai    a    myo] I'    •"■  1>  will     reach    the    age  of   sixty  without    dis- 

comfort,  while  a  hyperoj f  the  same  degree  would  be  able  to  overcome  his  hyperopia 

ami  to  bring  the  near  point  to  the  reading  distance,  at  the  latest,  up  to  twenty-five 
years. 

It   is  important   to  re mber  that  the  accommodation  cannot   he  sustained  at  its 

maximum.  There  must  always  be  a  reserved  power,  as  in  any  other  continuous  work, 
ami  that  is  why  the  near  point  is  said  to  he  at  lii'  cm.,  allowing  0.5  D  1  D  reserve 
above  the  accommodation   required  tor  the  average  reading  distance. 

working  distance  is  decidedly  arbitrary,  depending  on  the  kind  of  work  .lone 
or  tin- hal.it  of  the  individual  a-  regards  the  distance  the  work  is  held  from  the  eyes 
ami  on  the  visual  acuity,  lor  if  this  is  diminished,  the  work  must  lie  brought  nearer  in 
order  to  obtain  larger  images,  ami  the  accommodation  must  be  aided  accordingly. 

Visual  Acuity.  Vision  i-  measured  by  tin-  size  of  the  smallest  object 
which  c:in  he  recognized  at  a  fixed  distance  in  the  mosl  favorable  lighl  with 
the  best  optica]  adjustment.  The  size  of  the  objeel  i-  expressed  l>\  the  visual 
angle  formed  he  line-  that  pass  through  it-  extremities,  through  the  nodal 
points  of  the  eye,  to  the  inverted  image  mi  the  retina.  The  size  of  the  image 
1  Graefe  und  Saemisch  :   Handbucli  der  Augenheilk.,  Bd.  vi.  p.  466. 


VISUAL   ACUITY.  139 

on  the  retina  varies  as  the  distance  of  the  posterior  nodal  poinl  from  the 
retina,  which  distance  Is  greatesl  in  myopia  and  leasl  in  hypermetropia. 
Axial  ametropia   is  referred  to,  as  that   is  the  commonest   form. 

When  the  ametropia  i-  corrected  by  ;i  leu-  placed  at  the  anterior  focus  of 
the  eye.  the  retinal  image  i-  the  same  size  a-  if  the  eye  were  emmetropic. 

A  stronger  lens  is  needed  tor  the  correction  of  myopia  the  farther  the 
lens  is  placed  from  the  eye.  and  a  weaker  lens  suffices  for  hypermetropia  if 
removed  from  the  eye.  Differently  stated,  this  i-  :  a  concave  lens  loses 
strength  and  a  convex  lens  gains  strength  if  removed  from  the  eye,  which 
explain-  the  tendency  of  presbyopes  to  slide  their  glasses  down  the  nose  as 
the  presbyopia  increases.  It  is  obvious  that  to  attain  the  highest  visual 
acuity  for  a  great  distance  the  eye  must  he  placed  in  a  condition  to  see  to  the 
best  advantage;  that  is  to  say,  the  ametropia  must  he  corrected  lor  infinity, 
consequently  the  glas>  that  gives  the  highest  visual  acuity  is  the  measure  of 
the   static   retraction. 

The  distance  usually  chosen  for  the  examination  of  vision  i-  6  m.  So 
great  a  distance  is  taken  because  it  i-  desirable  to  measure  acuity  uninfluenced 
by  the  effect  of  accommodation,  and  rays  of  light  that  enter  the  eye  from  any 
point  on  an  object  6  m.  away,  however  wide  the  pupil,  are  practically  parallel 
and  meet  on  the  retina. 

Snellen's  type  are  so  devised  that  each  letter  subtends  an  angle  of  five 
minutes,  each  part  of  a  letter  and  each  space  being  one-fifth  of  the  whole  in 
linear  measurement.  A  visual  angle  of  five  minutes  has  been  assumed  as 
representing  the  average  of  a  great  many  measurements  of  the  eye-  of  indi- 
vidual- of  all  ages,  and  Snellen  acknowledges  that  a  great  many  young  per- 
sons have  a  greater  visual  acuity. 

It  has  been  said  above  that  visual  acuity  is  measured  by  the  ability  to 
recognize  an  object  at  a  given  distance.  Tin-  means  that  the  part-  of  which 
it  is  composed  can  be  differentiated  :  each  part  of  one 

of  Snellen'-   letter-  subtend-  an   angle  of  one   minute       VV  VV 

(Fig.  93).  ...  J  JPj 

The  perception  of  a  single  object,  however,  would       ^■CZ  ^hh 

_    •   i  i»   ifi      x     j-     i"      •  •  '    't.         •   •!  'iv  ii      Fig.  93. — Two  of  Snellen's 

not  be  a  reliable  test  ot  vision,  as  its  visibility  would  test-type, 

depend  on  the  intensity  of  the   light  by  which  it  was 

seen,  and  would  be,  in  some  measure,  independent  of  it-  size  and  the  dis- 
tance ;  for  instance,  a  fixed  star  is  visible,  although  its  apparent  size  is  almosl 
infinitely  small  and  it-  image  -mailer  than  one  of  the  perceptive  elements  of 
the  retina.  Two  star-,  however,  cannot  be  distinguished  as  separate  unless 
they  are  about  sixty  seconds  apart  ;  that  i-,  unless  the  distance  between  their 
imago  on  the  retina  equals  at  least  the  breadth  of  a  perceptive  element.  If 
the  distance  were  -mailer,  both  images  would  fall  upon  the  same  or  upon 
adjacent  element-.  In  the  first  case  both  would  produce  a  -ingle  sensation, 
and  in  the  second  case  there  would  be  two  sensations,  but  upon  adjacent  ele- 
ment-, so  thai  it  could  not  be  told  whether  there  were  two  points  of  light  or 
one  which  fell  upon  both  elements. 

From  the  fad  that  the  diameter  of  the  cone-  in  the  macula  corresponds 
quite  closely  to  the  smallest  distances  between  the  images  of  two  objects  that 
can  be  recognized  as  two,1  the  conclusion  has  been  drawn  that  the  cones  are 
the  perceptive  elements.2 

'  According  to  Kolliker,  the  cones  in  the  macula  lutea  vary  from  0.0045  nun.  to  0.00">4  nun. 

in  diameter,  while  a  visual  angle  of  60"  covers  on  the  retina  a  space  of  1 138  mm.  and  one 

of  73"  a  space  of  0.00526  mm. 

•  Helmholtz:   Handbuck  der  Phygiologisehen  Optik,  Zweite  Auflagi 


140  GENERAL    OPTICAL    PRINCIPLES. 

Snellen's  letters  are  arranged  in  lines,  over  each  of  which  are  Roman 
numerals  indicating  the  distance,  P.  at  which  the  letters  of  that  line  appear 
under  an  angle  of  five  minutes  or  the  distance  at  which  they  can  be  read  by 
an  eve  of  normal  vision.     The  distance  at  which  they  can  be  read  by  the  eye 

that  is  being  tested  is  d.     The  formula,  then,  for  visual  acuity  is  V-     ..      As 

examinations  arc  ordinarily  made  at  a  tixed  distance  of  about  six  meters,  "  d  " 
is  constant,  the  value  of  the  fractional  expression  being  varied  with  the  value 

of  the  "  D"  which  designates  the  smallest  legible  letters,  thus  V  is 

normal  vision.      V  =  —  indicates  that  what  the  patient  ought  to  see  at  sixty 

oO 
meters  he  can  see  at  only  six  meters,  an  acuity  of  <>.  1.      It  is  best,  however, 
to  leave  the  fraction   unreduced,  thus  recording  the  exact  distance  at  which 

the  test  wa<  made.     If  vision  is  inferior  to  — ,  the  test  types  may  be  brought 

bu  o 

nearer,  and  the  distance  recorded  at  which  the  largest  is  read,  as  — .     If  this 

is  not  enough,  the  distance  may  be  noted  at  which  the  fingers  of  the  out- 
stretched hand  can  be  counted  against  a  dark  background,  or,  still  farther, 
only  the  movements  of  the  hand  may  be  seen,  and  finally  light  perception 
only,  at  varying  distances,  or,  simply,  the  differentiation  of  light  from  dark- 
ness (L.  P.)  may  be  all  there  is  to  record. 

A  better  system  than  that  of  Snellen  is  one  devised  by  Monoyer,  in  which  tbe  lines 
progress  in  tenths  from  1.  to  0.1.    The  regularity  of  the  interval  is  a  decided  advantage, 
and  has  been  utilized  by  Dennett    with  the  modification  that 
the  size  of  every  letter  in  each  line  has  been  so  chosen  as  to 
ensure  its  uniform  visibility. 

For  the  illiterate,  characters  may  be  used  which   can  be 

described  without  being  named,  or  Burchardt's  series  of  dots 
Pig.  94.— Test-type  for  the  ,  ,      rril  *  ..i      t^>    •     *-cc        *. 

illiterate.  may  be  used,      lhe  most  common  are  the  hi  s  in  different  posi- 

tions (Fig.  94).  Guillery  proposed  to  measure  the  visual  acu- 
ity simply  by  the  use  of  a  black  dot  on  a  white  ground.  I5y  comparison  with  the  letters 
of  Snellen  he  found  that  such  a  dot  seen  at  an  angle  of  50"  would  correspond  to  the  nor- 
mal visual  acuity;  at  5  in.  it  would  have  a  diameter  of  L.2  mm.  An  acuity  of  one-half 
would  be  shown  by  the  ability  to  see  a  dot  of  double  the  area  at  the  same  distance.  The 
dots  are  placed  in  various  parts  of  squares  and  are  to  be  localized  by  the  patient.1 

Entoptic  Phenomena. — Objects  in  the  eye  in  front  of  the  sensitive 
layer  of  the  retina  intercept  light  that  passes  through  the  pupil  and  throw 
shadows  which  under  certain  conditions  can  be  perceived.  Since  Listing- tire 
(  saminati f  objects  in  our  owe  eye-  has  been  called  entoptic  observation. 

II*  a  clear  sky  is  looked  at  through  a  pin-hole  in  a  dark  card  placed  near 
the  anterior  focus  of  the  eye — the  rays  thus  reaching  the  retina  parallel — or 
if*  a  flame  al  a  distance  of  5  m.  is  seen  through  a  strong  convex  glass  held 
two  or  three  inches  from  the  eye,  a  bright  disk  of  light  will  be  seen  formed 
by  circles  of  diffusion,  upon  which  various  objects  arc  visible  :  (1)  The  traces 
of  the  lid-  on  the  cornea  formed  by  half  closing  the  eyes.  These  horizontal 
lines  remain  an  instanl  after  the  pressure  has  ceased,  and  in  some  cases  show 
a  more  lasting  effeel  of  constriction,  leading  to  an  irritable  condition  called 
" tarsal  asthenopia."  The  tears  and  drops  of  mucus  are  seen  following  the 
movements  of  the  lid-.  (2)  The  lens  or  some  <d*  its  parts  may  become  visible 
if  a  verysmall  opening  is  used,  the  light  being  homocentric.     Physiologically, 

1  Guillery:  Arch,  fur  Augenheilkunde,  xxiii.  S.  323. 
/;.  |  Phygioloquch  n  0/itil;.  <  ;<">tt inircii,  1S4">. 

i,   .1.  Bull:   Tram.  Eighth  Internal  Ophth.  Cong.,  Edinb.,  1894. 


m  3 


ENTOPTIC  PHENOMENA.  Ill 

the  radiating  star-shaped  figure  of  the  lens  and  numerous  small  round  objects 
like  hyaline  globules  may  be  seen.  These  increase  with  age  until  the  senile 
changeSj  the  beginning  of  cataract,  may  also  become  apparent  to  the  possessor 
in  this  manner  (Donders).  (3)  In  the  vitreous  there  are  always  floating  bodies, 
cells,  and  fibers,  which  as  m/uscce  volitantes  cause  alarm  to  the  nervous  observer 
till  he  is  assured  of  their  insignificance.  (4)  A  very  interesting  application 
of  the  entopic  method  is  the  observation  of  the  retinal  vessels  (PnrUinje). 
They  may  be  seen   in   three  ways  : 

[<()  In  a  darkened  room  a  candle  is  held  at  a  short  distance  from  the  eye 
which  regards  the  distance.  The  vessels  come  into  view  as  dark  lines  on  a 
yellowish  background.     They  seem  to  move  when  the  candle  is  moved. 

(b)  On  looking  through  a  stenopaic  opening  at  the  sky,  if  the  opening  is 
kept  in  motion,  the  vessels  are  distinctly  seen,  even  to  the  smallest  around 
the  macula. 

(c)  If  a  strong  light  is  focussed  on  the  sclera  as  far  as  possible  from  the 
cornea,  and  moved  slightly  from  side  to  side,  the  same  phenomena  occur. 
The  explanation  given  by  Heinrich  Muller  (1855)  is  that  the  shadow  of  the 
retinal  vessels  falls  on  the  sensitive  layer  of  the  retina. 

In  the  last  experiment  Muller  measured  the  movement  of  a  vessel  projected  on  a 
surface  at  a  known  distance,  and  the  movement  of  the  focus  on  the  sclera  which  pro- 
duced this  excursion,  and  calculated  the  distance  behind  the  retinal  vessel  at  which  the 
sensitive  layer  must  lie,  his  result  coinciding  very  closely  with  the  actual  distance 
between  the  vessels  and  the  layer  of  rods  and  cones. 

Kb'nig  and  Zumft1  have  recently  attempted  to  apply  this  principle  to  the 
analysis  of  color  vision,  and  have  claimed  that  different  colors  are  seen  at 
different  levels,  violet  being  perceived  by  the  most  anterior  portion  of  the 
sensitive  layer,  red  by  the  most  posterior.  Considerable  doubt  has  been 
raised,   however,  by  Koster2  as  to  the  accuracy  of  these  statements. 

1  Sitzungsberichte  der  koniglich.  preuss.  Akademie  der  Wissenschaft.  zu  Berlin  :  Mai,  1894, 
xxiv. 

2  Grae/^s  Archiv,  xli,  i,  S.  1. 


EXAMINATION  OF  THE  PATIENT  AND  EXTERNAL 
EXAMINATION  OF  THE  EYE;  FUNCTIONAL 
TESTING. 

By   G.  E.   DE  SCHWEINITZ,   A.  M.,  M.  D., 

OF    PHILADELPHIA. 


The  value  of  case-records  is  greatly  enhanced  if  a  systematic  method  of 
examination  is  pursued  with  each  patient.  The  following  order  of  examina- 
tion, based  upon  the  one  employed  by  S.  Weir  Mitchell  in  the  Infirmary  for 
Nervous   Diseases,  Philadelphia,  is  arranged  for  this  purpose: 

Name  ami  residence. 

Age,  sex,  race,  married,  single,  or  widowed. 

Family  history:  hereditary  tendencies;  general  and  ocular  health  of  parents, 
brothers,  sisters,  etc. 

Personal  history:  children,  their  general  and  ocular  health ;  miscarriages;  meno- 
pause;  former  illnesses;  syphilis  and  gonorrhea ;  injuries. 

Occupation:  relation  of  work  to  present  indisposition. 

Habits:  brain-use;  tobacco;  alcohol;  narcotics;  sexual. 

Date  ami  mode  of  onset  ami  supposed  cause  of  present  trouble ;  outline  of  its  course, 

Organs  of  digestion :  teeth;  tongue;  stomach;  bowels. 

Organs  of  respiration  :  nose;  throat:  Lungs. 

<  Organs  of  circulation  :  heart  ;  pulse  ;  blood. 

Kidneys:   examination  of  urine. 

Abdominal  organs  :   liver ;  spleen. 

Organs  of  generation:  menses;  leucorrhoea;  uterine  disease. 

Nervous  system:  intelligence;  evidences  of  hysteria  ;  hallucinations;  sleep;  ver- 
tigo;  gail  :  station;  tendon-  and  muscle-jerks;  paralysis;  tremor;  pain;  subjective 
Bensations;  convulsions ;  headaches  and  their  position. 

Eyes:  previous  attacks  of  inflammation;  injuries;  infections;  ocular  palsy  or 
squint  ;  amblyopia  ;  previous  use  of  glasses ;  ability  to  use  eyes. 

Direcl  inspection  and  examination  of  eyes :  inspection  of  the  skull  and  orbits  (sym- 
metry  or  asymmetry) ;  lids;  ciliary  borders ;  puncta  lacrymalia;  upper  and  lower  cul- 
de-sacs;  conjunctiva';  caruncles;  cornese  (oblique  illumination);  irides  (mobility  and 
color);  anterior  chambers  (depth  and  character  of  contents) ;  vision;  accommodation; 
balance  of  external  eye-muscles  ;  mobility  of  globe ;  tension;  light  sense;  color  sense; 
field-  of  vision;  held  of  fixation;  ophthalmoscope;  ophthalmometer;  retinoscope; 
refraction. 

Necessarily  the  examiner  will  modify  the  thoroughness  of  his  investiga- 
tions according  to  the  character  of  each  ease. 

Direct  Inspection  of  the  Eye  and  its  Appendages.— The  lids 
should  be  examined  for  distended  superficial  veins,  edema,  tumors,  tor  ex- 
ample, enlargement  of  the  Meibomian  -lands,  and  for  anomalies ;  their  edges 

lor  inllai ation,  parasites,  misplaced  cilia,  and  small  morbid  growths;  the 

pimcta  for  permeability,  deviation  or  retraction  from  the  globe,  pressure  a< 
tie  same  time  being  made  over  the  lachrymal  sac  in  order  to  express  from  it, 
through  the  puncta,  any  contained  Quid;  the  caruncles  and  plicae  for  swell- 
ing, foreign  bodies,  irritation  by  incurved  cilia,  and  -mall  morbid  growths, 
for  instance,  polyps  or  angiomas;  the  conjunctival  cul-de-sacs  for  abnormal 

I  12 


BLOOD-VESSELS  OF  THE  CONJUNCTIVA.  143 

secretion,  granulations,  foreign  bodies,  concretions  and  disturbance  of  the 
vascular  supply,  the  examination  being  carried  well  tip  into  the  upper 
fornix  after  thorough  eversion  of  the  lid. 

In  order  to  evert  the  lid  the  patient  should  rotate  the  eye  strongly  down- 
ward, while  the  surgeon  seizes  gently  the  central  eyelashes  of  the  upper  lid 
between  the  index  finger  and  thumb  of  his  left  hand,  and  draws  the  lid 
downward  and  away  from  the  globe,  placing  at  the  same  time  the  poinl  of 
the  thumb  of  his  right  hand  above  the  tarsal  cartilage  of  the  li<l  which  is  to 
be  everted,  steadying  his  remaining  fingers  upon  the  patient's  brow,  and  by 
a  quick  movement  turns  the  edge  of  the  lid  over  the  point  of  his  thumb, 
while  this  is  simultaneously  depressed.  If  the  patient  steadily  look-  down- 
ward during  this  manceuver  there  is  no  difficulty  in  everting  the  lid  without 
the  aid  of  the  pencil  or  match-stick  so  commonly  employed  as  a  lever. 

When  there  are  no  lashes  on  the  upper  lid  the  manipulation  i-  more  dif- 
ficult, but  it  can  he  accomplished  by  pushing  the  lower  lid  beneath  the  margin 
•of  the  upper  in  such  a  manner  that  it  acts  as  a  wedge  on  which  the  superior 
lid  is  then  everted. 

The  lower  lid  is  everted  readily  by  placing  the  tip  of  the  fore  finger  against 
the  vt]'^.'  of  the  lid  and  drawing  it  downward,  at  the  same  time  pressing  the 
finger  backward  until  the  lid  is  turned  over  it. 

The  surgeon  should  also  inspect  the  skin  of  the  face,  examine  for  scars, 
and  investigate  the  wrinkles  in  the  forehead  and  between  the  brows.  The 
supraorbital  ridge,  the  general  character  of  the  orbits,  and  the  position 
and  shape  of  the  globes  should  next  be  studied.  Palpation  of  the  orbit 
by  passing  the  finger  beneath  the  supraorbital  ridge  above,  along  the  mar- 
gin of  the  malar  bone  and  the  superior  maxillary  below,  and  to  the  outer 
and  inner  sides,  may  reveal  the  presence  of  accumulation-,  superficial  growths, 
enlargement  of  the  lachrymal  gland,  etc.  Finally,  the  action  of  the  orbicu- 
laris should  he  ascertained  by  causing  the  patient  to  close  his  eye-  a-  if  in 
sleep,  and  note  made  of  the  absence  or  presence  of  fibrillary  contraction. 
When  the  eye-  are  opened  the  length,  width,  and  symmetry  of  the  palpebral 
fissures  and  the  condition  of  the  commissural  angle-  may  he  studied  (see 
page  31  i. 

Blood-vessels   of   the   Conjunctiva. — In    health   only  a   tew  con 
spicuous    blood-vessels   are    to    lie    observed;    in    inflammation    many  more 
become   visible.     The  conjunctival    blood-supply   may    he  conveniently   di- 
vided, as  -Mr.   Nettleship   has  done,   into  three  systems: 

System.  I. — Posterior  conjunctival  vessels,  whose  congestion  produces  a 
bright-red,  velvety  color,  moving,  on  pressure  of  the  eyelid-,  with  the  shift- 
ing of  the  conjunctiva,  usually  associated  with  muco-purulent  secretion  and 
indicating  conjunctivitis. 

System  II. — Anterior  ciliary  vessels  composed  of  perforating  and  non- 
perforating  arteries  and  vein-.  The  perforating  arteries,  which  supply  the 
sclerotic,  iris,  and  ciliary  bodies  are  the  branches  seen  in  health  entering 
about  5  mm.  from  the  corneal  margin,  their  points  of  entrance,  in  dark- 
complexioned   people,   often   being  distinctly   tinted. 

The  non-perforating  (episcleral)  branches,  invisible  in  the  normal  eye, 
produce,  when  congested,  a  pink  zone  surrounding  the  cornea  ("ciliary  con- 
gestion," "  circumcorneal  zone"),  not  moving  on  pressure  "I'  the  lid-  with 
the  shifting  of  the  conjunctiva,  unassociated  \\  ith  purulent  discharge,  and  one 
indication  of  iritis. 

The  perforating  veins  and  their  non-perforating  (episcleral)  twigs,  when 
congested,  create  a  zone  of  dusky   hue.  often  a  sympl f    glaucoma,  or 


144 


EXTERNAL    EXAMINATION  OF  THE  EYE. 


appear  in  unequal  deep-seated  patches  of  lilac  or  violaceous  color,  pointing 
to  cyclitis  or  scleritis. 

System  III. — Anterior  conjunctival  vessels  and  the  plexus  of  capillaries 
surrounding  the  cornea,  derived  from  anterior  ciliary  vessels  through  whose 
numerous  small  branches  anastomosis  between  Systems  1.  and  II.  takes 
place.  Their  congestion  produces  a  circle  of  bright-red  injection,  often  partly 
on  the  cornea,  a  sign  of  inflammation  of  this  membrane,  and  typified  in  the 
early  vascular  stages  of  interstitial   keratitis. 

In  addition  to  these  three  varieties  of  congestion  numerous  departures  are 
noticeable,  making  it  impossible  to  specify  the  individual  system  involved. 


- —  Post.Cen/ 


Fig.  95.— Vessels  of  the  front  of  the  eyeball :  cm,  eilinry  muscle  :  Ch.,  choroid  ;  Set.,  sclerotic ;  V.  I'.,  vena 
vorticosa;  I., marginal  loop-plexus  of  cornea;  .-!»?.  unci  Post.  Conj.,  anterior  and  posterior  conjunctival 
vessels;  Ant.  Oil.,  land  F,  anterior  ciliary  arteries  and  veins  (after  Nettleship's  alteration  from  Leber). 

In  these  type-  is  found  a  definite  local  injection,  as  the  leash  of  vessels 
passing  to  a  corneal  ulcer;  or  all  systems  are  commingled  in  a  general 
inflammation. 

Temperature  of  the  Conjunctival  Sac. — This  may  be  measured 
with  a  suitable  thermometer  having  attached  to  it  eoneavo-convex  mercury 
plates  which  are  placed  in  the  lower  conjunctival  sulcus,  or,  more  accurately, 
as  in  physiological  experiments,  with  thermo-electric  couples.  Silex  '  found 
the  temperature  of  the  lower  human  conjunctival  ibid  to  lie  :\:>.~)~>  < '.  (!»o.!»!)° 
1'.  -i.  <■.  about  "J  < '.  lower  than  thai  of  the  rectum, — and  in  inflamed  eyes 
noted  nil  average  increase  of  0.98  C.  The  highest  conjunctival  temperature 
is  found  in  acute  iritis,  bu1  even  then  does  not  equal  the  normal  body-tem- 
peral  lire. 

1    [rekiva  of  Ophthalmology   1893,  wii.  |>.  151, 


THE    WIDTH  OF  THE  CORNEA. 


145 


Inspection  of  the  Cornea. — This  will  reveal  inflammation,  ulcera- 
tion, opacities,  the  track  of  former  blood-vessels,  exudates  upon  its  posterior 
surface,  and  foreign  bodies.  Slight  irregularities  may  be  detected  by  placing 
the  patient  before  a  window,  while  his  eyes  are  made  to  follow  the  uplifted 
finger  held  about  a  foot  from  his  face  and  moved  in  various  directions  ;  the 
image  of  the  window-bars  reflected  from  the  cornea  will  be  broken  as  it 
crosses  the  spot  of  inequality.  In  the  same  manner  abnormalities  in  the 
curve  of  the  cornea  may  be  roughly  ascertained,  because  if  the  curve  is  nor- 
mal the  reflection  does  not  change,  at  least  in  the  central  portion  of  the  cornea  ; 
if  the  curve  is  abnormal  or  the  surface  of  the  cornea  irregular,  there  is 
corresponding  distortion  in  the  size  or  shape  of  the  reflection. 

A  more  accurate  method  is  to  employ  a  keratoscope,  or  Pladdo's  disk,  as 
it  is  called.     This  instrument  consists  of  a  disk  shaped   like  a  target,  upon 

which  are  drawn  concentric  black  circles, 
a  sight-hole  being  in  the  center.  The 
patient  is  placed  with  his  back  to  the 
window,  while  the  surgeon  holds  the 
instrument  30  cm.  in  front  of  the  eye, 
and,  looking  through  the  central  aperture, 
observes  the  reflections  of  the  circles 
from  the  cornea.  If  these  are  broken 
or  distorted,  the  indications  of  irregu- 
larity in  the  surface  are  present  (Fig.  96). 
Any  irregularity  on  the  surface  of  the 
cornea  is  quickly  detected  by  the  method 
of  kerat&metry,  especially  with  the  oph- 
thalmometer of  Javal  andSchiotz  (see  page 


Fig.  %.— Placido's  disk  or  keratoscope. 


Fig.  97.— Priest  lev  Smith's  keratometer. 


197),  the  reflections  of  the  targets  being  greatly  distorted  as  they  cross  the 
point  of  irregularity. 

Abrasions  and  ulcers,  even  when  minute,  may  be  differentiated  by  drop- 
ping into  the  eye  a  concentrated  alkaline  solution  of fluorescin  (Griibler's  fluo- 
rescin  '2  per  cent.,  carbonate  of  soda  3.5  per  cent.),  which  colors  greenish- 
yellow  that  portion  of  the  cornea  deprived  of  it>  epithelium,  while  the  healthy 
epithelium,  or  even  that  epithelium  which  is  -imply  roughened  and  opaque,  as 
in  keratitis,  remains  unaffected.  A  minute  foreign  body  may  thus  he  located 
if  situated  in  the  centre  of  an  abrasion,  because  it  appears  as  :i  black  dm  sur- 
rounded by  a  green  area.  So,  also,  may  the  progress  of  a  corneal  ulcer  be 
studied,  the  color  test  differentiating  sharply  that  portion  of  the  ulceration 
which  i>  still  active  from  that  which  is  covered  with  new-formed  epithelium. 

The  "Width  of  the  Cornea. — This  may  he  measured  approximately  by 


146 


EXTERNAL    EXAMINATION  OF  THE  EYE. 


holding  before  it  a  rule  marked  in  millimeters  and  noting  the  number  of  spaces 
its  width  occupies,  or,  more  accurately,  by  employing  Priestley  Smith's  kera- 
tometer.  This  instrument  consists  of  a  scale  situated  between  two  plano-convex 
Lenses.  The  surgeon  places  his  eye  al  the  principal  focus  of  the  combination, 
and,  holding  the  scale  before  the  patient's  eye,  observes  that  the  cornea  sub- 
tends i>n  the  scale  exactly  its  width  I  Fig.  97).  The  average  horizontal  diam- 
eter of  the  normal  cornea  is  11.0  mm.  (Priestley  Smith). 

The  Sensibility  of  the  Cornea. — This  may  be  tested  by  gently  touch- 
ing the  surface  of  this  membrane  with  a  wisp  of  cotton  twisted  to  a  fine  point. 
[f  sensation  is  intact,  the  touch  will  instantly  be  followed  by  the  reflex  action 
of  winking.  As  a  control  the  opposite  eye  may  be  similarly  examined,  if  the 
cornea  is  found  insensitive,  the  forehead  and  face  should  he  examined  for  areas 
of  anaesthesia  cither  with  the  point  of  a  moderately  blunt  pin  or  with  an 
esthesiometer.       Thermic  as  well  as  tactile  sensibility  should  be  investigated. 

Oblique  Illumination. — The  surgeon  places  the  patient  two  feet  from 
the  source  of  illumination  and  focusses  a  beam  of  light  with  a  two-inch  or 
three-inch  lens  upon  the  cornea,  at  the  same  time  observing  the  surface  under 


Fig.  98     Method  of  oblique  illumination. 


examination  through  a  leu-  of  the  same  focal  distance,  which  act-  as  a  mag- 
nifier, held  between  the  thumb  and  fore  linger,  the  disengaged  fingers  being 
utilized  to  elevate  the  upper  lid  i  Fig.  98).  The  distance  of  the  lens  must  be 
varied  slightly  to  bring  the  various  tissue- — the  cornea,  iris,  or  crystalline 
leu- — within  its  focus,  the  patient  being  required  to  look  up,  down,  and  to 
either  side  while  the  anterior  surfaces  and  media  of  the  eye  are  illuminated. 
To  deteci  a  foreign  body  the  light  should  be  directed  at  an  acute  angle,  but 
it'  tiie  pole  of  the  lens  is  to  be  examined  the  light  should  be  thrown  perpen- 
dicularly into  the  pupil,  the  -ui-cuii  placing  his  eye  in  the  same  direction 
without  interfering  with  the  light.  By  this  method  minute  abrasions,  foreign 
bodies,  nebula',  and.  in  short,  all  corneal  changes,  may  be  examined.  The  cha- 
racter of  the  aqueous  humor,  the  depth  of  the  anterior  chamber,  the  surface  of 
the  iris,  .-\  nechiae,  atrophic  liber-,  -mall  tumors,  ami  persisting  pupillary  mem- 
brane are  readil)  studied, and,  finally, opacities  in  the  anterior  capsule  and  axis 
of  the  lens  can  be  investigated,  and  b\  focussing  deeply  even  the  anterior 
layers  of  the  vitreous.  Tin-  routine  examination  should  never  be  omitted. 
Recent!)    Dr.  Edward  .lack-on   ha-  designed  a  binocular  magnifying  lens 


THE  PUPIL.  1  17 

lor  examination  of  the  eye  by  oblique  illumination,  which  is  :i  material  aid. 
Two  lenses  are  placed  side  by  side,  and  so  joined  that  the  visual  line  of  the 
righl  eye  (tierces  the  right  lens  near  its  optical  center,  while  the  visual  line  of 
the  left  eve  pierces  the  left  lens  near  its  optical  center.  This  gives  each  eye 
an  undistorted  field  all  around  the  point  of  fixation,  and  these  fields  can  be 
combined  in  full  binocular  vision. 

In  place  of  this  lens  a  cornea/  loupe  may  be  employed.  This  i-  a  lens, 
properly  mounted,  by  which  the  cornea  is  strongly  magnified.  A  corneal 
microscope,  or  a  specially  prepared  lens  of  high  power,  permits  the  study  of 

minute  changes  in   this  membrane,  and   is  utilized  for  the  examinati >f 

traces  of  former  vascularization,  and  by  its  help  even  the  circulation  of  bl 1 

in  the  vessels  constituting  a  pannus  may  be  studied. 

The  Color  of  the  Iris.— Blue  and  gray  are  the  predominating  hue-  in 
the  irides  of  the  inhabitants  of  northern  countries;  brown  occur-  next  in 
frequency,  while  the  various  admixtures  produce  yellow  and  green  -hades. 
Perfectly  black  irides  are  never  seen,  but  dark  irides.  taking  the  whole 
population  of  the  world,  are  the  most  frequent  in  occurrence.  With  rare 
exceptions  the  color  of  the  iris  of  all  new-born  children  is  of  a  light  grayish- 
blue.  The  stromal  pigment  is  developed  subsequently,  and  the  color  of  the 
iris  does  not  become  fixed,  so  to  speak,  until  about  the  third  month. 

Slight  differences  in  shade  between  the  two  irides  are  not  uncommon. 
More  rarely,  even  in  health,  the  irides  differ  in  color  (chromatic  asymmetry), 
one  being  brown  or  greenish,  the  other  blue  or  gray.  Under  these  condition- 
one  iris  usually  corresponds  in  color  with  the  irides  of  one  parent,  and  the 
remaining  iris  with  those  of  the  other  parent.  Instead  of  uniform  pigmenta- 
tion a  single  triangular  patch  or  several  irregular  spots  of  dark  color  may 
appear  upon  one  or  both  irides  (  piebald  irides).  When  these  spots  are  small 
they  have  sometimes  been  mistaken  for  foreign  bodies.  While  chromatic 
asymmetry  is  perfectly  compatible  with  health,  it  is  stated  to  be  more  com- 
mon in  patients  with  neuropathic  tendencies — for  example,  in  chorea  and 
epilepsy.  In  25  of  50  cases  of  chorea  of  childhood  (Sydenham's  chorea)  ex- 
amined by  the  author  the  irides  were  equal  in  color  and  shade  ;  in  the  remain- 
ing 25  there  were  slight  differences  in  shade  or  tone.  In  only  1  of  these  25 
was  there  any  true  asymmetry  of  color.  In  some  instances  of  chromatic 
asymmetry  there  is  liability  to  disease,  especially  to  cataract,  on  the  pan 
of  the  lighter  eye.  This  susceptibility  may  be  present  in  several  members 
of  the  same  family. 

Discoloration  from  disease  causes  one  iris  to  be  green,  while  it-  fellow 
remains  blue.  This  indicates  iritis  or  cyclitis.  It  is  often  an  early  symp- 
tom of  inflammation  of  the  iris,  and  should  lie  looked  for  in  every  inflamed 
eye. 

The  Pupil. — The  size  of  the  pupil  in  health  varies  with  exposure  to  light 
and  with  accommodation  and  convergence.  It  i-  also  influenced  by  age,  the 
color  of  the  iris,  and  the  character  of  the  refraction.  Other  thin--  being 
equal,  the  pupil  is  generally  smaller  in  old  age,  in  blue  eye-,  and  in  eye- with 
hyperopic  refraction,  while  it  is  larger  in  youth,  dark  eyes,  and  eyes  with 
myopic  refraction.  There  is  no  physiological  standard  on  which  to  base  a 
measurement,  but  with  accommodation  at  iv-t  the  diameter  of  the  pupil  varies 
from  2.11  to  5.82  mm.,  the  average  diameter,  according  to  Woinow,  being 
4.14  iniii.  Under  similar  illumination  the  pupils  should  be  round  and  of 
equal  size,  although  a  large  Dumber  of  measurements — for  instance,  those 
made  among  healthy  military  recruits — indicate  that   slight  differences  in  the 

width  of  the  pupil-  are  compatible  with   health. 


148  FUNCTIONAL   TESTING. 

Measurement  of  the  Pupil. — The  pupil  can  be  measured  approxi- 
mately by   holding  before  it   a   rule   marked   in  millimeters  and  noting  the 

number  of  spaces  its  width  occupies.  The  chief 
objection  to  this  method  is,  as  Edward  Jackson 
points  out,  that  the  distance  subtended  on  the  rule 
is  less  than  the  diameter  of  the  pupil,  in  proportion 
as  the  distance  from  the  observer's  eve  is  less  to  the 
rule  than  to  the  pupil.  For  the  purpose  of  accurate 
measurement  a  number  of  instruments  have  been 
devised,  known  as  pupillometers.  A  simple  and 
useful  device  is  one  which  consists  of  a  scale  of  cir- 
cles held  close  to  the  observed  eye,  the  scale  being 
fig. 99.— simple  pupiiiometer.  slowly  rotated  until  that  circle  which  matches  the 
pupil  in  size  is  reached  (Fig.  99).  Priestley  Smith's 
keratometer  ( Fig.  !»7)  can  also  be  employed. 

The  Pupil-reactions  and  Methods  of  Testing-  Them. — A  uniform  light 
should  be  employed  and  the  character  of  the  light  should  be  stated.  As 
Turner  insists,  the  light  employed  for  testing  the  sensitiveness  of  the  retina 
or  visual  center  should  not  be  more  intense  than  that  to  which  the  eye  is 
usually  accustomed.  Therefore,  except  under  certain  circumstances,  exami- 
nations made  by  reflecting  light  into  the  eye  with  a  mirror  or  by  passing  a 
flame  in  front  of  the  eye  are  not  accurate.  It  is  much  to  be  regretted  that  in 
recorded  examinations  such  loose  statements  as  "pupils  dilated,"  "pupils 
contracted,"  "pupils  medium-sized,"  have  been  so  much  used. 

Mobility  of  the  Iris. — The  reflex  mobility  of  the  pupil  '  is  tested  to 
ascertain  the  presence  of  attachments  between  the  iris  and  the  lens  (synechia1), 
or  immobility  from  atrophy  of  the  iris,  or  to  examine  the  sensitiveness  to 
light   of  the  retina  or  visual  center. 

(a)  The  patient,  placed  before  a  window  in  diffuse  daylight,  with  one 
eye  carefully  excluded,  is  directed  to  look  into  the  distance  with  the  exposed 
eye.  which  is  then  shaded,  when,  in  the  absence  of  abnormalities,  a  consider- 
able dilatation  of  the  pupil  will  occur.  On  removal  of  the  covering  hand  or 
card,  contraction  to  the  same  size  as  that  which  existed  before  the  test  was 
applied  takes  place.  This  is  the  direct  reflex  action  of  thepupil,  and  is  brought 
about  by  a  muscular  contraction  of  the  sphincter  of  the  iris  following  the 
stimulation  of  the  optic  nerve. 

(h)  If  during  this  examination  the  other  pupil,  which  has  been  shaded  by 
a  card  or  covering  hand,  i-  observed,  it  will  be  found  acting  in  unison  with 
it-  fellow.  This  i-  the  consensual  or  indirect  reflex  action  of  the  pupil.  The 
iii-  response  to  light-stimulus  should  also  be  tested  with  both  eyes  open  and 
exposed  in  the  same  source  of  illumination.  The  eye-,  should  then  be  covered 
and  exposed  alternately  and  the  pupil-reactions  noted.  Under  normal  con- 
ditions the  pupils  should  be  equal,  not  only  with  both  eyes  open,  but  with 
one   eye   shaded. 

(c)  If  the  patient  is  required  to  look  into  the  distance  and  then  quickly 
direct  his  eye-  at  a   near  object   for  example,  the   point  of  a  pencil  held  at  a 

distance  of  about  10  cm. — pupillary  contraction  occiii's  under  the  infliieiic f 

accommodation  and  convergence ;  that  is,  the  sphincter  of  the  iris  contracts 
in  association  with  the  ciliary  muscle  and  the  internal  recti.  This  is  the 
associated  action  of  the  pupils  (convergence-reaction).      Accommodation   in- 

1  It  is  customary  to  speak  of  the  action  or  reaction  of  the  pupil,  although  really  the  mo- 
bility of  the  iris  ifi  ascertained.  For  convenience  :  "  mobility  of  the  iris"  is  Bynonymous  with 
"  pupil-reaction." 


THE  PUPIL  IN  DISEASE.  149 

creases  pupillary  contraction,  but  this  docs  not  take  place  under  the  influence 
of  accommodation  unassociated  with  convergence.  It  does  occur  with  con- 
vergence without  the  act  of  accommodation. 

(d)  A  second  reflex  action  of  the  iris,  the  other  being  its  contraction  under 
the  stimulus  of  a  beam  of  light  (direct  light-reaction,  paragraph  a),  consists 
of  a  dilatation  of  the  pupil  when  some  cutaneous  nerve  is  stimulated, 
especially  one  in  the  skin  of  the  neck.  This  is  the  skin  reflex  (pain-reaction), 
and  may  be  tested  by  pinching  the  skin  of  the  neck,  or,  better,  by  using  a 
farad ic  brush. 

(e)  Finally,  the  reaction  of  the  iris  to  the  mydriatics  and  myotics  may  be 
tried,  especially  that  produced  by  cocain,  which  in  the  normal  eye  should  cause 
nearly  full  mydriasis  and  widening  of  the  palpebral  fissure  from  stimulation 
of  the  sympathetic.     (For  the  physiology  of  pupil-phenomena  see  page  96.) 

Abnormal  Pupillary  Reactions,  or  the  Pupil  in  Disease.1 — When 
about  to  investigate  pupil-reactions  six  possibilities,  as  William  McEwen 
points  out,  should  suggest  themselves  to  the  examiner — namely,  (a)  The  action 
of  drugs  ;  (b)  ocular  disease  or  optical  defects ;  (c)  spinal  or  sympathetic 
lesions  ;  (d)  localized  cerebral  lesions  in  special  centers  or  tracts  ;  (e)  abeyance 
of  brain-function  ;  (/)  cerebral  irritation.  For  the  convenience  of  ascertain- 
ing in  what  portion  of  the  path  of  the  pupil-reflex  the  lesion  is  situated 
Magnus2  has  divided  it  into  the  following  three  portions: 

1.  The  Centripetal  Part,  including  the  Optic  Nerve,  Chiasms,  Tracts,  and  Connecting 
Fibers  to  the  Cortex. — If  there  is  interruption  of  the  conducting  power  of  one  optic 
nerve — for  example,  the  right — illumination  of  the  pupillary  area  on  that  side  fails  to 
elicit  either  the  direct  or  the  indirect  reflex  action  of  the  pupil.  On  the  other  hand, 
illumination  of  the  left  eye  causes  its  own  pupil  to  contract  (direct  reflex),  as  well  as 
the  pupil  of  the  right  or  affected  eye  (indirect  reflex). 

Lesions  affecting  the  chiasm  and  the  tract  are  accompanied  by  hemianopsia  (see 
page  481)  and  the  special  pupillary  phenomena  which  belong  to  this  condition,  while 
lesions  in  the  optical  pathway  between  the  corpora  quadrigemina  and  the  cortex,  although 
accompanied  by  probable  changes  in  the  visual  field,  are  unassociated  with  pupillary 
disturbances. 

2.  The  Part  of  the  Reflex  Ring  which  carries  the  light  Impulse  from  the  Corpora  Quad- 
rigemina to  the  Oculo-motor  Nuclei  (Meynert's  Fibers). — If  both  sides  are  affected,  neither 
pupil  reacts  to  the  impulse  of  light  falling  on  either  eye,  but  there  is  normal  reaction  to 
accommodation  and  convergence.     (See  Argyll-Robertson  symptom,  below.) 

3.  The  Centrifugal  Portion  of  the  Reflex  Ring  {the  Nucleus  of  the  Sphincter  of  the  Iris, 
the  Third  Nerve,  and  the  Termination  of  the  Third  Nerve  in  the  Iris).—  If  the  right  nucleus 
is  affected,  the  direct  light-reflex  action  of  the  right  pupil  is  abolished,  and  also  its 
indirect  reflex.  A  beam  of  light  directed  into  the  left  eye  is  followed  by  pupil-reaction  in 
that  eye  (direct  reflex).  Pupil-reaction  in  that  eye  also  follows  light  stimulus  of  the  oppo- 
site or  right  eye  (indirect  reflex),  but  is  somewhat  lessened  in  degree.  The  pupils  react 
normally  to  accommodation  and  convergence,  and  are  unequal,  the  right  being  the  wider. 

If  the  trunk  of  the  right  oculo-motor  is  atfectcd,  there  is  pupillary  immobility  under 
the  influence  of  light  directed  into  the  right  eve,  and  also  when  it  is  directed  into  the 
left  eye,  as  well  as  loss  of  accommodation  upon  the  right  side.  Light  falling  into  the 
left  eye  produces  on  this  side  a  normal  reaction  which  is  also  manifested  if  the  light  is 
directed  into  the  opposite  eye.  The  pupils  are  unequal,  the  right  being  the  larger. 
Similar  conditions  arise  if  the  peripheral  fibers  of  the  oculo-motor  at  their  termination 
in  the  iris  are  affected  upon  one  side. 

We  have  now  to  consider  a   little  more  in  detail  : 

1.  Dilatation  of  the  Pupil  (Mydriasis). — This  occur-  in  ocular  diseas< — for 
instance,  glaucoma — in  cases  of  non-conductivity  of  light  (optic-nerve  atrophy),  in 
orbital  disease,  and  under  the  influence  of  mydriatic  drugs.  It  is  further  seen  in  fright, 
emotion,  anemia,  in  depressed  nervous  tone,  neurasthenia,  aortic  insufficiency,  and   irri- 

1  The  following  paragraphs  are  abstracted  from  the  author's  chapter  on  "  Diseases  of  the 
Optic,  Oculo-motor,  Pathetic,  and  Abducens  Nerves,"  in   .1  Text-Book  q)    Nt 
American  Authors,  edited  by  I'".  X.  Dercum,  ls'."~>.  pp.  T'.i  1-sn:;. 

'-'  Klin.  Monatsbl.f.  Augenkeilk.,  xxvi.  p.  255. 


150  FUNCTIONAL    TESTING. 

tation  of  the  cervical  sympathetic.  It  is  noticed  in  vomiting,  forced  respiration,  and 
anemia  of  the  brain — for  example,  syncope  and  is  said  to  be  present  in  persons  of  low 
mental  development. 

In  disease  of  the  nervous  system  dilatation  of  the  pupil,  when  of  cerebral  origin, 
indicates  extensive  lesion;  when  of  spinal  origin,  irritation  of  the  part  (McEwen). 
Systematic  writers  have  divided  dilatation  of  the  pupil  into  irritation-mydriasis,  caused 
by  irritation  of  the  pupil-dilating  center  or  fibers,  and  ptirnfy/ic  mydriasis,  caused  by 
paralysis  of  the  pupil-contracting  center  or  fibers,  or  by  failure  of  the  stimulus  to  be 
conducted   from  the  retina  to  the  center. 

The  former  is  apt  to  be  -ecu  in  hyperemia  and  irritation  of  the  cervical  portion  of 
the  spinal  cord,  in  spinal  meningitis,  in  cases  of  tumor  of  the  spinal  curd,  and  also, 
under  certain  circumstances,  in  tumor  of  the  cerebral  contents,  in  psychical  excitement 

ir  example,  acute  mania  -and  in  tabes  dorsal  is  and  progressive  paralysis  of  the 
insane. 

The  latter,  which  is  also  known  as  iridoplegia,  is  found  in  disease  at  the  base  of  the 

brain  affecting  the  center  of  the  third  nerve,  in  pressure  of  the  cerebrum  when  in  great 

amount,   as  from   hemorrhage,   tumors,  advanced    thrombosis  of   the  sinuses,   or   large 

-  :    also   in  the   late  stages   of  HieningO-encephalitis.      It  is  said  to  be  present  iu 

acute  dementia  when  there  is  edema  of  the  cortex,  and  i.s  (bund  in  cerebral  softening. 
Hemorrhage  into  the  centrum  ovale  and  cerebral  peduncles  also  produces  mydriasis 
McEwen  I. 

•_'.  Contraction  of  the  Pupil  (Myosis). — This  appear-  in  congestion  of  the  iris, 
paralysis  of  the  sympathetic  and  also  of  the  fifth  nerve,  in  certain  fevers,  in  plethora, 
venous  obstruction,  mitral  disease,  and  under  the  influence  of  myotics. 

If  the  myosis  i-  of  cerebral  origin,  it  indicates  an  irritative  stage  of  the  affection  ; 
if  of  spinal  origin,  a  depression,  paralysis,  or  even  destruction  of  the  part  (McEwen). 
matic  writers  divide  contraction  of  the  pupil  into  irritation-myosis,  caused  by  irri- 
tation of  the  pupil-contracting  center  or  fibers,  and  paralytic  myosis,  caused  by  a  paral- 
ysis of  the  pupil-dilating  center  or  fibers,  or  by  a  combination  of  both. 

Irritation-myosis,  as  just  noted,  is  found  in  the  inflammatory  affections  of  the  brain 
and  its  meninges — e.g.  meningitis,  abscess  (al  first  the  myosis  is  on  same  side  as  le- 
sion), and  beginning  sinus-disease.  According  to  the  rule  previously  given,  myosis  may 
change  to  dilatation  if  the  products  of  disease  become  excessive  ;  hence  the  serious  prog- 
nostic import  of  mydriasis   under   these   circumstances.     .Myosis   is   seen    in    the   early 

-  of  cerebral  tumor,  in  small  hemorrhages  into  the  cerebellum,  and  at  the  onset  of 
cerebral  apoplexy.  Berthold,  quoted  by  Swanzy,  uses  myosis  as  a  diagnostic  symptom 
between  apoplexy  and  embolism.  McEwen  points  out  that  the  convulsions  arising 
from  meningo-encephalitis  are  accompanied  by  myosis.  while  those  due  to  epilepsy  are 
usually  associated  with  mydriasis.  Apoplexy  of,  or  pressure  upon,  the  pons  is  associated 
with  myosis. 

Paralytic  myosis  [spinal  myosis)  occurs  in  lesions  of  the  cord  above  the  dorsal  verte- 
bra. It  is  especially  noteworthy  in  tabes  dorsalis.  At  first  the  pupil  reacts  to  light 
and  convergence,  but  later  exhibits  the  Argyll- Robertson  phenomenon  (or  reflex  irido- 
plegia); that  i-.  it  responds  only  slightly  or  nol  at  all  to  the  ught-impulse,  but  the 
associated  action  of  the  iris — or,  in  other  words,  the  contraction  of  the  pupil  in  accom- 
modation and  convergent — is  preserved.  The  lesion  under  these  circumstances  is  prob- 
ably in  the  libers  which  pass  from  the  proximal  end  of  the  optic  nerve  to  the  oculo- 
motor nuclei.  Turner  contend-  that  a  single  lesion  in  the  fore  part  of  the  oculo-motor 
nuclei  in  the  Sylvian  gray  matter  is  the  cause  of  both  myosis  and  reflex  iridoplegia. 

Paralytic  myosis  is  also  met  with  in  paralysis  of  the  insane,  pseudo-dementia 
paralytica  of  syphilitic  origin,  bulbar  palsy  when  complicated  with  progressive  muscular 
atrophy  or  sclerosis  of  the  brain  and  spinal  cord.  and.  according  to  Mills,  in  some  forms 
of  multiple  neuritis.  The  iris  reacts  peculiarly  to  mydriatics,  which  dilate  this  type  of 
pupil  only  partially,  and  their  effeel  is  for  a  long  time  manifest.  Cocain,  however, 
readily  expand-  the  -mall  pupil  of  reflex  iridoplegia  (Heddseus).  Myotics  contract  it 
»"/  maximum. 

Unilateral  reflex  iridoplegia,  or  that  condition  when  one  pupil  is  unaffected  by  vary- 
ing degrees  of  illumination  of  both  eyes,  but  reacts  to  accommodation,  the  unaffected 
pupil  responding  to  separate  light  stimulus  of  either  eye,  may  exisl  with  or  without 
mydriasis,  and  usually  is  wider  than  its  fellow.  It  i-  seen  in  tabes  dorsalis  and  syphilitic 
cases.  It  i-  probably  due  to  lesion  in  the  sphincter  nucleus.  It  should  be  distinguished 
from  unilateral  reflex  blindness    see  '    1.  p.  1  19  . 

The  reverse  of  the  Argyll-Robertaon  symptom  has  been  observed,  and  indicates 
disease  in  a  special  part  of  the  oculo-motor  nucleus. 

Unequal  pupils  anisocoriaj  arc  rarely  -ecu  in  health,  although  it  is  stated  by 
one  I wanow)  that  among    I'M  healthy  military  recruits  the  right  pupil  was 


TESTING    ACUTENES8  OF    VISION.  Ill 

larger  in  49  and  the  left  in  53,  equal  width  being  found  in  only  12.  [f  there  is  recent 
wide  dilatation  of  one  pupil  and  do  disease  of  the  eye,  the  instillation  of  a  mydriatic 
may  be  suspected.  Unequal  pupils  occur  in  eyes  with  widely  dissimilar  refraction  if 
one  eye  is  blind,  in  aneurysm,  dental  disease,  traumatism,  and  in  diseases  of  the  nervous 
system.  If  the  disease  is  cerebral,  unequal  pupils  denote  unilateral  or  focal  disease. 
They  arc  not  uncommon  in  tal>es,  disseminated  sclerosis,  and  paralytic  dementia. 

Varying  inequality  of  the  pupils,  or  a  mydriasis  now  occurring  on  the  one  side 
and  now  on  the  other,  i-.  according  to  Von  G-raefe,  a  serious  premonitory  symptom  of 
insanity. 

Special  Pupillary  Phenomena. — The  hemiopic  pupillary  inaction  i-  referred 
to  on  page  480.  The  cerebral  <;,,•/,.,-  reflex  of  the  pupil  (Haab's  reflex  consists  of  a 
marked  bilateral  pupillary  contraction  which  takes  place  if  the  patient  >its  in  a  dark- 
ened room  and  directs  without  change  of  accommodation  or  convergence  hi-  attention 
to  a  bright  object  already    present   within   the  compass  of  tin-  field   of  vision. 

Harold  Giflbrd  has  described  an  orbicularis  pupillary  reaction;  that  is,  a  contrac- 
tion of  tlie  pupil  which  takes  place  when  a  forcible  effort  is  made  to  close  the  lids. 
The  discoverer  explains  tin-  as  the  result  of  an  overflow  stimulus,  attempted  closure  of 
the  lids  exciting  in  the  nucleus  of  the  orbicularis  fibers  of  the  facial  an  activity  which  is 
transferred  to  the  pupil-contracting  center.  The  test  is  of  use  in  determining  whether 
the  pupil  sphincter  is  paralyzed. 

Paradoxical  Pupil-reactions.— Dilatation  of  the  pupil  under  the  influence  of 
light-stimulus,  and  contraction  when  it  has  been  -haded,  have  been  described  in  cases 
of  meningitis.     A  good  deal  of  doubt  has  been  cast  upon  this  type  of  pupil-reaction.1 

Hippus,  which  is  a  normal  phenomenon  for  a  few  seconds  after  light-stimulus  to 
the  retina  and  optic  nerve,  consists  of  a  rhythmical  contraction  and  dilatation  of  the 
pupil  occurring  without  alteration  of  illumination  or  fixation.  It  is  seen  in  cerebro- 
spinal sclerosis,  disseminated  sclerosis,  neurasthenia,  hysteria,  psychical  disturbances. 
epilepsy,  and  acute  meningitis  in   its  early  stages.2 

Testing  Acuteness  of  Vision. — For  the  purpose  of  determining 
acuity  of  sight  test-types  are  employed,  in  which  the  letters  arc  of  various 
sizes  and  are  constructed  according-  to  the  methods  described  on  page  138. 

Inasmuch  as  many  good  eyes  possess  a  vision  of  five-fourths  of  the 
standard  angle,  Dr.  James  Wallace  of  Philadelphia  and  Dr.  Culver  of  Al- 
bany have  arranged  a  scries  of  test-types  in  which,  instead  of  an  tingle  of 
five  minutes,  one  of  four  minutes  has  been  substituted  as  the  basis  of  each 
letter. 

Dr.  Randall  points  out  that  the  order  of  the  letter-  should  be  adjusted  so 
as  to  bring  the  confusion-letters  in  the  same  alternation.  It  i-  preferable  to 
have  large  letters  at  the  top  of  the  card,  do  particular  advantage  accruing 
from  the  inverted  arrangement.  The  color  of  the  card  is  of  importance,  a 
cream  color  verging  on  the  India  tint  giving  the  best  definition  through 
lessening  of  irradiation  (Randall).  White  letter-  on  a  black  background  are 
also  employed. 

When  it  is  desired  to  test  the  acuity  of  sight,  the  patient  is  placed  6  meters 
from  the  type-card,  in  a  well-lighted  room,  and  each  eye  is  tried  separately. 
If  the  letter-  of  No.  6  2G  feet,  approximately)  are  read,  vision  is  Qormal  or 
1,  but  if  at  the  same  distance  no  smaller  letter-  than  those  numbered  is  60 
feet)  can  be  discerned,  vision  is  .1.  It  is  usual  to  express  these  results  accord- 
ing to  the  formula.   V=  — ,  in  which    V stands  for  visual  acuteness,  d  for 

the  distance  <d"  the  patient  from  the  card,  and  />  for  the  distance  at  which  the 
type  should  be  read,  s,(  that  in  these  instance-  the  vision   would   be  recorded 

{j  and  T,;-.  or  in  feet    -^-  ,     — —    (see  also  page  I  I"). 
X  A       I  j  A 

Any  other  distance  may  be  chosen,  provided  it  does  nol  place  the  patient 

For  a  full  accounl  of  this  condition  see  Gaz   hebdom.,  No.  62,  1896. 
-  The  author  de-ires  to  acknowledge  much  indebtedness  u<  Swanzy's  chapter  on   "  Hie 
Motions  of  the  Pupil"  in  the  preparation  of  the  section  devoted  t<>  the  pupil. 


1 52 


FUNCTIONAL    TESTING. 


closer  to  the  test-card  than  '•)  meters,  at  which  close  range  the  function  of  ac- 
commodation would  introduce  an  element  of  inaccuracy.    Thus,  the  scale  made 

15 
use  of  by  De  Wecker  and  elaborated  by  Oliver  assumes -jj- ( — ?==.,  approxi- 
mately), instead  of  |  as  ].  In  like  manner,  a  4-meter  distance  may  be  util- 
ized, as  lias  been  done  l>y  Edward  Jackson.  Rays  coming  from  letters  at  <>,  5, 
or  4  m.  have  so  little  divergence  when  they  reach  the  eve  that  they  are  usually 
considered  parallel;  hence  if  the  patient  sees  distinctly  at  this  distance,  his 
vision  is  perfect  at  the  longest  range.  In  point  of  fact,  however,  as  Frederick 
K.  Smith  has  insisted,  there  is  an  appreciable  divergence  of  rays  from  the 
distances  mentioned,  equivalent  respectively  to  ^,  ^,  and  J  diopter  lens.  In 
the  final  adjustment  of  glasses  this  divergence  should  he  recognized. 

For  the  purpose  of  a  control  test,  and  also  for  determining  the  visual 
acuity  of  illiterate  persons,  cards  are  employed  on  which  a  number  of  black 
dots  and  disks  of  various  sizes  are  placed,  which  should  be  counted  at  dif- 
ferent distances.  Among  the  best  known  of  these  are  Burchardt's  "inter- 
national tests/'  For  the  same  reason  Edward  Jackson  has  designed  a 
visual  test  which  is  an  incomplete  square,  the  incomplete  side  being  turned 
successively  in  different  directions  (see  also  page  140).  A  useful  test  for 
children  may  be  constructed  by  printing  on  a  card  small  pictures  of  well- 
known  objects  which  in  size  shall  approximately  conform  to  the  standard 
angle.     Such  a  series  has  been  published  by  Dr.  Wolffberg  of  Breslau. 

If  the  patient  fails  to  decipher  the  largest  letter  at  the  distance  employed, 
he  should  be  moved  closer  to  the  card.  Thus,  he  may  be  unable  to  read  the 
type  uumbered  60  at  6  m.,  but  may  discern  this  at  4  m.,  I=^o  Gr  yV°^nor" 
mal.  Still  further  depreciation  of  visual  acuity  is  recorded  by  requiring  the 
subject  to  count  the  outstretched  fingers  at  various  distances  (^,  1,  or  2  m.), 
V  =  counting  lingers  at  the  distance  measured.  When  the  ability  to  distin- 
guish form  (qualitative  light-perception)  no  longer  exists,  the  perception  of 
light  should  be  tried  by  alternately  screening  and  shading  the  eye,  or  by  illu- 
minating the  eye  with  light  reflected  from  a  mirror  or  focussed  through  a 
magnifier. 

I/ight-sense. — Having  determined  the  acuity  of  vision  by  means  of  the 
test-letters,  the  examiner  has  ascertained  the  form-sense,  and  may  proceed  to 


,i~y 


l-'n;.  ion—  l'hfitoinetrr  <>f  !•'<">  rst  it  iKiicIisi. 


investigate  a  -croud  subdivision  of  the  sense  of  sight,  the  light-sense,  which 
is  the  power  possessed  by  the  retina,  or  center  of  vision,  of  appreciating  vari- 
ations in  the  intensity  of  the  Bource  of  illumination.  An  instrument  called  a 
photometer  is  employed  for  this  purpose,  :m<l  consists  essentially  of  an  appa- 
ratus by  which  the  intensity  of  two  sources  of  light  may  be  compared — as,  for 


COLOR-SENSE.  153 

example,  in  the  apparatus  of  [zard  and  Chibret.  The  patient,  Looking  into 
the  instrument,  sees  two  equally  bright  disks.  One  disk  is  now  made  darker, 
and  the  power  of  the  eye  to  perceive  the  difference  in  the  illumination  of 
the  two  disks  is  ascertained  ;  or  one  disk  is  made  entirely  dark  and  then 
gradually  illuminated,  and  the  smallest  degree  of  light  noted  by  which  the 
patient  can  perceive  the  disk  coming  from  the  darkness.  The  former  is 
called  light-difference  ( L.  !>.),  and  the  latter  light-minimum  ( L.  M.i. 

Other  instruments  have  been  invented  by  Forster,  Landolt,  and  \l.  Wal- 
lace Henry.1  By  means  of  Forster's  photometer  (Fig.  100)  the  lowest  limit  of 
illumination  with  which  an  object  is  still  visible  (the  minimum  stimulus)  is 
ascertained.     The  following  description  is  taken  from  Fuchs  : 

"A  box,  A,  blackened  on  the  inside,  bears  on  its  anterior  wall  two  apertures  for  the 
two  eyes,  <i,  ".  which  look  through  these  apertures  at  a  plate,  7',  which  is  fastened  upon 
the  posterior  wall,  and  upon  which  large  black  stripes  upon  a  white  ground  are  placed 
as  test  objects.  The  illumination  is  produced  by  a  candle  of  one-candle  power,  A,  the 
light  from  which  falls  through  a  window,  F,  into  the  interior  of  the  box.  In  order  to 
make  the  illumination  perfectly  uniform,  the  window  is  covered  with  paper  which  is 
made  translucent  by  impregnating  it  with  fat.  By  a  screw.  S,  the  size  of  the  window 
can  be  altered  from  complete  closure  up  to  an  aperture  of  5  square  cm.  The  patient  is 
made  to  look  into  the  apparatus  with  the  window  closed,  and  the  plate  therefore  unillumi- 
nated.  Then  the  window  is  slowly  opened  until  the  stripes  upon  the  plate  can  be 
recognized.  The  size  of  the  opening  requisite  for  this  purpose  gives  a  measure  of  the 
light-sense  of  the  person  examined.  In  conducting  this  examination  the  precaution 
must  be  adopted  of  making  the  patient  stay  beforehand  in  the  darkness." 

Some  information  in  regard  to  the  light-sense  may  be  obtained  by  testing 
the  acuity  of  vision  on  two  cards  under  a  different  degree  of  illumination, 
and  by  comparing  the  results  with  a  similar  examination  of  a  subject  believed 
to  have  normal  power  of  appreciating  different  degrees  of  illumination.  flic 
patient  with  normal  light-sense  will  be  able  to  recognize  the  printed  letters 
when  the  patient  with  defective  light-sense  is  unable  to  read  them.  It  is 
very  important  in  many  cases,  especially  of  slight  retinal  change,  to  ascertain 
the  acuity  of  sight  under  full  and  under  diminished  illumination. 

Color-sense. — A  third  subdivision  of  the  sense  of  sight  is  the  color- 
sense,  or  the  power  which  the  retina  has  of  perceiving  color,  or  that  sensation 
which  results  from  the  impression  of  light  waves  having  a  certain  refrangi- 
bility.  This  examination  is  of  especial  interest  in  the  detection  of  color- 
blindness (see  page  603). 

Measurement  of  the  Vision  for  Colors. — Various  methods  are  em- 
ployed for  ascertaining  the  qualitative  and  quantitative  vision  for  colors. 
Direct  vision  for  colors  may  be  studied  by  placing  the  patient  at  a  given 
distance — for  example,  5  m. — from  a  chart  or  disk  of  graduated  colors.  In 
the  scale  of  De  Wecker  and  Masselon  the  colored  surface,  '2  em.  square, 
should  be  recognized  at  5  m.  ;  that  is,  the  chromatic  vision  I'  Cor  C  1  ; 
if  a  colored  test  must  be  four  times  this  size  in  order  to  be  recognized, 
C  =  \,  etc.  (True  and  Yalude).  Charles  A.  Oliver  has  designed  a  convenient 
apparatus  for  measuring  the  color-sense  in  this  manner  at  a  given  distance, 
and  has  found  that  red  requires  2|  mm.  of  surface  exposure  to  be  properly 
recognized  by  the  normal  event  5  in.  distance  ;  yellow,  a  slightly  increased 
area  ;  blue,  8|  mm.;  green,  10|   mm.  ;  and    violet,  22|  nun. 

Selection  Tests. — Usually  one  or  other  of  the  methods  which  consist 
essentially  in  testing  the  power  to  match  color-  conveniently  used  in  the  form 
of  colored  yarns  is  employed.  Practically,  all  of  these  tests  are  modifications 
of  Holmgren's  wools,  a  specially  commendable  method  being  thai  devised  by 

1  Ophthalmic  Review,  w..  Feb.,  1896. 


154  FUNCTIONAL    TESTING. 

Dr.  William  Thomson.  (For  the  full  consideration  of  these  tests  consult 
page  6<  ,;'>.  i 

Special  Tests. — In  order  to  obviate  the  change  which  occurs  in  the  color 
of  yarns,  etc.  the  color-sense  may  be  investigated  by  the  spectroscope,  which, 
however,  is  not  convenient  for  office-work.  The  changeable  colors,  which 
arc  colored  mixtures  like  those  of  wools,  may  be  produced  by  passing  polar- 
ized lighl  through  a  quartz  plate  and  again  through  a  Nicol-prism. 

The  following  account,  condensed  from  Carl  Weiland's  '  description  of 
the  Javal-ophthalmometer  as  a  chrommometer,  gives  the  essential  points  of 
instruments  constructed  for  this  purpose,  and  of  his  own  happy  modification 
of  the  ophthalmometer  : 

In  the  color-measurer  of  Rose  the  light  is  passed  through  a  Nicol-prism  first,  and 
then  by  a  diaphragm  through  a  double  refracting  prism,  from  where  it  enters  firsl  a 
quartz  plate  cut  at  right  angles  to  its  optic  axis,  and  finally  a  second  Nicol-prism.  Two 
circles  of  complementary  color.-  are  thus  produced,  which  change  continually  when  the 
upper  quartz  and  Nicol-prism  are  rotated,  but  always  remain  complementary  to  each 
other.  Konig's  ophthalmo-leukoscope  is  like  Hose's  instrument,  except  that  the  first 
Nicol-prism  is  wanting  and  that  quartz  plates  of'  different  thickness — 5,  Id,  or  15  mm. 
— are  used,  according  to  the  degree  of  color-saturation  required. 

In  Chibret's  chromato-photo-optometer  the  quartz  plate  is  cut  parallel  to  its  optic 
axis,  and  the  change  in  colors  is  obtained  by  inclining  the  plate  at  different  angles  to 
the  line  of  vision.  As  these  instruments  are  expensive,  Weiland  has  devised  a  chroma- 
tometer  which  lie  describes  as  follows  : 

The  color  attachment  to  .(aval's  keratometer  consists  "of  a  straight  metal  tube, 
about  I'  inches  in  diameter,  reaching  from  the  place  where  the  patient's  cornea  usually 
is  to  about  the  beginning  of  the  barrel  of  the  telescope,  and  so  fastened  to  the  head-rest 
thai  its  axis  coincides  witli  the  axis  of  the  instrument.  At  the  front  part  of  this  color- 
tube  (here  i<  a  plane  glass  plate  behind  which  a  Nicol-prism  is  fastened  in  a  cork. 
From  this  prism  the  polarized  light  passes  by  a  round  diaphragm  through  a  quartz  plate, 
cut  at  right  angles  to  its  axis  and  about  5  mm.  thick. 

"fhe  patient,  looking  with  the  Javal  through  this  tube,  will  see  two  large  color- 
fields  partially  overlapping  each  other.  These  color-fields  are  of  complementary  hues, 
while  the  place  of  overlapping  shows  white;  provided,  of  course,  that  white  light  as 
reflected  from  a  white  surface,  like  a  piece  of  white  paper,  is  employed  in  this  experi- 
ment. II'  now  the  arc  of  Javal  be  rotated,  while  the  color-tube  remains  in  the  same 
position,  the  colors  will  change  continually,  but  always  remain  complementary,  return- 
ing, however,  to  their  original  hues  after  the  arc  has  been  rotated  through  90°. 

"•  For  the  purpose  of  examination,  place  the  patient's  eye  at  the  ocular  of  the  in- 
strument, after  you  have  first  looked  in  yourself  and  given  to  the  new  color-tube  such  a 
position  that  blue  and  yeliow  appear,  because  thus  most  color-blind  persons  will  recog- 
nize two  different  colors.  Now  ask  the  patient  whether  the  two  colors  are  exactly  alike 
or  at  least  shades  of  the  same  color.  If  he  answers  No,  turn  the  barrel  of  the  Java! 
slowly  through   'J0°,  telling  the  patient   to   stop  you  as  soon    as  the  two  colors   are  the 

same.      Il   he  bas  g I  color-sense  he  will  always   see  two  different    colors,  but  if  he   is 

color-blind,  he  will  find  that  in  a  certain  position  of  the  arc  the  two  colors  will  appear 
alike,  or  at    least    as  much  alike  as  if  they  were  shades  of  the  same  color.      These  colors 

will  usuallj  be  green  and  rose  for  a  green-blind  person,  while  the  red-blind  person  gen- 
erally selects  a  more  bluish-green  and  a  rose  with  much  more  red  in  it.  This  suffices 
lo  prove  that  the  case  is  color-blind." 

Pseud o-isochromatic  Tests. — According  to  Mauthner,  certain  colors 
which  the  normal  eye  differentiates  appear  to  the  color-blind  person  "falsely 
of  the  same  color"— i.  e.  pseudo-isochromatic.  At  one  time  the  color-blind 
subject  will  describe  a-  alike  a  row  of  colors  which  are  not  so  ;  at  another 
time,  when  the  tesl  relate-;  to  the  recognition  of  letters  or  signs  on  a  colored 
ground,  he  will  not  see  them,  especially  when  the  color  of  the  ground  and  the 
letters  (figures,  signs,  etc.)  arc  pseudo-isochromatic  and  equally  clear. 

Daae  ha-  placed  ii| ,i  card  on  which  are  fastened  ten  horizontal  rows  of 

variously  colored  wools  one  row  \\  Inch  contains  only  red  wools,  one  which  coii- 

1  Archives  oj  Ophthalmoloyy,  xxiv.,  1895,  p.  349. 


MOBILITY  OF  THE  EYES. 

tains  only  green,  and  one  which  contains  only  purple.  I  n  the  other  seven  rows 
the  various  colors  arc  placed  next  to  each  other.  The  color-blind  person 
designates  row  s  a-  of  the  same  color  when  thi>  is  not  the  case  and  the  reverse. 
A  test  of  this  character,  according  to  Mauthner,  is  a  positivt  pseudo-isochro- 
matic  test,  because  it  depends  upon  the  positive  expressions  of  the  patient  in 
regard  to  color  similarity. 

Of  the  negative  pseudo-isoehromatic  tests — negative  because,  according  to 
Mauthner,  they  depend  upon  the  fact  that  the  color-blind  person  does  not 
read  figures  or  letters  which  are  drawn  upon  a  pseudo-isoehromatic  ground — 
the  plates  of  Stilling  may  be  mentioned  (see  page  <><)4).  Pseudo-isoehromatic 
powders  have  also  been  prepared  by  Mauthner  for  the  same  purpose. 

Simultaneous  contrast  tests  based  upon  experiments  with  colored 
shadows  are  not  satisfactory  in  practical  work.  Meyer's  discovery  thai  if  a 
gray  ring  or  border  is  placed  upon  a  colored — for  example,  red — piece  of 
paper,  and  then  covered  with  tissue-paper,  it  will  appear  to  the  normal  eye 
in  the  complementary  color — that  is,  green — has  been  utilized  for  practical 
work,  particularly  in  the  letters  devised  by  Pfliiger.  These  consist  of  black 
or  gray  letters  upon  a  colored  around.  The  letters  are  then  covered  by 
tissue-paper  and  appear  in  the  complementary  color. 

Lantern-tests  are  sometimes  employed,  and  are  of  great  value  in  the 
examination  of  railroad  employes  (see  page  604). 

Accommodation  is  measured  in  practical  work  by  finding  the  nearesl 
point  at  which  fine  print  can  be  clearly  deciphered.  The  type-  most  fre- 
quently adopted  are  those  known  as  Snellen's  0.5  or  Jaeger's  1.  Frequently, 
however,  the  types  in  common  use  are  very  badly  printed  and  constructed. 
The  letters  should  be  so  arranged  that  they  subtend  the  standard  angle  of 
five  minutes  at  a  given  distance;  for  example,  25  cm.,  50  cm.,  etc.  Ordina- 
rily, these  letters  are  arranged  upon  suitable  cards.  Excellent  series  have 
been  published  by  Schweigger,  by  James  Wallace,  and  by  Charles  A.  Oliver. 

In  order  to  study  the  phenomena  of  accommodation  the  studenl  should 
record — (1)  The  nearest  point  of  perfectly  distinct  vision  attainable  with  the 
smallest  readable  type,  or  the  punctum  proximum  (abbreviated  j>.  p,  or  simply 
//).  (2)  The  far  point  of  distinct  vision,  or  the  punctum  remotum  (abbreviated 
p.  r,  or  simply  r).  (3)  The  range,  amplitude  of  accommodation,  or  the  ex- 
pression of  the  amount  of  accommodative  effort  of  which  the  eye  is  capable. 
This  is  expressed  in  the  number  of  that  convex  lens  placed  close  to  the  cornea 
whose  focal  length  equals  the  distance  from  the  near  point  to  the  cornea,  and 
which  give-  rays  a  direction  as  if  they  had  come  from  the  far  point  ;  thus,  if 
the  near  point  be  at  I<>  cm.,  the  lens  which  expresses  the  amplitude  of  accom- 
modation  is  +  10  I).  10.      A  convenient   measure  is  a  stick  marked 

10 
on  one  side  in  inches  and  fractions  of  an  inch,  on  the  other  side  in  milli- 
meters and  centimeters  ;  on  the  edge  the  amplitude  of  accommodation  is 
expressed  in  diopters.  (4)  The  region  or  the  space  in  which  the  range  of 
accommodation  is  available.  (5)  Relative  accommodation,  or  that  independent 
portion  of  this  function  which  can  be  exercised  without  alteration  in  a  given 
amount  of  convergence,  and  is  divided  into  a  negative  portion,  or  that  portion 
which  is  already  in  use,  and  a  j»>si/ir<'  portion,  or  that  portion  which  is  not 
in  use.  If  the  patient  is  unable  to  read  the  line  tesl  print  at  any  distance, 
a  convex  leu-  should  be  placed  before  the  eye  and  the  near  (point  and  far  poinl 
recorded  with  its  aid  (see  also  page  134). 

Mobility  of  the  Byes. — This  i-  tested  by  causing  the  patient  t<>  follow 
with  his  eyes,  the  head  remaining  stationary,  the  movements  of  the  uplifted 


156  Fl  rN(  "/VO.V.  I  /.    TESTING. 

finger,  which  i-  directed  to  the  right,  to  the  left,  upward,  and  downward. 
Both  eyes  must  be  observed,  and  note  made  of  any  lagging  in  their  move- 
ments or  of  the  failure  of  either  eye  to  turn  into  the  nasal  or  temporal  eanthus. 
At  the  same  time,  the  relation  of  the  movements  of  the  upper  lid  to  those  of 
the  eyeball  is  recorded.  The  attention  of  the  patient  must  be  centered  upon 
the  moving  finger,  and  allowance  should  be  made  for  the  imperfect  mobility 
of  highly  myopic  eyes.  Anv  asymmetry  of  the  skull,  or  difference  in  the 
level  of  the  two  orbital  margins,  may  be  observed,  because  such  conditions 
are  not  infrequently  associated  with  ametropic  eyes,  especially  when  the  two 
<'\es  possess  great  inequality  in  refractive  conditions. 

Investigation  of  the  Balance  of  the  External  Bye-mnscles. — 
Under  normal  conditions  perfect  equilibrium  of  the  external  eve-muscles  is 
present,  but  preponderance,  for  example,  of  the  power  of  the  external  recti,  or 
vice  versd,  produces  a  tendency  to  divergence  or  convergence,  which,  however, 
is  overcome,  with  the  preservation  of  binocular  single  vision,  in  spite  of  the 
disturbed  equipoise.  This  condition  was  named  by  Von  Graefe  dynamic  stra- 
bismus, it  is  frequently  designated  insufficiency  of  the  ocular  muscles.  Dis- 
turbance of  the  normal  balance  (imbalance,  as  it  is  now  called)  creates  a  tend- 
ency for  the  visual  lines  to  depart  from  parallelism,  or  the  various  phorias  of 
<r.  T.  Stevens's  classification.  In  order  to  ascertain  the  condition  of  the 
ocular  muscles,  in  so  far  as  their  balance  is  concerned,  we  may  employ  the 
following  tests  : 

(1)  Approach  the  finger  to  within  a  few  inches  of  the  eyes,  which  are 
steadily  fixed  upon  its  tip,  and  note  if  a  convergence  to  a  distance  of  X  cm. 
( -)\  in. )  is  attainable.  If  one  eye  deviates  outward  before  this  point  is  reached, 
weakness  of  the  interni  is  present,  the  eye  possessing  the  weaker  interims  usu- 
ally being  the  one  which  exhibits  the  deviation.  This  test  is  a  rough  one,  and 
valuable  chiefly  for  ascertaining  which  of  the  interni  is  the  weaker. 

(2)  Require  the  patient  to  fix  upon  a  fine  object,  as  a  pin-point,  held 
below  the  horizontal,  'JO  or  25  cm.  from  the  eye,  and,  in  order  to  remove  the 
control  of  binocular  vision,  cover  one  eye  with  a  card  or  the  hand,  and  ob- 
serve whether  the  eye  under  cover  deviates  inward  or  outward,  and  returns 
to  fixation  when  the  cover  is  removed.  If  the  patient  fixes  the  object  accu- 
rately, and  the  manipulations  of  covering  and  uncovering  first  one  eye,  and 
then  the  other,  are  rapidly  performed,  trustworthy  results  will  be  obtained. 
I  M  general  terms,  each  millimeter  of  movement  of  the  deviating  eye  corresponds 
to  2°  of  insufficiency  as  measured  by  prisms.  In  the  case  of  the  interni,  if 
the  covered  eye  moves  in  to  fix,  with  several  distinct  impulses,  each  impulse 
should  be  multiplied  into  the  foregoing  result  (Randall). 

(."!)  Produce  vertical  diplopia  with  a  prism,  and  test  the  functions  of  the 
lateral  muscles  at  a  distance  of  6  m. 

A  small  flame  is  placed  against  a  dark  background  at  (J  m.  from  the 
patient  and  on  a  level  with  his  eyes.  In  an  accurately  adjusted  trial  frame  a 
prism  of  7°  is  Inserted,  base  down,  before  one  eyi — for  example,  the  right. 
Vertical  diplopia  i-  induced,  and  the  upper  image  belongs  to  the  right  eye. 
If  the  flames  stand  one  directly  over  the  other,  there  is  no  inclination  to 
divergence  or  convergence.  II'  the  upper  image  stands  to  the  left,  there  i- 
weakness  of  the  interni  ;  if  to  the  right,  of  the  externi.  That  prism  placed 
with  it-  base  in  or  out  before  the  left  eye.  according  to  circumstances,  which 
brings  the  two  images  into  a  vertical  line,  measures  the  degree  of  the  deviation. 

Thus  the  presence  or  absence  of  lateral  insufficiency  is  determined. 

(  I)  Produce  lateral  diplopia,  and  test  the  functions  of  the  vertical  muscles 
at  .i  distance  of  i;  m. 


BALANCE  OF  THE  EXTERNAL    EYE-MUSCLES.  157 

The  patient  is  seated  as  before,  and  a  prism  of  sufficient  strength  to  induce 
homonymous  diplopia  i>  placed  before  one  ey< — f'«>r  example,  the  right — i.  e. 
with  its  base  toward  the  nose.  II"  the  Images  are  on  the  same  level,  no  de- 
viating tendency  is  present.  II'  the  right  image  rises  higher  than  the  other, 
the  visual  line  of  the  right  eve  tends  to  be  lower  than  that  of  its  fellow,  and 
there  is  insufficiency  of  the  vertical  muscles.  That  prism,  placed  with  it~  base 
down  before  the  left  eye,  which  restores  the  images  to  the  horizontal  level 
measures  the  degree  of  deviation. 

(5)  Produce  vertical  diplopia,  and  tot  the  functions  of  the  lateral  muscles 
at  the  ordinary  working  distance,  or  30  cm.  For  this  purpose  it  is  customary 
to  employ  the  equilibrium  test  of  Von  Graefe,  in  which  a  card,  having  upon 
it  a  large  dot  through  which  a  fine  line  is  drawn,  is  held  25  or  30  cm.  from 
the  eyes,  diplopia  being  induced  by  means  of  a  prism  of  10°  or  15°,  base  up 
or  down,  before  one  eye.  A  more  accurate  test-object  is  a  small  dot  and  fine 
line,  or  a  single  word  printed  in  fine  type,  requiring  accurate  fixation  and  a 
sustained  effort  of  accommodation.  If,  the  prism  being  placed  base  down 
before  the  right  eye,  the  images  stand  exactly  one  above  the  other,  equilibrium 
is  evident;  if  the  upper  image  (image  of  the  right  cyel  stands  to  the  left  of 
the  lower  image,  there  is  crossed  lateral  deviation  ;  and  that  prism,  placed 
before  the  left  eye  with  its  base  toward  the  nose,  which  restores  the  image  to 
a  vertical  line  measures  the  tendency  to  divergence,  exophoria,  or  insufficiency 
of  the  internal  recti.  If  the  upper  image  stands  to  the  right  of  the  lower, 
there  is  homonymous  lateral  deviation  ;  and  the  prism  placed  before  the  left 
eye,  with  its  base  toward  the  temple,  which  restores  the  images  to  a  vertical 
line,  measures  the  tendency  to  convergence,  esophoria,  or  insufficiency  of  the 
external   recti. 

(6)  Ascertain  the  power  of  adduction  (prism-convergence),  abduction 
(prism-divergence),  and  sursumduction  (sursumvergence)  by  finding  the 
strongest  prism  which   the  lateral  and  vertical  muscles  can  overcome.1 

Beginning  with  adduction,  find  the  strongest  prism  placed  before  one  eve, 
with  its  base  toward  the  temple,  through  which  the  flame  still  remains  single. 
The  test  should  begin  with  a  weak  prism,  the  strength  of  which  is  gradually 
increased  until  the  limit  is  ascertained.  This  varies  from  30°  to  50°.  In 
this  test,  if  diplopia  occurs  when,  for  example,  the  strength  of  the  prism 
reaches  20°,  single  vision  may  not  return  until  the  prism  has  been  reduced, 
for  instance,  to  10°.  The  space  between  the  greatest  and  least  power  of 
adduction  has  been  described  as  the  "  region  of  diplopia"  (Reeves,  Lippincott, 
Gould  i. 

In  like  manner  abduction  is  tested,  the  prism  now  being  turned  with  its 
base  toward  the  nose  ;  (>°  to  8°  of  prism  should  be  overcome.  The  ratio  be- 
tween adduction  and  abduction  should  be  6  to  1  (Stevens) — i.  e.  if  adduction 
is  48°,  abduction  should  be  8°,  but,  according  to  Risley,  in  carefully  corrected 
or  emmetropic  eyes  the  ratio  is  3  to  1. 

Sursumduction,  or  the  power  of  uniting  the  image  of  the  candle  flame 
seen  through  a  prism  placed  with  its  base  downward  before  one  eye  with  the 
image  of  the  same  object  as  -ecu  by  the  other  eye,  is  ascertained  by  beginning 
the  trial  with  a  weak  prism,  }r°  or  1°,  and  gradually  increasing  ii-  strength. 
The  limit  i~  usually  ■'>  ,  but  may  be  as  high  a-  8    or  10°. 

If  the  eyes  of  the  patient   under  examination  are  ametropic,  the  proper 

'The  words  "power  of  adduction,"  etc  arc  here  used  with  the  significance  ordinarilj 
attached  to  them.  For  another  consideration  of  this  matter  tin-  student  Bhould  read  the  para- 
graphs relating  to  the  same  Bubject  in  I  »r.  I  taane's  discussion  of  "  Tin-  Anomalies  of  the  <  Ocular 
Muscles,"  p.  503. 


158 


II  \\< 'TIOXA  L    TKSTlSli. 


correcting  lenses  should  be  placed  before  them,  and  the  examination  for  the 
various  forms  of  insufficiency  made  through  this  glass.  It  is, moreover, ex- 
ceedingly important  that  the  correcting  glass  should  be  accurately  centered  ; 

otherwise,  in  a  lens  of  considerable  thickness,  a  prismatic  effect  would  he 
produced  which  would  utterly  preclude  accurate  determination  of  the  mus- 
cular condition-,  especially  of  the  vertical  muscles,  where  the  search  for 
fractions  of*  a  degree  of  deviation  is  sometimes  necessary.  It'  the  muscular 
examinations  have  been  undertaken  as  part  of  a  routine  preliminary  investi- 
gation of  an  eye,  they  should  be  repeated  after  the  refraction  has  been  accu- 
rately determined,  and,  if  anomalous,  corrected. 

Practically,  all  of  the  examinations  for  muscular  errors  can  be  made  with 
a  -erics  of  prisms  and  a  trial  frame,  hut  they  are  facilitated  by  the  use  of 
certain  instruments  of  precision,  especially  some  form  of  FJerschel  or  re- 
volving prism,  the  one  devised  by  Uisley  being 
the  best  (Fig.  101).  The  latter  consists  of  two 
prisms,  superimposed  with  their  bases  in  opposite 
directions,  constituting  a  total  value  of  45°. 
They  are  mounted  in  a  cell  which  has  a  deli- 
cately milled  edge,  and  fits  in  the  ordinary  trial 
frame.  The  milled  edge  permits  convenient 
turning  in  the  frame,  so  that  the  base  or  apex  of 
the  prisms  can  he  readily  placed  in  any  desired 
direction.  The  prisms  are  caused  to  rotate  in 
opposite  directions  by  means  of  a  milled  screw- 
head  projecting  from  the  front  of  the  cell.  With 
this  rotary  prism  the  strength  of  the  abducting, 
adducting,  and  supra- and  infraducting  muscles  can  he  measured.  If  the 
rotary  prism  is  placed  before  the  left  eye  with  the  zero  mark  vertical,  and 
the  screw  turned  to  the  right  or  left,  it  will  cause  the  base  of  the  resulting 


Fig.  101.— Risley's  rotary  prism. 


phorometer. 


prism    to    he   either    inward    or   outward,  that    i-,  toward    the    QOSe   or    temple, 

:i-  may  be  desired  ;  or  it  may  be  placed  with  the  zer ark  horizontal  and  the 

base  turned   upward  or  downward.     All  examinations  for  muscular  defects 


BALANCE  <)/'  THE  EXTERNAL    EYE-MUSCLES. 


159 


may  be  accurately  ascertained  with  Dr.  Gr.  T.  Stevens's  well-known  phorom- 

eter,  which  is  illustrated  in  Fig.  1*>'2. 

One  of  the  simplest  tests  of  the  ocular  muscle.-  is  the  obtuse-angled  prism 

of  Maddox.  This  is  composed  of  "two  weak  prisms  of  '■>  .  united  by  their 
bases.  On  looking  through  the  line  thus  Conned  al  a 
distant  plane,  two  false  images  of  it  are  seen,  one 
higher  and  one  lower  than  the  real  image  seen  by  the 
other  eve,  the  position  of  which,  to  the  right  or  the 
left  of  the  line  between  the  false  images,  indicates  the 
equilibrium  of  the  eye.  A  faint  hand  of  light,  of  the 
same  breadth  as  the  two  false  images,  is  seen  extended 
between  them"  (Fig.  103).  The  answers  of  the  patient 
may  be  materially  assisted  by  placing  a  red  glass  before 
one  eye  and  thus  tinting  the  real  image.  I  {'this  stands 
directly  in  the  center  between  the  two  false  images,  all 
forms  of  insufficiency  are  eliminated;  if  it  stands  to 
the  right  or  to  the  left,   there   is  insufficiency  of  the 


ts  for  insufficiency  of  oblique  muscles  Savage  :  i.insuffi- 
:  M  u-  obliqut    7.  insuffi:  ■.  n:  5     1  1   It  ml.  .1  :i  ?buqu< 


Fig.  103.— Position  of  the  Fig.  104.— Tests 

images  as  seen  through  the  ciency  of  left  super-  . 

obtuse-angled     prism    of  insufficiency  of  right  superior  oblique ;  l,  insufficiency  of  right  inferior 

Maddox   (Randall).  oblique  :  5,  equilibrium  of  oblique  muscles. 


external  or  of  the  internal  recti  ;  if  it  stands  above  or  below  the  center,  or  is 
fused  with  the  upper  or  the  lower  image,  there  is  insufficiency  of  the  superior 
or  inferior  recti. 

Insufficiency  of  the  oblique  muscles  (cyclophoria),  according  to  Savage,  may 
be  detected  "by  placing  a  Maddox-prism,  with  its  axis  vertical,  before  one 
eye  (the other  being  covered),  which  regards  a  horizontal  line  on  a  card  18  in. 
distant.  This  line  appears  to  he  two,  each  parallel  with  the  other.  The  other 
eye  is  now  uncovered,  and  a  third  line  is  -ecu  between  the  other  two.  with 
which    it   should   he   parallel.      Want   of  harmony  in    the  oblique   muscles  is 

shown   by  want   of  parallelism   of  the  middle  with   tl ther  two  lines,  the 

right  end  of  the  middle  line  pointing  toward  the  bottom  and  the  left  end 
toward  the  top  line,  or  vice  versd,  depending  upon  the  nature  o\  the  indi- 
vidual  case  "  '  (  Fig.    104). 


1  Much  doub 
the  phenomenon 
L894. 


,i   has  been  cast   upon  the  accuracy  of  this  test  by  V.  B.  Eaton,  who  considers 
a  physiologic  one.     Consult  Journal  of  the  American  Medkal    I  .Sept, 


160 


FUNCTIONAL    TESTING. 


The  rod-Jest,  also  designed  by  Maddox,  depends  upon  tlie  property  of 
transparent  cylinders  t<>  cause  apparent  elongation  of  an  object  viewed 
through  them,  so  that  a  point  of  light   becomes  a  line  of  light   so  dissimilar 

from  the  test-light  that  the  images  are  not 
united.  It  may  be  suitably  employed  by  having 
mounted  in  a  cell  which  will  tit  in  the  trial  frame 
a  transparent  glass  rod  colored  red,  |  in.  long, and 
about  the  thickness  of  the  ordinary  stirring-rod 
used   by  chemists,  or  a  series  of  glass  rods  placed 

ulie  above  the  other  (  Fig.    105). 

The  examination  for  horizontal  deviation  is 
thus  described  :  "  Seat  the  patient  at  (J  m.  from  a 
small  flame,  placed  against  a  dark  background, 
and  put  the  rod  horizontally  before  one  eye. 
If  the  line  passes  through  the  flame,  there  is 
orthophoria  (equipoise)  as  far  as  the  horizontal 
movements  of  the  eyes  are  concerned.  Should  the  line  lie  to  either  side  of 
the  flame,  as  in  most  people  it  will,  there  is  either  latent  convergence  or  latent 
divergence  :  the  former,  if  the  line  is  on  the  same  side  as  the  rod  (homonymous 
diplopia);  the  latter,  if  to  the  other  side  (crossed  diplopia)"  (Fig.  106). 

.1  R  0 


Fig.  105.   -Maddox-multiple-rod. 


i  i. -i  for  horizontal  deviation;  the  rod  is  before  the  righl  eye:  .1    the  line 
■  through  th  rthophoria  ;  B,  the  line  passes  to  the  right  of  the  flame    latentconvei 

or  ■  Bophoria  ;  C,  the  line  passes  to  the  left  of  the  flame    latent  divergence,  or  exophoria 

In  order  to  teal  the  vertical  deviation,  the  rod  is  placed  vertically  before 
'he  eye:  a  horizontal  line  of  light  appears,  and  the  patient  is  asked  if  the 
line  passes  directly  through  the  flame  or  if  it  appear-  above  or  below  it.  The 
following  ride,  quoted  from  Maddux,  will  suffice  to  indicate  the  "hyper- 
phoria" eye  :  "  [fthe  (lame  i-  lowest,  there  is  a  tendency  to  upward  deviation 
of  the  naked  eye  ;  if  the  line  ie  lowest,  of  the  eye  before  which  the  roil  i- 

placed"  '  (  Fig.    107). 

■  Dr  Swan  M    Burnetl  substitutes  for  the  Maddox-rod  a  6  I ».  cylinder. 


POWER   OF  CONVERGENCE. 


161 


The  measurement  of  the  extent  of  the  deviation  may  be  made  in  the  ordi- 
nary way  byn'nding  that  prism,  placed  before  the  naked  eye  (preferably  with 
therotary  prism  of  Risley),  which  brings  the  line  and  flame  together. 

In  order  to  avoid  the  awkwardness  of  the  phraseology  "  insufficiency  of 
the  internal  recti,"  etc.,  and  at  the  same  time  more  accurately  to  describe  the 


Fig.  107.— Maddox's  rod-test  for  vertical  deviation  ;  the  rod  is  before  the  right  eye  :  .1,  the  line  passes 
through  the  flame — orthophoria  ;  B,  the  line  passes  below  the  flame;  the  upper  image  belongs  to  tin-  left 
eyi — right  hyperphoria;  C,  the  line  passes  above  the  flame;  the  upper  image  belongs  to  the  right  eye 
—left  hyperphoria. 

muscular  anomalies,  the  following  terminology  has  been   introduced  by  Dr. 
George  T.  Stevens,  and  has  received  a  deservedly   wide  acceptation  : 

The  condition  in  which  all  adjustments  are  made  by  muscles  in  a  state  of  physio- 
logical equilibrium  is  called  orthophoria. 

Disturbances  of  equilibrium  are  known  as  heierophoria,  or  insufficiencies  of  the 
ocular  muscles. 

The  deviating  tendencies  of  beterophoria  may  exist  in  as  many  directions  as  there 
are  forces  to  induce  irregular  tensions. 

The  following  system  of  terms  is  applied  to  the  various  tendencies  of  the  visual 
lines : 

I.  Generic  Terms. —  Orthophoria:  A  tending  of  the  visual  lines  in  parallelism. 
Heterophoria  :  A  tending  of  these  lines  in  some  other  way. 
II.  Specific  Terms. — Heterophoria  may  be  divided  into — 

1.  Emphoria :  A  tending  of  the  visual  lines  inward; 

2.  Exophoria  :  A  tending  of  the  lines  outward  : 

3.  Hyperphoria    right  or  left)  :  A  tending  of  the  right  or  left  visual  line  in  a 
direction  above  its  fellow. 

This  term  does  not  imply  that  the  line  to  which  it  is  referred  is  too  high,  but  that  it 
is  higher  than  the  other,  without  indicating  which  may  be  at  fault. 

III.  Compound  Terms. — Tendencies  in  oblique  directions  may  be  expressed  as 
hyperesophoria,  a  tending  upward  and  inward  ;  or  hyperexophoria,  a  tending  upward  and 
outward.     The  designation  "  right"  or  "  left*'  must  be  applied  to  these  terms. 

Power  of  Convergence. — In  order  to  determine  the  maximum  of 
convergence  an  instrument  known  a-  an  ophthcUmo-dynamometer  may  lie  em- 
ployed. The  one  devised  by  Landoll  consists  of  a  metallic  cylinder,  blackened 
on  the  outside,  placed  over  a  candle  flame.  The  cylinder  contains  a  vertical 
-lit  0.3  mm.  wide,  covered  l>v  ground  g;las<.  The  luminous  vertical  line  thus 
produced  is  the  objeel  of  fixation.  Beneath  the  cylinder  i-  attached  a  tape 
measure  graduated  on  one  side  in  centimeters,  and  <>n  the  other  in  the  cor- 
responding number  of  meter-angles.  The  fixation  objeel  is  gradually  ap- 
proached in  the  median  line  toward  the  patient,  until  that  point  where  double 


162  FUNCTIONAL    TESTING. 

vision  occurs  is  reached,  or  the  nearest  poinl  (pimctum  proximum)  of  con- 
vergence, and  the  distance  in  centimeters  read  from  one  side  of  the  tape,  and 
the  corresponding  maximum  of  convergence  in  meter-angles  on  the  other. 

The  minimum  of  convergence  may  also  be  ascertained  with  the  instrument, 
bul  when  this  is  negativt  it  is  determined  by  finding  the  strongest  abducting 
prism  which  will  not  cause  diplopia  while  the  patient  is  fixing  a  candle  flame 
at  ii  in.  It'  the  number  of  the  prism  is  divided  by  7,  the  quotient  will  ap- 
proximately give  in  meter-angles  the  amount  of  deviation  of  each  eve  when 
the  prism  i-  placed  before  one.  The  amplitude  of  convergence  is  equivalent 
to  the  difference  between  the  maximum  and  minimum  of  convergence.1 

The  Field  of  Vision. — When  the  visual  axis  of  one  eye  is  directed  to 
a  stationary  point,  not  only  is  the  object  thus  "fixed"  visible,  hut  all  other 
objects  contained  within  a  given  -pace,  which  is  large  or  small  in  proportion 
to  the  distance  of  the  fixation  point  from  the  eye.  This  space  is  the  field  of 
vision  (conveniently  abbreviated  V.  F.),  and  the  objects  within  it  imprint 
their  images  upon  the  peripheral  portions  of  the  retina,  or  those  which  arc 
independent  of  the  macula  lutea.  In  contradistinction  to  visual  acuity  and 
refraction,  which  pertain  to  the  macula  in  the  act  of  direct  vision,  the  function 
of  sight  capable  of  being  performed  by  the  rest  of  the  retina  is  called  indirect 
vision. 

The  limits  of  the  visual  field  may  be  roughly  ascertained  in  the  following 
manner  :  Place  the  patient  with  his  back  to  the  source  of  light,  and  have  him 
ti\  the  eye  under  examination,  the  other  being  covered,  upon  the  center  of 
the  face  of  the  observer,  or  upon  the  eye  of  the  observer,  which  is  directly 
opposite  his  own  at  a  distance  of  2  ft.  Then  let  the  surgeon  move  his  fingers 
in  various  directions  midway  between  himself  and  the  patient  on  a  plane  with 
hi-  own  face,  until  the  limits  of  indirect  vision  are  determined,  controlling  at 
the  same  time  the  extent  and  direction  of  the  movements  by  his  own  field  of 
vision.  Instead  of  using  fingers  as  the  test-object,  the  author,  in  common 
with  many  surgeons,  is  accustomed  to  employ  a  black  rod  1<S  in.  long,  which 
i-  capped  with  an  ivory  ball  12  mm.  in  diameter.  Colored  balls  may  also  be 
employed  in  the  same  way,  and  a  fair  idea  of  indirect  color  vision  obtained. 

These  methods  suffice  to  discover  any  considerable  limitation  of  the  visual 
field,  but  should  always  be  supplemented  by  a  more  exact  procedure. 

If  it  i-  desired  to  have  a  map  of  the  field  not  larger  than  4o°  in  extent, 
let  the  patient  be  placed  25  cm.  from  a  blackboard,  which  may  be  con- 
veniently ruled  in  squares,  and  tix  the  eye  under  observation  upon  a  small 
white  mark.  The  observer  then  moves  the  test-object,  a  piece  of  white  paper 
1  cm.  square,  affixed  to  a  black  handle,  from  the  periphery  toward  fixation, 
until  the  object  i-  -ecu.  If  eight  peripheral  points  arc  marked  and  afterward 
joined    by  a  line,  a  fair   map  of  the   tield   of  vision  will   be  obtained,"  which 

1  Landolt'a  Refraction  mi, I  Accommodation  of  the  Eye. 
I  he  ralue  in  degrees  of  the  squares  on  the-  blackboard  may  la-  ascertained  by  the  follow- 
ing table,  provided  1 1 1 •  -  eye  i-  placed  exactly  at  25  cm.  from  the  fixation-poinl  : 
2.2  cm.         5°  in  tin-  perimeter  semicircle. 


I.I    • 

10° 

<;.:    ■■ 

L5 

9.1     " 

20 

11.7     " 

25° 

111      " 

30° 

17,'.     - 

:;:, 

21 

10° 

15 

30 

.Ml 

86.7    " 

13.3     ■ 

Ci, 

THE  FIELD   OF    VISION. 


163 


may  be  transcribed  upon  a  chart,  like  the  one  originally  suggested  by  .)<>v 
Jeffries  (Fig.  L08). 

In  like  manner,  a  campimeter  may  be  employed,  the  one  designed  by  De 
Wecker  being  a  useful  model.  It  may  be  understood  by  reference  to  Fig. 
109.     The  patient's  eye  regards  the  cross  in  the  center  of  a  black  vertical 


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I 

■**. 

*,, 

s— 

— 

r 
1 

. 

1 

!  X. 

[_ 

White 

Blue.... 
Red 

Fig.  108. — Limits  of  the  normal  field  for  white,  blue,  and  red, 
transcribed  upon  a  blackboard  (after  Norris). 


Fig. 


li  ►'.». — ( 'ampimeter  of  I  »e 

Wicker. 


table  while  the  test-object  is  moved  from  the  periphery  toward  the  center, 
and  the  outermost  limit  of  its  recognition  is  marked  on  the  radiating  line 
which  it  follows.  When  each  line  has  thus  been  traversed,  the  points  are 
joined  by  a  continuous  line,  and  a  graphic  representation  of  the  visual  Held 
results. 

The  field  of  vision  may  also  be  examined  on  a  flat  surface  at  a  greater 
distance  than  2o  to  30  cm.,  after  the  manner  proposed  by  Bjerrum.  The 
examinations  are  made  at  a  distance  of  2  m.  on  a  large  black  screen  2  m.  in 
breadth,  which  can  be  let  down  from  the  ceiling  to  the  floor.  At  this  dis- 
tance the  blind  spot  (see  p.  169),  instead  of  measuring  about  2.V  cm.,  as  on  an 
ordinary  perimeter,  measures  20  cm.  in  diameter,  and  everything  else  is  in 
the  same  proportion.  The  test-objects  used  by  Bjerrum  are  small  circular 
disks  of  ivory  fixed  on  the  ends  of  long  dull-black  rods.  They  vary  from 
10  to  1  mm.  in  diameter.  The  examination  is  begun  in  the  ordinary  way  at 
30  cm.  with  the  10-mm.  disk,  and  then  continued  at  2  meters' distance  with  a 
3-mm.  disk.  In  the  first  case  the  visual  angle  approximately  is  2  .  and  in 
the  second  -V.  The  normal  boundaries  in  the  firsl  instance  have  been  given  ; 
in  the  second  they  are  35°  outward,  o0°  inward,  28°  downward,  and  25 
upward.  The  method  is  valuable  for  finding  sector-shaped  defect-,  irregular 
limitation-,  and  especially  seotomata  (see  p.  169).1 

Beyond    15"   measurements  on  a  flat  surface  cease  to  be  accurate,  because 
the  object  i-  too  far  away  from  the  eye  ;   rays  perpendicular  to  the  visual  line 


1  Dr.  Joseph  E.  Willets  I  Aimtds  <;/'  Ophthalmology  and  Otology,  1896,  vol.  v..   No.  3, 
has  constructed  a  prismatic  perimeter  in  which  a  Dumber  of  prisms  or  cones  are  arranged,  which 
trun-init  or  refract  rays  of  light  to  that  part  <>('  tin-  retina  corresponding  t"  tli'  degrees  in  the 
present  perimetrical  chart.       ror  full  details  the  reader  i-  referred  to  the  article.) 


164 


FUNCTIONAL    TESTING. 


coming  from  a  peripheral  object   would  be  parallel  to  the  blackboard,  and 
could  not  arise  from  it   or  any  object   passed  across  its  surface. 

The  accurate  investigation  of  the  functions  of  the  periphery  of  the  retina 
requires  the  use  of  an  instrument  called  a  perimeter,  for  which  we  arc  chiefly 
indebted  to  A.ubert  and  Forster.  This  instrument  consists  essentially  of  an 
arc(or  a  semicircle)  of  wood  or  metal  marked  in  degrees  which  rotates  around 
a  centra]  pivot,  which  at  the  same  time  is  the  fixing  point  of  the  patient's 
eye,  placed  30  cm.  distant — i  e.  at  the  center  of  curvature  of  the  perimeter 
arc.     The   test-object,  1    or    1 1  cm.  in   diameter,   affixed   upon  a   carrier,   is 


'--  Perimel  imination  may  be  made  with  the  carrier  which  moveB  along  the  semi- 

circle, orth  i  maybe  carried  along  this  by  means  of  dark  disks  attached  to  a  long  handle, 

each  disk  containing  in  its  center  the  test-object.    The  patient's  chin  is  placed  in  the  curved  chin-rest ; 
the  notched  end  of  the  uprigbl  i>ar  is  brougnl  in  contacl  with  the  face,  directly  beneath  the  eye  to  be 
tied,  which  attentively   fixes  the  center  of  the  semicircle.    The  other  eye  should  be  covered, 
■  neatly  adjusted  bandage     1  be  n  cord  charl  is  inserted  at  the  back  of  the  instrument, 
in  Ivory  vernier  the  examiner  is  enabled  to  mark  exactly  with  a  pencil  the  point  on  the 
corresponding  to  the  position  on  ;  rcle  al  which  the  patient  Bees  the  test-ODject.     The 

then  joined  by  a  continuous  line,  and  a  map  of  the  Held  is  obtained. 

moved  from  without  inward  along  the  arc,  and  the  point  noted  in  each  me- 
ridian at  intervals  of  30  .  where  it  is  recognized.  Usually  the  examination 
is  begun  with  the  are  in  the  horizontal  position,  which  is  then  moved  from 
this  meridian  to  the  nexl  (e.g.  up  and  out),  and  so  on  until  the  whole  field 
has  been  investigated.  Generally  it  is  sufficient  to  examine  eight  meridians 
Fig,  II-., 

The  result  is  transcribed  upon  a  ••hart,  prepared  by  having  ruled  upon  it 
radial  lines  to  correspond  to  the  various  positions  of  the  arc,  and  concentric 
circles  to  note  the  decrees. 


THE   EI  ELD    OE    VISION. 


165 


Tlir  numbering  of  the  meridians  on  the  numerous  charts  which  have  been 

published  is  far  from  uniform,  as  may  be  -ecu  by  examining  the  accompany- 
ing diagrams  (  Figs.  111,112,113).   Noyes 
and  Knapp,1  in  order  to  secure  uniform 

n rds  of  the  visual  field,  have  advised 

the  designation  of  the  meridians  accord- 
ing to  the  method  employed  by  Ilelm- 
holtz  in  his  study  of  the  movements  of 
the  eye — viz.  "to  take  as  the  zero  point 
the  left  end  of  the  horizontal  meridian 
of  each  eye,  and  to  count  from  left  to 
right  as  the  hands  of  a  watch  viewed  by 
a  person  under  examination  move.  0° 
accordingly  marks  the  temporal  end  of 
the  horizontal  meridian  of  the  left  and 
the  nasal  end  of  the  same  meridian  of 
the  right  eye;  180°  marks  the  nasal  end  of  the  horizontal  meridian  of  the 
left  and  the  temporal  end  of  the  same  meridian  of  the  right  eve." 2 

Since  the  Aubert-Fiirster  instruments  appeared  the  perimeter  has  under- 
gone numerous  modifications  and  the  market  is  supplied  with  a  host  of 
models.     The  most  practical  and  time-saving  instruments  are  the  so-called 


Fig.  11L— Visual-field  chart  according  to 
Forster. 


Fig.  112. — Chart  for  Mcllardy's  registering  perimeter. 


Fig.  113.— Chart  for  perimeter  (Fig.  110). 


self-registering  perimeters,  especially  those  designed  by  Stevens,  McHardy, 
and  Priestley  Smith.  A  useful  model  for  bedside  examinations  ig  the  hand 
perimeter  of  Schweigger. 

The  size  qfthi  visual  field  varies  considerably  within  normal  limit-,  being 
influenced  by  the  character  of  the  light,  which  should  illuminate  with  equal 
intensity  all  portions  of  the  perimeter  are  in  each  position  ;  by  the  size  of  the 
test-object,  which  should  be  not  less  than  ]  and  not  greater  than  '2  cm.  in 
width  ;  by  the  attention  of  the  patient,  whose  eye  should  accurately  regard 
fixation  during  the  measurement  ;  and  by  the  patient's  physical  and  mental 
condition.      Indue  prolongation  of  the  examination  produces  retinal  tire  and 

1  Archives  of  Ophthalmology,  vol.  xv.  p.  207. 
[nstead  of  having  the  patient  fix  his  eye  npon  the  central  pivot,  it  may  be  directed  upon  :i 
porcelain  button  on  a  bar  placed  15°  from  the  center  to  the  left  it'  the  righl  • 
amined,  and  vice  versa  if  the  left  i^  under  observation.,     This  plan   originally  suggested    by 
Forster,  makes  the  optic-nerve  entrance,  and  not  the  macula,  the  i  entre  i  >f  the  visual  field. 


L66 


FUNCTIONAL    TESTIXU. 


corresponding  contraction  of  the  visual  field.  The  extent  of  the  field  of 
vision  is  also  somewhat  under  the  influence  of  the  size  of  the  pupil  and  the 
state  of  refraction,  being  larger  in  eyes  with  widely  dilated  pupils  or  with 
hyperopic  refraction,  and  smaller  in  eyes  with  contracted  pupils  or  with 
myopic  refraction.  Enlargement  of  the  visual  field  may  be  ooted  during 
accommodation  for  the  near  point  and  when  the  patient  wears  concave 
glasses  '  i  Mauthner). 

The  average  physiological  limits  of  the  form-field,  or,  what  is  practically 
the  same  thing,  the  field  when  this  has  been  measured  with  a  square  of  white 
l.V  cm.  in  width,  an — outward,  90  ;  outward  and  upward,  70°;  upward, 
50  :  upward  and  inward,-",:)  ;  inward,  60°;  inward  and  downward,  55°  ; 
downward,  72    ;  downward  and  outward,  85°. 

These  limits,  which  form  a  good  working  field,  arc  somewhat  exceeded 
by  the  mean  limits  resulting  from  the  examination  of  a  number  of  normal 
eyes,  as  recorded  by  Forster,  Landolt,  and  Baas.'  The  last-named  author 
finds  the  average  result  of  ten  observers  as  follows:  Outward,  99°  ;  upward, 
65°;  inward,  63'  :  downward,  76°.  Figures  indicating  a  "minimal  field," 
or  "smallest  physiological  field,"  have  been  recorded,  varying  from  90° 
i  Forster)  to  50  (Treitelj  outward  ;  55-21°  upward  ;  60-40°  inward  ;  70-40° 
downward.  Certainly,  in  the  judgment  of  the  author,  the  smaller  of  these 
limits  cannot  be  regarded  as  physiological,  and  the  greater  is  about  equal  to 
the  average  working  field  already  given. 

A-  we  ordinarily  measure  the  visual  field,  the  measurement  represents  the 
relative  visual  field,  in  contradistinction,  as  Baas  points  out,  to  the  absolute 

visual  field.  The  former  records  the 
limits  for  a  test-object  of  definite  size  ; 
the  latter  the  maximal  expansion 
which  it  is  possible  to  obtain.  The  fig- 
ures then  given  are  the  relative  visual 
field  (test-object  1-2  cm.),  and  trans- 
scribed  upon  a  chart  produce  Fig.  114. 
Examination  of  this  chart  shows 
that  the  field  of  vision  is  not  circular, 
being  greatest  outward  and  below, 
and  most  restricted  inward  and  above. 
This  restriction  depends  partly  upon 
anatomical  reasons — i.  e.  the  v<.\ixv  of 
the  orbit,  the  lids,  and  the  nose  inter- 
fere with  vision,  and  partly  upon 
physiological  reasons — i.  e.  the  per- 
cipienl  layers  of  the  retina  extend 
farther  forward  on  the  nasal  than  on 
the  temporal  side,  or,  as  Landolt 
expresses  it,  the  outer  pint  of  the  retina  is  less  used  than  the  inner,  and  its 
functions,  therefore,  are  less  developed.  Hence,  as  each  portion  of  the  field 
corresponds  to  the  opposite  portion  of  the  retina,  the  inner  part  is  smaller  than 
the  (.liter.     To  avoid  the  influence  of  the  physical  obstacles  afforded  by  the 

cranial    bones,  the   eye    should    be  made  to   li\  an  object   iii  each  meridian  •"><> 


i  g    L14.— Various  limit-  of  the  form-field:  a, 
I  ..  ragi  .  b,  average  working  field  . 

;-t  physiological  field. 


1  Convex  glasses  should  exercise  :i  contracting  influence ;  indeed,  Berlin,  quoted  by  Baas, 
found  .i  ring-shaped  defect  in  the  peripheral  visual  field  if  measured  through  strong  convex 
placed    ome  distance  from  tin 
rfie  ten  •    Baa  ,  Butz,  bonders,  Drott,  Hegg,  Landolt,  Reich,  Schon,  Stober, 

-  ■    B  D  Stuttgart,  1896,  p    i! 


I'OLOli-FIKlJ). 


L67 


Fig.  115.— Binocular  field  of  vision  (Moser). 


in  the  direction  opposite  to  that  under  measurement  or  else  suitable  rotation 
of  the  head  should  be  made. 

Binocular  Field  of  Vision. — The  field  of  vision  for  each  eve  having 
been  defined,  it  remains  to  point  out  that  the  field  of  vision  which  pertains  to 
the  two  eves,  or  that  portion  in  which 
binocular  vision  is  possible,  consti- 
tutes only  the  area  where  the  central 
and  inner  parts  overlap.  This  is 
evident  from  the  diagram.  The 
continuous  line  /,  bounds  the  field 
of  vision  of  the  left  eye,  and  the 
dotted  line  R  the  visual  field  of  the 
right  eye.  The  central  white  area 
corresponds  to  the  portion  common 
to  both  eyes,  or  to  that  area  in  which 
all  objects  are  seen  at  the  same  time 
with   both    eyes ;    the   shaded   areas 

correspond  to  the  portions  in  which  binocular  vision  is  wanting.  In  the 
middle  of  the  white  area  lies  the  fixation  point,/,  and  on  each  side  of  it  the 
blind  spots  of  the  right  and  left  eye,  r  and  /  (Fig.  115). 

Having  thus  determined  the  limits  and  continuity  of  the  visual  field, 
the  functions  of  the  peripheral  parts  of  the  retina  in  regard  to  perception 
of  colors,  acuity  of  vision,  and  appreciation  of  light  should  be  investi- 
gated. 

Color-field. — The  color-field  is  examined  in  the  manner  described  in 
connection  with  the  general  visual  field,  the  squares  of  white  in  the  instru- 
ment being  replaced  by  pieces 
of  colored  paper  1  to  2  cm.  in 
diameter.  The  order  in  which 
the  colors  are  recognized  from 
without  inward  is — (1)  blue, 
(2)  yellow7,  (3)  orange,  (4)  red, 
(5)  green,  (6)  violet.  In  prac- 
tical work  blue,  red,  and  green 
are  the  colors  employed.  Non- 
saturated  colors  are  not  correctly 
recognized  when  the  test-object 
is  first  m'cm.  Thus,  yellow  at  first 
appears  white;  orange,  yellow  ; 
red,  brown  ;  green,  white,  gray, 
or  gray-blue;  and  violet,  blue. 
The  investigation  of  this  zone 
of  imperfect  color-perception  is 
important  in  various  patholog- 
ical conditions,  especially  in  the 
study  of  the  visual  fields  of  hysteria  and  of  disseminated  sclerosis. 

The  physiological  extent  of  the  color-fields,  like  that  of  the  general  field, 
is  subject  to  variations  within  normal  limits,  which  are  represented  by  the 
figuresin  the  following  columns,  hi  each  left-hand  column  are  the  figures 
denoting  the  extent  of  an  average  color-field  mapped  with  1  cm.  square 
object,  while  in  each  right-hand  column  are  the  averages  of  the  results  of  ten 
observers  recorded  by  Baas,  the  Bize  of  the  t « -t -« >1  >i«  <t  being  20  mm.  in 
diameter  : 


Fk;.  116.— Diagram  of  the  field  of  vision  for  blue,  red,  and 
green  :  the  outer  continuous  line  indicates  the  limit  of  the 
form-field  ;  the  broken  lines,  the  limits  of  the  color-fields. 


l.;s  FUNCTIONAL    TESTING. 

Bine  Bed.  Green. 

Outward       30-84  65-75  ;>'»-65 

(  Outward    and    upward 60  15  "10 

I  pWard 40-45  33-39  27-34 

Upward  ami  inward 45  30  25 

[nward 45-50  30-39  2o-33 

[nward  and  downward 50  35  2"i 

Downward 58  62  45-50  30    13 

I  downward  and  outward ■">  ■))  ''' 

These,  when  transcribed  upon  a  chart,  are  represented  in  Fig.  116. 

A.s  may  have  been  inferred,  the  extent  of  the  color-field  is  greatly  governed 
l,v  the  size  of  the  test-object.  According  to  <  towers,1  who  has  recently 
reopened  this  subject,  with  a  sufficiently  large  area  of  color  it  will  he  found  that 
all  the  color-fields  differ  in  extent  very  little  from  the  fields  for  white.  Green 
alone  seems  to  fall  short  of  the  edge  of  the  white  field  by  aboul  5°.  The 
extent  of  the  color-field  is  further  governed  by  the  character  of  the  light,  the 
nature  and  saturation  of  the  color,  the  contrast  in  luminous  intensity  between 
the  colored  test-object  and  the  background.  To  quote  from  Ward  Holden  : 
Other  conditions  being  the  same,  the  field  becomes  larger  as  the  saturation, 
the  intensity,  or  the  size  of  the  color  is  increased  ;  and  the  field  is  larger  the 
less  the  contrast  in  luminous  intensity  between  test-object  and  background. 

The  Acuity  of  Vision  of  the  Peripheral  Parts  of  the  Retina.— 
This  diminishes  from  the  macula  to  the  periphery.  It  may  be  tested  with 
small  squares  of  Mack  paper,  separated  from  each  other  by  their  own  width, 
by  noting  the  point  in  each  meridian  where  they  are  recognized  as  separate 
objects.  The  tests  of  Landolt  and  Ito  are  6,  5,  -'5,  and  '1  mm.  black  quadrants 
on  a  white  ground.  Groenouw  employs  as  a  test-object  to  be  passed  along 
the  perimeter  arc  black  points  on  a  white  ground  of  .',,  \,  I,  2,  and  4  mm.  in 
diameter.  The  result  obtained  is  called  "  visual  acutenessfor  a  point."  2  The 
results  have  the  form  of  a  horizontal  oval  nearly  parallel  to  the  limits  of  the 
visual  field. 

The  Light-sense  of  the  Periphery  of  the  Retina. — This  may  bo 
tested  conveniently  with  Ward  Holden's  tests,  which  are  thus  described  by  the 
author  :  One  card  has  a  1-niiii,  black  point  on  one  side,  and  a  15-mm.  quadrant 
of  light  gray,  having  ±  of  the  intensity  of  white,  on  the  other.  With  a  peri- 
meter of  30  cm.  radius  the  black  point  and  gray  patch  arc  each  seen  by  a  normal 
eye  outward,  \->  ;  upward,  30°  j  inward,  35°  ;  downward,  35°.  The  second 
card  has  a  3-mm.  black  point  on  one  side,  and  a  darker  gray  patch,  having 
.;  the  intensity  of  white,  on  the  other.  Each  is  seen  on  the  perimeter  arc, 
outward.  To  :  upward,  15  ;  inward.  55°  J  downward,  55°.  Card  2  will 
reveal  slight  disturbances  of  light-sense  near  the  periphery,  and  card  1  in 
the  intermediate  and    central   zone-.      Groenouw's   and    Holden's  tests  are 

declared    by   their  author-   to   he   re    delicate  than    color-tests,  or  at    least 

equally   bo,  while  they   possess  the  advantage  of  being  more  intelligible  to 

tin-    patient. 

According  to  the  experiments  of  Landolt,  the  perception  of  light  is  the 
niosl  constant  function  of  the  healthy  retina,  and  remain-  marly  the  same 
throughout  it-  surface,  while  the  color-  and  form-sense  rapidly  lessen  toward 
the  periphery.  Progressive  diminution  of  light-sense,  however,  from  center 
to  periphery  will   be  found  it   test-objects  of  varying  luminous  intensity  with 

/  'i,, idh.  Soc.  I'  K.t  vmI.  \\    p,  ] •_'.     (For  further  particulars  the  reader  is  referred 

to  llii-  most  ini'-n  -tit 

;         remarks,  the  employment  of  a  jingle  point  as  :i  test  object  affords  information 

in. i  bo  mm  li  "i  the  form-sense  as  of  the  I i ^ 1 1 t--ti i-«-. 


FIELD   OF  FIXATION.  169 

the  illumination  of  ordinary  daylight  arc  employed.  For  practical  purposes 
in  cases  of  very  defective  vision  an  idea  of  the  retina'.-  sensibility  to  light 
may  be  obtained  by  passing  a  candle  flame  along  the  arm  of  the  perimeter  as 
a  test-object,  while  a  second  candle  flame  is  made  the  point  of  fixation.' 

The  most  frequent  departures  from  those  limits  of  the  visual  field  assumed 
to  be  normal  are  general  or  concentric  contraction  ;  contraction  limited 
especiallv  to  one  or  the  other  side  ;  peripheral  defects  in  the  form  of  re- 
entering angles;  absence  of  one  segment  or  quadrant;  and  absence  of  the 
entire  right  or  left   half  of  the  field  (see  page  472). 

Scotomas. — In  addition  to  these  defects,  search  should  be  made  for  dark 
areas  within  the  limits  of  the  visual  Held,  or  scotomas.  These  are  distinguished 
as  positive  when  they  are  perceived  by  the  patient  in  his  visual  field,  and  nega- 
tive when  within  the  confines  of  a  portion  of  the  visual  field  the  image  of  an 
external  object  is  not  perceived,  but  the  affected  area  is  not  discovered  until 
the  field  is  examined.  Negative  scotomas  are  further  divided  into  absolute 
and  relative.  Within  an  absolute  scotoma  all  perception  of  light  is  wanting, 
while  within  the  confines  of  a  relative  scotoma  the  perception  of  light  is 
merely  diminished.  The  latter  are  color  scotomas,  usually  for  red  and  green. 
Scotomas  are  further  subdivided,  according  to  their  situation  and  form,  into 
centred,  paracentral,  ring,  and  peripheral. 

In  every  normal  eye  there  is  a  jihysioloe/ieal  scotoma  which  may  be  re- 
garded as  the  type  of  an  absolute  scotoma  corresponding  to  the  position  of 
the  optic-nerve  entrance,  which  usually  may  be  found  15°  to  the  outer  side 
of  and  3°  below  the  point  of  fixation,  the  distance  from  fixation  being 
greater  in  hyperopic  than  in  myopic  eyes.  This  is  known  as  Mariotte's 
blind  spot.  Usually  the  form  of  the  blind  spot  is  not  round,  but  a  vertical 
oval,  its  upper  and  lower  end  being  somewhat  drawn  out  to  correspond  to 
the  larger  retinal  vessels.  Its  size  depends  upon  the  distance  from  the 
cornea.  In  Landolt's  experiments  on  his  own  eye  at  a  distance  of  35 
cm.  from  the  cornea  to  the  plane  of  projection  the  mean  height  of  the 
blind  spot  was  52  mm.  and  its  breadth  44  mm.  The  blind  spot  is  much 
enlarged  under  certain  conditions  ;  for  example,  by  retained  marrow-sheath 
or  by  papillitis. 

For  the  detection  of  scotomata  small  test-objects,  white,  gray,  or  colored, 
l  cm.  square,  are  employed,  which  are  moved  in  different  directions  from  the 
point  which  the  eye  under  observation  attentively  fixes,  and  the  spot  marked 
where  the  object  begins  to  disappear  or  change  its  color.  The  arm  of  the 
perimeter  is  usually  marked  near  the  center  in  half  degrees  for  this  purpose. 
All  examinations  around  the  center  of  the  field  of  vision,  and  hence  the  ex- 
aminations for  scotomata,  are  readily  made  upon  a  blackboard.  Berry  urges 
that  the  ordinary  test  for  scotomata  be  supplemented  by  making  an  examina- 
tion of  the  particular  area  of  the  field  at  a  distance  of  2  m.  or  more,  so  as  to 
obtain  a  larger  projection  of  the  blind  portion,  and  to  be  able  to  work  with 
small  retinal  images  without   necessitating  the  use  of  very  small   objects. 

Field  of  Fixation. — This  includes  all  points  which  the  eye  under 
observation  can  successively  fix,  the  head  being  perfectly  stationary.  Various 
methods  for  determining  the  limits  of  the  field  of  fixation  have  been  employed  ; 
for  example,  watching  the  image  of  a  candle  flame  on  the  center  of  the  cornea 

1  Readers  interested  in  the  acuity  of  vision  of  the  peripheral  parts  of  the  retina  and  testa 
for  the  light-sense  of  the  retinal  periphery  arc  referred  to  the  excellenl  papers  on  this  subject 
byGroenouw  [Archival  of  Ophthalmology,  \.\ii.,  L893,p.502)  :   Ward  Bolden    [bid.,  xxiii  . 
p.  10  ;  and   Karl   Baas  [loc.  cii.,  pp.  55!  57).     In  the  last-named  publication  the  literature  of 
the  entire  subjeel  is  reviewed. 


17(1  FUNCTIONAL    TESTING. 

as  the  eye  follows  the  test-light  moved  along  the  perimeter  arc  until  the  limit 
(.!'  movement  is  reached.  This  method,  suitable  to  amblyopic  eyes,  is  not  so 
accurate  as  one  which  requires  the  patienl  to  distinguish  letters.  The  patient 
is  seated  before  the  perimeter,  with  the  semicircle  horizontal,  precisely  as  if 
his  visual  field  was  to  be  examined,  and  the  eye  under  observation  (the  head 
being  perfectly  rigid")  is  made  to  followa  word  composed  of  test-letters  repre- 
senting the  minimum  acuteness  of  vision,  and  the  point  where  vision  ceases 
to  lie  distinct  marked  in  successive  meridians.1  Landolt's  measurements  of* 
the  field  of  fixation  undei  normal  conditions  are  as  follows:  Outward,  45- 
50    :  inward.  15    :  upward,  35-40    :  downward,  60  . 

l>r.  (I.  T.  Stevens  determines  the  rotations  of  the  eyes  with  a  special 
instrument  called  a  tropometer.  According  to  his  measurements,  the  most 
favorable  rotations  an — Outward,  50°;  inward,  ")5°  ;  upward,  33°  ;  down- 
ward. 50  .     i  See  also  p.  499.) 

Tension. — This  term  indicates  the  intraocular  resistance,  and  is  clini- 
cally demonstrable  by  palpating  the  globe  with  the  finger-tips.  The  middle 
and  ring  fingers  are  placed  upon  the  brow  of  the  patient,  the  tips  of  the  index 
fingers  upon  the  eyeball,  and  gentle  to-and-fro  pressure  made,  the  eyes  being 
directed  downward.  This  pressure  must  be  made  in  such  manner  as  not  to 
push  the  ball  into  the  orbit  ;  otherwise  no  information  of  its  true  resistance  is 
obtained.  The  tension  of  one  eye  must  always  be  compared  with  that  of  its 
fellow,  and  in  any  doubtful  case  the  results  may  be  contrasted  with  those 
obtained  by  examining  an  eye  known  to  be  normal  in  another  patient  of 
similar  age. 

Normal  tension  is  expressed  by  the  sign  Tn,  and  the  departures  from  it 
by  the  symbols  '.',  1,  2,  +  3,  and  —  ?,  —  1,  —2,-3:  the  plus  signs 
indicate  increased,  and  the  minus  signs  decreased,  resistance.  In  physiologi- 
cal experiments  various  kinds  of  apparatus,  constructed  upon  the  principle  of 
the  manometer,  are  employed,  and  for  clinical  purposes  instruments  known  as 
tonometers  have  been  devised.  In  practical  work,  however,  sufficiently  accu- 
rate data  are  obtainable  by  a  careful  use  of  the  educated  finger-tips. 

Protopsis,  or  protrusion  of  the  eye,  may  be  caused  by  orbital  diseases, 
tenotomy,  paralysis  of  the  ocular  muscles,  and  Graves's  disease;  while  en- 
largement of  the  ball  is  the  result  of  various  conditions  residing  within  the 
globe — myopia,  intraocular  tumor,  and  staphyloma.  If  the  cause  is  uni- 
lateral, the  resulting  condition  is  asymmetrical  and  the  two  eyes  may  be 
compared  by  observing  the  relative  positions  of  the  apices  of  the  cornea?  with 
each  other  :ind  with  the  line  of  the  brows. 

'I  he  eyeball  is  apparently  shrunken  (enophthalmos)  in  some  cases  of 
ptosis  and  in  wasting  of  the  orbital  fat.  and  is  diminished  in  size  in  high 
grades  of  hyperopia  and  congenital  failures  of  development.  As  Nettle- 
ship  ha-  pointed  out,  the  amount  of  exposed  sclera  decides  the  apparent  pro- 
trusion or  recession  of  the  eyeball. 

Position  of  the  Eyes. —  Instead  of  presenting  parallel  visual  axes,  one 
eye  maybe  deviated  i  n  ward,  out  ward,  downward,  or  upward,  constituting 
one  of  the  various  'ypc-  of  strabismus,  a  condition  which  may  or  may  not  be 
associated  with  diplopia. 

■  v  Wood  has  devised  a  useful  tot  for  this  purpose:  Trans.  Ophthalmolog.  Section  A.  M. 
L896,  262 


THE  OPHTHALMOSCOPE  AND  ITS  USE;  THE 
NORMAL  EYE-GROUND. 

By  B.  ALEX.  RANDALL,  A.  M.,  M.  I)., 

OF    PHILADELPHIA. 


Ophthalmoscopy  is  the  visual  exploration  of  the  eve,  and  is  more 
strictly  limited  to  the  study  by  transmitted  light.  Its  utilization  has  inau- 
gurated a  new  era  in  ophthalmology,  from  which  most  of  its  scientific  devel- 
opment dates ;  but  general  medicine  has  been  and  is  greatly  concerned  in  the 
information  thus  gained.  The  ophthalmoscope  ought  to  be  in  daily  use  in 
the  hands  of  every  physician,  and  it  will  be  when  the  erroneous  impression 
has  been  removed  that  its  use  is  difficult  to  learn.  A  half-hour's  good 
instruction  can  give  any  intelligent  person  command  of  its  technique  and  a 
dozen  illustrations  of  its  various  revelations ;  and  moderate  practice  alone, 
with  loyal  adhesion  to  the  cardinal  rules,  will  then  serve  to  widen  almost 
fid  maximum  the  field  of  its  employment.  Compared  with  medical  micros- 
copy, its  technique  is  very  simple,  although  reasonable  persistence  in  the  face 
of  difficulties  may  be  less  easy  when  dealing  with  a  patient  than  in  the  quiet 
conditions  of  laboratory  work.  The  beginner  must  not  expect  to  succeed  at 
once  under  adverse  conditions  which  would  try  or  even  battle  the  expert  :  the 
study  of  a  patient  in  bed  is  comparatively  hard,  even  with  an  electric-light 
ophthalmoscope,  and  when  intractable  or  otherwise  difficult  his  examination 
may  prove  beyond  the  power  of  any  one ;  yet  it  is  to  such  very  practical 
utilization  that  the  physician  may  at  once  unreasonably  desire  to  put  the  new 
accomplishment.  Restricted  at  first  to  easy  conditions,  the  aft  may  be  prac- 
tised with  few  failures  and  rapidly  growing  comprehension  ;  the  infinite 
variations  which  fall  within  the  physiological  limits  will  be  gradually  learned 
and  cease  to  be  frequent  enigmas,  and  the  physician,  made  duly  self-confidenl 
by  his  success,  will  not  too  easily  accept  defeat  when  difficulties  have  to  be 
surmounted.  Learning  that  real  cause  only  need  disturb  him,  he  will  seek 
the  ground  of  his  difficulties  in  the  narrow  group  of  requirements  ;  and  when 
these  have  all  been  met  can  feel  assured  that  he  has  located,  if  not  overcome, 
the  obstacles,  and  learned  as  much,  perhaps,  as  the  circumstances  would  permit 
to  any  one. 

The  Ophthalmoscope. — The  ophthalmoscope,  augen-spiegel  <»!'  the 
Germans,  is  a  mirror  for  throwing  light  into  the  eve.  Elaborate  and  costly 
forms  have  been  devised  in  numberless  variety,  intended  to  meet  almosf  every 
possible  requirement  in  the  way  which  the  designer  think-  I x~1  :  but  it  nm-t 
not  be  forgotten  that  any  one  can  in  a  moment  improvise  an  instrument 
better  adapted  sometime-  to  the  needs  of  the  ease  before  him  than  an\  which 
he  could  find  in  the  -hop-,  and  competent  for  a  considerable  group  of  cases. 
A    bit  of  looking-glass   with   a   hole  scratched   in   its  silvering,  two  or  three 

171 


L72 


THE  OPHTHALMOSCOPE  AND   ITS   USE. 


microscope-slides  held  together  in  the  fingers,  or  three  or  four  cover-glasses  in 
the  end  of  a  splil  stick — improvisations  of  the  original  Helmholtz-mirror — 
can  reveal  the  commencing  changes  at  the  macula  of  renal  disease  which  might 
easily  escape  the  user  of  the  most  high-priced  ophthalmoscope.  But  this 
"weak-light"  instrument  is  an  over-refinement  for  the  majority  of  eases:  the 
condensed  illumination  of  a  perforated  concave  mirror  is  more  generally  use- 
ful, and  the  brow-mirror  of  the  otologist  and  laryngologist  may  revert  to  its 
earlier  use.  when  Etuete  first  employed  it  for  ophthalmoscopy. 

Yet  an  instrument  designed  for  wide  diversity  of  ophthalmoscopic  work, 
and  convenient  in  size  and  construction,  is  naturally  to  be  preferred.  The 
original  ophthalmoscope  of  Helmholtz  is  practically  unknown  to  most  modern 


Pig  i  it. -i  >phthalm<  scope 
<.f  Helmholtz:  the  concave 
s)ia>l>-  /;  i-  sel  al  the  Bide  of 
the  handle,  ",  with  di>ks  of 
lenses  b)  centering  at  its 
■  hole.  In  front  "f  this  a 
triangular  case  projects,  car- 
rying three  thin  glass  plates 
at  an  angle  of  56  t< i  the  line 
of  Bight,  by  means  of  which 
the  light  is  reflected  ino ■  the 
i  eye. 


118  -Loring's  ophthalmoscope,  with  tilting  mirror,  complete 
disk  of  lenses  from  Lto  8  and  0  to  •  7,  and  supplemental  quadrant 
containing  0.  i  and  L6  D.  This  affords  66  glasses  or  combinations 
from   )  28  to  —24  D. 


oculists,  and  it-  surpassing  value  in  some  directions  has  been  eclipsed  l>v  less 
cumbersome  rival-  (Fig.  117).  The  convex  mirror  of  Zehender,  on  which 
the  lighl  is  concentrated  l.\  a  len-.  has  as  completely  passed  away,  and  almost 
every  ophthalmoscopisl  of  to-day  utilizes,  with  scant  or  no  recognition,  the 
perforated  mirror  of  Ruete.     Behind  this  is  generally  placed  the  revolving 

disk  of  lenses  added  by  the  optician  Reko ingle,  double,  or  even  treble — 

and  upon  these  fundamental  elements  have  been  rung  changes  more  numer- 
ous than  eonld  be  here  recorded.     8 •  of  the  besl  of  these  arrangements 

worthy  of  being  credited  to  the  designer  we  owe  to  the  lamented  Dr.  Edward 
<  i.  Loring.  The  i lifications  of  his  later  instrumenl  (Fig.  1 18)  are  all  ques- 
tionable gains  al  the  cost  of  undoubted   loss,  and  are  almosl  as  numerous  as 


OPTICAL   PRINCIPLES  OF   THE  INSTRUMENT. 


17:; 


the  individual  users.  That  of  the  writer  (Fig.  1  I'M  aims  at  unusual  com- 
pleteness of  the  series  of  lenses,  cylindrical  as  well  as  spherical,  brought 
seriatim  to  the  sight-hole  withoul  removing  the  instrument  from  the  eye,  and 
boasts  a  minimum  deviation  from  the  dimensions,  weight,  and  balance  of  the 
best  "Loring."  Dr.  Edward  Jackson's  admirable  use  of  slides  of  lenses 
(Fig.  120)  forms  the  simplest  of  "refraction-ophthalmoscopes,"  most  warmly 
to  be  commended  to  the  non-expert;  while  (  Ymper's  chain  of  lenses  (Fig. 
121)  or  Morton's  modification  of  it  otters  a  most  ingenious  solution  of  the 
difficulty  of  bringing  a  wide  series  of  uncombined  glasses  close  behind  the 
sight-hole  of  the  tilted  mirror.     For  the  practitioner  who  is  willing  to  make 

but  small  outlay  the  simple  Liebreich 
mirror,  with  its  clip  to  hold  its  few 
lenses,  will  prove  fairly  satisfactory. 

Optical  Principles  of  the  Instru- 
ment.— These  need  concern  its  user 
little  at  first.  Rule-of-thumb  methods 
will  suffice  for  the  great  majority  of 
cases,  and  the  minutue  of  the  dioptrics 


Fig.  119.— Randall's  modified  Loring  ophthalmoscope,  in  which  the  "quadrant"  i>  moved  by  tin-  <■.>._: 
below,  so  that  every  glass  can  in-  brought  to  the  sight-hole  without  removing  the  instrument  from  the 
eye.  A  disk  of  concave  cylinders  0.5  to  l.  Is  eccentrically  mounted,  so  that  each  can  he  brought  at  any 
desired  inclination  of  its  axis  into  combination  with  any  spherical.  Itgives51  spherical  lenses  or  com- 
binations Tin-  mirror  can  l»-  detached  to  substitute  a  weak-light,  plane,  or  more  concave  mirror,  or  left 
off,  uncovering  the  6  mm.  breadth  of  tie-  lenses  when  the  instrument  is  used  as  an  optometer.  The  disk 
of  cylinders  can  be  left  off  as  drawn,  or  attached  to  any  firm  of  ophthalmoscope. 

of  the  eye,  upon  which  depend  such  questions  as  the  amplification  of  the 
erect  image  and  the  height  or  depth  of  objects,  involve  formula--  from  which 
most  oculists  shrink.  We  will  consider  only  the  manifest  facts,  easily  ob- 
served and  verified,  which  go  to  make  up  the  possibilities  and  limitations  of  the 
instrument,  and  will  consider  the  refraction  and  accommodation  of  the  eye  only 
so  far  as  they  force  themselves  upon  the  attention  of  the  ophthalraoscopist. 

The  eye  is  a  camera  obscura,  provided  with  a  complex  lens-system  capable 
of  changing  focus  and  armed  with  a  diaphragm — the  iris — which  varies  the 
size  of  it-  central  opening — the  pupil — limiting  the  amount  of  light  which 
•  ■liter-  and  the  optical   imperfections  of  the  image.      This  pupil   generally 


174 


THE  ol'IITUM.Moso )/>/■:  a.X/)   ITS   USE. 


appears  Mack  because  the  light  entering  it  is  reflected  back,  alter  partial  ab- 
sorption, in  exactly  the  direction  from  which  it  came.  As  the  observer's  head 
i-  ii"i  generally  a  source  of  light,  but  an  obstacle,  cutting  oil' all  illumination 
from  ttiat  direction,  hiseye  receives  none  of  the  returning  rays.  If  the  pupil 
be  wide,  however,  and  the  retinal  sur- 
face less  than  the  focal  distance  behind 
it.  as  i~  common  in  children  and  in  ani- 
mals, it  i~  not  difficult  lo  obtain  a  red 


Fig   120      '  i  hthalmoscope,  «  iili  tw<> 

superposed  Blides  ol  ming  Bingly  01  com 

hlned  behind  the  Bight  hole  of  the  tilting  mirror. 

r  combinal  n  to 

18  D..  with  great  convenience,  and  is  exceedingly 

Bimple  and  thin 

Mice  naosl  other  ophthalmoscopes,  the 

i  licate  concave  glasses,  and  white  t" 
murk  convex,  makii 
combinations  unlikely. 


i     (  ouper's   ophthalmoscope,   wit 
□  i  ndless  chain  coming  singly  close  bt 

ric  tilting  mirror,  which  rotates  i 
left  when  tin  left  eye  is  to  be  examined,  in 
'""  -  modification  the  lenses  are  free  in  the  i 
in  i.  and  moved  by  the  sprocket  acting  below. 


h   71 
hind 

i  the 
Moi 

1 1  ;m 


reflex  from  within  the  eye.  Ophthalmoscopy  aims  to  secure  uniformly  this 
result,  by  bo  reflecting  a  beam  of  light  that  the  observer's  eye  is  always  in 
position  to  receive  the  returning  rays,  and  not  only  tool. tain  a  diffused  glare 
from  the  pupil,  but   to  see   numberless  details  within.     For  this  a  number 


DIR1AT  METHOD    OF  OI>l ITI 1 A  LMOSf  < >l> ) 


175 


of  optical  conditions  have  to  be  met,  depending  not  only  upon  the  refraction 
of  the  eye  in  general,  bul  upon  that  of  the  observed  eye  in  particular,  and 
involving-  even  the  conditions  of  the  observer's  eye.  To  these  we  first  must 
turn. 

By  the  law  of  the  conjugate  foci  of  lenses,  light  from  within  the  illumi- 
nated eve  emerges  in  parallel  rays  it'  the  eye  be  emmetropic,  divergent  if 
hyperopic,  convergent  if  it  be  myopic.  To  make  such  rays  furnish  a  clear 
image  of  the  interior  two  methods  are  in  vogue,  and  various  optical  apparatus 
is  needful  for  each.  The  simpler  method  is  known  as  the  "direct/'  or  that 
of  the  "upright  image,"  in  contrast  to  the  "indirect,"  which  gives  an  "  inverted 
image." 

Direct  Method  of  Ophthalmoscopy. — In  this  method  the  mirror  is 
placed  before  the  observer's  eye,  so  as  to  throw  light  through  the  pupil  of  the 
observed  eye,  and  the  two  are  brought  close  together  (  Fig.  122).  If  the  ob- 
served eye  be  emmetropic,  parallel  rays  pass  from  it  into  the  observer's,  and  if 
this  be  also  emmetropic,  a  clear  image  is  obtained  without  further  aid.      If 


B" 


"B" 


Fig.  122.— Diagram  of  the  direct  method  with  the  formation  of  an  upright  image:  rays  from  the  source 
^<f  light  L  are  received  upon  the  concave  mirror  M,  and  converged  upon  the  observed  eye  Obd.,  within 
which  they  cross  and 'illuminate  an  area  of  its  fundus.  From  an  area  A  B  thus  lighted,  rays  pass  out  of 
the  pupil  (parallel  if  it  be  emmetropic,  as  here  represented)  through  the  sight-hole  of  the  mirror,  and, 
entering  the  observer's  eye.  Obi:  are  focussed  upon  his  retina.  An  image  is  there  formed  as  though  the 
object  seen  were  at  a  great  distance,  and  the  perceptive  centers  project  it  into  space  as  though  the  object 
were  at  some  arbitrary  distance  (e.  .'/.  25  cm.).  By  the  laws  of  magnification  by  a  simple  lens  the  image  is 
embraced  between  the  lines  passing  from  the  optical  center  of  the  magnifying  lens  (trie  refracting  system 
of  the  observed  eye),  through  the  extremities  of  the  object,  and  has  the  size  .1'  /.",  .1"  />'".  etc.,  according 
to  the  distance  of  projection. 


the  observed  eye  be  hyperopic,  myopia  or  accommodation  in  the  observing 
eye  may  neutralize  it  and  permit  of  seeing  clearly  ;  if  not  exactly  thus 
adjusted,  a  convex  lens  must  be  introduced  to  render  parallel  the  divergent 
rays.  If,  on  the  contrary,  the  eye  be  myopic,  the  observer  must  employ  a 
concave  glass  to  Wring  the  convergent  rays  to  parallelism,  unless  himself 
hyperopic  enough  to  be  focussed  for  such  convergence.  'Thus  it  is  requi- 
site that  there  shall  be  a  series  of  concave  and  convex  lenses  at  command, 
which  may  be  skilfully  used  as  required  in  order  to  afford  clear  views  in  all 
conditions  of  refraction. 

But  this,  while  inconvenient  in  some  respects, constitutes  one  of  the  great 
advantages  of  the  direct  method  ;  for  the  lens  thus  required  to  give  a  sharp 
image  of  the  retinal  details  becomes,  under  proper  conditions,  the  measure  oj 
the  ametropia.  That  this  should  be  accurate  assumes  thai  the  observer  must 
be  emmetropic  or  allow  for  his  error  of  refraction,  and  make  no  accommodative 
effort  that  would  change  it  from  this  basis.  The  lens  thus  used  musl  be  prop 
erly  placed  before  the  observed  eye.  It  ought  to  be  about  13  mm.  from  the 
cornea,  at  the  anterior  focus  of  the  lens-system,  and  it  should  be  tilted  little  if 


176  THE  OPHTHALMOSCOPE  AND   ITS   USE. 

at  all,  since  thi<  has  a  distorting  effect.  The  ophthalmoscope  should  be  so 
constructed  as  to  givea  considerable  series  of  glasses  coming  seriatim  to  the 
sight-hole,  which  should  nol  be  too  small  nor  tunnel-like  from  thickness  of 
the  instrumenl  ;  ami  a>  the  \\gh\  must  be  taken  from  the  side  <>t' the  patient's 
head,  the  mirror  should  incline  in  the  needed  direction,  leaving  the  rest  of 
thi'  ophthalmoscope  straight. 

fhc  tidd  of  view  open  to  the  direct  method  is  never  larger  than  the 
pupil,  and  grows  steadily  smaller  as  one  draws  farther  away  from  the  ob- 
served eye.  So  the  advantage  of  a  dilated  pupil  is  evident  :  although  an 
expert  can  approach  SO  close,  locate  so  well  the  image  presented,  and  pro- 
ceeding from  it  to  each  other  desired  part  of  the  eye-ground,  can  build  up 
from  thi-  -cries  of  glimpses  so  satisfactory  a  mosaic,  that  he  may  explore  with 
ease  through  a  •"'>  mm.  pupil  when  a  tyro  might  find  difficulty  even  were  the 
pupil  dilated  to  <i  or  8  mm.  The  periphery  of  the  lens  and  the  extremes  of 
the  eye-ground  cannot  be  -ecu  through  a  contracted  pupil,  however  expert 
the  ophthalmoscopic  ;  and  a  case  demanding  such  study  must  have  a  drop  or 
two  of  a  mydriatic,  such  as  1  per  cent,  solution  of  homatropin  or  0.5  per 
cent,  of  atropin,  instilled  and  given  time  to  act. 

When  there  is  inequality  of  the  refraction  in  the  various  meridians  of  the 
e\c.  constituting  astigmatism,  there  is  a  distortion  of  the  image  of  the  eye- 
ground,  and  all  details  are  not  equally  well  seen  with  the  same  lens.  If,  as  is 
most  common,  thi-  he  due  to  exec--  of  curvature  of  the  cornea  in  its  vertical 
meridian,  tine  vertical  vessels  in  the  retina  will  be  sharply  seen  with  a  stronger 
convex  or  weaker  concave  lens  than  any  others,  especially  the  horizontal 
vessels  adjacent  ;  and  thus  a  ready  means  is  afforded  of  recognizing  and 
measuring  astigmatism  (see  also  page  199). 

Indirect  Method  of  Ophthalmoscopy. — The  indirect  method  has 
certain  decided  advantages.  The  magnification  obtained  is  less  and  the  field 
proportionately  larger;  hence  a  better  general  view  can  be  thus  gained. 
Then  its  sharpness  is  largely  independent  of  the  refraction  of  the  eye, un- 
steady movements  are  less  disturbing,  ami  it  can  supplement  the  direct 
method  in  many  important  relations.  Differences  of  level  count  for  less, 
although  (piite  perceptible,  and  may  reveal  their  true  relief,  previously  mis- 
understood.1 A  simpler  instrument  is  competent,  since  a  concave  mirror,  a 
double  convex  lens  of  2-3  inches  focus  (14—20  D.),  and  one  or  two  lenses  to 
clip  behind  the  sight-hole  meet  all  requirements. 

In  thi-  method  the  eye  is  illuminated  from  a  distance  <>f  25—30  em.,  and 
the  emerging  ray-,  unless  already  strongly  convergent,  are  intercepted  with 
tlic  convex  leu-  held  some  5  cm.  in  front,  so  that  they  are  brought  to  a  focus 
near  by.  Here  a  real  inverted  image  is  formed  in  the  air  (Fig.  123),  and  thi-. 
ami  not  the  eye-ground  it-elf,  i-  studied  by  the  observer,  generally  with  the 
help  of  a  convex  lens  to  magnify  it.  The  principle  is  the  same  as  that  of 
tin-  compound  microscope,  while  the  direct  method  is  like  the  use  of  a  simple 
leu-,  the  lens-system  of  the  observed  eye  serving  to  magnify  all  the  details 
of  it-  own  interior.  The  myopic  observer  may  often  dispense  with  any  mag- 
nifier back  of  hi-  minor,  and  if  the  observed  eye  he  very  myopic,  it  forms 
the  requisite  image  Dear  enough  in  front  to  obviate  the  need  for  an  object- 
glass.      Here,  then,   the   mere  c ;ave   mirror   may   serve    all    needs,   and    in 

circumstances    where    the    satisfactory    nse    of   the    direct    method    i-   very 
difficult. 

In  thi-  method  i h  depends  upon  the  clearness  of  the  object-lens  held 

Dear  the  observed  eye;  and  one  of  ample  size  and  of  material,  like  pebble, 
1  The  cupping  "i  glaucoma  was  mistaken  for  prominence  by  the  earlier  observers. 


MENSURATION  OF  FUND US-DE TAILS.  177 

not  easily  scratched,  has  distinct  advantage.  A  protecting  mounting  is  often 
useful.  The  reflection  from  the  pole  of  the  cornea  is  Less  troublesome  than 
when  contrasted  with  the  weaker  illumination  of  the  direct  method  ;  but  the 
reflections  from  the  front  and  hack  surfaces  of  the  objective  Lens  compel  a 
little  tilting  of  it   to  throw  them  out  of  the   way. 

An  element  of  astigmatic  distortion  is  thus  introduced  which  must  be 
allowed  for.  A  round  optic  disk  may  be  made  to  appear  oval,  the  longer 
diameter  corresponding  with  the  least  inclined  diameter  of  the  lens.  When 
the  eye  is  astigmatic  a  similar  distortion  of  the  disk  appears,  which  may  be 
modified  by  tilting  the  lens  ;  hut  irrespective  of  this,  to-and-fro  movement  of 
the  lens  corrects  and  reverses  the  apparent  lengthening  of  the  nerve-head, 
■which  reveals  whether  it  is  anatomically  or  only  optically  elongated. 


Fig.  123.— Diagram  of  the  indirect  method  Riving  an  inverted  image :  rays  from  the  source  of  light  L, 
converged  toward  the  observed  eye  Obd  by  the  concave  mirror  M,  are  intercepted  by  the  leni-  (>hj,  and 
after  coming  to  a  focus  diverge  again  and  fight  up  the  fundus.  From  a  part  of  the  illuminated  fundus 
A  B  rays  pass  out  of  the  pupil  to  be  again  intercepted  by  the  lens  O  and  form  an  inverted  real  image 
at  its  anterior  focus  A'  B'.  This  real  image  is  viewed  by  "the  observer's  eye  behind  the  sight-hole  of  tfie 
mirror  with  the  aid  of  a  magnifying-lens  Oc,  and  is  seen  enlarged,  as  at  A''  B". 

Size  of  the  Image  and  Mensuration  of  Fundus-Details. — The 

problems  as  to  the  amplifications  afforded  by  the  upright  and  by  the  inverted 
image  and  the  mensuration  of  objects  in  the  fundus  are  complex  and  varia- 
ble. Even  in  the  "  reduced  eye"  many  other  factors  must  be  determined  in 
order  to  permit  of  precise  statement  of  the  result.  Suffice  it  here  to  say  that 
in  the  emmetropic  eye  the  upright  image,  when  projected  to  10  inches,  is 
about  sixteen-fold  the  linear  size  of  the  retinal  surface  seen  ;  and  an  optic 
disk  1.5  mm.  in  diameter  will  seem  24  mm.  broad  when  projected  to  25  cm. 
An  easy  test  of  this  is  to  hold  a  quarter-dollar  or  shilling  before  the  one  eye 
while  the  other  views  the  disk,  and  find  the  point  where  the  images  seem 
of  equal  size  :  this  distance  will  vary  little  from  10  inches.  In  hyperopia 
the  enlargement  is  less,  in  myopia  more,  the  myopic  eve  having  virtually  an 
extra  magnifying  lens  in  it  as  contrasted  with  the  emmetropic,  and  still 
more  the  hyperopia  The  indirect  method  affords  about  one-third  as  much 
amplification  as  the  direct,  increasing  as  the  object-glass  is  weakened  and  the 
ocular  strengthened.  Hence  myopia  gives  smaller  and  hyperopia  larger 
images  by  this   method. 

Another  interesting  point,  still  more  practical,  is  the  mensuration  of  the 
axial  lengthening  or  shortening  as  afforded  by  prominence-  or  depressions  of 
the  eye-ground.  Having  determined  the  refraction  at  the  general  retinal 
level,  the  ability  (aside  from  astigmatic  condition-)  to  see  some  object  with 
stronger  convex  or  weaker  concave  Lenses  marks  its  protrusion  above  that 
level,  and  the  following  table  shows  the  amount  of  elevation  calculated  for 
the  "reduced  emmetropic  eye:" 

12 


ITS 


THE  OPHTHALMOSCOPE  AND   ITS   USE. 


Lengthening  or  Shortening  of  the   Eye  in   Axial  Ametropia  (Landolt). 


Myopia. 

Iiur 

Axial  Length. 

ii\  peropia. 

Decri 

Axial  length 

0 

0 

22.824 

() 

0 

22.824 

0.5 

0.16 

22.98 

0.5 

0.16 

22.67 

1 

0.32 

23.1  1 

1 

0.31 

22.51 

2 

• 

2 

0.62 

22.20 

3 

1.01 

23.83 

3 

0.92 

21.90 

4 

1.37 

24,19 

4 

1.21 

21.61 

5 

1.74 

24.56 

5 

1.50 

21.32 

. 

2.52 

25.34 

6 

1.7(3 

21.06 

10 

3.80 

■luy.i 

7 

2.03 

20.79 

15 

6.28 

29.10 

8 

2.28 

20.54 

20 

9.31 

32.13 

10 

2.78 

20.04 

<  >n  the  contrary,  the  need  of  stronger  concave  or  weaker  convex  lenses  to 
bring  the  objecl  sharply  to  view  demonstrates  its  depression  below  the  general 
level,  as  also  shown  in  the  table.  The  prominence  of  a  swollen  optic  nerve- 
head  or  of  a  tumor-mass  may  thus  be  measured,  and  comparison  will  show 
the  variations  of  it-  advance  or  recession.  So,  too,  a  glaucomatous  or  other 
cupping  of  the  nerve  or  the  staphylomatous  bulging  in  a  coloboma  may  be 
exactly  determined,  when  at  first  glance  it  may  have  seemed  doubtful  whether 
the  ill-focussed  surface  was  raised  or  depressed.  The  same  table  holds  ap- 
proximately for  general  conditions  of  axial  shortening  or  lengthening,  with 
the  proviso  that  emmetropia  (or  any  other  refraction)  may  exist  with  different 
axial  lengths  it'  only  the  power  of  the  refractive  media  be  adjusted  to  such 
lengths.  The  axis  of  23.8  nun.,  which  may  be  assumed  for  the  average  adult 
emmetropic  eye,  has  grown  from  some  16  mm.  in  infancy;  and  while  a 
diopter  or  so  of  congenital  hyperopia  may  possibly  have  been  outgrown, 
the  eye  may  be  said  to  have  changed  its  length  and  its  refraction  exactly 
pari  "passu?  As  the  other  diameter-  of  the  globe  are  generally  approxi- 
mately the  same  as  the  axis,  and  the  corneal  diameter  i-  about  one-half  as 
great,  a  correction  can  lie  thus  gained,  perhaps,  when  in  an  eye  not  show- 
ing typically  myopic  of  hyperopic  deformity  we  wish  to  estimate  from  the 
refraction  it-  exact  length  and  the  position  of  objects  not  on  the  retinal  level 
within,  as  may  he  desired  in  case  of  operation  for  the  removal  of  a  foreign 
body  in  the  vitreous.     (See  also  page  201.) 

The  mensuration  of  objects  or  distances  on  or  near  the  retinal  level  can 
generally  best  lie  given  in  terms  of  the  cardinal  object-  there  presented  for 
comparison — e.g.  "broad  a-  the  retinal  vein,*'  ''two  disk-diameters  out," 
etc.  The  actual  size  can  easily  he  then  estimated  with  a-  close  approxima- 
tion a-  would  he  possible  with  the  complicated  apparatus  devised  for  actual 
measurement. 

Examination  of  the  Media. — Previous  to  the  employment  of  either 
method  of  examination  of  the  fundus  it  is  generally  advisable  to  investigate 
the  media  lying  in  front  of  it  both  by  focussed  incident  light  (oblique  illumi- 
nation, see  page  I  16)  ami  by  transmitted  light. 

For  the  latter  it  suffices  to  illuminate  the  eye  with  the  concave  mirror 
from  eighl  or  ten  inches  away,  when  any  opacity  in  cornea,  lens,  or  vitreous 
will  appear  as  a  dark  silhouette  against  the  reddish  background.  Magnifica- 
tion of  tin-  by  a  convex  leu-  behind  the  mirror  enhance-  the  delicacy  of  the 
test,  and  often  brings  to  view  minute  details  otherwise  invisible.  Beginning 
.-it  some  25  cm.  away  with  a  I  I  >.  lens,  the  surgeon  can  study  each  eye, 
I  tot  1 1  looking  straighl  forward  and  in  oblique  positions  ;  and  then,  approaching 
closer  and   using  stronger  leu-.-.  In-  can   focus  at  will  upon  the  cornea,  lens- 

1  Randal]  :    /  \n„,.  Ophih.  Soc,  v.  1890,  p.  657. 


.1  UTO-OPHTHALMOSCOPY.  179 

layers,  anterior  or  posterior  capsule,  or  the  various  depths  of  the  vitreous, 
until  at  the  closest  range  the  strongest  available  amplification  may  be  utilized. 
Foreign  bodies  escaping  every  other  effort  at  their  detection  are  thus  readily 
seen,  and  opacities  or  vascularities  of  the  cornea  form  striking  objects. 

The  preliminary  observation  from  a  distance  has  a  great  advantage  also 
in  the  determination  of  refractive  errors,  for  little  or  no  eye-ground  detail 
comes  sharply  to  view,  except  in  hyperopia  or  marked  myopia  :  in  the  latter. 
slight  movement  of  the  eye  or  head  will  show  that  the  image  is  inverted. 
Irregularities  of  refraction  also  become  thus  readily  manifest,  flattened  facets 
left  by  loss  of  substance  appearing  like  blisters  in  a  window-pane  to  distort 
the  detail-  seen  through  them  and  give  the  image  as  in  high  hyperopia.  The 
condition  known  as  (tonicity  of  the  cornea  or  lens  may  thus  appear  to  give 
a  dark  center  or  surrounding  zone,  although  the  tissues  be  perfectly  trans- 
parent ;  and  if  the  observer  draw  back  a  meter  or  more  and  use  a  long-focus 
or  plane  mirror,  every  eye  will  give  shadows  in  the  pupil  with  slight  rotations 
of  the  mirror,  and  the  method  becomes  what  is  known  as  the  shadow-test  or 
retinoscopy,  our  most  delicate  means  of  estimating  the  refraction  (see  page 
202).  Notable  differences  of  eye-ground  level  are  conspicuous  when  studied 
from  a  distance  of  20  or  30  cm.,  and  this  constitutes  the  best  way  of  studying 
detachments  of  the  retina,  vitreous  opacities,  and  intraocular  tumors. 

Admirable,  too,  is  this  method  for  learning  the  position  of  opacities,  since 
the  movements  of  the  eye  are  about  a  fixed  center  of  rotation  back  of  the  pos- 
terior pole  of  the  lens  ;  and  every  visible  object  anterior  to  this  will  seem  to 
move  in  the  direction  of  the  gaze,  and  everything  posterior  in  the  opposite 
direction,  the  rapidity  and  extent  of  the  excursion  indicating  by  parallax  its 
distance  from  that  center. 

Auto-ophthalmoscopy. — A  word  may  also  be  said  as  to  auto-ophthal- 
moscopy,  although  its  value  is  limited.  Several  methods  may  be  employed, 
but  the  simplest  is  that  of  Coccius,  to  hold  the  plane  skiascopy-mirror  be- 
tween the  eye  and  the  shaded  light,  so  that  the  light  falls  into  the  pupil 
through  the  ample  sight-hole,  while  the  emergent  rays  are  caught  by  the 
margin  of  the  opening  and  reflected  back  to  the  macula  (Fig-  124).     Upon  the 


Fig.  12-t. —  To  illustrate  auto-ophthalmosi 

dark  background  behind  the  lamp  the  observer  will  then  project  the  image  of 
the  small  illuminated  area,  and  with  a  little  care  the  disk  can  be  found  and 
studied  and  the  vessels  followed  out  a  long  way  in  any  direction  except  close 
to  the  macula.  The  picture  is  not  a  mere  suggestion,  like  the  Purkinje 
image,  but  can  be  drawn  in  good  detail  ;  and  he  who  i-  working  up  eye- 
ground  sketches,  and  has  no  other  model  at  hand,  can  thus  often  freshen  his 
impressions  of  form  or  color  at  the  momenl  when  he  most  needs  them.  The 
inability  to  see  the  macular  vessels  is  compensated  by  the  endoscopic  methods 
of  bringing  them  into  view  (Fig.  134),  either  by  the  convex  mirror  of  Avres 
or  the  pin-hole  of  Mandcl~tainm. 

Illumination  is,  first  and  last,  the  most  important  element  of  success  in 
all  these  measures.     A   steady  and  ample  source  of  li-ht  of  fairly  uniform 


lso  THE  OPHTHALMOSCOPE  AND   ITS   USE. 

color  is  therefore  essential.  Daylight  is  undoubtedly  the  truest  illumination 
under  which  to  study  conditions  where  faint  gradations  of  color  arc  at  times 
all-important  ;  yet  even  within  the  hours  when  it  is  obtainable  it  varies  greatly 
in  any  consultation  room.  It>  use  may  be  ignored  except  as  a  matter  of 
curiosity  or  in  some  leukemic  conditions,  when  it  may  be  noteworthy  if  the 
fundus  look-  as  yellow  under  it  as  the  normal  eye  doe-  by  Lamplight. 

An  Argand  gas-burner,  so  mounted  upon  a  hinged  bracket  or  an  adjustable 
stand  that  it  may  be  shifted  to  any  desirable  position,  is  almost  always  ob- 
tainable or  may  be  substituted  by  any  good  oil  lamp.  A  second  chimney,  of 
glass  or  isinglass,  will  shut  off  much  radiant  heat  from  the  observer,  and  still 
more  from  the  patient  nearer  by  ;  while  an  opaque  chimney  of  iron  or  asbes- 
tos with  a  vertically  oval  opening  about  3  to  5  cm.  will  be  found  useful  in 
restricting  the  light  to  the  desired  direction,  leaving  everything  else  in 
shadow.  With  this  precaution  the  ophthalmoscopic  room  need  not  be  very 
dark,  although  strong  rays  of  daylight  should  be  excluded  by  shutters  or 
-hade-  ;  and  it  i-  very  well  to  have  several  blackish  surfaces  conveniently 
placed  to  form  fixation  points  for  the  patient's  gaze  during  examination.  The 
eyes  may  be  thus  kept  steady,  while  the  dark  surface  affords  nothing  to  call 
forth  accommodative  strain  or  pupillary  contraction.  Either  of  these  may 
prove  serious  obstacles  to  some  of  our  measures,  and  it  is  worthy  of  much 
care  to  avoid  them. 

The  test  and  glare  are  trying  even  to  well  eyes,  and  must  be  mercifully 
and  judiciously  tempered  for  over-sensitive  eases  if  we  would  obtain  full  suc- 
cess and  avoid  actual  injury.  Here  the  use  of  the  plane  or  weak-light  mirror 
may  have  decided  value,  or  the  reduction  of  the  light  by  turning  it  down  or 
narrowing  the  aperture  through  which  it  shines.  If  gas-fixtures  are  used,  it  is 
very  desirable  to  so  arrange  them  that  the  light  may  be  near  the  patient  or  the 
observer  a-  desired,  and  with  a  range  of  4  to  (i  m.  for  skiascopy — a  need  best 
met  by  having  a  bracket  at  each  end  of  the  room,  one  being  also  used  for 
illumination  of  the  test-type.  It  is  inadvisable  to  have  the  light  too  close  to 
the  patient,  and  much  heat  reflected  by  the  mirror  and  directly  radiated  from 
the  flame  may  be  -pared  him  by  putting  the  burner  a  foot  or  more  back  of 
his  head.  It  is  important,  too,  that  the  light  shall  be  as  nearly  as  possible 
behind  the  head,  so  as  to  avoid  needless  rotation  of  the  mirror;  but  it  must 
not  he  cut  olf  by  the  patient's  head  when  the  macula  or  temporal  retina  is 
being  studied.  It  will  be  found  that  if  it  is  far  enough  to  the  side  to  illumi- 
nate the  lid-margins  at  the  outer  canthus,  it  will  meet  all  conditions.  Mode- 
rate tilting  of  the  mirror  will  then  suffice  to  throw  the  light  into  the  eye.  and 
the  instrument  can  be  brought  so  close  that  it  touches  the  brow  and  eyelashes 
of  the  patient  without  having  the  light  (ait  off. 

Position  of  Surgeon  and  Patient. — One  of  the  cardinal  errors  of 
the  beginner  is  in  not  getting  close  enough  :  the  field  of  view  is  thus  rest rieted, 
the  corneal  reflex  more  disturbing,  and  refractive  errors  unduly  distorting  or 
blurring  to  the  detail-.  In  highly  ametropic  eves  great  differences  in  the 
required  lens  depend  upon  its  distance  from  the  anterior  focal  point  of  the 
eyi — some  13  nun.  from  the  corneal  pole;  and  in  high  myopia  a  satisfactory 
view  can  sometimes  be  obtained  only  when  the  observer's  brow  is  actually 
touching  that  .if  the  patient.  This  presupposes  the  condition,  essential  in 
in- --t  cases,  that  the  observer  use  hi-  right  eye  for  the  patient's  right  and  hold 

the  ophthalmoscope  in  hi-  right  hand,  and  nice  rcrsu. 

The  convenience,  or  even  the  possibility,  of  doing  this  depends  in  part 
upon  the  seating  of  patient  and  observer,  and  the  face-to-face  position  usual 
abroad  i-  nut  at  all  the  best.     It  is  better  that  the  observer's  chair  should  be 


POSITIOX  OF  si' IK ; EOS  ASD   VATIEST. 


181 


close  beside  the  patient's,  with  the  scats  fully  overlapping;  and  then,  unless 
very  discrepant  in  height,  each  may  -it  erect  and  at  ease.  A  child  is  often 
of  better  height  standing  by  the  ophthalmoscopies  seat,  and,  on  the  other 
hand,  satisfactory  studies  can  be  most  hastily  made  when  the  observer  stands 
bv  the  sitting  or  standing  patient.  If  the  light  be  on  a  swinging  bracket,  it 
can  be  instantly  swung  from  one  side  to  the  other,  while  the  ophthalmoscopic 
transfers  himself  and  his  seat  to  thai  side  for  the  study  of  that  eye.  Each 
will  learn  the  position  most  satisfactory  to  himself,  and  habitually  adopt  it. 
but  a  constrained  pose  is  to  be  deprecated  as  imperilling  accuracy  and 
thoroughness.  Children  often  tend  to  nod  forward  if  quiet,  or,  on  the  con- 
trary, to  wriggle  and  turn,  so  as  to  need  some  steadying  :  the  free  hand  may 
do  good  service,  therefore,  in  lightly  grasping  the  occiput,  while  the  thumb 
rests  in  the  concha,  controlling  any  rotation  (Figs.  125,  126). 

Limited  by  the  pupil  into  which  it  is  thrown,  the  beam  of  light  utilized 


Fig.  125.— Position  of  examiner  and  patient  for  direct  ophthalmoscopy,  with  seats  overlapping  ;ni<l 
brows  almost  in  contact.  The  right  hand  and  eye  are  used  in  examining  the  right  eye  of  the  patient, 
and  the  lamp  must  be  on  the  same  side  (De  Schweinitz). 

in  the  direct  method  is  that  from  a  portion  of  the  mirror  close  around  the 
sight-hole,  and  but  little  larger  than  the  pupil.  This  must  be  quite  accu- 
rately centered  with  the  pupil,  as  is  sometime-  best  done  by  throwing  the 
light  from  a  little  distance  upon  the  cheek,  when  the  dark  center  of  the  illu- 
minated area  marking  the  sight-hole  can  be  seen,  and  this  then  centered  in 
the  pupil.  At  the  bedside  a  light  with  a  lens  giving  a  parallel  beam  is  useful. 
\i'  a  candle  only  be  available,  inclination  of  this  gives  a  broader  (lame  and  a 
less  limited  area  of  light  on  the  retina. 

Three  principal  <>l>st<fl<.<  are  met  in  the  study  of  the  interior  ,.1"  the  eye  : 
rrjhffimis,   ojjacifirs,   and    refractive   >rr<>rs. 

Reflections. — To  the  beginner  these  are  very  annoying.     He  hardb 
approaches  sufficiently  close  to  the  eye.  hi-  fundus-illumination   i-  rarely  the 
best,  and  the  brilliant  comealreflex  seems  to  occupy  mosl  of  the  pupillary  sj 
and  frequently  is  regarded  as  the  whitish  optic  disk  for  which  he  is  instructed 
first  to  look.       In  a  narrow  pupil    thi-   reflection    from    the  cornea  (and    to  an 


182 


THE  OPHTHALMOSCOPE  AND   ITS   USE. 


extent  generally  unperceived  those  also  from  the  fro nt  and  back  surfaces  of 
the  lens]  is  ever  an  obstacle  which  the  expert  cannot  wholly  ignore,  and  may 
at  times  find  insurmountable.  Generally  he  can  look  to  the  inner  side  of  it 
or  through  its  margin,  and  approach  so  near  that  its  perception  is  slight. 
A  small  sight-hole  also  reduces  its  annoyance  by  increasing  the  fundus- 
illuminatioD  and  cutting  off  some  of  the  ray-  reflected   from  the  cornea. 

Reflections  are  present  at  all  the  boundaries  between  the  media,  but  only 
those  upon  the  retina  are  apt  to  be  noticed  when  not  specially  sought.  In 
childhood,  particularly,  the  whole  retina  is  often  covered,  especially  along  the 
larger  vessels,  with  shimmering,  "  watered-silk"  reflections,  which  shift  with 
each  motion  of  the  mirror,  and  by  the  reversed  direction  of  their  movement 
-how  that  they  are  formed  by  concave  surfaces  where  the  prominence  over 
the  vessels  passes  into  the  general  retinal  level.  Of  the  same  nature  is  the 
more  definite  reflex-streak    parallel   to  the  nasal  side  of  the  disk,   to  which 


be  the  same 

OUl  its  local 
[  can  use  l  lie 
hweinitz). 


I'M.   126     Position  ol  i  icaminerand  patient  for  indirect  ophthalmoscopy:  the  seating  can 

as  for  <  t  the  examiner  sits  a  foot  or  more  away,  holds  theobjeel  Lens  at  al 

distance  In  front  oi  thi  obsi  i  •  ■  'I  i  y<      teadying  ii  by  resting  the  other  fingers  on  the  face, am 

■  ye  and  band,  without  change  of  the  lamp,  to  examine  either  eye  of  the  patient  (De  Sc 

Weiss  has  called  attention  as  being  prodromal  of  myopia  (see  page  187,  Fig. 
132),  and  the  bright  streak  so-called  light-reflex)  always  to  be  seen  along  the 
retinal  vessels,  especially  the  arteries,  has  been  thus  explained. 

In  the  macular  region  a  halo  can  often  be  -ecu  by  the  indirect  method, 
generally  horizontally  oval,  and  having  a  diameter  two  or  more  times  that  oi 
the  disk.  Thi-  i-  less  easily  -ecu  in  the  upright  image,  unless  a  strongly 
concave  mirror  be  used  ;  and  unless  the  ring  of  reflecting  mirror  just  around 
the  sight-hole  be  centered  exactly  with  the  pupil,  only  a  portion  of  it  will  be 
visible.     So,  too,  as  to  the  little  reflection   from  the  fovea  centralis,  which  is 

apt  to  be  crescentic  or  coi a-shaped  unless  the  mirror  is  exactly  centered. 

Then  the  tiny  concavity  reflects  the  entire  ring  of  brightness  surrounding  the 
night-hole,  while  the  'enter  of  its  floor  gives  back  a  central  point  of  light. 
Like  ino-t  retinal  reflections,  these  are  besl  seen  when  the  surface  is  a  little 
beyond  the  focus,  and  are  more  apt  to  aid  than  disturb,  since  they  serve  to 
locate  the  points  deserving  minute  scrutiny,  and  arc  lost  as  the  retinal  struc- 
t Hi.-  are  precisely  ft icussed. 


LOCATION  OF  OPACITIES.  183 

Opacities  of  the  Media. — These  are  al  times  prohibitory  of  study  of  what 
lies  beyond  them,  ami  unless  their  presence  and  character  be  perceived  they 
may  prove  very  harassing  or  misleading  by  suggesting  partial  obscuration  of  the 
fundus  details,  retinal  lesions,  or  refractive  errors.  I >i it  due  employmenl  of 
focal  illumination  and  the  lighting  of  the  fundus  from  a  little  distance  will 
rarely  fail  to  reveal  the  real  difficulty  and  serve  to  locate  it  exactly.  Againsl 
the  red  field  of  the  illuminated  pupil  every  such  opacity  will  show  dark  in 
proportion  to  its  lack  of  transparency  :  with  a  magnifying  lens  behind  the 
mirror  most  minute  and  faint  objects  may  he  discerned  readily.  Not  only  real 
opacities,  hut  also  irregularities  of  surface,  such  as  conicity  of  the  cornea  or 
lens,  flattened  facets,  or  plications  a-  of  the  capsule,  can  be  thus  revealed, 
and  the  resultant  impairment  of  vision  correctly  interpreted.  Most  difficult 
of  all  are  the  cases  of  turbidity  of  the  media,  since  there  are  often  no  formed 
elements  to  give  definition  to  the  opacity,  which  merely  obscures  the 
view.  Where  the  aqueous  humor  is  at  fault  the  altered  appearance  of  the 
iris  often  furnishes  the  clue;  but  a  discolored  lens  or  a  turbid  vitreous 
can  at  times  puzzle  the  most  expert  and  permit  of  diagnosis  only  by 
exclusion. 

Location  of  Opacities. — This  is  of  frequent  importance.  When  far  hack 
near  the  retina  the  anterior  position  of  opacities  can  generally  be  appreciated, 
if  not  estimated,  by  parallax,  as  compared  with  the  movement  of  the  retinal 
vessels  ;  hut  the  expert  easily  measures  in  the  erect  image  by  the  interposition 
of  convex  lenses  how  much  forward  an  object  lies.  Near  emmetropia  each 
diopter  gives  a  difference  of  0.3  mm. — theoretically  increasing  to  the  myopic 
side,  decreasing  in  hyperopia  (e.  g.  +  6  D.  1.77  mm.  ;  —  6  D.  =  2.13  mm., 
Nagel).  Anterior  opacities,  on  the  other  hand,  are  generally  referred  to 
the  pupillary  margin,  and  by  their  motion  relative  to  it  in  movements  of  the 
eye  their  distance  hack  or  front  is  determined.  The  center  of  corneal  curva- 
ture, which  is  near  the  posterior  pole  of  the  lens,  may  also  he  used,  as  pointed 
out  by  Jackson  :  the  image  of  the  mirror  can  always  be  seen  in  the  line  of  this 
point,  and  any  motion  in  reference  to  it  determined.  As  previously  stated, 
the  rotation-center  of  the  globe  is  the  cardinal  point  of  reference  (p.  17!'). 

Refractive  Errors. — These  can  markedly  complicate  the  diagnosis  it'  the 
observer  be  not  well  posted.  It  is  often  surprising  how  much  can  he  discerned 
in  an  unfocussed  eye-ground,  not  only  when  hyperopia  allows  a  clear  view 
of  details  from  a  distance  <>r  to  an  observer  who  does  not  relax  his  accommo- 
dation, hut  even  when  considerable  myopia  or  astigmatism  precludes  sharp- 
ness of  definition.  To  the  indirect  method  these  case-  offer  small  difficulty: 
moving  the  objective  lens  a  little  to  or  from  the  eye  compensates  for  large 
axial  variations,  while  a  little  tilting  of  it  make-  or  correct-  astigmatism  as 
great  as  is  often  met.  Yet  even  to  the  direct  method  more  is  revealed  than 
might  he  expected,  and  careful  focussing  is  called  for  to  decide  whether  all 
the  distortion  or  blur  present  is  really  due  to  the  refractive  error.  Much 
anatomical  anomaly  or  pathological  lesion  can  he  concealed  by  the  imper- 
fection of  the  view;  and  minor  changes  in  nerve,  choroid,  and  retina  are  thus 
habitually  passed  over  unseen  or  ignored  by  ophthalmoscopists  of  long  ex- 
perience. The  habit  of  sketching  tin-  findings  in  the  examinations  ha-  here 
one  of  it-  prime  functions ;  and  the  use  of  stereotyped  forms  on  which  to  till 
in  detail-  is  to  he  condemned,  at  leasl  for  the  beginner.  Each  drawing,  how- 
ever rude  and  imperfect,  should  portray  with  all  possible  precision  the 
apparent    form  of  the  disk,  the    trend  of  its  vessels,  and    the  condition-  of  its 

margins  ;  since  the  minute  observation  here  called  for  may  prove  unexpectedly 
valuable  in  these  very  cases,  and   begets  an  exactness  of  perception  essential 


\s\  THE  OPHTHALMOSCOPE  AND   ITS  USE. 

and  invaluable  both  in  refraction-measurement  and  in  the  clinical  observation 
of  diseased  conditions. 

Differences  of  Level  in  the  Eye-ground. — These  are  always  to  be  ex- 
pected.  The  normal  disk  lias  a  prominence  which  justifies  its  name  of  papilla, 
although  its  center  is  often  excavated  nearly  to  the  level  of  the  cribriform  lamina. 
The  excentric  location  of  the  disk  commonly  exaggerates  the  greater  protrusion 
of  the  nasal  side,  and  its  major  vessels  are  decidedly  prominent.  This  promi- 
nence may  be  much  increased  by  edema  and  inflammatory  infiltration,  while 
the  lower  level  of  the  outer  margin  and  adjacent  posterior  pole  grows  deeper 
with  the  atrophic  changes  and  stretching  of  " posterior  staphyloma."  This 
phrase,  like  that  of  "conns,"  is  often  employed  as  to  conditions  not  strictly 
fulfilling  its  primary  meaning;  but  the  opposite  view,  that  bulging  at  this 
point  due  to  inflammatory  softening  does  not  take  place,  meets  daily  refuta- 
tion. These  points  must  always  be  taken  into  consideration,  not  only  in 
relation  to  the  present  refraction  of  the  eye,  but  also  as  to  its  past  and 
future. 

In  the  direct  examination,  then,  we  measure  the  direction  of  the  rays  of 
light,  which,  emerging  from  the  observed  eye,  form  u  sharp  image  on  the 
observer's  retina.  But  this  relation  is  affected  by  the  observer's  refraction  as 
well  as  the  patient's.  Only  upon  an  emmetropic  eye  will  parallel  rays  be 
exactly  focussed  ;  and  any  interposed  lens  needed  to  make  sharp  the  image 
measures  the  momentary  ametropia  of  the  patient  ±  that  of  the  observer. 
But  it  is  only  the  refraction  at  the  moment  which  is  measured,  and  this  may 
be  very  far  from  the  static  refraction  which  we  desire.  The  ophthalmoscopist 
must  learn  what  is  his  true  static  refraction,  and  as  far  as  possible  relax 
always  to  this  condition.  The  author  believes  every  one  can  learn  so  to  do, 
although  fatigue,  headache,  or  improper  conditions  will  at  times  preclude  util- 
ization of  the  faculty.  If  the  examiner  does  not,  any  fixed  allowance  for  his 
unrelaxed  accommodation  is  so  utterly  vague  as  to  be  of  little  value.  Those 
who  habitually  use  mydriatics  to  the  total  paralysis  of  accommodation,  and 
accept  in  their  measurements  nothing  as  "near  enough"  to  right  which  can 
possibly  he  improved  upon,  learn  that  total  relaxation  and  total  paralysis  are 
identical  in  almost  all  eases,  and  that  the  "tone"  of  accommodation  of  which 
Ponders  wrote  decreases  under  scrutiny  to  the  vanishing-point. 

The  Normal  Fundus. — The  prime  feature  and  landmark  of  the  eye- 
ground  is  the  nerve-head,  with  its  branching  central  artery  and  vein.  This 
lie-  some  15°  to  the  nasal  side,  and  a  little  higher  than  the  posterior  pole  of 
the  globe,  and  appears  ;i>  a  whitish  disk  from  which  the  vessels  ramify  in  the 
fundus  (Fig.  127).  It  is  surrounded  by  the  red  choroid,  which  usually  defines 
sharply  it-  margin  ;  and  the  frequenl  massing  of  choroid  pigment  here  may 
give  ;i  gray  or  black  edge,  which  is  occasionally  half  as  broad  as  the  disk. 
The  opening  through  the  choroid  is  normally  smaller  than  that  of  the  sclera, 
and  hides  all  trace  of  tin-;  hut  at  time-,  without  recognizable  absorption  of 
the  choroid  or  its  pigment,  a  ring  of  white  scleral  tissue  (scleral  ring)  can  be 
-^m,  partial  or  complete,  within  the  choroidal  ring.     (See  Plate  1.) 

Consisting  of  the  nerve-fibers  which  enter  to  the  retinal  level  and  then 
disperse,  the  disk  often  presents  :i  slight  prominence  or  papilla,  in  the  center 
of  which  the  diverging  tissues  forma  porus  <>j)/i<-ns.  This  may  be  incon- 
spicuous, especially  in  early  life;  hut  i-  ;it  time-  both  wide  and  deep,  one 
edge  or  perhaps  all  steep  or  overhanging,  while  pari  of  it  i>  usually  shelving. 
The  mos!  conspicuous  feature  is  the  group  of  branching  vessels.  Both  artery 
and  vein  may  come  to  tin'  summil  of  the  papilla  before  dividing,  but  com- 
monly both  branch  in  the  bottom  of  the  porvs,  while  occasionally  only  the 


Plate  i 


The  normal  fundus. 


THE  NORMAL  FUNDUS. 


185 


subdivisions  in  bewildering  number  emerge  from  the  nerve-head.  Little 
difficulty  should  be  experienced  in  distinguishing  the  broader,  darker  veins 
with  their  crimson  tint  from  the  scarlet  arteries,  which  arc  near  the  color  of 
the  background  ;  but  the  smaller  branches  differ  less  until  they  cease  to  be 
differentiable.  On  the  larger  veins  and  on  all  the  arteries  distinguishable  as 
such,  a  bright  streak  of  reflection  ("light-reflex")  marks  the  central  convex- 
ity and  shifts  slightly  with  variations  of  the  light. 

The  branching  is  usually  dichotomous,  giving  an  upper  and  a  Lowerartery, 
which   again   divides   into  a  temporal  and  a  nasal    branch,  while  the    veins 


/•VV-  ;_  - 


Fio.  127.— Normal  optic  nerve-head,  as  seen  with  the  ophthalmoscope  and  in  section  under  the  micro- 
scope, each  x  15  diameters.  The  slight  papillary  elevation,  with  its  central  porus,  the  central  vessels,  and 
the  beginning  of  their  ramification  in  the  flher-layer  of  the  retina,  the  sharp-cu1  margin  of  retinal  and 
choroidal  pigmentation  outlining  the  disk  and  slightly  emphasized  as  a  choroid  ring,  are  well  shown. 


prcs,. lit  fair  parallelism.  Small  vessels,  not  always  visibly  arising  from  the 
central,  generally  pass  outward  toward  the  macula  ;  and  at  this  margin 
especially,  independent  cilio-retinal  vessels,  not  always  of  small  size,  are  fre- 
quently met.  The  branches  pass  from  the  disk  with  sinuous  curving  sweep, 
as  a  rule,  and  with  slowly  diminishing  caliber  extend  toward  the  periphery. 
On  the  disk,  especially  as  they  curve  down  into  the  excavation,  the  veins  often 
present  visible  pulsation,  and  in  rarer  cases  of  disproportionate  pressure  the 
arteries  also  empty  and  fill,  particularly  in  glaucoma  ;  crossing  and  entwining 
of  vein  and  artery  are  com n  (Figs.  128,  129),  bul  it  i-  extremely  rare  for 


L86 


THE  OPHTHALMOSCOPE  AND   TTS   USE. 


vein  to  cross  vein,  or  artery   artery.      Anastomosis  of  the   vessels,  almost 
always  on  the  disk,  is  also  of  the  raresl  occurrence  (Fig.  L30). 


Entwined  retinal  vessels.    Twisting  of  a  retinal  vein  around  the  accompanying 
artery  on  their  way  to  the  region  supplied  is  not  unusual— generally  about  the  margin  of  the  disk:  such  a 

■  •f  an  artery,  as  the  superior  temporal  in  (1),  is  rarer,  as  is    also  the'  recurrent  turnof  the  upper 

nil  vein  to  twist  around  the  upper  nasal  artery  in  (2). 

The  rear  limit  of  the  nerve-head   i-  the  eribrifoivn   lamina,  at  which  the 
optic  nerve-fibers  lose  their  sheaths  ami  enter  the  eye  as  naked  axis-cvlinders. 


Pig  tnosing  veins  and  aberrant  artery. 

This  varies  in  depth,  bul  can  generally  be  distinguished,  especially  at  the 
porus;  :md  a  deep  excavation  generally  has  as  it-  bottom  this  mottled 
sieve-tissue. 


Till:   .XOh'MM.    I  CXI) IS. 


187 


*?«  I 


1  1 


K^0<i^\ 


■ 


Fig.  131.— Excavations  in  nerve-head  :  (1)  physiological,  (2)  atrophic,  and  (3)  glaucomatous  excavations. 

The  physiological  cap  or  excavation  is  usually  present,  and  similar  on  the 
two  sides,  and,  however  deep  and  sharp-cut,  always  leaves  a  marginal  ring 
of  the  disk  undepressed.     The  vessels  can  generally  be  seen  to  emerge  through 


Rantfail 

Fig.  132.— Curvilinear  reflex-streak  to  the  nasal  Bide  of  distorted  disk.    Tim  eye-ground 

the 


pto.  loss.— i  urviiinear  renex-streas  to  tne  nasal  side  ..i  distorted  disk.    The  eye-ground  appearance 
are  given  in  (1)  with  the  shimmering  yet  fairly  fixed  reflection  concentric  with  the  upp 
margin  of  a  stretching  myopic  eye.    in  (2)  (copied  from  a  section  of  such  an  eye     Wi     - 
is  Bhown  the  Bupra-traction  of  the  choroid  and  the  distortion  of  the  nerve-head.,  projectin 
nasal  -id'-,  and  furnishing  as  11  passes  Into  the  retinal  level  the  concave  surface  which 
reflection. 


188 


THE  OPHTHALMOSCOPE  AND   ITS   USE. 


this  tissue,  which  seldom  overhangs  the  cup  at  all  sid^s;  and  while  the  veins 
often  present  pulsation,  this  is  rarely  seen  in  the  arteries  unless  the  ocular 
tension  is  increased  or  aortic  regurgitation  is  present  (Fig.  131).  An  exam- 
ination of  the  diagrams  will  make  clear  the  differences  between  physiological 
and  pathological  excavations  (see  also  p.  382). 

<  M'tcn  there  is  a  curvilinear  reflex  a  little  outside  of  the  nasal  nerve-mar- 
gin, due  to  the  concavity  where  the  prominent  disk  sinks  into  the  adjacent 
ntinal  level  (Fig.  L32).  Weiss,  who  called  attention  to  this,  regards  it  as 
prodromal  of  myopic  stretching.  In  like  manner  a  double-ridged  crescentic 
area  to  the  nasal  side  was  proven  by  Jaeger  to  be  due  to  supra-traction  of  the 
choroid  ;  and  Nagel  and  Weiss  hold  it  to  be  a  feature  in  many  myopic  changes. 
While  none  of  these  things  are  pathognomonic,  they  deserve  to  be  seen  and 
weighed. 

The  macula  or  center  of  most  distinct  vision  near  the  posterior  pole  of 
the  eve  is  the  most  important,  hut  generally  least  conspicuous,  region  of  the 
retina.  The  pupil  is  apt  to  he  at  its  smallest  when  this  is  illuminated,  the 
eye  leasl  steady,  the  corneal  reflex  most  annoying,  and  the  accommodation  most 
variable.  Under  these  conditions  some  of  the  older  authorities  \\^v<\  to  he 
skeptical  as  to  the  visibility  of  the  macula  lutea.  "Yellow  spot"  it  is  not 
normally  in  lite,  hut  only  a  region  of  deeper  coloration,  generally  maroon  in 
tint,  with  a  little  shifting  reflex  at  its  center  (foveal  reflex).  This,  which  is 
an  inverted  image  of  the  ophthalmoscopic  mirror  given  back  from  the  pit- 
like fovea  as  a  concave  mirror,  lias  the 
form  of  the  illuminated  area  of  the  oph- 
M  thalmoscope — annular  if  the  sight-hole  is 
exactly  centered  before  the  pupil,  but 
generally  crescentic  or  comet-shaped  if 
excentrie.  A  tinier  central  point  from 
the  center  of  the  fovea  is  sometimes  seen. 


-^ 


A 


i  Hi ...  around  tbi  seen  In 

ntlrety  an<l  reflex  from  tin  i 


i     Minute  vascularization  of  the  macular  region 
copic  stud)  of  the  writer's  righl  eye  il- 
luminati  d  I  an  iugb  a  mo\  ing  pin-hole. 


Outside  of  the  macula,  where  the  change  in  retinal  thickness  hen-ins,  a  large 
ring  or  halo  (macular  reflex)  may  be  -ecu,  complete  only  when  the  mirror  is 
exactly  central,  generally  partial  and  taint  in  the  upright  image.     A.s  in  the 


/'//  YSIOLOGICA  L    VA  HI  A  TIONS.  1 89 

better  definition  of  the  indirect  method,  it  constitutes  a  horizontally  oval  ring 
decidedly  larger  than  the  disk,  and  from  1  to  2  disk-diameters  out  from,  its 
lower  border  (Fig.  133).  Like  all  retinal  reflexes,  these  phenomena  are  besl 
seen  with  a  strongly  concave  mirror,  and  seem  to  shift  somewhat  above  the 
retina,  fading  as  we  focus  down  to  the  exact  level  at  which  they  arist — 
an  additional  proof  that  they  arc;  real  images  formed  by  concave  reflecting 
surfaces.      With  advancing  life  all  such  reflexes  are  dim  or  lacking. 

The  center  of  the  macula  is  devoid  of  blood-vessel-,  a-  may  be  besl  seen 
by  the  entoptic  study  (Fig.  134);  and  the  ophthalmoscope,  failing  to  reveal 
the  capillaries  which  surround  it,  can  best  place  it  by  the  way  in  which  ves- 
sel- approach  it  from  all  sides  without  reaching  it  (with  rare  exceptions).  It- 
most  important  blood-supply,  like  its  nerve-fibers,  comes  from  the  temporal 
margin  of  the  disk,  and  the  occasional  presence  of  an  independent  cilio-retmal 
artery  has  saved  central  vision  in  some  cases  of  embolism  of  the  central 
artery.  More  than  in  thicker  parts  of  the  retina,  the  stipple  of  the  pigment- 
layer  should  be  recognizable  in  all  this  region,  and  furnishes  the  most  delicate 
focussing  object  in  measuring  the  refraction  in  the  optic  axis.  Senile  changes 
are  frequent  in  this  region;  albuminuric  and  other  lesions  are  here  most  cha- 
racteristic, and  sometimes  almost  prodromal ;  and  hemorrhagic  lesions  are  not 
very  rare;  so  its  scrupulous  study  should  be  the  rule  (see  pp.  416,  420). 

The  periphery  of  the  retina  offers  no  special  peculiarities,  and  is  diffi- 
cult to  see  only  in  proportion  to  the  narrowness  of  the  pupil.  It  is  the  seat 
of  the  earliest  changes  in  retinitis  pigmentosa  ;  its  underlying  choroid  may 
showr  equatorial  myopic  stretching  or  splotches  of  disseminated  choroiditis 
and  other  syphilitic  affections — lesions  that  are  often  most  marked  up  and  in  ; 
while  down  and  in,  where  skylight  falls  unobstructed  by  the  browr,  we  com- 
monly find  any  changes  due  to  its  irritation. 

The  color  of  the  eye-ground  is  a  composite  blending  of  factors  vary- 
ing in  value  in  every  case.  In  blondes  the  sheen  of  the  almost  invisible 
retina  is  backed  by  the  orange-red  of  the  chorio-capillarix,  veiled  by  little 
retinal  pigment :  back  of  this  are  the  broader  bands  of  choroidal  vessels, 
through  as  well  as  between  which  light  is  reflected  from  the  sclera.  Only  in 
the  albino  does  this  outer  coat  appear  in  its  full  whiteness,  while  in  mosl  eye- 
little  light  even  reaches  it  through  the  pigmented  tissues.  The  amount  of 
pigmentation  affects  the  tone  and  conceals  the  deeper  layers  in  varying  de- 
gree, until  in  the  negro  the  retinal  pigment  gives  a  slaty  tapetwm,  almost  as 
reflecting  as  that  in  the  lower  animals.  Every  gradation  of  pigmentation  can 
be  seen,  not  only  in  different  eyes,  but  almost  in  the  same  eye,  since  the 
periphery  is  generally  less  dark,  and  the  choroidal  structure  may  show  every- 
where except  in  the  macula,  where  the  pigment  is  richest.  These  peculiari- 
ties, especially  at  the  nerve-margin,  are  worthy  of  note,  verbal  or  graphic  as 
well  as  mental,  in  a  large  proportion  of  cases,  since  they  mark  minor  but  often 
important  changes  there  in  progress.  So  too  as  to  the  poms  opticus,  which 
is  rarely  marked  in  the  infantile  disk,  but  soon  becomes  definite,  and  at  times 
increases  greatly  through  atrophy  or  mechanical  pressure. 

Physiological  Variations  and  Congenital  Anomalies. — Among  the 
countless  deviations  from  an  ideal  relation  of  the  eye-ground  picture,  variation 
in  the  vessels  is  most  common.  Often  the  division  of  the  vessels  is  within  the 
nerve, and  only  the  branches,  perplex inedy  subdivided,  appear  on  the  disk.  I  he 
distribution  may  lie  accomplished  by  most  roundaboul  curves,  the  whole  group 
of  vessels  passing  inward,  or  in  some  other  direction,  before  separating  toward 
the  different  quadrants  of  the  retina.  The  main  blood-supply  of  the  lower  nasal 
retina  may  conic  from  the  upper  nasd  vessels  (Fig.   130)  or  any  similar  irrcg- 


190 


THE  orilTILM.Moscori:  AND   ITS   USE. 


ul.'iritv  ;  and  large  areas,  even  in  two  quadrants,  may  be  supplied  by  do  branch 
of  the  central  artery,  I  >ut  l>\  a  dlio-retinal  vessel  arising  at  the  edge  of  the  disk 
from  the  short  ciliary  vessels  or  communicating  with  the  choroidal  system  (Fig. 


Fig.  135.— Choroido-retinal  aberrant  artery. 

L35).  Tortuosity  of  vessels  may  be  mere  exaggeration  of  their  normal  sinu- 
osities ;  hut  at  times,  especially  in  strained  hyperopic  eves,  they  may  have  the 
marked  curves,  vertical  a<  well  as  lateral,  usual  in  neuro-retinitis.  Single 
loops  may  lie  across  the  disk  or  adjacent  retina  (Fig.  136)  or  protrude  into  the 
vitreous,  or  the  single  strand  of  the  persistent  hyaloid  artery,  generally  devoid 

of  hi I.  extends  forward,  in  rare  instances  reaching  or  branching  upon  the 

po-tcrior  capsule  of  the  lens.  Small  cystic  outgrowths,  especially  to  the  nasal 
side,  may  mark  a  more  atrophic  stage  of  its  condition  (Figs.  137,  138). 


Pio   181  'I  tortuoiu  \. 


i''i'..  187.    Persistent  hyaloid  artery. 


Supernumerary  depressions  of  the  disk  with  emerging  vessels  ar< casion- 

ally  Been  :  more  often  there  is  a  colobomatous  gap,  due  to  incomplete  closure 


CONGENITAL   ANOMALIES.  191 

of  the  fetal  cleft.  This,  which  is  normally  open  l>ut  for  the  sixth  or  seventh 
week,  may  be  held  open,  probably  by  intra-uterine  inflammation,  and  give  rise 
to  most  various  and  extreme  malformations.  The  disk  may  be  alone  coloboma- 
tous  and  -how  a  depression,  oftenesl  downward,  of  dark  aspect  and  apparently 


Fig.  138.— Cystic  outgrowth  on  disk.  Fig.  139.— Fibrous  outgrowth  on  disk. 

immeasurable  depth  (Fig.  140),  or  the  white  sheath  may  be  plainly  seen  beneath 
the  gap.  Sometimes  the  sheath  alone  is  involved,  and  the  disk,  superficially 
normal,  shows  a  peculiar  greenish  coloration  near  one  margin  that  can  be  traced 
into  its  depths.     Oftener  the  choroid  shows  a  defect,  usually  downward,  at  times 


Fig.  110.— Coloboma  of  nerve  and  sheath. 


involving  nerve  and  sheath,  and  perhaps  extending  broadly  as  far  forward  as 
can  be  seen  (Fig.  141),  while  coloboma  of  iris  or  lens,  or  both,  mark-  the 
greater  extension  (in  time  as  well  as  area).  Difficult  of  explanation  are  those 
rarer  cases  in  which  the  defecl  is  outward,  inward,  or  even  upward,  where 
the  fetal  deft  can  hardly  be  supposed  to  have  had  influence.  Gap  of  the 
retina  alone,  true  persistence  of  the  fetal  cleft   itself,  has  hardly  ever  been 


192 


THE  OPHTHALMOSCOPE  AND   TTS   USE. 


described:  some  representative  of  retinal  structure  is  usually  present,  when 
perhaps  not  even  a  vessel  marks  choroidal  tissue,  and  the  lack  or  stretching 
of  scleral  tissue  forms  a  considerable  staphylomatous  concavity.  Areas  of 
defed  at  or  near  the  macula  (Fig.  1  1_)  are  probably  not  related  to  the  fetal 
cleft,  latt  mark  mere  atrophy  and  non-development  resulting  from  fetal  in- 
flammation— a  process  that  may  leave  strands,  knobs,  or  falciform  folds  of 
membrane  protruding  into  the  vitreous  chamber,  and  is  doubtless  responsible 
tor  the  persistence  or  perversion  of  most  of  that  for  which  the  faulty  pre- 
natal development  is  held  accountable. 


Fig.  141.— Huge  coloboma  of  choroid,  involving  the  nerve-head  and  extending  to  iris. 

('mnis  was  the  name  early  given  to  the  atrophic  choroidal  changes  at 

the  nerve-margin,  which  s etimes   present  a   form  suggestive  of  a   cone. 

Oftener  it  i-  a  crescent  embracing  the  outer  half  of  the  disk — at  times  the 
nasal  or  other  margin — in  some  cases  annular,  though  generally  broadest  out. 
With  this  is  generally  associated  an  ectasia  or  staphyloma  posticum,  due  to 
coincident  atrophy  or  yielding  of  the  sclera.  Noted  at  first  exclusively  with 
myopia,  many  writers  have  denied  the  kin-hip  of  the  crescents  seen  in  other 
refractive  conditions  ;  and  there  is  little  doubt  that  several  groups  of  condi- 
tions ought  to  he  differentiated,  just  a-  there  are  high  myopias  in  the  illit- 
erate who  <lo  no  close  work,  unrelated  to  the  eye-strain  myopia  (Fig.  L43). 
Anv  close  and  experienced  observer  has  seen  at  times  one  of  these  forms 
(usually  distinct)  pass  into  another,  generally  with  elongation  of  the  visual 
axis  ;  and  he  recognizes  the  relation,  although  he  may  feel  unable  to  define  or 
explain  it.     Whether  Hasner's  theory  of  drag  by  the  too  short  optic  nerve 


CONGENITAL   ANOMALIES. 


L93 


apoD  it>  sclera]  insertion  has  general  or  only  occasional  truth,  the  crescent 
most   commonly  begins  at   the  outer  margin   as  a   region  of  altered   color, 


Fig.  142.— Coloboma  of  macula. 


doubtless  inflammatory.  Pigment  is  absorbed,  to  be  deposited  in  most  eases 
at  the  outer  margin  of  the  crescent,  and  as  the  atrophy  advances  the  area 
increases   in   size,  usually   by  the  demarkation   of  another  crescent   beyond. 


Fig.  143.— Distorted  myopic  disk  with  scleral  ring,  atrophic  and  semiatrophlc  conus,  aberrant  arter; 

Three  or  four  ere-eent-  al  once  may  be  thus  shown  in  one  eye  in  different 
stages  of  atrophic  change.  Rarely  the  process  retrogrades  and  n  cre»  i  nl  of 
altered  color  return-  to  the   normal.      Actual  development  of  a  large  myopic 

13 


1!>4 


THE  ol'IlTHAI.Moscori;  a\/>   its   USE. 


crescent  may  never  have  been  fully  observed,  lor  in  most  cases  it  and  the 
advance  of  the  myopic  stretching  can  he  stopped  by  atropine  and  alterative 
tonics  :  and  some  of  us  feel  that  our  lull  duty  has  not  been  done  in  a  case  that 


Fig.  144.— Underlying  conus  below,  up  to  emergence  of  vessels. 

does  progress.  Yet  clinical  study  has  been  long  and  extended,  and  definite 
enough  to  bridge  any  gaps  and  show  the  usual  identity  of  the  processes;  and 
strong  anatomical  evidence  to  the  contrary  could  alone  disprove  it. 


Pig.  1 15.— Retained  marrow  Bheatta  ;  huge  ana  Burrounding  disk. 

Probably  another  matter  i-  presented  l>v  the  condition  called  "congenital 
conus?'  tl conus  downward"  or  "underlying  conus."  It  has  the  form  of  a 
crescenl  of  whitish  color,  apparently  extending  in  inula-  the  margin  of  the 
nerve,  generally  below,  although  also  noted  in  or  nut  or  at  times  even  above. 
It   i-  probably  akin  to  coloboma  of  the  nerve-sheath,  although  not  merging 


<  'ONG  EN1 T.  {LA  NOM.  I  LIES. 


195 


into  this  condition,  seeming  to  underlie  the  upper  layers  of  the  nerve-head 
and  to  extend  in  at  time- as  far  as  the  central  vessels.  Most  like  the  "scleral 
ring-."  normally  or  morbidly  revealed,  it  yet  presents  recognizable  differences, 
which  seems  to  mark  dissimilarity  of  nature.  Where  it  is  marked,  full  acute- 
ness  of  vision  can  rarely  be  attained  ;  and  the  usual  presence  of  notable 
astigmatism  and  the  frequency  of  aberrant  vessels  passing  through  it  point  to 
it  as  a  congenita]  delect  (Fig.  144). 

An  interesting  anomaly,  sometimes  most  striking  in  appearance,  is  fur- 
nished by  marrow-sheaths  on  the  retinal  fibers.  Enstead  of  being  lost  outside 
of  the  hi  mi  mi,  these  elements  are  met  in  patches  at  or  near  the  disk,  of  white 
fringed  aspect,  partly  burying  the  retinal  vessels  under  their  opacity.     The 


Fig.  146.— Small  isolated  marrow-sheath  patch  up  and  out  near  macula. 

rule  in  the  rabbit  and  other  animals,  this  is  an  exception  in  man,  and  may 
constitute  a  huge  broadening  of  the  blind  spot  (Fig.  145).  If  extensive,  they 
are  apt  to  extend  outward  in  the  line  of  the  major  upper  and  lower  temporal 
vessels,  forming  a  crescentic  white  patch,  within  which  the  macula  is  seen 
decentered  out.  At  the  nerve  they  are  apt  to  overlie  the  margin  and  to  cast 
a  greenish  shadow  inward  ;  which  is,  of  course,  more  marked  if  there  be  any 
atrophy  of  the  nerve.  They  may  easily  be  mistaken  for  snowy  patches  oi' 
infiltration,  such  as  the  "snow-banks"  of  albuminuric  or  other  retinitis, 
although  generally  far  more  fibrillar  in  their  snowy  whiteness;  but  the  dif- 
ferentiation is  not  easy  when  they  form  small  isolated  patches  unconnected 
with  the  disk  (Fig.  146).  Vision,  except  in  the  broadened  blind  -pot,  may 
be  absolutely  unaffected  (see  also  p.  472j. 


METHODS  OF  DETERMINING  THE  REFRACTION 

OF  THE  EYE: 

OPHTHALMOMETRY;  OPHTHALMOSCOPY,  SKIASCOPY, 
OPTOMETRY;   THE  USE  OP  MYDRIATICS. 

By  EDWARD  JACKSON,   A.M.,  M.  D., 

OF    rilll.AKKI.I'III  \. 


Ophthalmometry,  more  properly  called  Keratometry,  is  the  measure- 
ment nt' the  curvature  of  the  cornea  and  the  astigmatism  due  to  the  differences 
in  that  curvature  in  different  directions.  The  ophthalmometer  consists  essen- 
tially of  a  telescope  furnished,  in  connection  with  its  object-lens,  with  some 
arrangemenl   for  doubling  the  images  formed  by  it. 

In  the  ophthalmometer  of  Helmholtz  and  that  of  Leroy  and  Dubois  this 
doubling  is  effected  by  covering  one-half  of  the  object-lens  by  a  piece  of  plate 
glass  inclined  in  one  direction,  and  the  other  half  with  a  piece  inclined  in 
the  opposite  direction.  The  separation  of  the  two  images  produced  by  this 
arrangement   is  the  same  at   whatever  distance  the  object  is  placed. 

In  the  ophthalmometer  of  Java!  and  Schiotz  the  doubling  is  effected  by  a 
double  prism,  and  the  separation  of  the  two  images  is  only  constant  at  a  con- 
stant  distance.  To  make  sure  that  the  images  formed  by  the  instrument  shall 
always  have  this  constant  distance  cross-hairs  are  placed  within  the  barrel  of 
the  tele-cope.  In  using  the  instrument  these  cross-hairs  must  be  in  focus 
when  the  images  are  fociissed  ;  that  is,  the  images  must  be  formed  at  the 
plane  of  the  cross-hairs.  To  effeel  this  the  eye-piece  is  so  adjusted  as  to 
accurately  focus  the  cross-hairs  for  the  observer's  eve,  and  then  the  images  are 
focussed  by  moving  the  telescope  to  or  from  the  eye  under  examination  until 
they  become  distinct  with  the  cross-hairs. 

The  curvaturt  <>i  Hi<  cornea  is  measured  by  determining  how  large  an 
object  i-  required  to  give  a  reflection  from  the  cornea  just  equal  to  the  separa- 
tion of  the  doubled  images.  Knowing  the  size  of  the  object,  the  size  of  its 
reflected  image,  and  the  distance  of  the  object  from  the  eye,  the  radius  of 
curvature  of  the  cornea  i-  ascertained  by  a  simple  calculation.  With  the 
ophthalmometer  of  .(aval — to  which  alone,  as  of  most  practical  value,  we  -hall 
refer  -the  distance  of  the  object  i-  always  practically  the  same.  It  is  deter- 
mined by  the  distance  from  which  the  image  of  the  corneal  reflection  will  be 

f  ' i  1 1 1 <  < I  at   t  he  cr<  '---hair-. 

The  size  of  the  corneal  reflection  i-  also  constant,  being  the  extent  to  which 
the  doubling  prism  separates  the  two  images  at  the  con-taut  distance.  This 
being  the  case,  the  size  of  the  object  and  the  curvature  (or  radius  of  curva- 
ture) of  tin'  cornea  are  inversely  proportioned  to  one  another,  so  that  a  scale 
can  be  calculated  upon  which  a  certain  size  of  object   will  correspond  to  a 


METHOD   OF  USING   THE  OPHTH A  LM< >M ETEB. 


197 


certain  radius  of  curvature  of  the  cornea.  Such  a  scale  lias  been  calculated 
and  laid  off  upon  the  arm  of  the  ophthalmometer.  Along  with  it  is  placed 
a  scale  of  diopters  of  refracting  power,  corresponding  in  an  average  eve  to 

the  different  lengths  of  the  radius  of  corneal  curvature. 

The  instrument  is  shown  in  Fig.  147.  The  most  striking  part  of  it  is  the 
great  metal  disk  which  shades  the  surgeon  from  the  light,  and  has  on  it- 
margin  figures  to  indicate  the  direction  in  which  the  arm  is  turned.  Through 
the  center  of  this  disk  projects  the  telescope,  and  just  below  it  the  arm,  placed 
horizontally,  is  shown,  with  the  two  mires  upon  it,  the  fixed  mire  to  the  ri<>4it,  the 
movable  mire  to  the  left.  On  the  right  of  the  picture  is  the  head-rest,  with 
adjustable  chin-support,  and  four  electric  lamps  attached  to  illuminate  the 
mires  when  good  daylight  from  a  space  of  open  sky  is  not  available.  The 
telescope  is  mounted  in  a  collar  which  allows  it  to  be  freely  revolved  on  its 


Fig.  147.— Javal-Schiotz  ophthalmometer. 


axis,  carrying  with  it  the  graduated  arm  and  mires,  allowing  the  curvature 
to  be  measured  in  any  meridian  of  the  cornea.  Unimportant  variation-  as 
to  the  disk  (which  is  in  some  models  omitted),  form  of  arm,  method  of  illum- 
inating, etc  are  suggested  by  different  writers,  but  the  essential  features  of  the 
instrument  are  those  above  indicated. 

Method  of  Using  the  Ophthalmometer. — To  use  the  ophthalmome- 
ter the  instrument  should  be  placed  where  strong  light  will  fall  upon  the 
mires.  The  patient's  face,  which  should  be  in  comparative  shadow,  is  placed 
in  the  head-rest,  one  eye  covered  with  a  metal  shade  and  the  other  directed 
into  the  barrel  of  the  telescope.  The  surgeon,  glancing  along  the  telescope, 
sees  that  it  is  turned  toward  the  patient's  eye.  Then  by  the  large  s< 
pa-sing  through  one  foot  of  the  tripod  he  adjusts  the  height  of  the  tele-cope, 
and  by  moving  the  whole  tripod  back  and  forth  focusses  the  corneal  in] 
within  the  instrument.  What  he  sees  is  the  doubled  reflection  of  the  disk 
and  mires,  one  image  of  each  mire  |  A  and  B,  Fig.  1  18)  being  close  togi  ther. 
The  movable  mire  is  then  shifted  back  or  forth  along  the  arm  until  the  cA^c 


198 


DETERMINING    THE  REFRACTION  OF  THE  EYE. 


of  its  central  image  just  touches  the  edge  of  the  central  image  of  the  other 
mire  (1,  Fig.  L49). 

It  will  be  noticed  thai  each  mire  is  crossed  by  a  black  line  parallel  to  the 
arm.  If  the  cornea  is  astigmatic,  these  lines  on  the  adjoining  images  of  the 
two  mires  appear  continuous  only  when  the  arm  is  turned  in  the  direction  of 
on,-  of  the  principal  meridians  of  astigmatism.  In  other  positions  they  seem 
relatively  displaced.  The  telescope  is  now  rotated  on  its  axis  until  the  direc- 
tion of  the  arm  i-  found  in  which  the  lines  on  the  two  mires  correspond. 
The  mire-  are  then  broughi  so  that  their  images  are  quite  accurately  in  con- 
tact, and  the  index  on  the  movable  mire  indicates  upon  the  scale  on  the  arm 
the  radius  ,,f  curvature  of  the  cornea,  and  corresponding  refraction  in  one  of 
the    principal    meridians. 

The  tele-cope  i-  next  rotated  until  the  arm  stands  at  right  angles  to  its 
former  position.  If  astigmatism  be  present,  it  will  be  found  that  in  this 
position  the  mires  either  separate  or  overlap.     If  they  overlap,  as  in  Fig.  149, 


Pigs,  i  18,  1 19.— Mires  or  targets  of  ophthalmometer. 

3,  the  number  of  steps  of  overlapping  indicates  the  number  of  diopters  of 
astigmatism.  If  in  this  second  position  the  mires  separate,  as  in  12,  Fig.  149, 
they  must  again  be  broughi  in  contact  and  then  rotated  hack  to  the  former 
direction,  in  which  they  will  now  overlap  and  so  indicate  the  amount  of 
astigmatism. 

If  during  the  examination  the  patient  looks  away  from  the  telescope,  so 
tli.it  some  portion  of  the  cornea  other  than  the  center  is  presented,  the  refrac- 
tion of  this  other  pari  of  the  cornea  will  he  indicated,  differing,  perhaps 
greatly,  from  thai  of  the  central  portion  of  the  cornea.  Commonly,  the  first 
position  in  which  the  mires  are  broughi  in  contact  will  he  with  the  arm 
horizontal.  Bui  if  it  is  found  that  in  this  position  the  black  line-  upon  them 
do  not  correspond,  do  not  come  opposite  one  another,  the  instrument  musi  be 
rotated  either  way  until  these  become  continuous  one  with  the  other.  The 
position  of  the  patient  during  the  examination  should  he  made  as  comfortable 
as  possible  by  having  the  heighl  of  the  instrumenl  or  of  the  patient's  chair 
freely  adjustable,  and  the  examination  musi  he  completed  quickly  before  the 
patienl  ha-  become  tired  or  restless.  Ophthalmometry  is  of  special  value  in 
cases  of  aphakia.     In  other  cases  the  corneal  astigmatism   which    it    gives 

suggests  approximately  the  meridians  and  amount  of  the  total  astigma- 
tism. 

Objective  Methods  for  the  Measurement  of  Refraction. — Rays 
of  lighi  to  he  focussed  on  the  retina  musi  enter  the  eye  with  a  certain  degree 
of  divergence  or  convergence  tor  each  degree  of  ametropia.     Rays  coming 


THE  OPHTHALMOSCOPE— DIRECT  METHOD. 


199 


from  any  point  of  the  retina  and  passing  oul  of  the  rye  travel  the  same  paths 
in  the  opposite  direction,  and  Leave  the  eye  correspondingly  convergent  or 
divergent.  The  retraction  of  the  eve  may  be  determined  l>v  ascertaining  what 
divergence  or  convergence  must  be  given  to  rays  in  order  that  they  shall  be 
focussed  on  the  retina.  Methods  that  do  this  arc  subjective  methods  for  meas- 
uring refraction.  Or  we  may  take  the  rays  from  the  retina  and  ascertain  the 
degree  of  convergence  or  divergence  which  they  have  <>n  emerging  from  the 
eye.  Methods  of  doing  this  arc  objective  methods  for  the  determination  of 
refraction. 

The  Ophthalmoscope. — 1.  The  Direct  Method. — The  retina  of  the 
patient  being  illuminated  by  the  ophthalmoscope,  rays  proceeding  from  it 
enter  the  eye  of  the  surgeon  and  are  focussed  on  his  retina.  If  the  surgeon 
is  emmetropic  parallel  rays  will  be  focussed  on  his  retina,  and  the  lens 
necessary  to  focus  there  the  rays  coming  from  the  patient's  retina  is  the  lens 
necessary  to  make  those  rays  parallel — i.  e.  the  lens  which  corrects  the 
patient's  ametropia. 

To  determine  which  lens  does  this  the  surgeon  watches  the  finest  visible 
details  of  the  fundus  of  the  patient's  eye.  When  the  focussing  is  imperfect, 
these  details  are  blurred  ;  when  perfect,  they  are  seen  clearly.  Suppose  a 
case  of  hyperopia,  illustrated  in  Fig.  150,  in  which  P  represents  the  eye  of  the 


Fig.  150. — Eye  of  patient  and  surgeon  measuring  H. 

patient,  and  S  the  eye  of  the  surgeon.  The  rays  from  the  patient's  retina 
leave  his  eye  divergent,  and  are  directed  to  focus  back  of  the  surgeon'-  retina. 
By  trial  the  convex  lens,  L,  is  found,  which,  rendering  the  rays  parallel  (see 
the  dotted  lines),  causes  them  to  be  focussed  on  the  surgeon's  retina.  This 
lens,  L,  which  renders  parallel  the  rays  coming  out  of  the  patient's  eye,  is  the 
correcting  lens,  the  lens  which  Mould  make  parallel  rays  from  some  distant 
object  convergent  enough  to  focus  them  upon  the  patient's  retina. 


i-  ii,.  l.i-  Rays  in  myopia. 


In  myopia  (illustrated  in  Fig.  151  i  the  rays  emerge  from  the  patient's  eye 
convergent.  A  concave  lens,  /,,  i-  required  to  render  them  parallel,  so  that 
they  can  be  focussed  on  the  surgeon's  retina  ;  and  this  concave  lens  is  the  cor- 


200  DETERMINING    THE  REFRACTION  OF  Till-:  EYE. 

recting  lens  which,  placed  in  the  same  position,  would  render  the  parallel  rays 
coming  from  some  distanl  objecl  sufficiently  divergent  to  be  focussed  on  the 
patient'-  retina. 

[f  the  patient's  eye  is  emmetropic,  the  rays  emerge  from  it  parallel, 
and  require  no  lens  to  secure  their  perfect  focussing  upon  the  surgeon's  retina. 

What  has  been  said  of  other  forms  of  ametropia  holds  for  regular  astig- 
matism :  only  the  ametropia  differs  in  different  meridians,  and  its  correction 
in  any  one  meridian  affects  the  distinctness  of  lines  in  the  fundus  running- at 
right  angles  to  that  meridian.  Thus  in  an  eye  where  the  hyperopia  in  the 
horizontal  meridian  requires  a  1  D.  convex  lens  for  its  correction,  and  the 
hyperopia  in  the  vertical  meridian  requires  a  21).  convex  lens  for  its  correc- 
tion, the  I  1  >.  convex  lens  renders  clear  the  vessels  which  run  horizontally, 
and  a  2  I  >.  convex  lens  i-  required  to  render  clear  the  vertical  vessels;  the 
difference  between  the  two  lenses,  1  I).,  is  the  amount  of  astigmatism  present. 

In  the  practical  use  of  the  ophthalmoscope  to  measure  retraction  the  chief 
difficulty  is  due  to  the  influence  of  accommodation  in  the  eye  of  either  the 
patient  or  the  surgeon.  In  any  case  the  effect  of  accommodation  is  the  same 
as  the  effect  of  a  convex  lens,  partly  correcting  hyperopia  and  diminishing  its 
apparent  amount  ;  or  adding  to  myopia,  and  to  that  extent  increasing  its  appa- 
rent amount.  Accommodation  in  the  surgeon's  eye  is  guarded  against  by 
practice.  Yet  always  in  young  eyes,  particularly  when  tired  or  irritated, 
there  i<  a  chance  of  some  accommodation  being  present.  In  the  patient's  eye 
accommodation  is  reduced  to  the  minimum  by  making  the  ophthalmoscopic 
examination  in  a  thoroughly  dark  room  of  sufficient  size,  with  the  gaze 
fixed  on  blank  space  to  encourage  the  complete  relaxation  of  the  ciliary 
muscle.  Using  these  precautions,  the  influence  of  accommodation  is  still  to 
l>e  guarded  against  by  choosing,  as  most  nearly  correct,  the  strongest  convex 
or  the  weakesl  concave  lens  with  which  the  details  of  the  fundus  are  clearly 
visible. 

In  determining  astigmatism  one  should  first  seek  the  strongest  convex  or 
weakesl  concave  lens  with  which  the  vessels  running  in  any  one  direction  are 
still  clearly  -ecu.  This  lens  will  give  the  hyperopia  or  myopia  present  in  the 
meridian  at  right  angle-  to  those  vessels.  These  vessels  run  in  one  of  the 
principal  meridians  of  astigmatism,  the  other  being  at  right  angles  to  this. 
Having  determined  the  direction  of  the  meridians  and  the  lens  required  by 
one  of  them,  the  next  point  i-  to  find  what  lens  renders  clear  the  vessels  run- 
ning at  righl  angles  to  those  seen  clearly  with  the  first  lens.  The  difference 
between  the  two  lenses  gives  the  degree  of  astigmatism. 

A  not  In  r  source  of  error  in  measuring  refraction  with  the  ophthalmoscope 

Hi-  in  the  differences  in  the  refractii f  the  same  eye  through  different  parts 

of  the  dioptric  media.  Thu-  the  refraction  at  the  centre  is  never  the  same 
a- the  refraction  at  the  margin  of  the  widely-dilated  pupil,  [n  some  eyes 
without  ;i  mydriatic  the  pupil  dilated  in  the  dark  room  shows  a  very  different 
refraction  at  it-  margin  from  that  ai  it-  center.  The  refraction  at  the  center 
of  the  pupil  is  commonly  what  i-  of  importance,  and  the  error  which  might 
occur  by  measuring  refraction  through  the  edge  of  the  pupil  must  l>e  guarded 
against. 

\jain.  the  refracti f  the  eye  varies  at  different    part-  of  the  retina. 

In  a  perfectly  spherical  eye  the  refraction  at  the  macula  is  least  hyperopic  or 
most  myopic.  The  refraction  of  the  anterior  parts  of  the  retina  and  choroid 
may  be  highly  hyperopic,  even  in  eye-  quite  myopic  at  the  macula.  Then, 
too,  the  depth  of  the  fundus  may  vary  in  other  ways,  a-  from  posterior 
staphyloma  or  cupping  or  swelling  of  the  optic  nerve  entrance. 


THE  OPHTHALMOSCOPE— INDIRECT  MEZlHOp.  201 

It  is  therefore  important  to  select  for  the  measurement  of  refraction  the 
details  «>t'  a  certain  part  of  the  fundus,  generally  as  Dear  the  macula  as  pos- 
sible. For  astigmatism  the  examiner  should  take  as  test  lines  the  vessels  run- 
ning from  the  disk  to  the  macula,  with  their  lateral  branches.  The  large 
vessels  as  they  pass  upward  and  downward  from  the  optic  disk  are  particularly 
liable  t<>  protrude  into  the  vitreous,  and  thus  give  an  appearance  of*  astigma- 
tism when  none  is  really  present.  The  pigment-layer  of  the  retina  and  the 
vessels  are  usually  the  parts  the  retraction  of  which  is  measured;  but  the 
attention  may  be  fixed  upon  anv  other  detail  seen  within  the  eye.  In 
glaucoma  the  refraction  of*  the  bottom  of  the  cup  may  be  compared  with  the 
refraction  at  the  margin  of  the  cup,  or  in  optic  neuritis  the  summit  of  the 
swelling  may  have  its  refraction  compared  with  that  of  the  retina  beyond  the 
swelling.  J5y  its  refraction  the  surgeon  may  seek  to  locate  an  opacity  in  the 
vitreous.  The  distances  in  front  of  the  plane  of  emmetropia  indicated  by  a 
certain  hyperopia,  and  the  distances  behind  that  plane  indicated  by  an  equal 
myopia,  are  shown  in  the  following  table,  calculated  for  the  average  eye,  hav- 
ing an  antero-posterior  axis  of  22.824  mm.  (see  also  page  ITS). 


iopters. 

H.  Diminution. 

M.  Increase. 

Diopters. 

H.  Diminution. 

M.  Increase 

1 

0.31 

0.32 

7 

2.ii:; 

2.52 

•j 

0.62 

0.66 

8 

2.28 

2.93 

3 

0.92 

1.01 

9 

2.53 

3.35 

4 

1.21 

1.37 

10 

2.78 

3.80 

5 

1.50 

1.74 

15 

3.91 

6.28 

6 

1.76 

2.13 

20 

4.90 

9.31 

2.  Indirect  Method. — In  using  the  ophthalmoscope  by  the  indirect 
method  rays  coming  from  the  retina  are  focussed  by  the  object  lens  to  form 
a  real  inverted  image  between  that  lens  and  the  surgeon's  eye.  When  they 
emerge  from  the  eye  parallel,  this  image  is  formed  at  the  principal  focus  of 
the  object  lens.  When  they  emerge  divergent,  as  in  hyperopia,  the  image  in- 
formed farther  from  the  lens.  When  they  emerge  convergent,  as  in  myopia, 
it  is  formed  close  to  the  lens.  By  ascertaining  the  exact  distance  of  the 
image  from  the  object  lens  one  may  determine  the  refraction  of  the  eye. 
This  has  been  attempted  by  placing  a  screen  where  the  inverted  image  is 
most  distinct,  and  measuring  its  distance  from  the  object  lens,  but  this 
method  is  not  of  practical  value. 

A  modification  of  this,  the  Schrrridt-JRimpler  method,  instead  of  the  screen 
has  a  source  of  light  of  peculiar  form,  enabling  the  surgeon  to  judge  when 
it  i-  accurately  focussed.  To  use  it  the  object  lens  is  placed  exactly  its  focal 
distance  from  the  principal  plane  of  the  eye,  and  by  trial  the  surgeon  finds 
what  distance  the  ophthalmoscopic  mirror  must  be  held  from  the  lens  to  give 
the  most  distinct  view  of  the  image  of  the  source  of  light  upon  the  fundus. 
This  is  obtained  when  the  focus  of  the  mirror  coincide-  with  the  focus  of  the 
object  lens;  and  a  scale  attached  to  the  lens  gives  for  each  position  of  this 
image  the  amount  of  hyperopia  or  myopia  to  which  it  corresponds.  Fig.  152 
represents  the  course  of  the  rays  in  this  method,  the  solid  lines  indicating  the 
rays  reflected  from  the  ophthalmoscopic  mirror  and  entering  the  eye.  and  the 
broken  lines,  the  rays  coming  from  the  patient's  retina  to  the  eye  of  the 
surgeon. 

By  the  indirect  method  the  nearer  to  the  eye  the  object  lens  is  held  the 
-mailer   i-  the    inverted    image  in  myopia,  and  the    larger    it    i-   in   hyperopia. 

The  change  of  size  due  to  the  change  of  distant 1'  the  lens  in  froni  of 

the  patient's  eye  varies  with  the  degree  of  ametropia.  Hence  the  presence 
and  kind  of  ametropia  of  high  degree  can  be  recognized  by  varying  the  dis- 


202 


DETERMINING    THE   REFRACTION  OF  THE  EYE. 


tance  of  the  lens  from  the  eye.     In   hyperopia  the  withdrawal   of  the  lens 
from  the   eve  make-  the  image  smaller,  in    myopia   it  makes  it   larger.     la 


PlG.  152.-  Course  of  rays  in  Schmidt-Rimpler's  method. 

astigmatism  such  withdrawal  makes  the  disk  relatively  larger  in  the  direction 
of  the  meridian  of  greatest  refraction,  and  relatively  smaller  in  the  meridian 
of  least  refraction.  This  change  in  the  form  of  the  disk  is  an  evidence  of 
astigmatism,  most  noticeable  in   high  mixed  astigmatism. 

Skiascopy  ;  Retinoscopy  ;  The  Shadow-test. — The  method  of  de- 
termining refraction  with  the  ophthalmoscope  by  the  position  of  the  inverted 
image  is  of  little  practical  value,  because  of  the  difficulty  of  ascertaining  the 
exact  position  of  that  image  and  its  nearness  to  the  eye.  Skiascopy  is  essen- 
tially a  method  of  determining  the  distance  of  the  inverted  image  from  the  pa- 
tient's eve  with  great  accuracy.      Fig.  153  represents  an  eye  in  front  of  which 


Fig.  153.— Eye  with  convex  lens  placed  before  it. 

i-  placed  a  convex  lens,  causing  the  rays  from  a  point,  /'.  of  the  retina  to  he 
focussed  at  /.' .•  tin-  lens,  L,  may  he  regarded  as  composed  of  two  lenses,  // 
and  //' — //  strong  enough  t<>  render  parallel  the  rays  emerging  from  the 
eye,  and  L"  able  to  take  parallel  ray-  and  focus  them  at  /.'.  By  subtracting 
tin-  strength  of  /."  from  that  of  L.  it  i-  easy  to  get  //,  the  correcting  lens. 
Suppose  L  to  have  a  strength  of  5  JD.,  and  R  to  be  1  m.  (the  focal  distance  of 
a  I  I>.  lens)  from  /,.  /."  will  be  I  D..  and  5  —  1  I  D.,  the  strength  of  V 
required  to  a irrecl  the  byper< >pia. 

The  strength  of  /,"  to  he  deducted  from  t  li.it  of  /,  is  found  by  determining 
the  distance  of  /•'  from  the  leu-,  h.  Fig,  154,  representing  the  patient's  eye 
(myopic)  focussing  the  rays  from  .1  nt  C  and  from  /»' at  />.  it  will  he  noticed 
that   if  tie-  Burgeon's  eye  be  placed  m  .Y.  nearer  the  patient's  eye  than  0  D} 

the  ray  reaching  it  fr I  comes  through  the  upper  part  of  the  pupil,  so  that 

.1  will  appear  al  a  in  that  direction,  lint  if  the  surgeon's  eye  he  placed  at 
.V,  beyond  C  />.  the  point    .1  will  appear  to  he  located  in  the  lower  part  of 


SKIASCOPY;    Iti: n.Xoscoi'Y;    THE  SHADOW-TEST.         203 

the  pupil  inward  a',  the  ray  from  .1  reaching  the  surgeon's  eye  from  that 
direction.  In  the  same  way,  from  N,  B  will  appear  in  the  lower  pari  of  the 
pupil,  and  from  .Y\  in  the  upper  part  of  the  pupil. 


Fig.  154. — Showing  how  the  rays  cross,  and  so  change  their  relative  positions  at  the  plane  of  reversal,  I>  < '. 

This  reversal  in  the  apparent  position  of  any  given  points  of  the  retina 
occurs  at  the  distance  of  Cand  D.  Closer  to  the  eye  the  point  really  above 
appears  above  ;  the  retina  is  seen  in  an  erect  image.  Farther  from  the  eye, 
the  point  really  above  appears  below,  and  the  point  really  below  appears 
above;  the  retina  is  seen  in  the  inverted  image.  The  change  from  the  erect 
to  the  inverted  image  occurs  at  the  point  for  which  the  patient's  eye  is 
focussed,  either  by  its  own  myopic  refraction  or  a  lens  placed  before  it ;  which 
point  is,  therefore,  called  the  point  of  reverse/. 

The  position  of  the  point  of  reversal  is  determined  with  practical  accuracy 
by  observing  the  apparent  direction  of  movement  of  light  and  shade  in  the 
pupil.  The  light  is  thrown  on  the  eye  with  a  mirror,  usually  a  special  form 
of  the  ophthalmoscope  mirror,  which  may  be  either  plane  or  concave.  If 
plane,  it  should  have  a  small  sight-hole,  2  or  2^  mm.  in  diameter,  with  its 
margin  free  from  reflections.  By  turning  the  mirror  slightly  in  different 
directions  the  light  reflected  from  it  on  the  patient's  face,  and  also  the  portion 
entering  his  eye  and  falling  on  the  retina,  are  made  to  move  correspondingly. 
The  movement  of  light  and  shade  as  it  appears  in  the  pupil  is  now  watched. 
When  the  apparent  movement  is  in  the  same  direction  as  the  real  movement 
of  the  light  on  the  retina,  the  erect  image  is  being  watched,  and  the  surgeon's 
eye  must  be  inside  of  the  point  of  reversal,  as  at  N  (Fig.  154).  When  the 
apparent  movement  in  the  pupil  is  the  opposite  of  the  real  movement  of  light 
on  the  retina,  an  inverted  image  is  being  watched  and  the  surgeon's  eye  is 
beyond  the  point  of  reversal,  as  at  X'.  By  studying  these  opposite  move- 
ments on  the  two  sides  of  the  point  of  reversal   that    point    is   located. 

With  a  certain  movement  of  the  mirror  there  is  always  the  same  move- 
ment of  the  light  on  the  face  whether  the  mirror  be  plane  or  concave.  Thus, 
when  the  mirror  is  made  to  face  upward  the  light  moves  upward  across  the 
patient's  face.  If  the  mirror  is  turned  down,  the  light  moves  down  across 
the  patient's  face.  With  the  plane  mirror  the  light  on  the  retina  always 
moves  in  the  same  direction  as  the  light  on  the  fact — in  the  same  direction, 
or  with  the  mirror.  Willi  the  concave  mirror  the  light  on  the  retina  always 
moves  in  the  direction  opposite  to  that  of  the  light  on  the  face — always  moves 
against  the  mirror  (Fig.  loo).  The  reason  for  this  is  that  with  the  plane 
mirror  the  light  enters  the  eye  as  though  coining  from  an  image  (called  the 
immediate  source  of  light)  as  far  behind  the  mirror  :i-  the  real  or  original 
source  is  in  front;  but  with  the  concave  mirror  the  immediate  source — the 
point  from  which  the  light  seems  to  come  to  the  eye — is  a  small  inverted 
image  of  the  original  soura    of  light,  formed   in   fronl   ol   the  mirror. 

Hence,  with  the  plane  mirror,  if  the  lighl  in  the  pupil  appear-  to  move 
vilh  the  mirror — with  the  lighl  on  the  fact — the  surgeon  know-  that  the  point 


204 


DETERMINING    THE  REFRACTION  OF  THE   EYE. 


of  reversal  is  not  between  him  and  the  patient.  But  when,  with  the  same 
mirror,  the  apparenl  movement  of  light  in  the  pupil  is  against  the  mirror — 
in  the  opposite  direction  to  the  movement  of  light  <>n  the  fact — ho  knows  that 
the  point  <>t'  reversal  is  between  him  and  the  patient — that  he  is  beyond  the 
point  of  reversal  and  looking  at  the  inverted  image.  ( >n  the  other  hand, 
when  with  the  concave  mirror  the  Light  in  the  pupil  appears  to  move  with 
the  mirror — with  the  light  on  the  face — the  surgeon  knows  that  this  is  the 
opposite  of  the  real  movement  of  light  pn  the  patient's  retina,  and  that,  there- 
fore, he  is  watching  an  inverted  image.  But  if  with  the  concave  mirror  the 
light  in  the  pupil  appears  to  move  against  the  mirror — against  the  light  on 
the  face — knowing  this  to  be  the  direction  of  the  real  movement  of  light  on 


Fig.  155.— Course  of  rays  in  skiascopy  with  concave  mirror:  A  A,  one  position  of  mirror  giving  imme- 
diate source  of  light  at  I,  and  illuminating  retina  toward  a  ;  i:  />'.  another  position  of  mirror  with  imme- 
diate source  of  light  at  /'.  and  retina  illuminated  toward  b, 

the  retina,  he  knows  he  is  watching  an  erect  image,  the  point  of  reversal  being 
somewhere  behind  him. 

Rate  of  Movement,  Form,  and  Brightness  of  the  Light-area. —  Besides 
the  direction  of  the  movement  of  light  and  shadow,  the  brightness  and  form 
and  rate  of  movement  of  the  illuminated  area  in  the  pupil  are  of  practical 
importance.  At  the  point  of  reversal  a  single  point  of  the  retina  appears  to 
occupy  the  whole  area  of  the  pupil.  As  the  point  of  reversal  is  departed 
from,  more  and  more  of  the  retina  is  >cvn  in  the  pupil.  Hence,  near  to  the 
point  of  reversal  a  slight  movement  of  the  light-area  on  the  retina  will  appear 
to  carry  the  light  entirely  across  the  pupil — the  light  and  shadow  move  in  the 
pupil  swiftly.  But  at  a  greater  distance  from  the  point  of  reversal  they  move 
slower. 

The  apparent  form  of  the  light-area  in  the  pupil  is  also  modified  by  the 
nearness  of  the  surgeon  to  the  point  of  reversal.  The  actual  form  of  the 
light-area  on  the  retina  is  commonly  circular.  This  circle  appears  greatly 
magnified  when  the  surgeon  is  near  the  point  of  reversal,  and  only  a  >mail 
pan  of  its  margin  can  be  seen  in  the  pupil  at  one  time,  the  boundary  between 

lighl   and   shade  appearing  al st  a  straight  line.      While  faraway  from  the 

point  of  reversal,  especially  if  the  surgeon  be  near  the  pupil,  the  whole  area 
of  retinal  illumination  may  be  seen  in  the  pupil  as  a  complete  circle.  More 
important  -till  in  determining  the  apparent  form  of  the  light-area  are  regular 
astigmatism,  alienation,  and  irregular  astigmatism,  to  be  presently  con- 
sidered. 

The  brightness  of  the  light-area  in  the  pupil  depend-  on  the  concentration 
of  the  lioht  thrown  into  the  eye  and  the  extent  to  which  the  retina  is  magni- 
fied. The  immediate  Bource  of  lighl  being  commonly  near  the  mirror,  the 
light    i-    most    concentrated    on    the    retina  when    the    mirror   is    held    near  the 

point  of  reversal.     Bui  just  al  the  point  of  reversal  the  magnification  of  the 


PRACTICAL  APPLICATION  OF  SKIASCOPY. 

retina  makes  the  illumination  appear  feeble,  so  thai  the  brighesl  area  of  light 
in  the  pupil  is  obtained  about  1  or  '1  D.  from  the  point  of  reversal. 

Practical  Application  of  Skiascopy. — The  room  should  be  thor- 
oughly darkened,  and  the  source  of  light  shaded  with  an  opaque  chimney 
having  a  circular  opening  opposite  the  brightest   part   of  the  flame. 

For  the  plane  mirror  the  source  of  light  should  be  so  arranged  that  it  can 
be  brought  quite  close  to  the  mirror  and  moved  with  the  mirror  to  or  from 
the  patient's  eye,  and  the  opening  in  the  shade  should  be  5  or  10  mm.  in 
diameter. 

For  the  concave  mirror  the  flame  is  to  be  hack  of  the  patient's  head. 
generally  as  far  from  the  mirror  as  possible;  and  if  a  .-hade  is  used,  the 
opening  should  be  10  to  20  mm.  in  diameter. 

When  not  otherwise  stated,  the  following  description  refers  to  skiascopy 
with  the  plane  mirror.  It  may  be  applied  to  the  concave  mirror  by  reversing 
the  significance  of  the  direction  of  movement  of  the  light  in  the  pupil  : 

1.  Hyperopia. — Without  a  lens  the  light  moves  across  the  pupil  with  the 
light  on  the  face.  The  convex  lens,  L  (Fig.  153),  strong  enough  to  overcome 
the  hyperopia  and  to  give  a  point  of  reversal.  R,  is  placed  before  the  eye. 
The  surgeon,  then  varying  his  distance  from  the  patient's  eye,  tries  the  move- 
ment of  light  and  shadow  alternately  from  within  R,  where  the  movement  is 
with,  and  from  beyond  R,  where  the  movement  is  against,  the  light  on  the 
face.  The  position  of  the  point  of  reversal  is  thus  determined.  Its  distance 
from  the  patient's  eye  is  then  measured  or  estimated.  This  is  the  focal  dis- 
tance of  the  over-correcting  effect  of  the  lens  L,  which  over-correcting  effect, 
subtracted  from  the  whole  strength  of  the  lens,  leaves  the  strength  required 
to  correct  the  hyperopia. 

Suppose  a  5  D.  convex  lens  placed  before  the  eye  gives  movement  with  the  light  on 
the  face  at  20  in.  (51  cm.),  and  against  the  light  on  the  face  at  30  in.  (76  cm.),  the  point 
of  reversal  taken  as  midway  is  at  about  the  focal  distance  of  a  1.5  diopter  lens;  the 
over-correcting  effect  of  theoD.  lens  equals  5.  -  1.5  =  3.5  D. — the  strength  of  the  lens 
required  to  correct  the  hyperopia. 

In  making  the  final  determination  of  the  refraction,  if  the  freedom  of  the 
eye  from  astigmatism  and  aberration  allows  the  movement  of  light  and  shadow 
to  be  easily  watched  at  a  greater  distance,  a  weaker  lens,  giving  a  point  of 
reversal  farther  from  the  eye.  may  be  used.  But  if  there  be  much  irregular 
astigmatism  or  aberration,  the  determination  can  be  more  correctly  made  with 
a  point  of  reversal  still  closer  to  the  eye. 

2.  Myopia. — From  the  myopic  eye  the  rays  emerge  already  convergent  to 
meet  in  a  point  of  reversal  that  can  lie  determined  without  the  use  of  any 
lens,  except  in  myopia  of  very  low  degree.  Commonly,  however,  it  i-  too 
close  to  the  eye  for  accuracy,  and  a  concave  lens  partly  correcting  the  myopia 
should  lie  placed  before  the  eye,  and  the  remaining  myopia  measured  ami 
added  to  the  strength  of  the  concave  lens   for  the   total    myopia. 

F<»r  example,  in  a  case  of  myopia  of  10  P..  a  concave  9  D.  lens  being  placed  before 
the  eve,  the  point  of  reversal  i-  round  at  1  in.  This  corresponds  to  myopia  of  1  1>.. 
whirl'],  added  to  '.» I>.,  the  strength  of  the  lens,  gives  L0  D.,  the  total  myopia.  In  the  case 
ot  \.rv  low  myopia,  as  only  0.25  !>..  a  convex  1  1  >.  lens  i-  placed  before  the  eye,  and  the 
point  of  reversal  found  in  this  case  at  ::i  in.  (78.5  cm.),  indicating  1.25D.  ot'  myopia. 
From  this,  by  subtracting  1  D.,  the  strength  of  tin-  lens,  we  gel  0.25D.,  the  myopia 
originally  present. 

:;.    Emmetropia  \-  shown  when  the  convex  lens  placed  befor* 
a  point  ot'  reversal  jusi  at  it-  focal  distance. 


206  DETERMINING    THE  REFRACTION  OF  THE  EYE. 

1.  Regular  Astigmatism. — In  regular  astigmatism  the  ray-  coming  from 
the  retina  emerge  from  the  cornea  with  different  degrees  of  divergence  or 
convergence  in  different  meridians.  For  the  two  principal  meridians  there 
are.  therefore,  always  the  two  separate  points  of  reversal,  their  distance  apart 
indicating  the  amounl  of  astigmatism. 

When  in  such  an  eve  a  point  of  reversal  is  found,  it  is  soon  discovered 
that  it  is  a  point  of  reversal  only  for  the  movement  in  one  direction.  The 
surgeon's  eye,  placed  at  this  point,  sees  the  retina 
magnified  enormously  in  the  direction  of  the  one 
meridian,  and  magnified  much  less  in  the  other  prin- 
cipal meridian.  This  makes  the  light-area  in  the 
pupil  appear  elongated  in  the  direction  of  the  first 
meridian,  giving  it  a  band-like  appearance,  shown  in 
Fig.  156. 

To  make  this  hand-like  appearance  most  distinct, 
the  immediate  source  of  light  should  he  at  the  point 
of  reversal  for  the  other  meridian.      With  the  plane 

Fig.    156.— Band-like  appear-    mj1Tor   the    surgeon  must   place    his  eve   at    the    point 
ance  in  shadow  tesl  °  tr  '  ' 

of  reversal  nearest  the  eye,  where  he  will  get  move- 
ment undistinguishable  in  one  meridian,  and  with  the  light  on  the  face  in  the 
other.  The  original  source  of  light  is  then  to  be  pushed  away  from  the 
mirror,  its  reflection  (the  immediate*  source)  retreating  correspondingly  behind 
the  mirror  until  it  reaches  the  point  of  reversal  for  the  other  principal 
meridian.  The  direction  of  the  band-like  appearance  is  to  he  carefully  noted 
as  the  direction  of  the  principal  meridian  of  greatest  refraction — the  direction 
for  the  axis  of  a  convex  cylinder  that  would  correct  the  astigmatism.  The 
direction  of  the  other  principal  meridian,  the  direction  for  the  axis  of  a  con- 
cave cylinder  to  correct  the  astigmatism,  will  he  at  right  angles  to  this. 

With  the  concave  mirror  the  surgeon's  eye  should  he  placed  at  the  point 
of  reversal  that  is  the  farthest  from  the  eye  and  the  original  source  of  light 
brought  closely  to  the  mirror,  causing  its  conjugate  image  (the  immediate 
source  of  light)  to  go  farther  from  the  mirror  and  closer  to  the  patient's  eye, 
until  it  reaches  the  nearer  point  of  reversal,  and  the  hand-like  appearance 
appear-  mosl  distincl  in  the  meridian  of  least  refraction.  In  this  position 
the  hand  cannot  he  seen  to  move  in  the  direction  of  its  length,  but  at  right 
angles  it  also  move-  with  the  light  on  the  face. 

1  laving  determined  the  direction  of  the  principal  meridians  of  astigmatism, 
the  hyperopia  or  myopia  in  each  is  to  he  measured  separately,  just  as  hyper- 
opia or  myopia  would  he  measured  in  any  other  case,  with  the  light  as  near 
the  plane  mirror  a-  possible  or  as  far  away  as  convenient  from  the  concave 
mirror.  fhe  difference  of  refraction  between  the  two  meridians  is  the 
amount  of  astigmatism.  When  it  has  been  determined,  a  cylindrical  lens 
correcting  it   should  he  placed  with  the  proper  spherical  lens  before  the  eye, 

and  the  tesl  applied  to  ascertain   if  the  correction  is  really  complete. 

Aberration. —  In  most  eyes  the  refraction  at  the  edge  of  the  dilated  pupil 
is  more  myopic  or  less  hyperopic  than  at  the  center.  In  this  form,  called 
positivt  aberration,  the  point  of  reversal  for  the  edge  of  the  pupil  i-  nearer 
the  eye  than  the  point  of  reversal  for  the  center,  and  from  the  latter  point 
movement  of  lighi  against  the  light  on  the  face  i-  to  be  noticed  in  the  edge 
..I'  the  pupil.  This  light  in  the  edge  is  brighter  than  the  light  at  the  center 
of  the  pupil,  and  great  care  nin-t  be  taken  to  avoid  error  on  this  account. 
\\  I h  ii  the  center  of  the  pupil  i-  the  mure  myopic  it  is  called  negativt  aberra- 
tion,     fhe  circular  distribution  of  aberration  largely  determines  the  shape  of 


SUBJECTIVE  METHODS  OF  TESTING   REFRACTION.       207 

light  and  shadow  in  the  pupil,  making  it  more  circular  when  otherwise  it 
would  be  of  different  shape,  as  in  regular  astigmatism. 

When  aberration  is  present  the  point  of  reversal  for  the  margin  of  the 
pupil  may  be  close  t<>  the  surgeon's  eye,  while  the  point  of  reversal  for  the 
center  is  far  from  it.  In  this  ease  the  movement  of 
the  light  in  the  center  of  the  pupil  will  be  slow,  while 
in  the  margin  it  will  be  swift.  The  light-area  then 
appears  to  swing  around  a  fixed  center,  and  assumes 
an  angular  shape,  shown  in  Fig.  157.  This  i-  the 
appearance  presented  in  conical  cornea  where  the  cen- 
ter of  the  pupil  is  more  myopic  than  the  margin. 

Irregular  Astigmatism. — The  differences  of  re- 
fraction due  to  the  lens-changes  preceding  cataract, 
or  the  irregularities  of  the  cornea  following  phlycten- 
ular keratitis,  break  up  the   liffht  and   shadow  in   the      FlG-   157.— Angular   apjpear- 

.,    .    .  ,,    .  L  ,  °  „.  ance  m  liiu'li  aberration, 

pupil  into  small  irregular  areas,      the  surgeon   must 

find  which  of  these  areas  is  most  likely  to  be  of  use  for  eye-work,  and  measure 
the  refraction  in  it.  To  do  this  it  may  be  necessary,  on  account  of  the  small- 
no-  of  the  area,  to  come  quite  close  to  the  patient's  eye.  Here  a  small  source 
of  light  and  a  small  sight-hole  in  the  mirror  are  of  great  importance. 

Subjective  Methods  of  Testing  Refraction. — To  determine  what 
lens  is  required  to  bring  perfectly  to  a  focus  the  rays  entering  the  eye  we  may 
resort  to  tests  based  upon  a  single  point  of  light.  Thomson's  ametrometer 
consists  of  two  small  gas-flames,  one  fixed  and  the  other  movable  along  a 
graduated  arm,  which  can  be  revolved  about  the  first  as  a  center.  The  dis- 
tance of  the  two  flames  apart  when  their  diffusion-areas  appear  to  just  touch 
each  other  gives  the  degree  of  ametropia  in  the  meridian  parallel  to  the  grad- 
uated arm.  Hotz  uses  two  small  holes  in  a  disk  placed  in  front  of  a  window 
or  lamp-flame.  To  the  patient  having  astigmatism  each  of  the  points  of  light 
so  obtained  appears  elongated,  and  by  turning  the  disk  so  that  these  elongated 
image-  lie  in  the  same  line,  an  index  enables  the  surgeon  to  read  off  the  direc- 
tion of  the  principal  meridians  of  astigmatism. 

The  simple  optometer  consists  essentially  of  a  convex  lens  which  i-  placed 
close  to  the  eye,  and  a  graduated  arm  extending  from  it  on  which  moves  a 
card  bearing  test-type.  In  emmetropia  the  type  can  be  seen  distinctly  only 
as  far  as  the  focal  distance  of  the  lens.  In  hyperopia  it  i-  read  to  a  greater 
distance,  and  in  myopia  only  to  a  lesser  distance,  corresponding  to  the  degree 
of  the  ametropia. 

Either  of  the  above  subjective  methods  maybe  found  of  service  where 
others  are  not  available;  but  they  are  not  commonly  used,  and  by  the  sub- 
jective method  of  determining  refraction  is  commonly  meant  the  method 
with   trial-lenses  and   test-letter-. 

The  trial  case  contains  a  sufficient  series  of  spherical  and  cylindrical 
lenses,  with  trial-frames  in  which  they  can  be  placed  before  the  eye,  prisms, 
solid,  pin-hole,  and  -lit  disks,  and  colored  glasses.  By  combining  two  or 
more  lenses  together  a  very  few  convex  and  concave  lenses  can  be  made  to 
answer  for  any  case  of  ametropia,  but  where  many  cases  are  to  lie  tested  con- 
venience and  economy  of  time  demand  a  fairly  complete  sel  of  lens*  5.  Hiis 
may  include  pair-  of  convex  and  concave  lenses,  with  0.12  P.  intervals  t<> 
1.5  D.,  0.25  I),  interval-  to  I  I).,  and  0.50  I  >.  interval-  to  8  1  >.,  for  both 
spherical-  and  cylindrical-.  Then  for  the  -pherical-,  1  I  >.  Intervals  to  20  I  >.. 
with,  perhaps,  25  D.  and  30  D.  added.  The  prisms  may  run  by  1 -centred 
interval-  to  10,  with  the  12,  15,  2<>,  and  30  centred  prisms  in  addition. 


:><>*  DETERMINING    THE  REFRACTION  OF  THE  EYE. 

To  use  the  trial-lenses,  test-letters  suited  to  the  distance  adopted  are  to  be 
hung  in  a  strong  light,  cither  natural  or  artificial,  the  latter  being  preferable 
because  it  can  be  made  more  uniform.  The  test-card  should  always  have  one 
or  two  lines  of  letters  .-mailer  than  those  intended  to  be  read  at  the  distance 
adopted.  Thus  for  »>  in.  there  should  be  a  line  of  5-m.  letters.  Some  pa- 
tient- have  visual  acuteness  greater  than  ^. 

Use  of  the  Trial  Case. — The  pinhole  disk  furnishes  a  ready  means  of 
distinguishing  between  imperfect  vision  due  to  ametropia  and  imperfect  vision 
due  to  other  causes.  In  the  former  case  the  placing  the  pin-hole  opening 
before  the  eve  lessens  the  diffusion-areas  upon  the  retina  and  improves  vis- 
ion ;  it'  the  imperfection  of  vision  is  not  due  to  ametropia,  the  pin-hole  disk 
rather  makes  it  worse. 

The  slit  is  used  in  discovering  astigmatism  of  moderate  or  high  degree 
and  the  direction  of  its  principal  meridians.  In  astigmatism  the  diffusion- 
areas  on  the  retina  are  wider  in  the  direction  of  one  principal  meridian  than 
in  the  direction  of  the  other.  The  slit  limits  them  at  right  angles  to  its 
length,  but  not  in  the  direction  of  its  length.  When,  therefore,  it  is  placed 
before  the  eve,  turned  in  one  direction,  it  cuts  down  the  diffusion-area  in  its 
larger  dimension,  giving  the  greatest  improvement  of  vision.  At  right  angles 
to  thi<  it  limits  the  diffusion-area  in  the  other  direction,  in  which  it  isalready 
raosl  limited,  and  gives  the  least  improvement  of  vision.  These  directions 
of  the  principal  meridians  of  the  astigmatism  being  found,  the  slit  may  be 
turned  in  the  direction  of  one  meridian  and  spherical  lenses  tried  until  one  is 
found  correcting  the  ametropia  in  this  meridian,  and  giving  the  best  vision 
obtainable  through  the  slit.  The  same  is  done  for  the  other  meridian,  and  in 
this  way  the  correcting  lenses,  both  spherical  and  cylindrical,  may  be  deter- 
mined.   This  test  has  practical  value  as  an  approximate  and  confirmatory  test. 

In  the  ordinary  use  of  test-hnses  each  eye  is  tested  separately,  the  other 
being  covered  by  a  solid  disk  or  ground  glass.  When  accommodation  is 
absent  the  aim  is  to  find  the  lenses  which  give  the  best  vision.  Some  idea 
of  the  ametropia  is  given  by  previous  objective  tests  and  the  acuteness  of  vision 
without  a  lens.  The  concave  or  convex  lens  expected  to  correct  it  approxi- 
mately i-  placed  before  the  eye  and  the  vision  with  it  noted.  Then  weak- 
additional  convex  or  concave  lenses  are  held  in  the  hand  in  front  of  this, 
trying  firsl  the  one,  then  the  other.  If  the  first  lens  has  been  convex,  and 
the  additional  convex  spherical  further  improves  vision,  a  convex  lens  cor- 
respondingly stronger  i-  substituted.  The  trial  is  then  repeated,  and  this  is 
continued  until  a  lens  is  found  which  can  neither  be  increased  nor  diminished 
in  strength  without  lessening  the  acuteness  of  vision. 

If  the  eye  i-  free  from  astigmatism,  this  is  the  lens  desired  ;  but  to  test 
BUCh  freedom  from  astigmatism  cylindrical  lenses  should  be  tried.  The 
cylindrical    lens   is   to  be   held   in    front  of  the  spherical    lens   selected,  and    its 

;i\i-  turned  in  different  direction-,  a-  vertical,  horizontal,  and  oblique  to  the 
right  ami  to  the  left.  For  this  purpose  the  astigmatic  lens,  convex  in  one 
meridian  and  equally  concave  iii  the  meridian  perpendicular  thereto,  is  prefer- 
able to  either  the  con\c\  . .f  concave  cylinder.  Such  astigmatic  lenses  should 
be  included  in  the  trial  case. 

Having  ascertained  thai  in  Borne  one  direction  the  cylindrical  lens  im- 
proves vision,  BUCh  a  lens  LS  to  be  placed  in  the  trial-frame,  cither  with  the 
spherical  lens  already  there  or  with  one  slightly  weaker  if  the  cylindrical  lens 
i-  of  the  same  kind,  or  a  slightl)  stronger  if  the  cylinder  is  of  the  opposite 
kind.     Thus,  if  tl 'iginal  spherical   lens  was       2  !>..  and        1   I  >.  is  the 


MYDRIATICS.  209 

cylinder  to  be  combined  with  it,  the  spherical  should  be  changed  to  1.5  I  >. 
If  it  is  preferred  t<>  use  a  —  1  I),  cylinder,  the  spherical  lens  should  be 
changed  to  2.5  I>.  After  this  the  cylinder  is  to  be  slightly  turned,  first  t" 
one  side  and  then  to  the  other,  the  patient  being  required  to  indicate  when 
the  turning  makes  his  vision  worse.  This  i>  repeated  until  it  is  pretty  cer- 
tain just  what  direction  of  the  cylinder-axis  gives  the  best  vision.  Then 
weak  convex  and  concave  spherical  lenses  arc  to  he  tried  in  front  of  the 
combined  spherical  and  cylindrical  lenses,  to  see  if  either  will  .-till  further 
improve  the  vision, and  these  are  followed  with  the  astigmatic  lens  and  a  new- 
trial  of  the  direction  for  the  axis.  This  routine  is  to  he  repeated  until  any 
change  in  any  factor  of  the  combination  impairs  the  acuteness  of  vision. 

The  combination  thus  arrived  at  is  the  correcting  lens  of  the  eve  for  the 
distance  at  which  the  test  is  made.  It'  this  distance  he  4  or  (5  m.,  0.25  or 
0.17  I),  must  he  subtracted  from  the  convex  or  added  to  the  concave  spherical 
lens  to  make  it  the  perfect  correction  for  truly  parallel  rays  from  more  dis- 
tant objects.     The  same  process  is  repeated  for  the  second  eye. 

When  the  power  of  accommodation  is  present,  the  aim  must  he  to  find  the 
strongest  convex  or  the  weakest  concave  spherical  lens  that  gives  the  besl 
vision.  Cylindrical  lenses  will  be  tried  as  above,  preferably  before  attempt- 
ing the  final  determination  with  the  spherical  lens.  The  determination  of 
the  spherical  lens  is  best  effected  by  testing  both  eyes  at  once  and  beginning 
with  convex  lenses  that  are  too  strong  or  concave  lenses  that  are  too  weak 
to  permit  of  the  best  vision.  Then,  if  convex,  before  removing  such  glasses 
the  next  weaker  lenses  should  be  placed  before  the  eyes.  In  this  way  what- 
ever relaxation  of  accommodation  has  been  secured  under  the  first  lenses  is 
preserved.  If  vision  is  yet  not  perfect,  a  still  weaker  lens  is  substituted  in 
the  same  way,  and  so  on  until  the  best  vision  of  which  both  eyes  are  capable 
is  obtained. 

The  eyes  are  then  to  be  tested  separately  by  covering  each  of  them  alter- 
nately. If  it  is  found  that  only  one  eye  has  attained  to  its  best  vision,  the 
lens  before  the  other  eye  is  to  be  still  further  weakened  until  it,  too,  has 
obtained  its  best  vision.  The  lenses  thus  chosen  will  be  found  to  correct  the 
total  hyperopia  in  the  majority  of  even  young  persons. 

In  myopia  the  spherical  lenses  are  to  be  made  successively  stronger,  and 
when  the  best  vision  is  obtained  the  eyes  are  to  be  toted  separately  by  alter- 
nate covering. 

MYDRIATICS. 

The  drugs  atropin,  duboisin,  hyoscyamin,  hyoscin,  daturin,  ami  scopol- 
amin,  alkaloid-  obtained  from  members  of  the  Solanacese,  and  bomatro- 
pin.  a  derivative  of  atropin,  constitute  the  true  mydriatic-.  Applied  to  the 
eye.  they  produce  dilatation  of  the  pupil  and  paralysis  of  the  accommoda- 
tion, which  after  a  time,  varying  with  the  drug  and  the  amount  of  it  em- 
ployed, entirely  pa—  es  away.  In  some  cases  the  dilatation  of  the  pupil  is  of 
use  in  the  determination  of  refraction,  since  it  render-  easier  the  use  of  the 
ophthalmoscope,  skiascopy,  and  the  test-lenses.  But  the  chief  value  of  these 
drug-  in  this  connection  lies  in  their  action  as  cycloplegics.  By  paralyzing 
the  ciliary  muscle  they  eliminate  the  influence  of  accommodation. 

In  healthy  eye-  a  -ingle  drop  of  !  of  the  following  solutions  is  usu- 
ally sufficient  to  accomplish  this:  atropin,  1  :  100,  duboisin,  hyoscyamin,  or 
scopolamin,  1  :  250.  Of  homatropin  hydrobromate  a  single  drop  of  even  a 
saturated  solution  will  not  paralyze  the  accommodation.  It  musl  I"  used  by 
repeated  instillations  of  a  2  to  I  per  cent*  solution  at  shoii  intervals.  An) 
of  the  other  drugs  will  prove  effective  in  weaker  solutions  if  the  instillal 
1 1 


210         DETERMINING   THE  REFRACTION  OF  THE  EYE. 

are  repeated.  In  practice  it  is  customary  to  prescribe  either  atropin,  dubois- 
in,  or  hyoscyamin  in  solutions  of  the  strength  named,  to  be  instilled  at  the 
patient's  home  three  times  a  day  for  one  or  more  days.  The  repeated  instil- 
lations are  necessary  to  guard  against  their  possibly  imperfect  character. 

Homatropin  should  be  instilled  by  the  surgeon  or  a  trained  assistant,  and 
the  instillations  repeated  every  five  or  ten  minutes  until  from  four  to  six  have 
been  made  ;  and  after  its  use  the  determination  of  the  refraction  should  be 
completed  within  one  or  two  hours,  as  it  often  begins  to  lose  its  control  of 
the  ciliary   muscle  soon  after  that  time. 

In  the  choice  of  the  mydriatic  homatropin  has  the  advantage  of  greater 
brevity  of  action.  The  accommodation  completely  recovers  from  its  effect, 
usually  within  forty-eight  hours,  while  after  atropin  two  or  three  weeks  are 
required  before  it  is  quite  recovered,  and  after  the  use  of  the  other  drugs 
named  from  one  to  two  weeks  must  elapse.  Scopolamin,  1  :  500,  is  an  effi- 
cient mydriatic,  u^ed  by  making  two  instillations  one  hour  apart.  Accommo- 
dation will  completely  return  in  six  days.  Even  weaker  solutions  may  be 
efficacious. 

In  using  these  drugs  certain  alarming  intoxicating  effects  must  be  borne 
in  mind.  While  in  the  amount  mentioned  most  people  do  not  experience 
these,  in  exceptional  cases  a  single  drop  of  one  of  the  solutions  mentioned, 
except  of  homatropin,  may  cause  severe  symptoms  of  intoxication.  These 
are— dryness  and  redness  of  the  throat  and  skin,  with  delirium  and  inco- 
ordination of  movement,  especially  inability  to  walk.  The  patient  is  not 
usually  much  disturbed,  but  his  friends  may  be  greatly  alarmed,  although 
from  any  such  dose  these  symptoms  are  quite  unattended  by  danger.  On 
their  appearance  the  use  of  the  drug  must  be  suspended,  the  patient  kept 
quiet,  given  water  freely,  and,  if  decidedly  delirious,  small  doses  of  an 
opiate. 

Homatropin  is  much  the  least  likely  to  produce  such  symptoms,  and 
duboisin,  hyoscyamin,  and  scopolamin  (which  may  be  but  different  names 
for  the  same  drug)  are  the  most  likely  to  produce  them.  In  the  eyes  of  a 
few  persons  these  mydriatics  produce  marked  conjunctival  irritation  or  in- 
flammation, and  the  homatropin  solutions  mentioned  always  produce  a  tem- 
porary hyperemia  of  the  conjunctival  and  pericorneal  vessels  during  the 
period  of  absorption. 

Cocain,  a  drug  of  an  entirely  different  class,  possessing  little  or  no  power 
to  paralyze  the  ciliary  muscle,  may  be  useful  to  dilate  the  pupil  in  persons 
over  fifty  years  of  age  whose  pupils  are  small  and  whose  power  of  accommo- 
dation i-  not  sufficient  to  interfere  with  tests  for  refraction.  A  single  instilla- 
lion  of  a  2  pel-  cent,  solution  is  followed  after  thirty  minutes  or  an  hour  by 
decided  enlargement  of  the  pupil,  yet  with  very  little  inconvenience  and  no 
danger. 

All  drugs  which  cause  dilatation  of  the  pupil,  except  cocain,  are  danger- 
ous in  ey<-  presenting  the  essential  changes  of  glaucoma,  since  they  may  pro- 
duce a  glaucomatous  outbreak,     lint  if  such  a  revelation  of  the  presence  of 

glaucoma  IS  promptly  met  by  the  proper  treatment,  it  can  hardly  be  regarded 

a-  unfortunate  for  the  patient.     No  eye  in  which  this  accident  can  occur  is 

likely  long  to  escape  glaucoma,  and  without  the  mydriatic  the  advent  of  this 
disease  mighl  lie  so  insidious  as  to  escape  detection   until  irreparable  damage 

had   been   done. 

Whether  mydriatics  should  be  used  in  the  great  mass  of  refraction  cases 
is  a  debated  question.     That  with  their  use  the  determination  of  refraction 

can    be     more    certainly   exact     cannot     be    doubted.      The    question    is    as    to 


(1ENERAL    PLAN   OF  EXAMINATION. 


211 


whether  the  increased  certainty  and  accuracy  are  worth  the  discomfort  and 
loss  of  time  from  ordinary  occupations  that  the  mydriatic  causes.  In  deciding 
this  question  the  desires  of  the  patient  and  the  appreciation  of  exactness  in 
his  work  on  the  part  of  the  surgeon  will  be  the  determining  factors. 

Table  of  the  DiJ'cmit  Mydriatics. 


u  w  qi 

fsolu- 
monly 

which 
utions 
a  no- 
effect. 

be 

ins   to 
e. 

a 

o 

Name  of  druj;  and  salt  com- 

3-p S 

°e 

-cgu 

"32 

s?.s 

jU 

monly  used. 

>o'3j, 

■C  o 

3  cc  ^-~" 
«       3  XI 

XI  TJ  * 

:-7. 

elat 

in  ■ 
con 

<d.2  2 

L.S  3 

[me 
sue 
pro 

tice 

0 

a 

« 

GO 

H 

m 

w 

OS 

A  tropin  sulphate   .... 

30 

1:120 

12  min. 

1  hour. 

4  davs. 

L5  (lavs. 

Daturin  sulphate   .... 

60 

1:200 

10      " 

40  min. 

3     " 

10    " 

Hyoscyamin  sulphate  .    . 

75 

1:240 

10     " 

40     " 

2     " 

8    " 

Duboisin  sulphate  .... 

75 

1:240 

10      " 

40    " 

2     " 

8     " 

Scopolaniin   hydrochlorate. 

75 

1:1000 

15     " 

1  hour. 

12  hours. 

6    " 

Homatropin  hydrobromate. 

1 

1:40 

15     " 

1     " 

3     " 

2    " 

Cocain    hydrochlorate    .    . 

(  Not  com- ) 
I  parable.  1 

1  :  125 

30     " 

1    " 

2     " 

12  hours. 

With  cocain  the  anesthetic  effect  passes  off  before  dilatation  of  the  pupil 
is  fairly  commenced.  The  new  local  anesthetic,  eucain,  is  usually  regarded 
as  having  no  mydriatic  effect,  but  Wagenmann  states  that,  by  a  strong  solu- 
tion repeatedly  applied,  some  dilatation  of  the  pupil  may  be  produced. 

GENERAL  PLAN  OF  EXAMINATION. 

The  acuteness  of  vision  for  each  eye  separately,  and  the  near  point  of 
distinct  vision,  should  be  first  ascertained.  If  vision  be  imperfect,  the  pin- 
hole disk  may  be  tried  to  see  if  such  imperfection  is  due  to  ametropia  or  to 
other  causes.  Then  the  eye  should  be  examined  with  the  ophthalmoscope  by 
the  direct  method.  This  gives  a  rough  approximation  of  the  refraction. 
especially  as  regards  hyperopia  or  myopia.  After  this  skiascopy  may  be 
used  or  a  mydriatic  employed.  Then  the  corneal  astigmatism  may  be 
measured  with  the  ophthalmometer. 

When  the  mydriatic  has  produced  its  full  effect,  the  refraction  is  to  be 
carefully  measured  by  skiascopy,  and  then  to  be  tested  by  the  trial-lenses, 
commencing  with  the  glass  fixed  upon  by  the  shadow -test.  The  value  of  the 
results  obtained  by  the  subjective  method  depends  largely  on  the  patient  not 
being  wearied   by  prolonged  testing. 

After  the  correcting  lenses  have  been  thus  ascertained,  the  eye  should  be 
allowed  to  recover  from  the  mydriatic  and  the  trial  with  lenses  repeated. 
Such  a  routine,  carefully  followed  by  one  of  fair  skill,  cannot  fail  to  give 
accurate  and   reliable   results. 


NORMAL   AND   ABNORMAL    REFRACTION: 

EMMETROPIA,   AMETROPIA,   HYPEROPIA,   MYOPIA,  ASTIG- 
MATISM,   PRESBYOPIA. 

r.v    EDWARD  JACKSON,  A.M.,  M.D., 

OF    PHIL  WKI.rill  \. 


Distinct  vision,  by  which  the  existence  and  position  of  different  objects 
are  recognized,  as  contrasted  with  mere  perception  of  light,  depends  on  the 
assorting  or  focussing  of  the  light  that  falls  on  the  retina.  Imperfect  focus- 
sing of  this  light  causes  imperfect  vision.  To  avoid  this  the  accommodation 
may  be  strongly  exerted,  contraction  of  the  pupil  secured  by  a  bright  light, 
or  the  space  between  the  lids  narrowed.  But  efforts  of  this  kind  to  improve 
vision,  if  frequently  or  constantly  resorted  to,  are  liable  to  exhaust  the  en- 
durance of  the  nervous  system  or  disturb  the  nutrition  of  the  eyeball  and  its 
appendages. 

Errors  of  refraction  lead  either  to  imperfect  vision  or  to  eye-strain. 
They  may  lead  to  both,  but  generally,  in  so  far  as  the  vision  is  imperfect, 
there  has  not  been  eye-strain,  and  in  so  far  as  there  has  been  eye-strain  the 
imperfection  of  vision  has  been  partly  overcome.  If  the  defect  be  great,  the 
part  of  it  overcome  may  cause  eye-strain,  while  beyond  this  some  remains  to 
render  the  vision  still  imperfect. 

Normal  and  Abnormal  Refraction :  Emmetropia  and  Ame- 
tropia.—  Refraction  may  be  regarded  as  normal  when  it  gives,  under  the 
requirements  to  which  the  eyes  are  subjected, distinct  vision  without  injurious 
effort.  It  is,  for  practical  purposes,  abnormal  when  distinct  vision  is  pre- 
vented by  imperfect  focussing  of  light  on  the  retina  or  is  obtained  only  by 
excessive  effort — by  eye-strain. 

In  emmetropia  light  from  distanl  objects  (parallel  rays)  is  accurately 
focussed  on  the  retina  without  accommodative  effort.  Any  departure  from 
this  optical  condition  of  the  eye  constitutes  ametropia.  Emmetropia  is  the 
ideal  state  of  refraction.  In  it  not  only  are  rays  from  distant  objects  per- 
fectly focussed  without  effort,  but  ray-  from  near  objects  are  focussed  upon 
the  retina  with  the  minimum  exertion  of  accommodation  ;  not  only  are  distant 
object-  seen  distinctly,  but  the  full  extent  of  the  accommodation  is  available 
for  the  distinct  seeing  of  near  object-.  It  is  true  that  the  myopic  eye  may  be 
able  to  see  object-  -till  nearer  to  the  eye,  but  the  gain  of  a  very  few  inches  or 
a  fraction  of  an  inch  of  distinct  near  vision  is  more  than  balanced  by  the 
loss  of  distinct  vision  for  everything  beyond  a  certain  very  limited  distance; 
and  the  gain  in  lessened  accommodation  required  for  near  object-  is  more 
than  balanced  bv  loss  through  the  increased  need  for  convergence.  Careful 
examination  of  large  numbers  of  eyes,  particularly  among  school-children, 
-how -  that  the  actual  experience  of  life  full}  supports  the  theoretical  advantage 
of  emmetropia. 

The  3ame  observations  -how  th:it  exact  emmetropia  is  comparatively  rare. 

212 


EYE-STRAIN.  213 

The  writer  among   1000  eyes  found  the  following  proportions  of  ametropia 
of  different   kinds,  and  of  emmetropia  : 

Frequency  of  Ametropia. 

Compound  hyperopic  astigmatism 1610  eves,  or  40.2  per  cent. 

Byperopia   .' 1225   '  '  30.6  " 

Compound  myopic  astigmatism 3* » 1     "            9.  " 

Mixed  astigmatism 207     "            6.7  " 

Simple  hyperopic  astigmatism 249     "            6.2  " 

My,, pin    ' 158     "             •"). 

Simple  myopic  astigmatism     ,'.'••            •_'.  " 

Emmetropia 51     "            1.3  " 

It  may  be  asked,  If  emmetropia  is  the  ideal  state  of  refraction,  why  is  it 
SO  rarely  found'.'  The  answer  is  that  the  shape  of  the  eye  results  from  pro- 
cesses of  growth  resisting1  intraocular  pressure,  and  cannot  he  a  rigid,  definite, 
mathematical  form.  The  ideal  form  for  any  part  of  the  body,  and  the  ideal 
of  proportion  between  different  parts,  are  never  found  in  life.  The  deviations 
of  the  eye  are  insignificant  compared  with  the  deviations  of  the  other  organs, 
but  sufficient  to  cause  errors  of  refraction  of  practical  importance  in  a  very  large 
proportion  of  eyes.  The  study  above  referred  to  indicates  that  the  largest 
number  of  eyes  have  low  hyperopia  ;  <)2  per  cent,  show  hyperopia  of  1.5  I). 
or  less,  including  hyperopic  astigmatism.  The  eye  has  been  evolved  to  meel 
the  requirements  of  life  among  the  lower  animals  and  savages,  for  whom 
myopia,  even  of  low  degree,  would  be  a  very  dangerous  defect.  Deviation 
of  the  eye  in  that  direction  caused  the  extinction  of  individuals  and  families. 
The  requirements  of  modern  civilized  life,  however,  rapidly  extend  in  the 
direction  of  near  eye-work,  so  that  hyperopia  becomes  a  serious  defect.  Even 
the  emmetropic  eye  may  be  unable  to  meet  the  requirements  of  close  work  ; 
and  as  the  power  of  accommodation  diminishes  with  age,  it  loses  the  power 
of  distinct  vision  at  short  distances,  requiring  optical  assistance  in  all  ca-e- 
(presbyopia). 

Hye-strain. — The  symptoms  arising  from  excessive  efforts  to  prevent 
indistinctness  of  vision  may  be  considered  under  this  head.  They  arc  largely 
the  same  in  different  forms  of  ametropia,  and  may  also  arise  from  excessive 
eye-work,  insufficient  light,  or  other  unfavorable  conditions,  even  though  the 
eyes  be  emmetropic.  Eye-strain  is  caused  by  excessive  use  of  the  accommo- 
dation, from  too  long  hours  of  close  work,  or  by  looking  at  small  objects 
brought  too  near  the  eye;  or  because  of  deficient  vision,  or  in  making  good 
the  defect  of  hyperopic  eyes  ;  or  by  ordinary  near  work  after  the  accommoda- 
tion has  diminished  with  age  (  presbyopia).  It  may  also  arise  from  excessive 
efforts  to  keep  the  eyes  properly  directed,  as  of  convergence  where  objects 
have  to  be  brought  too  close  on  account  of  uncorrected  myopia,  or  from  the 
effort  of  accurately  co-ordinating  muscular  movements,  as  those  of  accommo- 
dation and  convergence.  It  may  come  by  exhaustion  of  the  visual  centers 
in  the  effort  to  appreciate  blurred  and  imperfect  retinal  images,  or  it  may  lie 
due  to  the  use  of  eye-  otherwise  normal  at  a  time  when  the  general  nutrition 
is  impaired  by  wasting  disease  or  exhaustion  by  effort  in  other  directions. 

Eye-strain  may  be  manifested  by  failure  of  near  vision  after  use  of  the 
eye-  {relaxed,  accommodation)  or  by  temporary  blurring  of  distant  vision 
{spasm  of  accommodation) ;  by  changes  in  the  retina-  swelling  and  opacity, 
with  dilatation  of  the  retinal  vessels  and  exaggerated  reflexes j  by  change-  in 
the  optic  nerv< — redness,  haziness,  or  opacity  or  swelling  of  the  nerve-head  ; 
l>y  changes  in  the  choroid,  including  increased  redness,  or  alteration  of  color 
by  edema  or  atrophy  ;  and,  secondary  to  the  changes  in  the  choroid,  by  opaci- 


214  NORMAL   AND   ABNORMAL   REFRACTION. 

ties  in  the  vitreous  and  the  crystalline  lens,  and  softening  of  the  sclera  with 
local  bulging  |  posterior  staphyloma). 

The  progressive  changes  in  refraction,  to  be  discussed  under  Myopia,  arc 
also  symptoms  of  eye-strain.  Acute  or  chronic  conjunctivitis  may  arise  from 
the  same  cause.  This  may  amount  to  a  slight  exaggeration  of  the  irritation 
fell  when  the  eyes  are  tired,  or  it  may  develop  into  a  chronic  catarrhal  con- 
junctivitis, practically  incurable  even  by  removal  of  the  original  cause. 
When  the  conjunctivitis  is  severe,  corneal  disease  may  be  associated  with  it, 
and  if  chronic  it  is  apt  to  be  attended  with  changes  in  the  lids,  marginal 
blepharitis,  styes,  etc.  Eczema  of  the  lids  and  neighboring  parts  has  also 
been  ascribed  to  eye-strain  and  relieved  by  wearing  glasses. 

The  symptoms  manifested  outside  of  the  eye  and  its  appendages  are — 

Headache. — This  i-  often  spoken  of  a-  reflex,  hut  is  better  regarded  as 
due  to  aerve-exhaustion.  It  is  commonly  frontal,  in  some  cases  extending  to 
the  occipul  or  throughout  the  whole  head.  Sometimes  it  is  strictly  limited 
to  one  sid( — hemicrania.  It  may  he  directly  associated  with  the  use  of  the 
eyes,  or  be  apparently  constant,  or  may  occur  at  certain  times,  apparently  not 
determined  by  any  particular  eye-work,  and  yet  in  the  latter  case  may  be  as 
completely  cured  by  the  careful  relief  of  eve-strain  as  when  more  evidently 
connected  with  eye-work.  The  headache  of  eye-strain  is  not  mi  generis.  It 
has  the  same  characters  a-  headache  arising  from  entirely  different  causes. 
In  many  instances  it  is  (tartly  due  to  eye-strain  and  partly  to  the  other 
causes.  If  the  other  causes  can  be  discovered  and  removed,  it  may  he  cured 
without  the  wearing  of  glasses  or  any  reduction  in  eye-work.  More  fre- 
quently  it  is  cured  by  the  correction  of  ametropia  or  faulty  habits  of  using 
the  eyes.  Sometimes,  when  removal  of  one  factor  has  given  temporary  relief, 
hut  the  headache  return-,  the  discovery  and  removal  of  the  other  factor  may 
be  necessary  to  make  the  relief  permanent. 

Neuralgic  pains  in  other  portions  of  the  body  or  attacks  of  migraine  may 
arise  from  eve-strain.  Anorexia,  nausea,  vomiting,  palpitation  of  the  heart, 
and  similar  disturbances  may  he  due  to  eye— train.  Nervousness,  which  the 
patient  -peak-  of  as  an  intolerable  desire  to  cry  out  or  do  some  violent  act, 
Liability  to  keep  quiet  after  prolonged  eye-work,  peevishness  and  irritability 
of  temper,  are  among  its  manifestations.  For  the  rarer  forms  of  disturbance 
the  therapeutic  test  by  relief  from  the  -train  will  be  necessary  to  establish  the 
diagnosis.  Eye-strain  may  cause  certain  motor  disturbances,  as  twitching  of 
the  lids,  tonic  blepharospasm,  and  in  rare  cases  choreiform  movements  or 
epileptiform  seizures,  or  it  may  We  the  most  substantial  cause  of  hysterical 
manifestations.  With  these,  as  with  headache,  eye-strain  is  usually  but  one 
of  two  or  more  factors. 

Hyperopia. — Hyperopia,  Hypermetropia,  or  Far-sightednesSf  is  the  error 


/ 

I  [g   i  &    The  course  ■  i  raya  in  a  hyperopic  eye. 


of  refraction  which  arises  when  /A*  retina  is  situated  in  front  oj  the  principal 
focus  of  tTu    dioptric  surfaces. 

Fig.  158  represents  a  hyperopic  eye  able  to  focus  parallel  rays  at  /  behind 


HYPEROPIA.  215 

the  retina  and  /  the  lens  which,  turning  the  rays  toward  r,  the  virtual  "far 
point"  of  the  eye,  causes  them  to  !>e  focussed  on  the  retina  and  corrects  the 
hyperopia. 

The  hyperopic  eye  is  adjusted  for  convergent  rays,  and  these  are  not 
encountered  in  nature.  Without  accommodation  it  sees  indistinctly  at  all 
distances.  By  the  exertion  of  accommodation  it  sees  clearly,  hut  only  by  the 
exertion  of  accommodation  exceeding  (by  the  amount  of  its  hyperopia)  that 
required  of  the  emmetropic  eye;  and,  having  to  use  some  accommodation 
constantly,  it  is  deprived  of  the  periods  of  rest  which  come  to  the  emmetropic 
eye  when  tixed  on  distant  objects.  The  greater  amount  of  accommodation 
required  of  it  causes  the  hyperopic  eye  to  sutler  earlier  from  the  diminution 
of  accommodation  by  age,  and  afterward  the  further  loss  of  accommodation 
deprives  it  of  distinct  distant  vision.  We  have  from  hyperopia  Liability  to 
eye-strain  and  indistinctness  of  vision,  either  of  which  may  become  an  indica- 
tion for  correction  of  the  defect  by  convex  lenses. 

Causes,  Varieties,  and  Course. — Hyperopia  is  due  in  the  majority  of 
cases  to  antero-posterior  shortening  of  the  eyeball,  axial  hyperopia.  This  is 
caused  not  so  often  by  a  flattening  of  the  globe  as  by  a  diminution  in  all  its 
diameters.  The  other  causes  for  it  are — flattening  of  the  curvature  of  the 
cornea  or  crystalline  lens,  hyperopia  of  curvature,  and  removal  of  the  crys- 
talline lens  (accidental  or  operative),  or  its  congenital  absence  or  dislocation 
— aphakial  hyperopia.  It  is  possible  to  conceive  also  of  hyperopia  due  to 
a  low  index  of  refraction  of  the  crystalline  lens — index-hyperopia. 

At  birth  nearly  all  eyes  are  hyperopic.  It  is  possible  that  during  the  first 
years  of  life  there  is  some  general  tendency  for  hyperopia  to  diminish,  although 
this  is  not  proven  (see  p.  178).  On  the  other  hand,  from  early  adult  life  to  old 
age  there  is  a  general  tendency  for  hyperopia  to  slowly  increase,  due  to  the 
gradual  increase  in  size  of  the  crystalline  lens.  As  Priestley  Smith  has  shown, 
the  lens,  like  other  structures  of  epithelial  origin,  continues  to  increase  so  long 
as  it  continues  healthy,  increasing  one-third  in  bulk  between  twenty-five  and 
sixty-five  years  of  age.  Increase  in  the  size  of  the  lens,  supposing  it  to  keep 
the  same  shape,  causes  an  equal  increase  in  its  focal  distance  and  a  correspond- 
ing increase  of  hyperopia.  This  is  independent  of  the  apparent  Increase  due 
to  the  failure  of  accommodation,  and  continues  after  all  power  of  accommoda- 
tion has  been  lost. 

The  varieties  of  hyperopia  recognized  in  practical  work  arc  based  on  the 
relations  of  hyperopia  to  the  accommodation.  They  can  lie  best  illustrated 
by  an  example:  Suppose  a  case  of  hyperopia  of  1<>  I>.  in  which  the  total 
accommodation  is  only  <S  I).  When  the  full  power  of  accommodation  is 
exerted,  there  remains  2  D.  of  uncorrected  hyperopia.  This,  a  part  of  the 
hyperopia  which  no  effort  of  the  accommodation  can  correct,  i-  called  the 
absolute  hyperopia.  It  often  happens  where  there  i-  considerable  hyperopia 
and  good  accommodation  that  the  accommodation  is  not  fully  relaxed  at  any 
time  when  the  eyes  are  \\<v<\,  even  for  distant  vision.  If  this  part  of  the 
accommodation  amounts  to  2  I).,  then  so  much  hyperopia  is  always  corrected 
when  the  eyes  are  in  use;  it  i-  called  latent  hyperopia.  Besides  the  2  D.of 
accommodation  that  cannot  be  relaxed,  there  remains  6  I  >.  of  accommodation 
which  can  lie  relaxed  or  exerted,  and  which,  therefore,  can  lie  used  t"  COrrecl 
an  equal  amount  of  hyperopia,  but  which  hyperopia  can  be  left  uncorrected  at 
will.  This  part  of  the  hyperopia  which  can  be  corrected  or  not  by  the  accom- 
modation is  called  facultative  hyperopia.  The  absolute  hyperopia  and  the 
facultative,  added  together,  give  the  manifest  hyperopia.  The  mai 
hyperopia,  with  the  latent  hyperopia,  together  constitute  the  total  hyperopia. 


216 


NORMAL   AND  ABNORMAL   REFRACTION 


The  relations  of  these  different  varieties  or  parts  of  the  hyperopia  may  be 
better  understood  bv  the  following  diagram : 


Total  accommodation. 
Involuntary    V  Voluntary  A. 


Latenl  II. 


Facultative  II. 


Absolute  1  [. 


Manifest  1 1. 


Total  hyperopia. 


The  subject  may  be  -till  further  illustrated  by  considering  whal  happens 
when  successive  convex  lenses  are  placed  before  an  eye  with  ;i  hyperopia 
of  I"  D.,  and  a  total  accommodation  <>f  8  I  >.  Without  any  lens  the  vision 
of  -ucli  an  eve  is  imperfect.  A  weak  convex  lens  improves  it,  and  the  im- 
provement continues  as  the  strength  of  the  lens  is  increased  up  to  '1  I)., 
which  correct-  the  absolute  hyperopia,  and.  with  all  the  power  of  accommo- 
dation added  to  it,  focusses  parallel  rays  on  the  retina,  giving  good  distant 
vision.  A-  the  convex  lens  is  made  stronger  the  vision  i>  not  further  im- 
proved, hut  the  best  vision  is  obtained  with  less  exertion  of  accommodation. 
Thus,  with  a  1  I >.  lens  it  is  necessary  to  exert  only  !i  D.  of  accommodation, 
and  with  a  7  I ).  lens  only  •'>  I  >.  of  accommodation.  'Phis  continues  until  all 
the  manifest  hyperopia  i-  corrected  by  an  8  D.  lens,  the  vision  remaining 
clear  with  only  2  1 ).  of  accommodation.  If,  however,  a  still  stronger  lens  is 
placed  before  the  eye,  the  accommodation  being  able  to  relax  no  farther,  the 
2  I),  of  aeco odation,  plus  the  leu-,  gives  an  over-correction,  blurring  dis- 
tant vision.  The  portion  of  the  accommodation  which  cannot  be  relaxed  has 
been  indicated  in  the  above  diagram  as  involuntary,  and  the  part  that  can  be 
relaxed  or  exerted  at  will  is  voluntary  accommodation.  By  the  use  of  a 
mydriatic  the  total  accommodation,  both  voluntary  and  involuntary,  is  relaxed 
and  the  total  hyperopia  revealed. 

A-bsolute  hyperopia  only  occurs  after  the  power  of  accommodation  for 
objects  at  a  distance  from  the  eye  has  fallen  below  the  amount  of  hyperopia. 
In  early  life  it  i-  only  seen  in  hyperopia  of  the  highest  degree.  After  middle 
age,  the  power  of  accommodation  being  lost,  it  appears  in  all  hyperopic  eves, 
and  when  the  accommodation  is  entirely  gone  all  hyperopia  is  absolute. 
Latent  hyperopia  may  not  he  present.  Many  persons  with  strong  accommo- 
dation are  able  to  relax  it  entirely  when  looking  at  distant  objects  through 
convex  lenses.  In  other  eyes  it  i-  constantly  present,  and  in  still  others  is 
presenl  only  part  of  the  time.  The  inability  to  relax  the  accommodation  is 
often  spoken  of  as  spasm  oj  accommodation.  Such  spasm  is  most  likely  to 
or.  ai  i'  w  hen  the  eye-  a  re  irritated  or  fatigued.  The  facultative  hyperopia,  lying 
between  the  latent  and  the  absolute,  varies  with  these,  decreasing  as  either  of 
them  increases, and  on  the  whole  tending  to  diminish  with  age  along  with  the 
diminishing  accommodation.  In  measuring  refraction  without  a  mydriatic 
the  important  point  is  to  get  as  much  of  the  hyperopia  manifest  as  possible, 
and    to   do   this    the    two   eye-    must    be    tested    toe-ether,   as    recommended   on 

page  209. 

Willi  reference  to  these  dill'eivnt  varietio  it  i-  essentia]  always  to  hear  in 
mind  ihat  their  relations  to  each  other  are  not  fixed — thai  there  is  no  constant 
ratio  between  the  manifest  and  the  latent  hyperopia  at  any  particular  age  or 
for  the  individual.  The  proportion-  may  vary  from  day  to  day,  <>r  even  from 
minute  to  minute. 

Symptoms. — Since  hyperopia  may  be  corrected  by  accommodation,  only 
the  highest  degrees  give  rise  to  symptoms  in  early  childhood.  The  earliest 
symptom  is  convergent  squint,  arising  with  the  effort  of  accommodation.     This 


HYPEROPIA.  Ill 

effort  being  great,  the  nervous  impulse  overflows,  causing  additional  muscular 
contraction-  in  muscles  closely  associated  with  that  of  accommodation,  and 
especially  excessive  contraction  of  the  internal  recti  muscles.  Convergenl 
squint  of  this  kind  is  apt  to  begin  before  six  years  of  age,  and  is  mosl 
commonly  associated  with  hyperopia  of  high,  but  not  the  highest,  degree. 
Squint  occurs  where  the  hyperopia  can  be  corrected  by  greal  exertion  of  the 
accommodation.  When  this  is  too  difficult  imperfect  vision  is  accepted.  Such 
imperfect  vision  may  be  noticed  by  a  careful  observer  in  early  childhood,  but 
commonly  is  not  detected  until  the  child  begins  to  read.  It  is  then  found  that 
to  increase  the  size  of  the  imperfect  retinal  images  the  book  is  held  very 
close  to  the  eyes,  as  in  myopia.  This  practice  in  early  childhood  quite  as 
frequently  indicates  high  hyperopia. 

ruder  the  influence  of  school-work  lower  grades  of  the  delect  begin  to 
cause  eye-strain.  This  often  shows  itself  in  local  congestion  and  inflammation 
of  the  conjunctiva  and  lids,  conjunctivitis,  styes,  photophobia,  and  frequent 
winking  on  account  of  the  conjunctival  irritation.  In  later  childhood  begins 
the  liability  to  headache  ;  young  children  rarely  complain  of  ocular  headache. 
During  school-life  even  the  lower  grades  of  hyperopia  are  liable  to  cause  eye- 
strain, but  afterward,  most  eyes  being  used  to  better  advantage  and  not  being 
so  severely  taxed,  the  low  degrees  of  defect  are  less  likely  to  cause  trouble, 
although  headaches  established  during  childhood  may  be  continued,  and 
periods  of  poor  health   may  cause  the  development  of  eye-strain. 

As  the  time  approaches  when  even  emmetropic  eyes  sutler  from  presbyopia, 
hyperopic  eyes  manifest  the  same  symptoms  earlier,  in  proportion  to  the  degree 
of  hyperopia.  These  symptoms  are — failure  of  the  vision  for  near-work, 
particularly  in  the  latter  part  of  the  day  or  when  tired  or  working  by  poor 
light  :  print  has  to  be  held  farther  from  the  eyes  in  order  to  be  read,  and 
conjunctival  irritation  and  inflammation  again  occur,  often  in  repeated  acute 
attacks  that  are  ascribed  to  "cold."  Still  later,  as  the  power  of  accommo- 
dation falls  so  low  that  it  can  no  longer  correct  the  hyperopia,  indistinctness 
of  vision  is  developed. 

Treatment. — While  any  departure  of  the  refraction  of  the  eye  from  the 
emmetropic  standard  constitutes  an  error  or  an  anomaly  of  refraction,  it-  is 
only  when  under  the  conditions  of  work  imposed  upon  the  eye  such  an  error 
or  anomaly  causes  interference  with  vision  or  strain,  that  the  refraction  is  to 
be  considered  abnormal.  Treatment,  therefore,  is  not  indicated  by  the  mere 
existence  of  hyperopia,  but  by  the  fact  that  the  hyperopia  has  caused  symp- 
toms, or  is  likely  to  cause  them,  under  conditions  of  work  to  which  the  eyes 
are  about  to  be  subjected.  Many  hyperopic  eyes,  therefore,  do  not  require 
the  aid  of  correcting  lenses,  but  when  symptoms  arise  that  may  with  prob- 
ability be  ascribed  in  part  to  this  error  of  refraction  the  correcting  lenses 
should    be   used. 

How  they  are  to  be  determined  lias  been  sufficiently  indicated  in  the  pre- 
ceding section  (page  IDS).  The  general  rule  should  be  to  give  the  full 
correction — that  is,  the  lens  which  makes  the  hyperopic  eye  similar  to  the 
emmetropic  eye,  enabling  it  to  focus  parallel  rays  on  the  retina  without  any 
exertion  of  accommodation,  and  to  focus  divergent  rays  with  the  least  effort 
of  accommodation.  To  this  general  ride  certain  objections  are  offered  which 
inn-t  he  carefully  considered,  and  certain  exception-  W  llich  must  he  recognized. 

It  i-  urged  that  if  some  eyes  continue  normal  with  uncorrected  hyperopia, 
other-   may  continue   normal  with   their  hyperopia   but    partly  corrected,  and 

that   the    ride    should    lie   to    give  the   weake-t    glass  thai    will   allow    the    USC    of 

the  eye-  with  comfort.     But   it   is  impossible,  except   by  trial,  to  know  that 


218  NORMAL   AND   ABNORMAL    BEFRACTLON. 

any  incomplete  correction  will  be  sufficient  in  the  particular  case.  The  full 
correction  promises  the  greatest  degree  <>r  the  greatest  probability  of  relief 
after  the  eye  has  once  become  accustomed  to  it.  The  inconvenience  <>f  wear- 
ing glasses  is  the  same  with  a  partial  as  with  a  full  correction  ;  therefore,  if 
the  patient  must  wear  glasses  at  all,  he  oughl  to  have  from  them  the  greatest 
benefit  or  the  greatest  certainty  of  benefit  obtainable. 

The  second  objection  to  divine  the  full  correcting  lens  is  that  if  a  portion 
of  the  hyperopia  is  latent — and  it  is  often  incorrectly  assumed  that  this  is  so 
in  nearly  all  cases — the  wearing  of  the  lull  correction  renders  distant  vision 
indistinct.  If  the  latent  part  of  the  hyperopia  were  a  fixed  amount,  this 
objection  would  have  more  practical  weight.  As  it  is,  one  cannot  correct  the 
manifest  hyperopia  of  to-day  and  be  sure  that  the  same  lens  will  not  over- 
correct  it  to-morrow.  As  long  as  latent  hyperopia  is  allowed  it  will  vary, 
and.  at  certain  times,  lead  to  blurring  of  distant  vision  unless  a  very  wide 
margin  is  left  for  such  variation.  On  the  other  hand,  it  is  only  necessary  to 
wear  constantly  the  full  correcting  lenses  to  render  the  total  hyperopia  mani- 
fest. Sometimes  this  is  accomplished  in  a  few  minutes  or  a  few  days;  in 
other  cases  it  may  take  week.-,  but  if  the  glasses  are  a  true  correction  and 
are  steadily  worn,  it  can  always  he  brought  about.  This  manifestation  of 
total  hyperopia  is  doubted  by  some  ophthalmologists,  partly  because  of  the 
failure  of  patients  to  wear  their  glasses  constantly  or  always  to  look  through 
them  when  worn,  hut  chiefly  on  account  of  the  inaccuracy  of  supposing  that 
the  correcting  leu-  for  a  limited  distance,  15  or  20  feet,  is  a  true  correction 
for  greater  distances.  Such  a  lens  causes  a  very  perceptible  blurring  at 
greater  distances,  very  annoying  to  persons  accustomed  to  distinct  vision,  and 
never  to  be  overcome  by  any  amount  of  persistence  in  wearing  glasses.  The 
person  who  under  a  mydriatic  sees  perfectly  at  4  m.  with  a  1  I),  convex  lens 
never  will  see  perfectly  at  a  longer  distance  with  that  lens — never  will  accept 
such  a  leu-  with  satisfaction,  not  because  of  any  "spasm  of  accommodation," 
but  because  it  is  not  his  correcting  lens  for  parallel  rays ;  it  is  0.25  D.  too 
strong.     (See  also  page  209.) 

A  third  objection  is  that  even  if  finally  accepted  the  full  correction  is 
harder  to  becom<  accustomed  to  than  a  partial  correction.  This  seems 
plausible,  but  experience  indicates  that  it  is  not  the  case  unless  the  partial 
correction  i-  so  incomplete  a-  to  give  a  very  diminished  assistance  to  the  eye. 
It  appears  to  be  easier  for  an  eye  to  learn  to  relax  its  accommodation  entirely 
than  to  learn  the  new  partial  relaxation  that  a  partial  correction  of  the  hyper- 
opia renders  necessary.  Some  surgeons  claim  it  is  best  to  arrive  at  full  cor- 
rection by  successively  increasing  partial  corrections,  due  full  correction 
may  at  first  cause  the  greater  trouble,  but  this  is  at  its  maximum  during  the 
first  two  up  three  day-,  and  after  that  it  rapidly  diminishes ;  it  is  certainly  less 
in  the  aggregate  than  is  entailed  l>\  ;i  series  of  increasingly  stronger  glasses, 
which,  moreover,  cause  greater  expense. 

The  wearing  of  correcting  lenses  should  be  constant.  This  should  be 
the  rule  iii  hyperopia,  although  not  so  essential  as  in  myopia  and  astig- 
matism. Some  indication-  ;i-  to  the  constancy  with  which  glasses  should  be 
woin  may  be  drawn  from  the  symptoms.  Headache,  particularly  if  continu- 
ous  or  occurring  without  apparent    connection  with  any  particular  use   of  the 

eyes,  is  very  much  more  likely  to  be  relieved  when  the  lenses  are  worn  con- 
tinuously.   The  -at  in'  i-  true  of  chronic  conjunctivitis  and  marginal  blepharitis 

and    of  inflammatory  change-  within    the   eye.      Where    there    is    headache   or 

irritation  directly  following  special  use  of  the  eyes,  a-  in  reading  or  sewing, 

which  quickly   passes  away  when  -iieh  eye-work   i-  suspended,  it    i-  likely  that 


MYOPIA.  219 

relief  will  be  afforded  by  using  the  correcting  lenses  only  during  the  periods 
of  such  work. 

It  is  often  necessary  to  have  the  glasses  worn  continually  at  first,  until 
the  headache  or  chronic  inflammation  has  been  entirely  cured  and  the  eyes 
have  learned  the  habit  of  relaxing  accommodative  effort  when  not  working. 
After  this  it  may  be  quite  enough  to  use  the  glasses  only  when  the  accommo- 
dation will  he  especially  taxed.  Again,  many  children  have  trouble  from 
hyperopia,  requiring  the  use  of  correcting  lenses  during  school-life,  who, 
when  they  leave  school,  can  lav  aside  glasses  and  continue  free  from  any 
symptoms  of  eye-strain. 

Exceptions  to  the  prescribing  of  a  full  correction  are  made — first,  in  young 
persons  with  good  accommodation  and  high  degrees  of  hyperopia  and  with 
comparatively  trifling  symptoms,  occurring  only  when  the  eyes  are  especially 
taxed;  second,  in  cases  in  which  it  is  impossible  to  persuade  the  patient  to 
submit  to  some  present  inconvenience  in  the  hope  of  future  benefit.  Under 
these  circumstances  the  only  thing  to  do  is  to  give  a  very  incomplete  correc- 
tion at  first  and  increase  the  strength  of  the  lenses  slightly  at  short  intervals. 
Patients  who  take  this  attitude  are  generally  in  a  position  to  bear  the  increased 
expense,  and  if  it  is  explained  that  the  first  glasses  are  only  for  temporary 
use  and  are  to  be  changed  after  short  intervals,  perhaps  changed  several  times 
at  such  intervals,  the  partial  correction  may  be  resorted  to.  Deficiency  of 
convergence  or  marked  exophoria  may  also  be  considered  as  an  indication  for 
not  completely  correcting  hyperopia. 

In  cases  of  convergent  squint  the  constant  wearing  of  the  full  correction 
is  always  to  be  tried.  Apart  from  the  wearing  of  correcting  lenses,  there  is 
no  treatment  for  hyperopia  ;  but  the  symptoms  that  arise  from  it  may  be 
relieved  by  diminished  use  of  the  eyes,  especially  for  near  work,  or  by  im- 
provement of  general  health,  and  by  the  influences  and  remedies  that  bring 
it  about. 

Myopia.— Myopia,  Brachymetropia,  Short-sight,  or  Near-sightedness,  is 
the  error  of  refraction  existing  when  the  retina  is  situated  hack  of  the  principal 
focus  of  tin-  dioptric  surfaces,  and  rays  of  light  to  be  focussrd  upon  if  must 
enter  flu    eye  divergent  from  some  comparatively  near  point. 

Fig.  159  represents  a  myopic  eye  focussing  parallel  rays  at/in  the  vitreous, 


/ 

Fig.  159. — The  course  of  rays  in  a  myopic  eye. 


and  requiring  the  lens  /,  which  will  cause  them  to  diverge  from  /■,  the  far 
point  of  the  eye,  in   order  that    they   shall    be   focussed   on    the   retina. 

Causes,  Tendency,  and  Varieties. — Myopia  may  occur  as  the  result  of 
a  simple  congenital  tendency  to  the  formation  of  too  Ion-  an  eyeball  or  too 
great  curvature  of  its  dioptric  surfaces,  but  the  great  mass  of  myopic  eyes 
must  be  regarded  as  pathological.  They  exhibit  distinct,  and  often  very 
grave,  Lesions  of  the  ocular  tissues,  to  which  the  myopia  may  lie  secondary, 
but  which  it  tends  to  aggravate. 

The  sclera  i-  distended  by  a  normal  intraocular  pressure  of  25  or  30  mm. 
of  mercury.     This  pressure  preserves  the  form  of  the  eyeball  and  the  proper 


220  NORMAL   AND   ABNORMAL    REFRACTION. 

relation  of  the  dioptric  surfaces  to  each  other  and  to  the  retina.  The  normal 
sclera  resists  this  pressure  without  yielding.  Acute  disease, .diathetic  impair- 
ment "1'  general  nutrition,  a  local  inflammatory  process  starting  with  con- 
gestion of  the  choroid  ('nun  eye-strain,  or  a  congenital  nutritive  deficiency 
lower-  the  resisting  power  of  the  tissue,  leaving  it  unable  to  withstand  the  in- 
traocular pressure.  Distention  then  occur.-,  commonly  near  the  posterior 
pole  of  the  eye,  causing  elongation  of  the  antero-posterior  axis  of  the  eyeball. 

When  such  distention  is  started,  anything  tending  to  increase  intraocular 
tension  or  to  diminish  the  resisting  power  of  the  sclera  favors  it.  Different 
writers  attach  different  degrees  of  importance  to  the  various  possible  factors. 
Some  believe  a  diathetic  vice  of  nutrition  essential  to  the  production  of 
myopia  :  some  regard  external  pressure,  dependent  largely  upon  the  form  of  the 
orbits  and  the  width  between  them,  as  most  important  ;  some  consider  inflam- 
matory changes  within  the  eye  as  the  chief  cause  of  distention  ;  some  ascribe 
an  important  influence  to  accommodation,  and  others  to  excessive  convergence. 
The  writer  recognizes  the  possible  influence  of  all  these  factors,  but  believes 
excessive  convergence  is  by  far  of  the  greatest  practical   importance. 

It  is  universally  recognized  that  prolonged  near  work  favors  the  occurrence 
and  increase  of  myopia.  Such  near  work  causes  physiological  hyperemia, 
often  exaggerated  by  poor  light  or  excessive  minuteness  of  the  objects  looked 
at  ;  faulty  position  of  the  head,  leading  to  venous  congestion  of  the  eves  ;  con- 
finement indoors  to  a  sedentary  occupation,  which  impairs  nutrition  ;  strain  of 
accommodation  ;  and  excessive  convergence  which,  sooner  or  later,  increasing 
myopia  renders  necessary. 

When  the  eye  has  become  myopic  its  elongation  makes  convergence  abnor- 
mally difficult,  and  the  continued  use  of  the  eye  for  near  work,  because  it 
cannot  he  used  for  distinct  distant  vision,  increases  the  amount  of  convergence 
required  of  it.  With  weakened  sclera,  with  increased  pressure  of  the  extra- 
ocular muscles  from  increased  convergence-effort,  and  the  pressure  abnormally 
continuous,  the  tendency  is  for  distention  to  increase.  Myopia  tends  to  be 
progressive.  Probably  all  cases  of  myopia  are  at  the  start  progressive.  Some 
myopias  cease  to  increase  when  the  requirements  of  excessive  near  work  made 
temporarily  or  during  school-life  are  relaxed.  Others  become  stationary  from 
increasing  rigidity  and  resisting  power  of  the  sclera  which  seem  to  come  nor- 
mally with  increasing  age.  Still  other  cases  continue  progressive  until  conver- 
gence becomes  too  difficult  to  he  sustained,  when  the  more  defective  eye  is  per- 
mitted to  deviate,  and  divergent  squint,  either  intermittent  or  constant,  is  estab- 
lished. After  this,  the  muscular  pressure  of  convergence  ceasing,  the  myopia 
ceases  to  increase.  In  a  lew  cases,  however,  the  sclera  is  so  thinned,  its  resist- 
ing power  so  low,  thai  distention  continues  until  the  intraocular  changes  pro- 
duce blindness.     To  these  the  term  malignant  myopia  is  properly  applied. 

Myopia  reaches  much  higher  degrees  than  hyperopia,  and  the  high  myopias 
constitute  a  larger  proportion  of  the  cases;  myopia  of  over  20  I  >.  i-  as  common 
;i-  hyperopia  of  1 0  I  >. 

In  Bpeaking  of  degrees  of  myopia  we  may  designate  as  low  myopia  that 
oi  less  than  2.5  I>.,  where  some  accommodation  is  habitually  employed  for 
near  work.  Moderate  myopia  LS  from  2.5  D.  too  I).,  where  near  work  can 
he  done  without  accommodation.  High  myopia  ranges  from  5  to  lo  I).,  in 
which  work  1-  besl  done  at  the  far  point  of  distinct  vision.  Very  high  myopia 
i-  above  Hi  I>.,  and  is  usually  accompanied  by  greal  alteration  in  the  shape 
of  the  eyeball  ami  changes  in  it-  coats. 

Symptoms  and  Complications. — Myopia  renders  indistinct  all  objects 
situated  beyond  the  tin-  point  of  the  eye.     Such  indistinctness  is  not  always 


MYOPIA. 


221 


noticed  if  it  begins  in  early  childhood  or  comes  <m  very  gradually,  although 
generally  it  is  detected  by  the  patient  or  his  care-takers,  especially  by  inability 
to  see  letters  on  the  blackboard  at  the  ordinary  distance.  The  indistinctness 
is  removed  by  bringing  the  object  closer  to  the  eye,  by  placing  before  the  eye 
a  solid  disk  or  card  with  a  pinhole  opening,  or  by  looking  through  a  con- 
cave lens.  The  changes  within  the  eyeball  often  prevent  lull  vision  even 
with  correcting  lenses.  The  small  moving  specks  or  shadow-  due  to  points 
of  haze  or  unequal  retraction  in  the  vitreous  humor,  noted  in  all  eyes  under 
certain  optical  conditions,  are  especially  noticeable  in  myopic  eyes.  Such 
eyes  are  also  especially  liable  to  vitreous  opacities,  which  give  rise  to  more 
extensive  clouds  and   shadows   upon   the   retina. 

Objectively,  the  myopic  eyeball  may  appear  noticeably  enlarged  and  elon- 
gated, especially  when  turned  strongly  toward  the  nose  ;  and  the  lids  over  ii 
prominent  or  widely  separated.  The  pupil  is  often  rather  large,  and  appar- 
ently sluggish,  because  less  often  contracted  in  the  act  of  accommodation  or 
convergence.  The  myope  has  a  vacant  or  even  stupid  look,  due  to  inability 
to  see  and  respond  to  expression  on  the  faces  of  others,  and  shows  a  distinct 
inclination  toward  reading  and  other  pursuits  which  do  not  require  clear  dis- 
tant vision. 

The  ophthalmoscope  commonly  reveals  intraocular  changes  closely  asso- 
ciated with  the  causation  and  increase  of  the  myopia.     The  most  characteristic 

of  these  are  alterations  in  the  choroid,  as 
congestion  and  edema,  causing  reddening, 
blurring  of  details,  and  lighter  patches 
("  woolly,"  "  fluffy,"  or  "  patchy  "  choroid), 
and  changes  in  which  the  pigment  in  parts 
of  the  fundus  is  reduced,  while  it  may 
be  increased  in  others  ("disturbed"  or 
"  moth-eaten  "  choroid  or  choroidal  atro- 
phy, "  slight,"  "  partial,"  or  "  complete  "). 
These  changes  are  most  frequent  at  the 
outer  side  of  the  optic  disk,  usually  tak- 
ing a  crescentic  form — the  myopic  crescent 
represented  in  Fig.  160.  An  eye  may 
present  two  or  three  well-marked  suc- 
cessive crescents,  the  one  next  the  disk 
characterized  by  nearly  or  complete  cho- 
roidal atrophy,  the  next  showing  partial 
atrophy,  and  the  outer  one  mere  conges- 
tion or  disturbance  of  the  choroid.  The  continued  succession  of  such  areas, 
extending  outward  and  passing  on  to  complete  atrophy,  gives  rise  to  a  trian- 
gular area  of  atrophy  extending  to  the  temporal  side  of  the  disk,  the  so- 
called  conu8.  The  disturbed  area  may  extend  around  the  disk,  forming  a 
ring  of  atrophy  usually  broadest  to  the  temporal  side  (see  also  pp.  192,  193 
Such  an  area  is  often  the  seat  of  softening  of  the  sclera,  with  consequent 
distention  and  thinning — posterior  staphyloma.  When  this  occur- at  the  tem- 
poral side  of  the  disk  the  optic-nerve  entrance  is  tilted,  so  that  it  is  seen  more 
obliquely.  The  disk  appears  a  narrow  oval.  The  vessels,  drawn  upon  by 
the  distention,  pass  more  directly  outward  ;  the  temporal  side  of  the  opening 
in  the  sclera  through  which  the  nerve  enters  is  made  prominent  a-  a  white 
crescent,  also  a  "myopic  crescent."  The  whole  appearance  i-  well  eliara* 
izeil  as  a  "dragged  disk."  If  these  changes  occur  at  the  lower,  nasal,  or 
upper   side,  the   disk    is    found    "dragged"    in    that    direction.      Iii    the    later 


Pig.  Hiii.— The  myopic  crescent.  Figure 
illustrates  also  the  lamina  cribrosa  and  a 
cilio-retinal  vessel. 


222  NORMAL    AND  ABNORMAL   REFRACTION. 

stages  of  high  myopia  similar  lesions  of  the  choroid  are  to  be  found  in  other 
parts  of  the  fundus,  especially  about  the  macula,  where  a  small  lesion  may 
cause  greal  impairment  of  vision.  In  the  earliest  stages,  and  later  if  under 
the  influence  of  eve-strain  the  myopia  Is  increasing,  general  hyperemia  and 
disturbance  of  the  choroid  mav  be  noticed.  Late  in  the  course  of  high  myopia 
vitreous  opacities,  cataract,  especially  nuclear  and  posterior  polar,  and  detach- 
ment of  the  retina  are  Liable  to  occur. 

Course. — The  best  statistics  of  eye- examined  at  birth  show  that  practically 
none  are  then  myopic.  But  high  myopia  is  sometimes  encountered  in  early 
childhood,  and  probably  sometime-  doc-  exist  from  birth.  In  the  great  mass 
of  cases  it  certainly  develops  later.  In  a  very  few  it  seems  to  occur  through  a 
healthy  development  of  the  eyeball,  to  go  on  without  choroidal  changes  or 
other  evidences  of  disease  up  to  adult  life,  and  then  to  become  stationary. 
In  the  great  mas-  of  cases  axial  myopia  begins  in  a  period  of  marked  ocular 
congestion  accompanying  near  work  ;  then  at  times  it  becomes  stationary  ;  at 
other  times,  those  of  especial  strain,  it  rapidly  increases.  When  the  myopia 
is  arrested  during  early  life  it  continues  for  some  years  stationary  ;  later,  by 
the  slow  growth  of  the  lens,  referred  to  under  Hyperopia,  it  may  be  lessened 
or  finally  disappear  entirely.  In  a  few  cases  myopia  begins  during  adult  life 
or  old  age  in  connection  with  degenerative  changes  in  the  choroid  and  sclera, 
and  may  be  a  symptom  of  diabetes.  Curvature  myopia  may  begin  at  any 
time  of  life  after  disease  causing  corneal  distention,  conical  eornea,  or  after 
injury  causing  partial  dislocation  of  the  lens.  Index-myopia  comes  in  old  age 
as  a  precursor  of  cataract,  the  so-called  second  sight. 

Treatment. — The  indistinctness  of  vision  is  remedied  by  concave  lenses. 
Permanent  avoidance  of  near  work  will  usually  check  the  progress  of  myopia, 
but  it  is  generally  necessary  to  check  its  progress  while  near  work  is  con- 
tinued, and  fortunately  this  also  is  possible  for  the  great  mass  of  cases  by 
the  use  of  correcting  lenses.  Two  factors  in  near  work  that  mijxht  tend  to 
increase  myopia  are  accommodation  and  convergence;  but  accommodation  is 
far  more  tasked  in  hyperopia,  and  hyperopia  eyes  show  no  such  tendency  as 
the  myopic  eyes  to  distention  of  the  eyeball.  On  the  other  hand,  hyperopia  is 
an  obstacle  to  straining  convergence,  while  myopia  favors  or  compels  it. 
The  tendency  of  myopia  to  increase  does  not  disappear  when  by  its  progress 
accommodation  i-  reduced  to  a  minimum  or  becomes  unnecessary;  but  it  does 
often  cease  when,  binocular  vision  being  given  up,  convergence  is  no  longer 
required.  If  excessive  convergence  causes  myopia  and  keeps  it  progress- 
ive, the  first  indication  for  it-  treatmenl  i-  its  optical  correction,  that  the 
patienl  may  have  distinct  vision  to  induce  him  to  turn  his  attention  toward 
distant  objects,  and  to  free  him  from  the  necessity  of  excessive  convergence. 

The  correcting  glasses  for  myopia  should  be  worn  constantly.  Wearing 
them  only  for  distant  vision  greatly  lessens  their  usefulness.  It  i-  most 
important  for  a  young  person  to  use  the  correcting  lenses  constantly,  so  that 
in  the  requirements  made  on  accommodation  he  shall  have  a  constant  check 
to  excessive  convergence.  The  tear  that  accommodation  may  prove  injurious 
has  frequently  led  to  the  use  of  a  partial  correction  only  for  near  work.  This 
rarely  prove-  permanently  satisfactory.  Convergence  to  a  near  working  point 
without  some  accommodation  is  impossible  ;  and  this  accommodation  make-  it 
necessary  to  bring  the  object  -till  closer  and  further  tax  the  convergence. 

The  fear  that  normal  accommodation  i-  bad  for  a  myopic  eye  has  led  to  the 
prescription  of  lenses  strong  enough  to  greatly  improve  distant  vision,  yet  weaker 
than  the  lull  correction.  Such  lenses  ma\  be  very  dangerous  to  the  myopic 
eve.      Looking  obliquely  through  them  increases  their  effect  and  renders  dis- 


MYOPIA.  223 

taut  vision  more  distinct.  The  patient  discovers  this  and  avails  himself  of  it. 
But  looking  obliquely  through  a  lens  gives,  besides  the  increased  power  of  the 
spherical,  the  ell  ret  of  a  cylindrical  element  and  aberration,  which  vary  with  the 
direction  and  amount  of  obliquity,  and  which  subject  the  eye  to  a  strain  similar 
to  that  caused  by  uncorrected  astigmatism — a  strain  all  the  harder  upon  the 
eye  because  it  is  inconstant.  Glasses  which  may  be  made  thus  to  approximate 
tlie  full  correction  for  myopia  are  the  most  dangerous  that  can  be  worn.  Yet 
because  their  use  has  often  resulted  disastrously  many  surgeons  hesitate  about 
giving  the  stronger  lenses  of  a  full  correction,  although  these  would  be  really 
free  from  such  a  danger.  If  for  any  reason  something  less  than  the  full  cor- 
rection is  given,  it  should  be  carefully  considered  whether  its  use  is  liable  to 
be  thus  perverted  and  cause  injury. 

The  general  rule  is,  in  myopia  give  correcting  lenses  for  constant  use.  To 
this  there  are  certain  exceptions.  With  presbyopia  it  becomes  necessary  to 
give  weaker  lenses  for  near  work.  Again,  when  binocular  vision  has  been 
given  up,  strain  of  convergence,  the  chief  indication  for  the  use  of  correcting 
lenses,  is  removed,  and  a  full  correction  may  induce  a  renewed  effort  of  con- 
vergence to  restore  binocular  vision.  On  this  account  it  will  generally  be 
better  not  to  give  a  correcting  lens  for  the  worse  eye.  Person-  who  have 
reached  middle  age  or  later  life  without  the  use  of  lenses  often  find  it  difficult 
or  impossible  to  become  accustomed  to  them.  Improved  vision  will  often 
not  compensate  for  the  discomfort  and  inconvenience  given,  so  that  these 
eases  must  be  made  exceptions.  With  very  high  myopia  a  lens  slightly 
weaker  than  the  full  correction  gives  an  image  more  like  that  to  which  the 
patient  has  been  accustomed,  and  which  is,  therefore,  preferred.  When  this 
i>  the  ease,  there  is  no  temptation  to  get  an  increased  effect  by  looking  ob- 
liquely through  the  lens.  Some  persons  object  to  the  diminished  retinal 
images  caused  by  strong  concave  lenses,  and  prefer  very  much  weaker  lenses. 
If  one  weak  enough  to  entail  no  strain  when  looking  through  it  obliquely 
answers  the  purpose  without  any  risk  of  excessive  convergence,  it  may  be 
wiser  to  give  it.  Occasionally,  too,  the  full  correction  may  be  given  for  dis- 
tant vision,  and  something  deducted  (1  or  2  D.)  from  the  glass  for  near  work, 
until  the  habit  of  accommodating  normally  for  near  objects  has  been  formed. 
Patients  should  be  warned  of  the  dangers  of  looking  obliquely  through  con- 
cave glasses. 

Besides  using  correcting  lenses,  the  myope  must  learn  to  keep  his  near 
work  as  far  from  his  eyes  as  possible.  The  lenses  are  chiefly  useful  by 
enabling  him  to  have  a  greater  working  distance,  and  no  benefit  as  regards  the 
progress  of  the  myopia  or  the  health  of  the  eye  can  be  expected  unless  the 
opportunity  to  diminish  the  strain  of  convergence  is  utilized.  As  an  aid  to  a 
greater  working  distance, good  light  and  the  avoidance  <>)'  reading  very  fine 
print  or  prolonged  looking  at  other  minute  objects  must  be  attended  to.  ('are 
must  be  taken  to  avoid  protracted  near  work.  It  should  be  interrupted  by 
frequent  intervals,  during  which  the  convergence  may  be  allowed  to  relax  and 
the  eve-  to  fix  on  some  distant  object.  The  po-itioti  of'  the  head  is  also 
important,  particularly  in  young  persons.  Reading  while  lying  down  or  in  a 
bent  posture,  causing  pressure  on  the  veins  of  the  neck,  favors  ocular  con- 
gestion, and  should  especially  be  avoided.  Use  of  the  eyes  during  periods 
of  impaired  nutrition, as  from  acute  disease,  during  greal  physical  exhaustion, 
etc.,  may  also  be  dangerous.  Outdoor  life,  besides  demanding  distant  rather 
than  near  vision,  act-  l>v  improving  general  nutrition.  When  choroid;'!  con- 
gestion i-  marked,  the  influence  of  complete  rest  of  the  eyes  for  ■  »me  days 
under  the  influence  of  a  mydriatic  may  promptly  check  a  process  that  t<  rids 


224  NORMAL   AND   ABNORMAL    UEFRACTLON. 

to  soften  and  rapidly  distend  the  sclera.  When  increase  of  myopia  does  occur 
thf  lenses  should  be  promptly  changed  accordingly. 

The  operative  treatment  of  myopia  by  removal  of  the  crystalline  lens  by 
discission,  followed  by  extraction  it'  the  patient's  age  makes  it  necessary,  is 
claimed  nol  only  to  improve  vision  by  removal  of  high  myopia,  making  com- 
paratively weak  glasses  necessary,  but  also  to  exert  an  influence  in  checking 
the  progress  of  the  myopia,  and  actually  to  cause  a  diminution  in  the  antero- 
posterior axis  <>('  the  eyeball.  In  the  judgment  of  the  writer  it  is  not  proper 
to  resori  to  it  in  any  ease  where  the  progress  of  the  myopia  can  he  arrested 
by  the  wearing  of  correcting  lenses  and  ordinary  hygienic  precautions.  But 
where  glasses  cannot  be  comfortably  worn  or  with  them  the  myopia  continues 
distinctly  progressive,  it  is  proper  to  extract  the  crystalline  lens.  This  ope- 
ration may  also  he  resorted  to  in  cases  of  high  myopia  in  one  eye  and  in 
myopia  with  commencing  lens  opacity.  In  such  eyes  cataract  often  remains 
incomplete  for  many  years,  and  grows  no  easier  of  extraction — it  may  even 
become  more  difficult  to  remove  because  of  the  larger  nucleus  when  ripe  than 
when  the  opacity  begins  to  interfere  with  vision.  The  reduction  in  myopia 
by  extraction  of  the  lens  varies  in  different  eyes,  usually  between  If)  and  20  D. 
Generally,  it  will  not  he  exactly  corrected  by  the  removal  of  the  lens  ;  glasses 
for  both  near  and  distant  vision  will  be  required,  accommodation  being  lost 
with  the  removal  of  the  lens. 

Astigmatism. — Its  Nature  and  the  Vision  of  Astigmatic  Eyes. — 
Astigmatism  is  always  an  ametropia  of  curvature.     If  is  a  defect  in  which  rays 

front  a  single  /mint  do  not  after  refraction  tend  to  meet  at  a  single  point. 

In  irregular  astigmatism  the  curvature  is  irregular  and  the  refraction 
differs  in  the  different  parts  of  the  pupil. 

In  regular  astigmatism  the  refraction  is  the  same  in  different  parts  of  the 
pupil,  lint  differs  at  the  same  point  in  different  directions.  This  depends  upon 
inequality  of  curvature  of  the  dioptric  surfaces  in  the  different  directions. 

A  familar  illustration  of  the  kind  of  surface  causing  it  is  found  in  the 
curve  of  the  edge  of  a  watch.  The  curve  in  the  plane  parallel  to  the  face  of 
the  watch  is  weaker  than  the  curve  in  the  plane  perpendicular  to  the  face. 
The  inequality  of  curvature  causes  the  rays  to  be  refracted  more  strongly  in 

the  directi f  the  stronger  curve,  and  in  that  plane  to  come  to  a  focus  before 

they  have  reached  a  focus  in  the  plane  of  the  weaker  curve.  Instead  of  being 
focussed  to  a  single  point,  they  are  focussed  successively  to  two  lines  at  right 
angles  to  each  other  and  separated  by  a  certain  interval. 

In  most  cases  of  regular  astigmatism  the  fault  depends  chiefly  upon 
inequality  of  curvature  in  the  cornea,  although  there  is  usually  also  some 
inequality  in  curvature  in  the  crystalline  lens.  It  is  common  to  speak  as 
though  the  astigmatism  were  due  entirely  to  the  corneal  curvature,  but  it 
should  lie  remembered  that  this  is  only  exceptionally  the  case. 

In  considering  the  refraction  of  the  astigmatic  eye  it  i>  only  necessary  to 
follow  tip'  course  of  the  rays  as  regards  two  meridians,  called  the  principal 
meridians  —viz.  the  meridian  of  greatest  curvature  or  greatest  refraction,  and 
the  meridian  of  least  curvature  or  least  refraction.  In  regular  astigmatism 
these  are  always  perpendicular  to  each  other.  In  some  eyes  they  are  not 
perpendicular,  but  in  such  eyes  the  astigmatism  i^  not  regular,  or  if  a  part 
of  it  he  regular,  there  i-  present  also  some  irregular  astigmatism,  which  can- 
not !.!■  corrected  by  an}  lens.  (See  page  206.)  When  the  refraction  has 
been  corrected  in  the  principal  meridians  all  of  the  regular  astigmatism,  all 
the  astigmatism  that   is  corrigible,  is  corrected   lor  all   meridians. 

The  focussing  of  lighl   l>\  the  astigmatic  eye  may  be  illustrated  by  Fig. 


ASTIGMATISM. 


225 


161,  in  which  the  circle  represents  the  cornea  as  seen  from  the  front;  aa 
represents  the  principal  meridian  of  greatesl  refraction,  and  b  l>  the  principal 
meridian  of  least  refraction.  By  the  vertical  curvature  all  rays  entering  the 
upper  half  of  the  cornea  arc  brought  down  to  the  level  of  the  central  ray 
when  tbey  reach  the  point/,  and  all  rays  entering  the  lower  half  of  the  cornea 
are  brought  up  to  the  central  ray  at  the  same  point.      At/  all  the  rays  have 


Fig.  161.— Illustrating  the  refraction  of  the  rays  in  the  principal  meridians. 

been  brought  to  the  level  of  the  central  ray,  but  they  have  not  been  focussed 
to  a  point,  for  in  the  meridian  of  least  refraction,  b  b,  they  have  been  less 
turned  from  their  original  course,  and  therefore  from  side  to  side  arc  -till 
spread  out  the  distance//.  Not  until  they  have  travelled  on  to  the  point  </ 
are  those  from  the  right  half  of  the  pupil  and  from  the  left  half  of  the  pupil 
all  collected  to  the  center  line  of  the  pupil.  By  the  time  they  have  been 
thus  collected  from  side  to  side  they  have  begun  to  spread  downward  and 
upward,  so  that  they  occupy  vertically  the  distance  g  g.  A  horizontal  line, 
//,  into  which  all  the  rays  are  collected,  is  the  focus  for  the  vertical  meridian. 
title  first  focal  line;  and  g  g,  a  vertical  or  second  focal  tine  in  which  all  these 
rays  are  afterward  collected,  is  the  focus  for  the  horizontal  meridian  or  hori- 
zontal curvature  of  the  cornea.  The  interval  between //and  g  g,  depending 
on  the  difference  of  curvature  in  the  directions  a  a  and  b  b,  called  the  focal 
interval  of  Sturm,  shows  the  amount  of  astigmatism. 

To/ and  g  the  rays  from  a  single  point  outside  of  the  eye  are  collected, 


Fig.  162.— Illustrating  the  appearance  "f  lines  running  in  different  directions  a    -  'lie  normal 

•    •  and   '■  i  ii'  :i  -i  ig  Mi.-ii  [c  eye. 

forming  at  each  a  focalline;  at  all  other  distances  behind  the  cornea  they 
spread  out,  making  an  area  of  diffusion  which  is  commonly  an  ellipse,  though 
atone  point  between/and  g  it  becomes  a  circle.  The  focussing  of  the  rays 
from  a  point  outside  of  the  eye  upon  a  line  of  the  retina  gives  rise  to  the 
peculiar  def'eet  of  vision    produced  by  astigmatism.      This  defect   i-  such  that 

1.0 


226  NORMAL   AND  ABNORMAL   REFRACTION. 

lines  running  in  the  direction  of  the  local  line  on  the  retina  arc  seen  clearly, 
except  that  their  ends  shade  nil'  gradually,  but  the  lines  running  in  other 
directions  appear  blurred,  as  in  Fig.  162. 

a  represents  lines  running  in  three  directions,  as  seen  by  an  emmetropic 
eye.  6  represents  the  impression  such  lines  make  on  the  retina  of  an  astig- 
matic eye:  1  shows  them  running  in  the  direction  of  the  focal  lines  on  the 
retina,  so  that  these  overlap  each  other,  giving  the  impression  of  a  distinct 
line  ;  .">  shows  them  running  at  right  angles  to  the  focal  lines  mi  the  retina, 
so  that  they  overlap  the  spaces  on  either  side,  giving  the  greatest  blurring ) 
and  'J  shows  them  running  obliquely,  so  that  the  overlapping  causes  blurring, 
l)iit  le--  than  that  for  .">.  All  lines  looked  at  by  the  astigmatic  eye  are  seen  in 
one  of  these  ways  at  any  given  time.  The  eye  may,  by  change  of  accommo- 
dation, so  vary  its  refractive  power  as  to  bring  first  one  and  then  another 
focal  line  upon  the  retina,  making  the  lines  clear  at  first  in  one  direction 
and  then  in  the  other. 

Symptoms  of  Astigmatism. — Generally  lines  can  he  seen  clearly  only 
when  they  run  in  some  one  direction,  and  this  direction  is  that  of  one  of  the 
principal  meridians.  This  necessarily  occasions  a  certain  indistinctness  of 
vision,  which  i-  peculiar  in  that,  when  tested  by  the  test-letters,  some  of  these 
on  account  of  the  direction  of  their  characteristic  lines  are  more  blurred  than 
others.  The  patient  may  mix-all  several  of  the  letters  of  a  certain  size,  and 
yet  recognize  other-  of  bul  half  that  size.  In  general,  the  indistinctness 
due  to  astigmatism  is  not  more  than  half  as  great  as  that  produced  by  myopia 
or  hyperopia  of  equal  amount. 

It  has  been  stated  that  the  astigmatic  eye  seeks  to  overcome  indistinctness 
of  vision  by  unequal  contraction  of  different  parts  of  the  ciliary  muscle, 
causing  unequal  convexity  of  the  crystalline  lens  in  different  meridians.  It 
ha-  not  been  certainly  prosed  that  this  occurs.  But  the  indistinctness  may 
be  partly  overcome  by   rapid  changes  from  one  state  of  accommodation   to 

another,  causing  first    tl ie  focal   line  and  then  the  other  to  fall   upon  the 

retina  in  such  quick  succession  that  their  impressions  may  aid  in  a  single 
mental  perception.  Either  use  of  the  accommodation  leads  to  eye-strain  with 
all  it-  possible  manifestations — pain,  congestion  or  inflammation  of  the  eye  and 
its  appendages,  headache,  and  other  manifestations  of  disturbance  of  the  general 
uervous  system.  In  childhood  the  difficulty  of  the  imperfect  images  hinders 
the  development  of  the  power-  of  visual  perception,  and  even  of  the  general 
mental   processes,      [ndistinctness  of  vision,  though   present    from  early   life, 

may    - -what  diminish  as  the  patient    learns  to  use   his  eyes,  hut    increases 

again  when  age  ha-  caused  the  impairment  or  complete  loss  of  accommoda- 
tion. High  astigmatism,  especially  myopic,  with  the  greatest  defect  in  the 
vertical  meridian,  i-  quite  a-  likely  to  cause  partial  closure  of  the  lids,  with 
secondary  disturbances  of  the  cornea,  as  is  myopia. 

Varieties. —  Astigmatism  with  the  ruh  is  astigmatism  with  the  meridian 
of  greatest  refraction  vertical  or  nearly  so,  as  it  is  in  a  large  majority  of 
cases. 

Astigmatism  against  the  ruh  mean-  that  the  meridian  of  greatest  refraction 
i-  horizontal  or  nearly  -o.  The  number  of  cases  of  this  kind  is  comparatively 
small,  hiit  they  grow  more  frequenl  alter  middle  life.  The  astigmatism  that 
follows  cataract  extraction,  iridectomy,  and  similar  corneal  sections  is  usually 
of  this  kind,  because  3uch  sections  are  generally  made  in  the  upper  margin 
of  the  cornea,  and  their  influence  is  to  flatten  the  cornea  in  the  meridian  per- 
pendicular to  their  length.     Astigmatism  against  the  rule  has  also  been  noted 

a-  a   forerunner  of  glaucoma. 


ASTIGMATISM.  227 

Oblique  astigmatism  means  that  the  direction  of  the  principal  meridians 
departs  much  from  the  vertical  and  horizontal,  and  approaches  rather  to  15 
and  135  degrees.  Some  writer-  believe  thai  astigmatism  against  the  rule  and 
oblique  astigmatism  are  mosl  likely  to  cause  inconvenience,  or  to  cause  more 
inconvenience  than  astigmatism  with  the  rule  of  equal  amount.  This  may  be 
explained  by  the  fact  that  only  line-  parallel  to  the  principal  meridians  can 
be  perfectly  focussed  on  the  retina,  and  that  the  greatest  number  of  lines 
looked   at    are  either  vertical   or   horizontal. 

\\  hile  the  amount  of  astigmatism  and  the  direction  of  it-  principal  me- 
ridian-are independent  of  the  position  of  the  retina,  the  relation  of  the  retina 
to  the  focal  lino  determines  the  variety  under  which  astigmatism  i-  classified  ; 
thus,  in  Fig.  163,  suppose  c  represents  the  cornea,  the  -olid   lines  represent 


Fig.  163.— Figure  illustrating  varieties  of  astigmatism. 

rays  as  refracted  in  the  vertical  meridian,  and  the  broken  lines  the  rays  as 
refracted  horizontally,  /  to  be  the  position  of  the  anterior  focal  line,  and  g  the 
position  of  the  posterior  focal  line.  When  the  retina  passes  through /the 
defect  is  called  simple  hyperopic  astigmatism — hyperopic  because  a-  regards 
the  meridian  of  least  refraction  and  the  focal  line  g  the  eye  i>  hyperopic — 
simple  because  it  can  be  corrected  by  the  simple  cylindrical  lens  which  cor- 
rects the  meridian  of  least  refraction. 

When  the  retina  is  situated  at  A  the  astigmatism  is  called  compound 
hyperopic.  The  eye  is  hyperopic  for  both  meridians,  for  both  focal  lines,  and 
it  can  be  corrected  only  by  a  compound  cylindrical  or  sphero-cylindrical  lens. 

When  the  retina  passes  through  g  the  defect  i-  simph  myopic  astigmatism, 
the  eye  being  myopic  for  the  meridian  of  greatest  refraction  and  the  focal 
line/',  and  capable  of  correction  by  a  simple  cylinder  correcting  the  meridian 
of  greatest  i'e fraction. 

When  the  retina  is  at  m  the  astigmatism  is  compound  myopic,  the  eye 
being  myopic  for  both  focal  line- and  meridians,  and  it-  ametropia  i-  only 
corrected  by  a  compound  cylindrical  or  sphero-cylindrical  lens. 

When  the  retina  i-  situated  between  /and  g  the  eye  i-  hyperopic  for  g 
and  the  meridian  of  least  refraction,  and  myopic  for  /  and  the  meridian  of 
greatest  refraction;  the  astigmatism  i-  called  mixed,  and  requires  for  the 
correction  of  the  ametropia  a  lens  convex  in  one  meridian  and  concave  in  the 
other.  It  is  evident  that  simple  increase  in  the  antero-posterior  axis  of  the 
eyeball  by  distention  will  cause  the  same  case  of  astigmatism  to  pa--  from 
compound  hyperopic  to  simple,  then  to  mixed,  afterward  to  simple,  and 
finally  to  compound  myopic.  In  case  of  astigmatism  becoming  myopic  these 
changes  successively  occur  in  the  course  of  the  progressive  distention  of  the 
eyeball  (see  also  pages  127  ami  128). 

Correction  of  Astigmatism. — This  is  effected  when  ray-.  Instead  of  being 
focussed  to  two  focal  line-,  are  focussed  to  a  single  point.  I'hc  corre  tion  of 
the  ametropia  present  requires  that  for  parallel  ray-  tin-  point  shall  fall  upon 
the  retina,      lint   the  astigmatism  may  be  fully  corrected,  although  a  certain 


228  NORMAL   AND  ABNORMAL    REFRACTION. 

amount  of  other  ametropia  (hyperopia  or  myopia)  remains  uncorrected. 
Astigmatism  i-  corrected  by  any  cylindrical  lens  <>r  combination  of  lenses 
that  makes  up  for  the  difference  of  refraction  in  the  two  principal  meridians. 
Thus  a  convex  cylinder  with  its  curve  parallel  to  the  meridian  of  least  refrac- 
tion, and  equal  in  strength  to  the  difference  between  the  two  principal  me- 
ridians, will  correct  any  case  of  astigmatism.  A  concave  cylinder  with  its 
curve  parallel  to  the  meridian  of  greatest  refraction,  and  strong  enough  to 
make  the  difference  between  the  two  meridians,  will  correct  it  equally  well. 
Or  a  convex  cylinder  correcting  a  part  of  the  astigmatism  may  lie  placed  with 
it-  curve  in  the  direction  of  the  meridian  of  least  refraction,  and  a  concave 
cylinder  strong  enough  to  correct  the  remainder  of  the  astigmatism  with  its 
curve  parallel   to  the  meridian  of  greatest    refraction. 

In  general,  any  case  of  astigmatism  may  he  corrected  by  one  of  three 
combinations  of  lenses.  Take,  lor  instance,  a  hyperopic  astigmatism  in 
which  the  horizontal  meridian  is  hyperopic  4  I).,  and  the  vertical  meridian 
hyperopic  2  I).  The  astigmatism  may  he  corrected  (1)  by  a  convex  2  D. 
cylindrical  lens  placed  with  its  curve  horizontal  (axis  vertical),  and  the  addi- 
tional hyperopia  corrected  by  combining  with  this  a  convex  2  D.  spherical  lens. 
This  astigmatism  may  he  corrected  (2)  by  a  concave  2  I),  cylindrical  lens 
placed  with  its  curve  vertical  (axis  horizontal).  This  woidd  have1  the  effect 
of  increasing  the  hyperopia  of  the  vertical  meridian,  and  to  correct  the 
hyperopia  a  convex  1  I),  spherical  lens  would  he  required.  It  would  also  be 
possible  (3)  to  correct  the  astigmatism  with  a  convex  4  I),  cylinder  with  its 
curve  horizontal  (axis  vertical)  and  a  convex  2  D.  cylinder  with  its  curve 
vertical  (axis  horizontal).  The  one  cylinder  would  bring  the  posterior  focal 
line  on  the  retina  without  affecting  the  anterior  focal  line,  and  the  other 
cylinder  would  bring  the  anterior  focal  line  on  the  retina  without  affecting 
the  posterior  line.  In  this  way  hoth  focal  lines,  brought  to  the  same  distance 
from  the  cornea,  would  become  a  single  point,  and  the  astigmatism  would  be 
corrected,  and  with  it  also  the  hyperopia. 

For  the  one  case  of  astigmatism  any  of  the  following  lenses  might  he 
chosen,  the  correction  being  optically  as  good  with  one  as  with  another  : 

(1)  I- 2D.  sph.  O      2 D.  cyl.  axis  90°  (vertical) ; 

(2)  tD.sph.C        2D.  cvl.  axis  180°  (horizontal); 

(3)  2  I),  cyl.  axis  180     =       I  I  >.  cyl.  axis  !'0°. 

Looking  at  these,  it  will  he  seen  that  (1)  has  on  the  whole  the  weakest 
surfaces.  It  is  theoretically  possible  with  it  to  get  ihc  thinnest  lens  and  the 
one  having  usually  the  least  aberration.  It  is  also  the  lens  most  commonly 
-elected  in  testing  the  eye  with  trial  glasses,  ami  the  one  most  frequently 
prescribed. 

It  will  he  observed  that  (2)  ha-  one  convex  and  one  concave  surface. 
The  spherical  surface  ha-  to  he  stronger  than  that  of  (1),  and  therefore 
causes  more  aberration;  hut  this  j^  a  matter  of  very  little  importance. 
It  i-  of  greater  importance  that  b)  placing  the  concave  surface  toward  the 
eye  and  the  convex  surface  away  from  it  something  of  a  periscopic  effeel  can 
he  obtained  by  this  second  leu-  allowing  the  eye  to  he  turned  in  different 
directions  without  causing  so  much  obliquity  of  the  visual  axis  to  the  lens 
surfaces.  On  this  accounl  (2)  will  prove  on  the  whole  the  most  satisfactory 
fir  ;i  large  proporl ion  of  cases. 

With  reference  to  (3),  it  will  he  noted  that  it  include-  two  cylindrical  sur- 
faces with  their  axes  exactly  perpendicular.     Such  a  lens  is  very  hard  to 


ASTIGMA  TISM.  229 

grind  sufficiently  accurate  for  practical  purposes,  and  impossible  to  grind  with 
theoretic  accuracy.  Its  surface-,  too,  are  stronger,  and  therefore  cause  inure 
aberration.  On  every  account  this  form  of  lens,  the  crossed  cylinder,  is  to  be 
avoided.  It  lias  rarely  Keen  used  except  for  mixed  astigmatism,  where  it 
gives  weaker  surfaces  than  either  of  the  sphero-cylindrical  lenses.  But  this 
doe-  not  compensate  for  the  increased  expense  and  necessary  inaccuracy  of 
crossed  cylinders,  and  it  is  better  never  to  employ  them. 

The  following  formulas  will  illustrate  this  subject  a-  regards  mixed 
astigmatism  : 

(1)  -  1  D.  sph.  O-h  2  D.  cyl.  axis  90°  ; 

(2)  +  1  D.  sph.  O -2D.  cyl.  axis  180°  ; 

(3)  +  1  D.  cyl.  axis  90°  O  -  1  I).  cyl.  axis  180°. 

In  compound  myopic  astigmatism  the  same  thing  holds,  as  the  following 
equivalent  formulas  will  indicate  : 

(1 )  -  2  D.  sph.  O  -  2  D.  cyl.  axis  1 80°  ; 

(2)  -4D.  sph.  O  -  2  D.  cyl.  axis  90°  ; 

(3)  -4D.  cyl.  axis  180°O-2D.  cyl.  axis  90°. 

In  simple  astigmatism  the  correetion  for  the  better  meridian  is  <>  ;  and 
one  element  of  formulas  (2)  and  (3)  becomes  0,  so  that  the  two  become  alike. 
In  simple  hyperopic  astigmatism  we  would  have  the  following: 

(1 )  or  (3)  +  2  D.  cyl.  axis  90°  ; 

(2)  -  2  D.  sph.  0-2D.  cyl.  axis  180°  ; 

from  which  one  may  choose  the  simple  cylinder,  which  is  the  cheapest  lens, 
or  the  sphero-cylindrical  lens,  which  gives  the  better  periscopic  effect. 
In  simple  myopic  astigmatism  the  formulas  are  thus  : 

(1)  or  (3)   -2D.  cyl.  axis  180°; 

(2)  -  2  I),  sph.  O  +  2  D.  cyl.  axis  90°. 

"Wearing1  Glasses  for  Astigmatism. — -The  whole  treatment  of  astig- 
matism consists  in  the  wearing.of  glasses.  Since  astigmatism  interferes  with 
distinctness  of  vision  at  all  distances,  and  since  it  entails,  when  uncorrected, 
a  use  of  the  accommodation  entirely  different  from  that  of  emmetropic, 
hyperopic,  or  myopic  eyes,  it  is  important  that  the  lenses  correcting  it  should 
be  worn  constantly.  This  is  essential  in  all  cases  at  first.  Sometimes  a 
patient,  by  wearing  glasses  constantly  acquires  the  habit  of  using  the  accom- 

modatioi rmally  and  can  continue  to  so  use  it  by  sacrificing  something  ol 

distinctness  of  vision  on  laying  aside  his  correcting  lenses  at  times  when  the 
eyes  are  not  to  be  especially  taxed.  Such  persons,  after  the  con-taut  use  of 
cylinders  for  some  time,  are  able  to  do  without  using  them  constantly  when 
the  eye-  are  not  employed  on  work  requiring  distinct  vision.  [n  general, 
however,  a  patient  having  much  astigmatism  maybe  warned  that  he  will 
always   require  the  help  of  correcting  lenses. 

Cylindrical  lenses,  contrary  to  what  is  sometimes  expected,  are  often  dif- 
ficult to  become  accustomed  to,  especially  if  they  are  strong,  if  the  patient  is 
advanced  in  years,  and  if  the  axes  of  the  cylinder-  before  the  two  eye-  inti-t 
be  turned  in  different  direction-.     Strong  cylinders  are  never  satisfactory  at 


230  NORMAL  AND  ABNORMAL    REFRACTION. 

first.  With  sonic  persons,  especially  when  past  middle  life,  the  difficulty  of 
becoming  accustomed  to  them  is  so  great  that  they  are  very  likely  to  give  up 
the  attempt.  This  should  he  carefully  considered  before  ordering  glasses. 
Any  cylindrical  lens  changes  somewhat  the  shape  of  the  retinal  images  and, 
therefore,  the  apparent  shape  of  objects  looked  at.  When  the  axes  are  turned 
in  different  directions  the  distortion  of  the  retinal  images,  corresponding  to 
the  directions  of  the  axes,  differs  in  the  two  eyes,  so  that  it  becomes  difficult 
to  fuse  the  two  impressions  they  make  and  secure  binocular  vision.  These 
unpleasant  effects  may  he  diminished  by  wearing  for  a  time  an  incomplete 
correction  of  the  astigmatism  or  by  bringing  the  lenses  particularly  close  to 
the  eye-. 

Aberration. — A  spherical  lens  does  not  perfectly  focus  the  rays  passing 
through  it.  In  general  it  acts  toward  the  edge  as  a  stronger  lens.  This  may 
lie  illustrated  by  the  following  diagram,  which  shows  the  course  of  the 
parallel  rays  as  refracted  by  a  convex  spherical  surface  (Fig.  164).  The  rays 
passing  through  the  center  are  focussed  at/,  the  principal  focus  of  the  lens, 
and  those  passing  through  the  margin  are  focussed  closer  to  the  lens.  The 
unequal  distribution  of  light  in  the  circle  of  diffusion,  its  concentration  to  a 


i  re,  L64.     figure  illustrating  spherical  aberration. 

ring  at  the  edge  and  a  point  at  the  center  of  that  circle,  may  he  studied  with 
a  strong  convex  lens  focussing  light  upon  a  card. 

In  the  human  eve  the  periphery  of  the  crystalline  lens  is  more  convex 
than  the  center,  and  acts,  therefore,  as  a  stronger  lens  than  the  center,  just  as 
in  the  ordinary  spherical  lens.  The  periphery  of  the  cornea,  on  the  other 
hand,  is  always  more  or  less  flattened.  Within  the  pupil,  in  the  majority  of 
eyes,  the  increased  convexity  of  the  crystalline  lens  predominates,  so  that 
they  present  a  stronger  refraction,  higher  myopia  or  lower  hyperopia,  at  the 
periphery  of  the  pupil  than  at  its  center.  This  condition  the  writer  has 
called  'positivi  aberration.  When  the  opposite  occurs  the  refraction  is 
Stronger,  the  myopia  higher  or  the  hyperopia  lower  at  the  center  of  the 
pupil  than   near  it-  margin,  constituting  negative  aberration. 

Aherration  [day-  an  important  pail  in  skiascopy,  determining  the  form 
and  size  oi  the  lighl  area  in  the  pupil,  causing  reversal  of  the  movement  of 
lighl    in   tin'  periphery  (in  positive  aberration)  to   he  perceived  closer  to  the 

eye  than    the    vement  of   lighl    at    the  center,  where   it   is  of   more   practical 

importance. 

W  hen  aberration  is  confined  chiefly  to  the  extreme  periphery  of  the  pupil, 
where  it  is  -Inn  off  b)  the  pupillary  contraction  in  a  strong  light  or  during 
near  work,  it  ha-  no  influence  on  the  working  power  i>{'  the  eye.  When 
it  begins  near  the  center  of  the  pupil,  causing  the  eye  to  be  more  hyperopic 
when  the  pupil  i-  contracted  by  a  strong  light  or  tor  close  work  than  when 
more  dilated,  it  ha-  an  important  influence  in  producing  eye-strain,  and  may 


AXISOMF/ritOPIA.  231 

be  a  cause  of  error  in  the  selection  of  lenses.  An  eve  with  positive  aberra- 
tion will  often  select  with  the  undilated  pupil  a  convex  lens  0.25  I  >.  stronger, 
or  a  concave  0.*25  I),  weaker,  than  it  will  accept  while  the  eye  i>  fully  under 
the  mydriatic. 

Aberration  is  to  be  recognized  by  skiascopy  and  considered  in  the  choice 
of  lenses.  It  cannot  be  exactly  corrected  by  any  particular  lens,  but  is  some- 
times an  indication  for  the  wearing  of  a  stronger  lens  than  one  which  will  allow 
of  perfect  distant  vision,  such  a  lens  being  found  in  these  cases  decidedly  more 
helpful.  High  negative  aberration  is  sometimes  diw  to  increased  refractive 
power  in  the  nucleus  of  the  lens — incipient  senile  cataract — or  to  conical 
cornea. 

Irregular  astigmatism  is  recognized  by  skiascopy,  causing  appearances 
represented  in  Fig.  165  A  and  B.  Traumatism  or  disease  of  the  cornea,  leaving 
irregularities  of  its  surfaces  (Fig.  165,  .1),  tissue-changes  in  the  lens  preceding 
cataract  (Fig.  165,  B),  and  occasionally  faulty  development  of  the  cornea  or  lens1, 
cause  irregularities  of  refraction  that  prevent  the  perfect  focussing  of  light  to 
a  point  by  the  dioptric  media.  Such  defects  are  not  capable  of  correction  by 
lenses.  The  eye,  however,  often  presents  within  the  area  of  the  pupil  small 
areas  in  which  the  refraction  is  comparatively  uniform,  which  areas  may  be 
corrected  by  some  combination  of  lenses,  and  the  vision  and  comfort  of  the 


Fig.  165.— Appearances  of  irregular  astigmatism  recognized  by  skiascopy. 

patient  thus  be  greatly  improved.  The  practical  thing  to  do  is  to  study  these 
cases  carefullv  by  ophthalmometry  and  skiascopy,  and  to  correct  the  mosl 
regular  portion  of  the  cornea. 

In  a  few  cases,  where  no  lens  can  render  much  service,  it  may  be  worth 
while  to  try  a  stenopaic  spectacle.  This  is  an  Opaque  disk  in  front  of  the  eye 
with  a  narrow  slit  or,  more  commonly,  a  single  pin-hole  opening  in  it.  Such 
an  apparatus  often  gives  a  noticeable  improvement  of  vision,  but  it  is  rarely 
found   very  serviceable  because   it    interfere-   with   the   visual   field. 

Anisometropia.— Some  inequality  in  the  refraction  of  the  two  eyes  is 
the  rule,  and  occasionally  this  is  such  as  to  render  one  eye  hyperopie  and  the 
other  mvopic,  or  one  astigmatic,  while  the  other  is  i'wc  from  astigmatism. 
Such  a  difference  constitutes  arkisometropia.  The  importance  oi  the  dif- 
ference depends  entirely  on  its  degree,  and  nol  on  whether  it  amounts  to  a 
difference   in    the   kind   of  ametropia. 

The  general  rule  when  the  difference  is  not  great  i-  t<>  give  each  eye  its 
exact  correction.  If  the  difference  between  the  two  correcting  lenses  is  very 
great,  they  affeel  the  size  of  the  retinal  images,  so  that  bi :ular  vision  be- 
comes difficult.  When  one  leu-  i-  much  stronger  than  the  other.  looking 
through  the  periphery  produces  a  correspondingly  differenl   prismal 

Causing    object-    to    be    -ecu    double,   of   the    etTofl     to     ll-e    the     illKCJ.-    falling  OH 

the   two    retina-   causes    -train    of  the   extraocular   muscles. 


232  NORMAL   AND  ABNORMAL   REFRACTION. 

For  the  above  reasons  the  full  correction  of  anisometropia  cannot  always 
be  practised.  It  is  generally  safe  to  prescribe  the  correcting  lenses  for  both 
eyes  when  these  differ  less  than  1  1>.  [f  they  differ  not  more  than  '2  D.,  they 
will  generally  be  accepted,  although  this  cannot  always  be  assumed.     If  they 

differ  more  than  l'  D.,  the  patient  will  find  it  very  difficult  or  impossible  to 
use  them  for  satisfactory  binocular  vision,  although  a  few  persons  will  prefer 
to  have  anisometropia  of  ■">  or  I  I),  fully  corrected.  When  the  difference  of 
refraction  cannot  he  fully  nut  by  difference  of  glasses,  the  rule  is  to  correct  the 
better  eve  and  to  allow-  the  worse  eye  the  full  correction  of  its  astigmatism, 
with  a  spherical  lens  equal  to  that  of  the  better  eye  or  a  little  stronger. 
Sometimes  if  both  eye-  have  good  vision,  but  cannot  work  together,  one  may 
be  corrected  for  distant  vision  and  the  other  given  a  leu-  that  will  adapt  it 
for  near  seeing.  Congenital  anisometropia  often  gives  little  trouble,  but 
anisometropia  coming  on  from  change  in  the  refraction,  as  in  progressive 
myopia,  i-  likely  to  be  very  annoying.  The  similar  effect  produced  by 
glasses  not  accurately  suited  to  the  eyes  is  also  very  annoying.  Acquired 
anisometropia,  particularly  from  0.5  to  2  I).,  is  especially  liable  to  give  rise 
to  squint,  and  its  correction  is  indicated  to  preserve  or  restore  binocular 
vision. 

Presbyopia.1 — The  failure  of  accommodation  with  age  leads  finally  to 
complete  inability  to  change  the  optical  condition  of  the  eye,  so  that  only  rays 
of  a  certain  convergence  or  divergence  can  be  focussed  upon  the  retina.  In 
the  great  majority  of  eye-,  which  are  hyperopic,  this  renders  necessary  the 
use  of  convex  lenses  for  near  vision.  For  this  purpose  the  need  of  lenses  i- 
felt  —the  eve  is  presbyopic—  as  soon  as  the  power  of  accommodation  has 
diminished  so  that  it  is  unequal  to  the  task  of  keeping  the  crystalline  lens 
convex  enough  to  focus  rays  accurately  on  the  retina  when  the  eye  is  engaged 
in  ordinary  near  work.  When  this  occurs  either  symptoms  of  strain,  such  as 
congestion  and  pain  in  the  eye,  conjunctivitis,  or  headache,  arise,  or  after  the 
effort  has  been  sustained  for  some  time  the  ciliary  muscles  suddenly  relax 
and  all  near  objects  become  blurred.  If  the  eyes  are  now  rested  for  a  minute, 
the  power  of  distinct  near  vision  returns,  but  if  the  near  vision  is  continued, 
it  again  fail-,  and,  persisting  in  the  attempt,  such  failures  become  more  and 
more  frequenl    until  the  effort  is  given  up. 

The  failure  is  first  for  object-  at  the  shortest  distance  from  the  eye,  as 
-mall  objects  or  line  print  that  needs  to  be  broughl  close  in  order  to  be  seen. 
Objects  that  may  be  held  farther  away,  or  the  same  object  in  a  strong  lighi 
which  will  render  it  distinguishable  at  a  greater  distance,  may  still  be  clearly 
seen,  the  patient  noticing  only  that  he  requires  good  lighl  and  has  to  hold 
thin--  farther  from  the  eyes  than  formerly.  Presbyopia  i>  caused  first  by 
the  increasing  rigidity  of  the  crystalline  lens,  which  limit-  its  tendency  to 
become  more  convex  when  the  tension  of  the  suspensory  ligament  is  removed 
by  contraction  of  the  ciliary  muscle.  Subsequently  the  ciliary  muscle  also 
becomes  weakened  or  undergoes  atrophy,  and  the  power  of  accommodation  is 

completely    lost. 

Presbyopia  i-  relieved  by  supplementing  the  insufficient  focussing  power 
of  th,.  crystalline  lens  by  a  convex  lens  of  the  necessary  strength  placed  before 
the  eye.  In  choosing  such  a  lens  it  i-  to  be  borne  in  mind  that  we  have  to 
enable  the  eye  not  only  to  see  clearly  at  the  required  di-tance  for  an  instant, 
but  to  sustain  distinct  vision  at  that  distance  over  periods  of  continuous  use. 
The  maximum  contraction  of  ,i  gele  is  always  one  that  cannot  be  long  sus- 
tained ;  hence  the  leu-  giving  the  patient  a  near  point  where  he  wishes  to 
1  For  additional  consideration  of  ilii-  Bubjecl  Bee  page  137. 


PRESBYOPIA.  233 

work  will  be  insufficient  for  continuous  work.  With  most  persons  only 
two-thirds  of  the  accommodation  can  be  long  kept  up.  A  few  can  sustain 
three-fourths  of  it,  bul  others,  particularly  young  persons  suffering  from 
weakness  of  accommodation,  can  comfortably  sustain  only  one-half  of  the 
full  amount. 

In  correcting  presbyopia,  then,  we  not  only  find  the  near  point  of  distinct 
vision,  but  from  that  near  point  and  the  refraction  of  the  eye  calculate  the 
total  power  of  accommodation.  Then  assuming  that  two-thirds  of  this 
accommodative  power  is  available  for  continuous  work,  the  difference  be- 
tween that  available  accommodation  and  the  accommodation  required  for  the 
sort  of  near  work  to  be  done  is  the  strength  of  lens  that  should  be  given  to 
correct  the  presbyopia.  This  may  be  illustrated  by  examples  of  different 
errors  of  refraction. 

Suppose,  first,  a  case  of  presbyopia  in  emmetropic  eyes.  The  nearesl 
point  of  distinct  vision  being  18  inches  (45.5  cm.),  corresponding  to  2.25  D. 
of  accommodation,  two-thirds  of  this,  which  may  be  assumed  as  available  for 
near  work,  equals  1.5  D.  Now,  if  the  patient  wishes  to  use  the  eyes  for 
ordinary  reading,  writing,  sewing,  etc.  at  a  distance  of  b'>  inches  (33  cm.), 
where  3D.  of  focussing  power  will  be  required,  3.  —  1.5  I).  1.5  I),  will  be 
the  strength  of  the  convex  lens  that  should  be  given  to  supplement  accom- 
modation— to  correct  the  presbyopia.  If  the  patient  has  been  wearing  such 
a  lens  or  one  nearly  as  strong,  and  still  shows  evidence  of  undue  strain  of 
the  eyes  for  near  work,  it  may  be  that  he  cannot  sustain  two-thirds  of  his 
total  accommodation,  but  requires  the  presbyopic  correction  to  be  made  some- 
what stronger,  as  1.75  -or  2  D.  On  the  other  hand,  if  such  a  patient  has 
been  reading  without  any  lens  and  without  much  inconvenience,  it  may  be 
assumed  that  he  can  sustain  more  than  two-thirds  of  his  total  accommodation, 
and  therefore  a  weaker  lens,  as  the  1  or  1.25  D.,  may  be  given. 

Suppose  in  another  case  the  patient  has  hyperopia  of  2D.,  and  a  near 
point  of  distinct  vision  of  1<>  inches  (40  cm.),  corresponding  to  2.5  D.  of 
focussing  power,  to  which  is  added  the  2D.  needed  to  correct  the  hyperopia, 
making  4.5  D.  of  total  accommodation.  Two-thirds  of  this  accommodation, 
or  •']  D.,  would  only  correct  his  hyperopia,  and  leave  1  D.  to  adapt  the  eye 
for  near  vision  at  a  distance  of  1  m.  If  such  a  patient  is  to  work  at  13 
inches  (33  cm.),  where  3D.  of  focussing  power  is  needed,  he  will  require  the 
help  of  a  lens  equal  to  3  D.,  — 1  D.,  or  2D.  The  increased  use  for  accom- 
modation will  cause  the  hyperopic  eye  to  suffer  earlier  from  presbyopia  if  it 
has  not  the  help  of  correcting  lenses  for  the  hyperopia.  It  will  also  be  noted 
that  with  a  certain  near  point  the  hyperopic  eye  requires  a  stronger  supple- 
mentary lens,  since  that  near  point  represents,  with  a  greater  amount  of 
accommodation,  a  greater  need  for  it.  The  lens  required  in  the  above  case 
might  be  found  by  correcting  the  hyperopia  with  a  2  D.  convex  lens,  when  it 
would  be  found  that  the  near  point  was  at  !)  inches  (23  cm.)  I  1.5  D.  of  accom- 
modation), and  that  two-thirds  of  this  accommodation.  3D.,  would  be  suf- 
ficient for  work  at  13  inches  (.'}.'»  cm.).  Hence  no  further  correction  for 
presbyopia  would  be  required,  the  correction  of  the  hyperopia  causing  the 
presbyopia  to  disappear. 

By  myopia  the  need  for  a  presbyopic  correction  is  postponed  and  dimin- 
ished. Thus,  an  eye  with  myopia  of  ."»  D.  will  be  able  to  work  at  13  inches 
(33  cm.)  without  any  lens  and  without  accommodation,  and  tor  that  kind  of 
work  will  never  suffer  from  presbyopia.  Take  another  case,  where  the  myopia 
is  1  I),  and  the  near  point  found  at  22  inches  (57  cm.  |,  corresponding  to  1 .75  1  >. 
of  focussing  power  ;  subtracting  from  thi^  1    1  >.  of  myopia  leaves  0.75  1  >.  as  the 


234  NORMAL   AND  ABNORMAL    REFRACTION. 

total  accommodation.  Of  this  two-thirds, or  0.5  D., being  available  for  near 
work,  is  to  be  added  to  the   1    D.  of  myopia,  making  1.5  D.  of  available 

focussing  power,  and  for  work  to  be  done  at  13  inches  there  will  be  need  in 
addition  for  a  convex  lens  of  1.5  D.  That  is,  in  myopia  of  1  L).,  with  only 
0.75  D.  of  accommodation,  the  same  help  is  required  as  in  emmetropia  with 
accommodation  of  2.25  D.  With  myopia,  as  with  hyperopia,  the  total  accom- 
modation may  also  he  found  by  first  correcting  the  myopia  and  then  taking 
the  near  point. 

In  astigmatism  the  accommodation  can  only  be  accurately  determined  by 
taking  the  near  point  after  the  correction  of  the  astigmatism,  and  the  amount 
of  convex  spherical  to  be  added  for  near  work  on  account  of  presbyopia  will 
then  be  determined  as  though  the  eye  had  been  originally  emmetropic.  Some- 
times in  giving  lenses  for  presbyopia  with  astigmatism,  while  the  concave 
cylinder  is  better  for  distance,  the  convex  cylinder  with  its  axis  turned  at 
right  angles  is  better  for  near  work.  Suppose  a  ease  of  simple  myopic  astig- 
matism requires  for  its  correction  —  1.5  D.,  cylinder  axis  180°,  and  with  this 
correction  before  the  eye  the  near  point  is  18  inches  (46  em.),  the  accom- 
modation 2.25  I).  The  spherical  to  be  added  for  near  work  at  13  inches  (."18 
cm.)  would  be  1.5  D.,  and  a  convex  1.5  D.  spherical,  combined  with  the 
concave  1.5  IX,  cylinder  axis  180°,  is  the  optical  equivalent  of  the  convex 
1.5  IX,  cylinder  axis  J)0°.  For  distant  vision  such  an  eye  may  be  given 
—  1.5  I).,  cylinder  axis  180°,  and  for  near  vision   f  1.5  I).,  cylinder  axis  90°. 

Course. —  Presbyopia  usually  begins  between  the  ages  of  forty  and  fifty. 
With  hyperopia,  which  may  have  given  no  earlier  evidence  of  its  presence,  it 
begins  younger  ;  with  myopia,  later  or  not  at  all.  Even  with  emmetropic 
eyes  the  increasing  rigidity  of  the  lens  may  require  the  use  of  convex  glasses 
before  the  age  of  forty,  and  with  a  few  the  need  of  a  presbyobic  correction  is 
deferred  until  after  the  age  of  fifty. 

In  all  cases  after  it  has  begun  presbyopia  is  progressive.  The  power  of 
accommodation  continues  to  diminish  until  it  is  entirely  lost,  and  such  dimi- 
nution causes  the  necessity  for  increasing  the  strength  of  the  supplementary 
lenses — the  presbyopic  correction.  Generally,  the  lenses  should  be  changed 
often  enough  to  have  a  difference  of  not  more  than  0.75  D.,  or  about  once 
every  two  or  three  years  from  forty-five  to  fifty-five.  Most  patients  require 
the  same  correction  for  presbyopia  for  both  eyes.  In  a  lew  cases  this  is  not 
so,  the  accommodation  failing  faster  in  one  eye  than  in  the  other,  and  re- 
quiring a  correspondingly  stronger  supplementary  lens.  In  such  cases  the 
eye-  should  be  repeatedly  tested  to  make  sure  that  there  is  actually  a  differ- 
ence between  them,  and  the  tests  repeated  at  short  intervals. 

The  Mounting  of  Glasses. —  Lenses  are  commonly  supported  before  the 
eyes  by  spectacle  or  eye-glass  I  pince-nez)  frames.  The  former  have  the  advan- 
tage of  more  rigidly  fixing  the  position  of  the  lens  before  the  eve.  The  latter 
are  more  readily  removable  when  the  lenses  are  not  required  for  eon-tan t  use. 
The  proper  adjustment  of  the  frames  is  a  matter  of  much  importance,  since 
the  right  lens  in  the  wrong  position  doe-  not  have  its  proper  effect,  and  may 
be  entirely  unsatisfactory  (see  pages  236—240). 

The  Period  of  Adaptation.  —  Weak  lenses,  less  than  1  I>..  may  prove 
satisfactory  and  comfortable  from  the  -tart  or  within  a  few  days  after  begin- 
ning to  wear  them.  Children  may  become  accustomed  to  even  strong  lenses 
in  a  very  few  days.  Correcting  lenses  will  generally  be  accepted  without 
complaint  when  the  eye  is  kepi  tor  some  time  under  the  influence  of  a 
mydriatic.  Hut.  apart  from  these  exceptions,  lenses  are  rarely  accepted  with 
entire  comforl  at  first. 


THE  PERIOD   OF  ADAPTATION.  235 

The  period  of  adaptation  during  which  the  first  discomfort  diminishes  and 
passes  away  may  last  from  two  to  six  weeks,  or  even  longer;  during  this 
period  convex  lenses  are  Likely  to  cause  blurring  of  distant  vision,  concaves 
render  near  work  noticeably  more  fatiguing,  and  cylinders  cause  distortion 
of  objects  and  an  indefinite  discomfort.  These  unpleasant  effects  may  from 
the  start  he  more  than  balanced  by  the  benefits  experienced,  yet  it  is  prudent 
in  all  cases  to  warn  the  patient  that  some  weeks  must  elapse  before  the  glasses 
can  be  expected  to  do  their  best.  With  such  a  warning  most  people  encounter 
the  necessary  difficulties  without  loss  of  confidence.  But  if  permitted  to  put 
on  the  glasses  expecting  immediate  satisfaction,  they  become  disappointed, 
lose  faith  in  the  prescriber,  and  are  likely  to  refuse  to  give  them  a  fair  trial. 
The  good  of  the  patient  and  the  reputation  of  the  surgeon  both  demand  that 
a  careful  explanation  of  the  period  of  adaptation  should  be  given  when  the 
glasses  are  prescribed. 


SPECTACLES  AND  THEIR  ADJUSTMENT. 

By  R.   .J.    PHILLIPS,   M.  I)., 

OF    PHILADELPHIA. 


A  spectacle-lens  should  be  so  placed  that,  in  use,  the  line  of  sight 
passes  through  the  optical  center  perpendicular  to  the  plane  in  which  the 
glass  lies.  These  simple  conditions  would  be  extremely  easy  to  satisfy  were 
it  not  for  the  tact  that  the  organ  of  vision  must  of  necessity  be  extremely 
active  and  mobile.  The  eyeball  may,  in  fact,  be  rolled  in  its  socket  about 
60°  in  every  direction  from  a  point  immediately  in  its  front,  while  movements 
of  the  head,  or  even  of  the  entire  body,  are  constantly  called  in  requisition  as 
greater  range  of  vision  is  required.  These  facts  destroy  at  once  the  possi- 
bility of  so  placing  a  glass  that  its  center  may  be  coincident  with,  and  its 
plane  be  perpendicular  to,  the  line  of  sight  under  all  circumstances.  Only  a 
glass  fastened  to  the  eye  and  moving  with  it  could  fulfil  these  conditions. 

Though  the  glass  cannot  be  attached  to  the  eye,  it  can  be  and  is  attached 
to  the  head,  which,  as  has  been  noted,  is  nearly  constantly  in  motion,  seconding 
the  activity  of  the  eyes.  The  necessity  of  looking  through  the  center  of  the 
glass  limits  for  the  wearer  the  range  of  the  eyes  in  their  sockets,  and  increases 
in  a  corresponding  degree  the  excursions  made  by  the  head.  This  augmented 
head-motion,  which  can  he  noticed  in  almost  all  wearers  of  glasses,  arises 
partly  also  from  the  effort  to  bring  the  plane  of  the  lenses  perpendicular  to 
the  line  of  sight.  The  only  exception  to  these  statements  is  in  the  case  of  a 
person  who  i-  wearing  a  glass  which  under-correct s  his  ametropia,  and  who 
looks  through  it  obliquely  in  order  to  increase  its  refractive  effect.  The  more 
exactly  the  glass  and  frame  are  fitted  to  the  requirements  of  the  case,  the  le— 
of  this  auxiliary  head-movement  will  he  required  ;  some  increase  in  it  must, 
however,  he  accepted  as  one  of  the  concomitants  of  wearing  spectacles.  When 
a  person  with  glasses  raises  his  head  continually,  markedly  elevates  <>r  de- 
presses hi-  chin,  or  forcibly  twists  hi-  spectacle  frame  in  his  fingers,  he  is 
instinctively  seeking  to  correel    faulty  refraction   or  faulty  frame-fitting. 

Spectacle-  are  ordered  to  he  worn  either  constantly,  or  for  near  work  only, 
or  for  distant  vision  only.  It  will  he  readily  understood  that  the  circumstances 
under  which  near  work  i-  usually  done  admit  of  the  most  exact  adjustment 
of  the  glass.  S\\c\\  work  i-  usually  held  in  the  hands  or  occupies  a  desk  or 
bench  having  a  fixed  position  relative  to  the  workman.  It  is  below  the  level 
of  hi-  eye-  and  within  reach  of  his  hand-,  and  only  slight  excursions  of  the 
eyes  arc  required  in  it-  performance.  As  the  line  of  sighl  is  directed  down- 
ward, the   •'  near"    glass    [n,   Fig.   166)  must  he  placed    below  the    level    of  the 

eye  ;  at  least  its  optical  center  must  be  so  placed.  It  must  face  strongly  down- 
ward in  order  to  bring  it-  plane  perpendicular  to  the  line  of  sight  (6).  It 
should  face  slightly  inward  for  the  same  purpose,  since  the  visual  axes 
converge  in   near   vision.     Tin-  convergence   necessitates,  further,  that    the 

optical  center-  of   the  glasses  -hall  he   placed   from    I   to  li  nun.  nearer  together 


A  DJ I  TSTM  ENT  OF  SPEt  "/'.  I  ( 7.  /;-  /.  ENSES. 


237 


Fig.  166.— Showing  position  of  lenses  before  eye. 


than  are  the  centers  of  the  pupils,  since  the  visual  axes  would  otherwise  pass 
t<>  their  inner  sides.  If  an  isosceles  triangle  is  constructed  with  the  inter- 
pupillary  distance  as  its  base,  and  the  visual  axes,  directed  toward  a  near 
object,  as  its  remaining  sides,  it  will  he  apparent  that  the  farther  from  the 
eyes  a  pair  of  glasses  stand  and  the  nearer  to  the  eyes  the  work  is  situated,  the 
less  should  he  the  distance  between  the  optical  centers  of  the  glasses.  The  pre- 
cise distance  between  optical  centers  which  any  given  case  may  require  may 
thus  be  determined. 

In  "  distant"  vision  the  gaze  may  be  directed  toward  any  point  of  the  hori- 
zon or  firmament,  and  yet,  practically,  the  relation  of  the  line  of  sight  to  the 
face,  and  consequently  to  glasses  at- 
tached to  the  face,  does  not  vary 
greatly.  A  distant  object  would  have 
to  change  its  position  considerably  in 
order  to  move  through  rive  degrees 
of  one's  field  of  view.  Hence  rapid 
changes  in  the  direction  of  the  line 
of  sight  are  seldom  required.  Ample 
time  is  afforded  for  whatever  adjust- 
ments of  the  head  and  trunk  may 
be  necessary.  Distant  vision  usually 
takes  place,  therefore,  with  the  visual 
axes  directed  forward  perpendicular 
to  the  plane  of  the  face  (a,  Fig.  166). 
When  glasses  are  ordered  for  this  use 
alone  they  should  have  optical  centers 
separated  by  the  same  interval  as  that  between  the  pupils  (since  they  will  not 
be  used  during  convergence),  and  should  face  directly  forward,  lying  in  a  plane 
parallel  to  the  general  plane  of  the  face  (d,  Fig.  166).  The  optical  centers 
of  the  lenses  should  stand  at  the  same  height  as  the  pupils. 

In  the  greater  number  of  cases  the  spectacles  prescribed  are  intended  for 
constant  use — that  is,  the  wearer  will  need  them  as  well  in  viewing  distant 
objects  as  in  work  near  at  hand.  It  is  evident  that  to  place  the  lenses  in  the 
exact  position  desirable  for  either  of  these  purposes  would  render  their  use 
awkward  for  the  other,  in  the  height  of  the  optical  centers  as  well  as  in 
their  distance  from  each  other,  and  in  the  facing  of  the  glass,  we  are  therefore 
forced  to  place  "constant"  glasses  in  a  position  intermediate  between  that 
best  for  distant  vision  and  that  best  for  near  work.  This  intermediate  posi- 
tion is  selected,  not  at  all  because  these  glasses  are  used  at  an  intermediate 
distance,  but  because  from  tin-  position  they  may  be  readily  shifted,  at  leasl 
approximately,  by  a  motion  of  the  head  into  either  of  the  other  positions. 
The  distance  between  the  optical  centers  of  "near"  glasses  should  be  from  I 
to  <i  mm.  less  than  are  the  centers  of  the  "distanl  "  glasses  intended  for  the 
same  patient.  This  dimension  is,  of  course,  unaffected  by  movements  of  the 
head.  Nevertheless,  in  order  to  reduce  the  unavoidable  discrepancy  to  the 
minimum,  the  distance  between  the  centers  of  the  "constanl  "  glasses  should 
be  2  or  :\  mm.  less  than  that  proper  for  the  "  distant  "  glasses.  By  a  similar 
concession  the  "constanl  "  glass  is  faced  moderately  downward  and  itscenters 
placed  somewhat  lower  than  those  of  the  "distanl  "  glass,  but  not  so  low  as 
those  of  the  "  near  "  glass. 

In  i  hi-  connection  the  occupation  of  the  patient  should  be  considered.     A 

seamstress  or  I kkeeper,  for  instance,  if  wearing  a  glass  constantly  should 

have  it  adjusted  almosl  like  a  " near "  glass,  while  persons  engaged  in  outdoor 


238 


SPECTACLES  AND    TllF.lli  ADJUSTMENT. 


occupations  will  require  an  adjustment  much  nearer  that  proper  for  a  "dis- 
tant "  glass. 

The  greater  the  strength  of  the  prescribed  lens  the  more  necessary  is 
attention  to  these  details,  since  the  efieel  of  slight  obliquity  of  the  lens  to  the 
visual  axis  is  greater  in  stronger  lenses,  as  is  also  the  effect  of  deceleration. 
In  bifocal  glasses,  therefore,  in  which  there  is  both  a  stronger  and  a  weaker 
lens,  thf  former  must  dominate  the  position  of  the  spectacles.  Convex  bifo- 
cals in  which  the  "near"  element  is  the  stronger  should,  therefore,  approach 
the  "near"  spectacles  in  position,  while  concave  bifocals  are  placed  more 
nearly  like  a  "  distant  "  glass,  as  the  "  distant  "  element  is  here  the  stronger. 

A  spectacle  frame  i>  a  kind  of  tripod,  its  points  of  support  being  the  top 
of  each  ear  and  the  bridge  of  the  nose.  It  is  not  possible  to  make  an  indif- 
ferently selected  point  on  the  bridge  of  the  nose  serve  as  the  support  of 
spectacles.  Nearly  always  it  will  be  found  that  there  is  one  particular  point 
at  which  they  tend  to  rest.  In  adapting  spectacles  to  any  given  face,  there- 
fore, the  problem  is  to  bring  the  optical  centers  to  the  position  previously 
determined  that  they  should  occupy  with  reference  to  the  eyes,  while  at  the 
same  time  their  support  is  placed  at  this  best  adapted  point  on  the  crest  of  the 
uose.  The  spectacle  bridge  known  as  the  "saddle"  bridge  is  the  only  one 
which  allows  of  unlimited   variation   in   the  relation  of  these  two  points. 

In  fitting  a  frame  to  the  face  the  curved  portion  of  the  bridge  between  a 
and   A.  Fig.  167,  should  be  adapted  to  the  bones  of  the  nose  at  the  point  at 


Fig.  L67.    Saddle  bridge. 


Fig.  ltis.— Saddle  bridge. 


which  it  i-  supported.  Having  once  received  the  proper  shape,  this  portion 
of  the  bridge  should  not  be  altered,  as  its  only  function  is  to  furnish  a  firm, 
equally  pressing  support  for  the"arms"c  and  '/,  by  means  of  which  the 
centers  of  the  glasses  may  lie  carried  higher  or  lower  on  the  face  or  the  dis- 
tance between  them  varied.  These  variations  are  accomplished  by  alterations 
in  the  ;  1 1 1  •_;  b  •  -  of  the  wire  at  a  and  />.  The  length  of  the  arms  c  and  <l  governs 
the  distance  of  the  glasses  from  the  eves. 

En  prescribing  or  recording  the  measurements  of  a  spectacle  frame  it   is 

Sufficient  to  give  the  distance  between  the  centers  of  the  glasses,  with  the 
height,  depth,  and  width  of  the  bridge.  The  height  is  the  distance  of  A,  Fig. 
His  (the  top  of  the  bridge  above  the  line  o  o,  joining  the  centers  of  the  glasses  ; 

hence  the  distance  iVoii)  //  to  g.  'Die  depth  is  the  distance  between  the  top  of 
tin-  bridge  (/,  Fig.  167)  and  the  point  e  on  the  plane  in  which  the  glasses  lie. 
This  distance  may  be  a  negative  one— thai  is,/may  be  buck  of  e.  In  the 
former  instance  the  measurement  is  recorded  as  out,  in  the  latter  instance  as  in. 
The  width  of  the  base  of  the  bridge  is  the   distance  between    a   and    h.      The 

measurements  of  .-i    spectacle    front    may,  therefore,  be   r< rded    in  a  single 

line,  for  example  : 

<>0  mm.        5  mm.  n/>        .'hum.  out        20  mm.  base. 

The  direction  in  which  the  front  of  a  spectacle  faces  dependson  the  angle 
which  it  forms  with  the  side  piece-  or  temples.     II'  these  latter  are  inclined 


METHODS  OF  TKSTISO   LENSES. 


239 


toward  the  bottom  of  the  frame,  the  glasses  when  in  use  will  face  downward. 
It  should  be  remembered  that  hook  temples  arc  simply  hooks.  They  cannot, 
with  comfort,  be  made  to  exert  the  force  of  a  spring  or  a  clamp  upon  the 
skin.  They  should  touch  the  skin  throughout  the  greatest  possible  portion 
of  their  extent,  so  as  to  distribute  the  weight  they  carry,  and  should  not  be 
allowed  to  press  unequally  owing  to  inequalities  of  the  surface.  Their  proper 
form  i-  a  straight  line  from  the  hinge  of  the  frame  to  the  top  of  the  ear, 
where  a  sharp  curve  joins  that  portion  which  is  accurately  fitted  to  the  back 
of  the  ear,  with  which  it  is  in  contact. 

In  eye-glasses  !  pince-nez)  the  same  adaptability  to  differently  proportioned 
faces  is  found  in  the  "offset  guard,"  which  in  spectacle-  is  attained  by  means 
of  the  "  saddle  bridge."  The  nose-pieces  of  these  guards  should  be  accurately 
moulded  in  every  case  to  the  sides  of  the  nose  at  the  point  where  they  obtain 
the  best  bearing  surface.  Fixed  points  of  support  for  the  lenses  are  thus  ob- 
tained. The  height  of  the  lenses  before  the  eyes  will  now  depend  on  the  point 
of  attachment  of  the  "  arm  "  of  the  guard  to  the  nose-pieces.     In  Fig.  169,  for 


abed  e  y 

Fig.  169.— Guards  of  eye-glasses. 

example,  the  guard  marked  b  will  carry  the  lenses  higher  than  the  one 
marked  e.  The  direction  in  which  the  lenses  face  is  controlled  by  the  size  of 
the  angle  in  the  arm  of  the  guard.  Thus,  in  the  figure,  at  a  the  arm  has  a 
right  angle  and  will  render  the  plane  of  the  lenses  nearly  vertical  ;  that  is, 
the  latter  will  face  directly  forward,  while  at  b  the  angle  is  greater  than  a 
right  angle,  and  the  glasses  will  face  more  downward. 

The  distance  of  the  glasses  from  the  eyes  depends  upon  the  length  of  this 
arm  of  the  guard.  The  longer  it  is,  the  farther  forward  the  glasses  will  be 
held;  d  and  g,  in  the  figure,  have  longer  arms  than  a  or  b.  Variations  in 
the  distance  between  the  centers  of  the  lenses  may  to  a  limited  extent  be  pro- 
cured by  an  arm  which  is  bent  so  that  its  free  end  doe-  not  lie  in  the  same 
plane  as  the  nose-piece.  If  greater  latitude  is  required  it  must  be  procured 
by  variation  in  the  transverse  diameter  of  the  lens  used,  or  by  alteration  of 
the  length  of  the  "stud"  which  connects  the  lens  with   the  guard. 

Methods  of  Testing  Lenses. — Toensure  accuracy  and  comfort,  spec- 
tacles, before  being  worn,  should  invariably  be  critically  examined  a-  to  the 
strength  of  the  lenses  and  the  fit  of  the  frame. 

The  most  convenient  method  of  determining  the  strength  of  lenses  is  the 
well-known  one  of  neutralization  by  means  of  the  test-case  lenses  of  known 
strength.  In  practising  this  manceuver  the  len-  is  held  about  a  foot  before 
the  eye  and  an  object  several  yards  away  is  sighted.  <  >n  moving  the  lens 
slowly  across  the  line  of  sight  the  object  seen  through  it  appears  to  move  also. 
In  the  case  of  convex  lenses  this  apparent  movement  is  in  a  direction  contrary 
to  the  motion  imparted  to  the  lens,  or,  in  the  language  of  the  refraction  room, 
i-  ••  against  it."     With  concave  lenses  the  apparenl  movement  of  the  object  i- 

ill  the  same  direction  a-  the  movement  of  the  lens,  Or  "  with   it."      I  f  a  convex 

and  a  concave  lens  of  equal  strength  are  held  together,  all  this  apparent  ra 
ment  ceases ;  they  "  neutralize "  each  other.     The  surgeon  is,  therefore,  able 


240 


SPECTACLES   ANT)    THEIR   ADJ ISTMENT. 


to  quickly  discover  the  strength  of  an  unknown  spherical  lens  by  trying  it 
with  lenses  of  the  opposite  sign  until  that  one  is  found  which  fa  uses  all  move- 
ment <it"  the  objecl  to  cease.  The  strength  of  this  lens  is  the  same  as  that  of 
the  unknown  one. 

A  cylindrical  lens  is  recognized  by  the  fact  that  that  portion  of  a  vertical 
line  -ecu  through  it  assumes  an  oblique  position  when  the  lens  i>  rotated 
about  it-  optic  axis  (a,  Fig.  1  7<M.  If'  the  rotation  of  the  lens  is  continued,  the 
motion  of  the  displaced  portion  of  the  line  is  reversed  and  its  continuity  is 
restored,  asal  l>.  This  appearance  is,  therefore, presented  in  two  positions  of 
the  cylindrical  lens.  In  one  position  the  vertical  line  marks  the  axis  of  the 
cylinder;  in  the  other  the  line  is  at  a  right  angle  to  the  axis.  To  locate  the 
axis  an  object  presenting  crossed  lines,  as  at  c,  Fig.  171,  is  selected;  the  lens  is 
so  held  that  each  line  appears  unbroken  and  is  first  moved  horizontally,  then 
vertically.  The  line  across  which  motion  is  apparent  marks  the  axis  of  the 
cylinder.     The  cylindrical   lens  of  the  opposite  sign  which  neutralizes  this 


Fig.  L70. — Method  of  testing  cylindrical  lenses. 


Fig.  171.— Method  of  testing  sphero-cylindrical  and 
prismatic  lenses. 


motion  discloses  the  strength  of  the  cylinder  under  examination.  Care  must 
l»e  taken  that  the  axes  of  the  two  coincide. 

In  a  sphero-cylindrical  lens  the  cylindrical  element  is  recognized  by  its 
causing  on  rotation  an  apparent  obliquity  of  a  portion  of  a  vertical  line,  just 
;>-  did  the  simple  cylinder.  On  viewing  the  crossed  lines,  c,  however,  and 
moving  the  lens  first  horizontally,  then  vertically,  apparent  motion  of  the 
objecl  i>  imparled  in  both  directions,  hut  in  one  it  is  more  rapid  than  in  the 
other.  In  neutralizing,  the  least  rapid  movement  may  he  firsl  obliterated  by 
means  of  a  spherical  lens.  This  gives  the  strength  of  the  sphere  in  the  com- 
bination. Holding  these  two  together,  one  proceeds  to  neutralize  the  cylin- 
drical element  by  means  of  a  cylinder  of  opposite  sign,  precisely  as  though  no 
sphere  were  present. 

<  )n  rotating  :i  />rixni>i/i<-  lens  about  one's  line  of  sight  an  apparent  dis- 
placement of  ;i  vertical  line  takes  place,  a-  at  '/,  Fig.  171.  When  the  line  is 
continuous  it  marks  the  base-apex  line  of  the  prism.  At  right  angles  to  this 
is  the  meridian  of  maximum  displacement.  The  prism  being  held  ;ti  one 
meter's  distance  from  the  object,  each  centimeter  of  apparent  displacement  of 
the  line  shows  one  centrad  of  strength  in  the  prism. 

The  <>/>lirti/  center  of  a  lens  is  located  l>v  using  crossed  line-,  a-  al  <■,  Fig. 
171,  except  that  lor  this  purpose  the  lens  is  held  within  about  a  foot  and  the 

line-    should    hi'    tine.       When    each  of  the    lines    is   continuous    their   crossing 

point   marks  the  optical  center. 

The  distance  between  centers  being  found  correct  and  a  final  inspection 
disclosing  no  flaws  or  scratches  in  the  glass,  no  bends  of  the  frame,  or  want 
of  symmetry  between  it-  two  sides,  the  spectacles  are  ready  for  the  wearer. 


DISEASES   OF  THE   EYELIDS. 

By    15.    L.   MILLIKIN,   M.  D., 

OF   CLEVELAND,    OHIO. 


Congenital  Anomalies. — Partial  or  complete  absence  of  the  eyelids 
(ablepharia)  is  occasionally  met  with  as  a  congenital  defect.  It  may  occur 
in  one  or  both  eyes. 

Lagophthalmos  is  a  defect  in  which  the  eyelids  arc  wanting  and  the 
orbit  is  divested  of  any  covering  for  the  globe.  An  abnormal  shortness  of 
the  lids,  which  prevents  their  fully  covering  the  eyeball,  has  been  similarly, 
and  perhaps  more  correctly,  so  designated  by  many  authors. 

Cryptophthalmos  is  a  condition  in  which  the  eyeball  is  completely  con- 
cealed by  the  skin,  which  is  stretched  over  the  orbital  cavity.  Sometimes 
the  eyeball  is  absent.  Under  the  latter  circumstances,  however,  the  name  is 
not  an  accurate  one. 

Cleft-eyelid  (coloboma  palpebral)  is  a  congenital  defect  in  which  there 
is  a  fissure  of  the  lid,  usually  triangular,  with  the  base  toward  the  ciliary 
margin.  The  fissure  may  exist  in  either  the  upper  or  lower  lid,  theformer 
being  the  usual  seat.  It  has  also  been  reported  in  the  upper  and  lower  lids 
on  each  side.  The  cleft  involves  the  entire  thickness  of  the  eyelid  and  is 
rounded  off  at  its  margins.  It  occurs  oftener  with  cases  of  hare-lip  than  with 
anomalies  of  the  eyeball  itself. 

Symblepharon  is  a  condition  of  union,  either  partial  or  complete,  between 
the  eyeball  and  the  lid-. 

Another  unusual  congenital  anomaly  is  a  union  between  the  margins  of 
the  lid-borders  (ankyloblepharon).  This  attachment  may  be  thread-like  or 
involve  a  considerable  intermarginal  surface.  The  external  angle-  of  the  lids 
may  be  adherent,  producing  the  defect  known  as  blepharophimosis,  result- 
ing in  a  shortening  of  the  palpebral  opening. 

Ectropion  is  an  eversion  of  the  edges  of  the  eyelids,  frequently  accompa- 
nied by  enlargement  of  the  eyeball. 

Entropion  is  an  inversion  of  the  edges  of  the  lid-,  and  is  usually  asso- 
ciated with  the  incurving  of  the  lashes — a  condition  known  as  distichiasis. 

Epicanthus  is  an  unusual  congenital  anomaly  caused  by  a  fold  of  skin 
which  stretches  across  the  inner  palpebral  space  connecting  the  eyebrow  with 
the  bridge  of  the  nose,  the  fold  thus  covering  all  the  structures  located  at  the 
inner  canthus.  It  is  generally  bilateral,  and  gives  rise  to.  or  i-  associated 
with.  ;i  Battening  of  tin-  bridge  of  the  nose.  Slight  degrees  of  it  may  exist  in 
children  at  birth,  and  with  the  development  of  the  nasal  bones  tin-  deformity 
gradually  passes  away. 

Associated  with  epicanthus  may  be  microphthalmos  (sometimes  only 
apparent  on  account  of  the  diminished  palpebral  opening),  strabismus,  droop- 
ing of  the  upper  lid,  ami  anomalies  of  the  lachrymal  passagi 

Epicanthus  may  be  remedied  by  an  operation  in  which  the  redundant 
i  a  211 


242  DISEASES  or  THE  EYELIDS. 

skin  is  removed   from  the  bridge  of  the  aose  and  the  edges  of  the  wound 
brought   together   with    sutures. 

Congenital  ptosis  is  :i  drooping  of  the  upper  lid  over  the  eyeball.  It 
may  be  on  one  side  or  bilateral,  and  never  amounts  to  complete  closure  of  the 
lids.  In  thi-  condition  there  is  inability  to  raise  the  eyelid  except  by  wrink- 
ling the  forehead  through  the  action  of  the  occipito-frontalis  muscle.  The 
anomaly  is  not  infrequently  associated  with  other  malformations,  as  epican- 
thus,  paralysis  of  the  eye-muscles,  etc.  It  may  be  corrected  by  operative 
procedures,  described  on  page  557. 

Erythema  of  the  lids  is  a  form  of  hyperemia  of  the  skin,  usually  due 
to  external  irritation,  such  as  burns,  traumatism,  and  poisoning,  or  it  may  be 
indicative  of  some  systemic  disturbance.  It  is  often  well  marked  in  inflam- 
matory condition-  of  the   eye. 

Treatment  will  depend  largely  upon  the  cause,  the  erythema  often  dis- 
appearing with  the  cure  of  the  primary  lesion.  Locally,  soothing  lotions, 
lead-water  or  extract  of  hamamelis,  will  be  all  that  is  required. 

Erysipelas  is  rarely,  if  ever,  a  primary  affection  of  the  lids.  It  usually 
develops  from  a  similar  lesion  of  the  lace.  The  danger  in  this  disease  is  that 
it  may  involve  the  deeper  tissues  of  the  orbit,  affecting  the  retina  or  the  optic 
nerve,  and  thus  eventuate  in  blindness.  In  severe  eases  it  may  produce 
sloughing  of  the  eyelids,  with  consequent  deformity.  The  disease  is  cha- 
racterized by  great  swelling,  increased  tension  of  the  lids,  smooth  and 
brawny   skin,  deep   redness,   and   the  formation   of  vesicles  or  abscesses. 

Tlu'  treatment,  both  local  and  general,  must  be  such  as  is  usually  adopted 
for  erysipelas  in  other  portions  of  the  body. 

Abscess  of  the  lid  (phlegmon)  is  characterized  by  an  acute  swelling  of 
the  eyelid,  somewhat  localized,  indurated  in  the  central  portion,  accompanied 
by  much  redness  of  the  skin,  heat,  throbbing  pain,  malaise,  and  fever.  The 
swelling  is  frequently  very  marked,  the  skin  toward  the  height  of  the  inflam- 
matory stage  in  the  severer  cases  often  presenting  a  brawny  appearance. 
Abscesses  resull  from  external  injuries,  from  disease  of  the  orbital  walls,  or 
they  may  arise  from  infectious  causes  or  occur  during  illness — e.  </.  influenza. 
The  tendency  for  the  abscess  to  "point"  is  quite  characteristic.  Abscesses 
occasionally  lead  to  extensive  sloughing  of  the  lid-tissues,  and  when  they  are' 
not  early  opened  they  may  result  in  lagophthalmos,  ectropion,  etc. 

Treatment. — In  the  early  stage  ice-packs  may  sometimes  abort  the 
development  of  the  abscess.  Should  the  inflammation  continue  to  increase, 
recour-e  should  be  had  to  hot  packs  and  poultices  to  hasten  the  "pointing." 
As  soon  a-  there  is  evidence  of  pus  a  free  opening  should  lie  made  into  the 
center  of  the  induration  and  deep  enough  to  give  vent  to  the  pus.  In  mak- 
ing the  incision  care  should  be  exercised  that  the  fibers  of  the  orbicularis  are 
not  cut  across.  The  abscess-cavity  may  be  washed  out  with  peroxid  of 
hydrogen   or  bichlorid   solution,    1    i<»  2000,  until   recovery  takes  place. 

Furuncles  and  carbuncles  are  rare.  With  them  develops  a  ".-ore" 
or  central  slough.  Otherwise  they  present  the  same  symptoms  as  an  abscess 
and  require  similar  treatment. 

Anthrax  pustule  (iii<ili<iii<iiii  pustule)  is  a  specific,  infection-  disease, 
due  to  inoculation  by  the  poison  of  anthrax  (bacillus  anihrads),  and  is  generally 
transferred  to  mini  from  animals  affected  with  the  disease.  Usually  it  occurs 
in  persons  working  among  animals,  a-  hostlers,  tanners,  farriers,  butchers, 
shepherds,  etc.  The  disease  is  characterized  l>v  marked  edema,  redness, 
beat,  pain,  localized  hardness  or  induration,  the  lasl  indicating  the  point  of 
infection.     In  malignanl  pustule,  as  in  erysipelas,  there  may  be  very  exten- 


HORDEOLUM.  243 

sive  sloughing  of  the  eyelid,  producing  at  times  a  condition  of  lagophthalmos. 
A.fter  sloughing  of  the  lids  the  ciliary  margins  alone  may  remain  intact  on 
account  of  the  rich  vascular  supply.  There  is  usually  marked  general  de- 
pression, with  fever.  By  absorption  of  the  anthrax  poison  into  the  deeper 
tissues  orbital  cellulitis,  or  even  meningitis,  may  ensue  with  fatal   results. 

Treatment. — This  must  be  governed  by  general  surgical  principles.  As 
soon  as  there  is  any  evidence  of  pus  the  swelling  should  be  freely  opened, 
with  one  or  more  deep  incisions,  in  order  to  prevent  infiltration  and  possible 
involvement  of  the  deeper  structures  of  the  orbit.  The  incision,  followed  by 
hot  poultices  or  by  compresses  of  absorbent  cotton  or  gauze,  wrung  out  of  hot 
bichlorid-of-mercury  solution,  1  to  2<)(><)  or  1  to  5000,  will  be  very  efficient. 
The  administration  of  iron  and  quinin,  tonics,  stimulants,  and  good  diet  i- 
of  decided  value. 

In  cases  of  extensive  sloughing  of  the  skin  of  the  lids  marked  lagoph- 
thalmos and  ectropion  can  be  prevented  by  fastening  the  remaining  marginal 
portion  of  the  lid  to  its  fellow  by  two  or  three  stitches  The  granular  sur- 
face may  then  be  treated  with  repeated  skin-grafts  applied  according  to  the 
Thiersch-method.  If  this  method  cannot  be  followed,  then  the  proper  plas- 
tic operative  procedures  for  these  deformities  must  be  undertaken,  as  indicated 
on  page  555. 

Ulcers  of  the  lids  may  be  due  to  contusions,  burns,  and  various  injuries, 
as  well  as  to  lupus,  scrofula,  syphilis,  and  herpes.  The  symptoms  will  vary 
with  the  cause  ;  likewise  the  treatment. 

Hordeolum  (Stye). — According  to  the  location,  hordeolum  may  be 
hordeolum  externum  or  hordeolum  internum.  Hordeolum  externum  is  an 
acute  inflammation  of  one  or  more  of  the  glands  of  the  hair-follicles.  Horde- 
olum internum  is  an  acute  inflammation  of  the  Meibomian  glands.  In  other 
words,  hordeolum  or  stye  is  a  circumscribed  inflammatory  process,  and  is  due- 
to  infection  of  the  sebaceous  glands  or  connective  tissues  of  the  lid,  usually 
associated  with  the  staphylococcus  pyogenes  aureus  or  albus. 

Symptoms. — These  are  rapid  edema  of  the  lids,  redness  and  tenderness 
coming  on  after  a  short  time — a  day  or  two — often  quite  severe  pain,  and 
sometimes  fever  and  general  disturbance.  A  hard  lump  or  point  of  indu- 
ration is  felt  at  the  seat  of  inflammation.  Within  a  few  days  the  color  of 
the  tissue  over  the  stye  changes  from  a  red  to  a  yellow  hue,  and  the 
abscess  "points."  If  allowed  to  take  its  course,  the  abscess-sac  ruptures, 
the  pus  escapes,  and   the  symptoms  rapidly  abate 

In  hordeolum  internum  "pointing"  of  the  absees>  takes  place  on  the 
inside  of  the  lid  through  the  palpebral  conjunctiva  ;  in  hordeolum  externum, 
near  the  margin  of  the  lid  through  the  skin.  The  latter  variety  is  much  the 
more  common. 

Styes  usually  oceiii' in  persons  subject  to  blepharitis,  the  chronic  inflamma- 
tion of  the  latter  affection  affording  good  soil  for  acute  infectious  inflammation 
of  the  solitary  glands.  The  infectious  character  is  well  indicated  by  the  fad 
that  persons  arc  very  liable  to  successive  attacks  of  styes,  which  occur,  in 
many  cases,  at  frequenl  intervals  over  a  period  of  months.  Young  persons 
are  generally  the  subjects  of  this  disease,  especially  if  they  arc  scrofulous, 
anemic,  or  poorly  nourished. 

These  two  varieties  of   hordeolum    presenl   essentially  the  same  clinical 
picture.     With  both  there  is  inflammation  of  the  sebaceous  glands,  and  they 
are  analogous  to  acne  in  the  skin.     The  marked  swelling  of  the   former,  as 
distinguished  from  the  hitter,  i-  due  to  the  anatomical  character  of  the  ti- 
in  which  the  inflammation  takes  place. 


244  DISEASES  OF  THE  EYELIDS. 

Treatment. — In  the  early  stage  an  attempt  may  be  made  to  abort  the 
development  of  a  stye  by  the  application  of  cold  or  very  hot  packs,  or  by 
touching  the  month  of*  the  gland  involved  with  the  sharpened  point  of  a  stick 
of  nitrate  of  silver.  [f  unsuccessful  in  this/'  pointing"  of  the  abscess  should 
be  encouraged  by  warm  fomentations  or  properly  applied  poultices.  Early 
opening  of  the  stye  is  important.  A.s  soon  as  there  is  an  indication  of 
softening  in  the  center  of  the  induration  a  free  incision  should  be  made  into 
the  tumor  in  order  to  evacuate  the  contents  and  to  prevent  the  extension  of 
the  necrotic  process.  Care  should  be  taken  that  the  incision  is  made  parallel 
to  the  fibers  of  the  orbicularis  muscle,  so  that  no  deformity  may  remain. 
Subsidence  of  the  symptoms  is  rapid  after  evacuation  of  the  contents  of  the 
abscess.  Between  the  attacks  treatment  should  be  directed  toward  improving 
the  general  health  and  alleviating  the  inflammation  of  the  lid-margins;  refrac- 
tive errors,  which  may  cause  styes,  should  be  corrected.  Sulphid  of  calcium 
has  some  repute. 

Bxanthematous  Eruptions  of  the  I/ids. — Ulcer  of  the  lids,  due  to 
variola  or  small-pox,  is  of  not  infrequent  occurrence.  The  parts  attacked 
are  the  hair-follicles  and  sudorific  follicles  and  glands.  The  results  of 
severe  attacks  are  pitting,  cicatricial  contraction  of  the  lids,  with  ectropion  and 
loss  of  the  eyelashes,  which,  when  permanent,  produces  the  condition  called 
madarosis. 

Treatment  is  directed  toward  limiting  as  much  as  possible  the  ulcerative 
process.  Protecting  the  pustules  by  (lusting  with  a  dry  powder,  such  as 
starch  and  zinc  oxid,  in  equal  parts,  or  touching  the  ulcerated  portion  with 
a  sharpened  stick  of  nitrate  of  silver,  has  been  advantageously  employed. 

Vaccine  Blepharitis  (  Vaccine  Ophthalmia,  Vaccinia  of  the  Eyelids). 
— This  occasionally  occurs  from  infection  from  a  vaccination  idcer.  It 
usually  affects  the  borders  of  the  lids,  and  is  characterized  by  the  rapid  for- 
mation of  an  ulcer  of  the  lid-margin,  accompanied  by  much  redness,  swell- 
ing of  the  lids  and  of  the  preauricular  and  submaxillary  glands,  together 
with  general  fever,  malaise,  etc.  In  the  early  stage  the  vesicles  appear  with 
pitted  center,  but  later  the  pustules  are  quite  characteristic.  In  the  last 
stages  of  the  ulceration  they  resemble  syphilitic  ulcers,  and  must  be  differen- 
tiated from  these  by  the  history  and  progress  of  the  case.  Associated  with  the 
disease  of  the  lid,  marked  conjunctivitis  occurs,  often  simulating  a  diphtheritic 
membrane. 

Treatment  is  directed  toward  allaying  the  early  inflammatory  symptoms, 
and  later  touching  the  ulcers  with  a  '2  or  3  per  cent,  solution  of  silver  nitrate. 
Aseptic  washes  to  keep  the  eye  clean  should  also  be  used. 

Kczetna  appears  either  on  the  eyelids  alone  or  is  associated  with  general 

eczema  of  the  face.  It  occur-  also  from  the  irritative  secretions  in  chronic 
conjunctivitis,  or  in  children  as  the  result  of  rubbing  the  secretions  from  the 
eye  upon  the  lids.  It  is  most  frequent  in  scrofulous  or  badly  nourished 
children.  Eczema  is  caused  in  adults  by  epiphora,  ectropion,  etc.,  the  tears 
running  over  the  cheeks  excoriating  the  surface,     [n  these  cases  the  Lesions 

.ire  usually   found  on  the  lower  lid. 

Treatment  must  be  directed  primarily  to  the  cause.  Locally,  zinc  oint- 
ment or  Hebra's  diachylon  ointment,  spread  on  lint  or  muslin  and  applied 
constantly,  is  satisfactory.  Painting  the  -kin  with  a  2  to  10  per  cent,  solu- 
tion of  nitrate  of  silver  has  been  found  to  be  very  serviceable ;  only  the  latter 
in  strong  solution  blackens  the  -kin  on  exposure  to  light.  Its  action,  how- 
ever, in  moist  or  ulcerative  eczema,  i~  very  effective. 

Herpes  zoster  ophthalmicus  i>  the  term  applied  to  that  variety  of 


n  lev ii A  urns.  245 

herpes  zoster  which  attacks  the  skiii  of  the  eyelids  and  other  areas  supplied 
by  the  first  division  of  the  trigeminus  nerve.  The  disease  is  characterized 
by  the  formation  of  vesicles  over  the  terminal  portion  of  the  nerve.  The 
attack  is  preceded  by  severe  neuralgic  pain  over  this  area,  succeeded  by  tin' 
formation  of  vesicles  over  the  forehead,  the  eyelids,  the  nose,  cheek,  and  the 
upper  lip,  the  disposition  of  the  vesicles  depending  upon  whether  the  firsl  or 

s( \\^\  division  of  the  trigeminus  is  affected.     The  third  division   is  rarely 

affected.  The  vesicles  first  contain  a  clear,  limpid  fluid,  but  rapidly  become 
cloudy  and  purulent,  and  finally  dry  into  crusts.  On  removal  of  the  latter, 
deep  ulcers  are  found.  After  healing,  permanent  scars  remain,  which,  by 
their  peculiar  grouping,  indicate  the  nature  of  the  attack.  Not  infrequently 
the  cornea  is  affected,  which  greatly  complicates  the  case.  These  ulcers  of 
the  cornea  may  result  in  permanent  opacities.  Iritis  and  cyclitis  are  not 
uncommon,  especially  if  the  nasal  branch  is  affected  ;  indeed,  there  may  be 
a  destructive  inflammation  of  the  whole  eye  (ophthalmitis).  Palsy  of  the 
ocular  muscles  and  atrophy  of  the  optic  nerve  may  follow  herpes. 

The  cause  of  herpes  zoster  is  obscure,  but  it  is  an  inflammatory  affection 
of  the  trigeminus.  Persistent  neuralgia  may  remain  after  an  attack  of 
herpes. 

Treatment. — This  is  symptomatic.  The  vesicles  should  not  be  opened, 
but  these  should  be  dusted  over  with  a  drying  powder  (rice  starch)  and  the 
ulcers  allowed  to  heal  beneath  the  crusts.  Removal  of  the  latter  is  productive 
of  much  pain.  Internally  morphin,  quinin,  and  iron,  according  to  indica- 
tions, must  be  given.  Keratitis  and  iritis  require  the  usual  measures  elsewhere 
described. 

~Bleph.a.ritis(Blcpharitix  ma  rc/hudis,  Blepharitis  ciliaris,  Blepharo-adenitis, 
Blepharitis  ulcerosa,  Psoropldhalmia,  Lippitudo  ulcerosa,  Tinea  tarsi,  Sycosis 
tarsi). — On  account  of  the  peculiar  anatomical  structure  of  the  margin  of  the 
eyelid  this  region  is  subject  to  a  variety  of  diseases,  with  somewhat  character- 
istic symptoms,  forming  a  group  by  themselves.  Rich  in  vascular  and 
glandular  structures,  the  edges  of  the  lids  are  the  seat  of  marked  inflamma- 
tory disturbances,  the  more  especially  as  they  are  greatly  exposed  to  external 
irritation.  Therefore  disorders  of  the  margins  of  the  lids  are  among  the  most 
common  of  all  diseases  of  the  eye.  In  intensity  of  inflammation  there  are  all 
degrees,  ranging  from  a  mere  red  fringe  of  the  lids  to  a  disorganization  of 
their  borders. 

Two  principal  varieties  of  marginal  blepharitis  have  been  described, 
according  to  the  symptoms — (1)  squamous  or  simple  blepharitis,  and  ('2) 
ulcerated  blepharitis. 

(1)  Simple  Blepharitis  (Blepharitis  squamosa). —  In  this  variety  the 
margins  of  the  lids  are  bordered  with  a  red  fringe,  fine  bran-like  scales  ap- 
pearing at  the  roots  of  the  cilia  and  between  them,  which  drop  off  if  the  ey<  - 
are  rubbed.  There  is  also  a  tendency  for  the  cilia  to  fall  out  if  disturbed  : 
they  grow  again  perfectly.  When  the  scales  arc  removed  the  skin  beneath 
is   found    to    be    hypercinic,  but    not    moist    or   ulcerated. 

In  another  variety  instead  of  the  scales  there  is  a  wax-like  secretion  which 
adheres  to  the  lashes, gluing  them  together,  but  on  its  removal  there  is  no 
evidence  of  ulceration  beneath,  the  tissues  appearing  simply  red  and  hy- 
pereinic. 

(2)  Ulcerated  Blepharitis. —  In  this  variety  there  are  hyperemia,  red- 
ness, shedding  of  lashes,  and  crusts.  When  the  crusts  are  removed  by  wash- 
ing an  ulcerative  process  is  evident  beneath  them.  Many  yellowish-white 
points  appear,  from  the  center  of  each  of  which  protrudes  a  cilium.     Upon 


246  DISEASES  OF  THE  EYELIDS. 

pulling  out  the  lash  there  is  often  found  adhering  to  the  root  a  small  rounded 
drop  of  pus.  Si  ill  deeper  is  found  a  small  ulcerated  base  extending  into  the 
hair-follicle.     The  cilia  are  readily  removed  on  the  slightest  traction. 

As  the  disease  progresses  the  hair-follicles  are  successively  involved  in 
the  ulcerative  process,  until,  not  infrequently,  the  entire  series  of  cilia  is 
destroyed,  leaving  cicatrices  with  their  attendant  and  consequent  deformity. 
When  the  cilium  has  fallen  out  a  new  one  takes  its  place,  of  a  different  color, 
more  or  less  stunted  in  its  growth,  and  in  a  malposition  the  result  of  cica- 
tricial contraction  of  the  ulcerated  hair-follicles.  The  lashes  thus  become 
more  and   more   stunted  and   misplaced  or  entirely  destroyed. 

By  the  cicatricial  contraction  the  lashes  may  be  turned  backward  so  as  to 
touch  the  eyeball,  giving  rise  to  a  condition  of  trichiasis,  or  the  entire  line 
of  lashes  may  be  destroyed,  leaving  the  lid  bald — madarosis.  Another  result 
of  the  ulcerative  process  may  be  the  gradual  eversion  of  the  lower  eyelid,  due 
to  the  cicatricial  contraction,  which  pulls  the  conjunctiva  forward  upon  the 
lid-border,  the  lid  itself  falling  away  from  the  eyeball  and  permitting  the 
tears  to  run  over,  in  turn  increasing  the  irritation  (lippitudo,  or  "  blear- 
eye  ").  The  final  result  is  an  ectropion.  Hypertrophy  of  the  body  of  the  lid 
not  infrequently  ensues,  due  to  the  long-continued  inflammation,  and  pro- 
duces drooping  of  the  upper  lid  (hypertrophic  blepharitis).  It  may  be  seen, 
therefore,  that  blepharitis  ulcerosa  is  a  much  more  serious  condition  than 
blepharitis  squamosa. 

The  patient  sutlers  little  inconvenience  as  the  result  of  the  disease  in  the 
milder  forms,  and  consults  a  physician  more  on  account  of  the  disfigurement 
than  from  any  great  annoyance.  In  the  more  pronounced  forms  the  sensi- 
tiveness to  light,  the  irritation,  the  sticking  of  the  lids  in  the  morning,  etc. 
are  real  discomforts.  Patients  are  unable  to  use  the  eyes  for  close  work  with 
comfort,  and  when  the  lashes  are  greatly  displaced,  with  the  resulting  corneal 
irritation,  they  become  almost  helpless. 

Etiology. — The  causes  of  blepharitis  are  twofold — viz.  local  and  general. 
The  heal  causes  are  external  irritations  due  to  vitiated  air,  smoke,  injuries, 
and  chronic  conjunctivitis,  especially  if  associated  with  excessive  lachryma- 
tion,  inflammation  of  the  laehrymo-nasal  passages,  and  disease  of  the  rhino- 
pharynx.  Abnormal  shortness  of  the  lids  may  excite  the  affection  (Fuchs). 
Among  the  general  causes  are  the  exanthemata,  scrofula,  anemia,  tuberculosis, 
syphilis,  or  malnutrition  from  any  cause. 

Stubborn  varieties  may  depend  upon  eczema,  eczema  seborrhoeicum,  and 
seborrhea,  and  acne  of  the  surrounding  facial  areas.  Staphylococci  are 
found  in  the  pustules,  and  occasionally  the  tricophyton  fungus  {/>.  tricophy- 
tiea).  The  demodex  fotticulorum  has  also  been  seen  in  the  lid-margin.  Re- 
fractive errors  unquestionably  play  an  important  rdle  in  the  causation  of 
marginal  blepharitis,  :i-  well  as  in  other  irritative  and  inflammatory  lid- 
diseases  ;  but  they  have  not  yet  been  accorded  their  due  weight  as  causative 
factors  in  these  affections.  Correction  of  these  errors  by  proper  glasses  will 
alone  very  often  relieve  ;i  patient  from  troublesome  blepharitis,  which  other 
methods  seem  powerless  to  effect. 

Pathology- —  In  blepharitis  the  inflammatory  process  involves  chiefly 
the  cilia  and  glands.  In  squamous  blepharitis  scales  are  produced  on 
tin-  lid-margins  and  the  cilia  fall  out.  These  grow  thinner  and  shorter 
.Hid  li  --  pigmented,  and,  ;i-  the  epidermis  is  casl  off,  they  entirely  liiil  to 
grow. 

In  blepharitis  ulcerosa  the  epithelium  and  often  the  papillae  are  destroyed 
.it  the  -eat  of  u Ice ra t ioi i,  and  if  the  ulcerative  process  extends  deeply  into  the 


SYPHILIS  OF  THE  EYELIDS.  247 

tis-iu's  of  the  hair-follicles,  thecilia  are  permanently  destroyed  and  cicatricial 
contractions  take  place. 

Prognosis. — Blepharitis  is  essentially  a  chronic  disease.  It  may  la-t  for 
years  and  not  infrequently  for  a  lifetime.  In  young  persons  it  may  disappear 
spontaneously  as  they  grow  older,  while  in  other  cases  it  persists  in  spite  of 
all  treatment.  It  is  essential  that  treatment  should  be  vigorous  to  prevenl 
permanent  lesions. 

Treatment. — The  treatment  must  have  reference  to  both  general  and 
local  conditions,  as  well  as  to  the  causes.  Faulty  states  of  the  general  health 
should  be  corrected  by  appropriate  means.  Excessive  use  of  the  eyes  should 
be  prohibited,  refractive  errors  should  be  examined,  and  proper  glasses  pre- 
scribed. Chronic  conjunctivitis,  so  generally  present  in  these  cases,  should 
be  relieved,  and  any  obstruction  to  the  free  discharge  of  the  tears  through  the 
proper  channel  should  be  removed. 

For  the  milder  forms  of  blepharitis  the  non-irritating  ointments  give  the 
most  satisfactory  results.  After  carefully  removing  the  scales  and  crusts 
with  warm  water  by  gently  washing  them  off,  an  ointment  should  be  well 
rubbed  into  the  roots  of  the  lashes  and  along  the  margin  of  the  lids,  usually 
night  and  morning.  For  this  purpose  a  1  per  cent,  ointment  of  white  pre- 
cipitate, as  being  especially  mild,  has  been  much  used.  The  yellow  and  red 
oxids  of  mercury  are  also  favorite  prescriptions  in  the  proportion  of  one-half 
to  two  grains  to  the  dram  of  vaselin  or  simple  cerate.  A  5  per  cent,  solu- 
tion of  chloral  hydrate,  alternating  with  a  salve  of  pyrogallol  (1  :8)and  a  2  to 
3  per  cent,  sulphur  ointment,  have  been  well  recommended. 

In  the  severer  cases  associated  with  deposits  of  hard  and  strongly  adherent 
crusts,  which  glue  the  lashes  together,  the  use  of  a  solution  of  five  grains  of 
carbonate  of  sodium  to  the  ounce  of  water  is  most  effective  in  removing 
them.  It  is  important  not  to  irritate  the  bases  of  the  ulcers  too  much  by 
violent  means  of  removing  the  crusts.  A  pledget  of  absorbent  cotton,  moist- 
ened with  the  above  solution,  enables  the  patient  or  surgeon  to  remove  the 
crusts  effectually  and  without  force.  After  the  margins  of  the  lids  and  cilia 
have  been  cleared  of  crusts  the  various  ointments  can  be  applied  thoroughly 
to  the  diseased  structures.  In  case  of  ulceration  touching  the  ulcers  with  a 
five-  to  twenty-grain  solution  of  nitrate  of  silver,  or  with  a  sharpened  point  of 
a  silver-nitrate  stick,  acts  most  favorably.  Where  abscesses  occur  the  cilia 
should  be  epilated  with  proper  forceps,  in  order  to  give  the  remedies  an 
opportunity  of  acting  upon  the  diseased  structures.  No  hesitation  need  be 
exercised  about  removing  the  cilia,  for  new  hairs  will  replace  those  removed, 
even  if  they  are  repeatedly  pulled  out.  When  the  disease  has  resulted  in 
extensive  cicatricial  disturbances,  as  trichiasis,  etc.,  proper  operative  measures 
alone  are  to  be  recommended.  For  the  condition  of  madarosis  no  treatment 
avails. 

Phthiriasis  (blepharitis pediculosd)  is  an  affection  resembling  blepharitis, 
and  is  associated  with  it.  The  ciliary  margins  presenf  a  dark  appearance, 
which  is  due  to  the  presence  of  the  nit-  of  the  pediculus  pubis.  (  Hose  exami- 
nation with  a  magnifying-glass  of  the  borders  of  the  lid  will  reveal  the  bases 
of  the  .'ilia  full  of  the  black  eggs  of  the  lice,  and  generally  many  individual 
lice  clinging  to  the  la-he-.  Rubbing  mercurial  ointment  into  the  margin-  oi 
the  lids  destroys  the  lice  and  their  eggs. 

Syphilis  of  the  eyelids  i<  a  somewhal  rare  affection.     Ib>v<  ver,  nol 
only  is  the  primary  ulcer  mef  with  in  this  situation,  bul  also  secondary  a 
tertiary  lesions.     Both  sofl  and  indurated  chancres  occur  on  the  -!  in  of   the 
lids.     The  former  i-  an   ulcer  with  a   ragged  edge  and   with  a  tendency  to 


248  DISK A.s/;s  OF  Till:  EYELIDS. 

spread.  It  appears  without  history  of  injury  or  other  cause.  The  hard, 
indurated  base  of  the  ulcer  in  the  other  ease  is  sullicieiitlv  indicative  of  its 
nature,  and  in  due  time  secondary  manifestations  of  the  disease  are  likely  to 
appear. 

Nol  infrequently  the  lids,  along  with  other  portions  of  the  skin,  are  the 
seai  of  secondary  eruptions.  During  the  third  stage,  occasionally,  ulcers  and 
gummata  appear  in  the  lids,  the  latter  often  presenting  a  striking  similarity 
to  chalazia.  These  sometimes  develop  rapidly  and  undergo  extensive  ulcera- 
tive changes,  producing  ectropion,  lagophthalmos,  etc. 

Treatment  must  include  the  proper  constitutional  remedies,  while  the 
extension  of  the  ulcerative  process  must  be  combated  by  the  use  of  the  cau- 
tery (nitrate  of  silver)  and  propel-  washes,  or  with  compresses  moistened  with 
bichlorid-of-mercury  solution. 

Tumors  and  Hypertrophies. — Many  benign  growths  occur  in  the 
eyelids,  important  on  account  of  the  disfigurement  which  they  produce. 
A  mono;  these  arc  papillomata,  or  warts,  which  grow  on  the  lids  and  their 
borders.  Occasionally,  from  irritation,  these  growths  may  assume  an  epitheli- 
omatous  type  and  prove  serious.  Their  early  removal,  with  cauterization  of 
their  bases,  should  he  practised. 

Angioma  (nevus)  occurs  on  the  lids  or  their  margins  as  a  congenital 
growth.  A  nevus  appears  as  a  bright-red  -pot,  not  elevated,  and  usually  is 
located  near  the  margin  of  the  lid.  Its  tendency  is  to  increase  in  area  some- 
what rapidly. 

The  cavernous  variety  is  usually  elevated,  sometimes  gives  a  pulsatile 
sensation,  and  consists  of  greatly  enlarged  vessels.  It  disappears  under 
pressure  and  becomes  much  enlarged  when  the  patient  stoops  over.  Some- 
times there  may  be  a  bruit  present  if  the  orbit  as  well  as  the  lids  is  involved 
or  if  the  dilatation  of  the  vessels  is  extreme.  The  conjunctiva  may  also  par- 
ticipate in  the  diseased  process.  A  phlebolith  in  a  varix  of  the  conjunctival 
veins  has  been   reported  by  Swan   M.    Burnett. 

Small  Devi  may  be  excised  or  cauterized  with  nitric  acid  or  with  the 
electro-cautery  by  means  of  the  platinum  point.  Electrolysis  may  likewise 
be  employed  with  advantage.  In  the  larger  varieties  the  growth  may  be 
cauterized  at  numerous  points  at  a  little  distance  from  one  another,  as  the 
cicatricial  contraction  of  the  -cars  will  cut  off  the  vascular  supply  between. 
As  little  scar  as  possible  should  be  aimed  at,  and  frequent  sittings  may  be 
advisable. 

bare  forms  of  benign  growths  are  fibroma,  adenoma,  papilloma,  enchon- 
droma,  neuroma,  and  lipoma.  The  last-named  growth  may  produce  a  form 
of  ptosis — the  so-called  ptosis  lipomatosus.  All  of  these  growths  should  be  re- 
moved if  they  produce  any  disturbing  effects,  and  this  is,  as  a  rule,  not  diffi- 
cult  of  accomplishment. 

Cutaneous  horns  sometimes  attain  a  considerable  size.  They  arise  from 
the  skin  of  the  lids,  often  near  the  margin, and  sometimes  involve  a  large 
proportion  of  the  lid-area,  'flic  excrescence  is  slow  in  its  development  and 
attains  a  horn-like  hardness,  especially  toward  its  extremity.  The  growth 
should  be  cm  off  and  a  plastic  operation  replace  the  l< >>i  cutaneous  tissue. 

Xanthelasma  (xanthoma,  mtiligoidea)  occur-  in  the  form  of  rounded 
spots  of  various  sizes  on  the  surface  of  the  skin  of  the  eyelids.  The  patches 
are  often  situated  on  the  eyelids  near  the  inner  angle,  vary  in  size,  and  -how 
a  tendency  to  increase  in  numbers.  They  have  a  peculiar  dark-yellow  color, 
which  is  their  prominent  feature.  They  give  rise  to  no  discomfort.  They 
occur  mostly  in   women  of  advanced  years. 


CHALAZION. 


249 


The  yellow  or  brownish-yellow  patches  may  lie  either  on  the  surface 
of  tlic  skin  (xanthelasma  planum)  or  rise  above  it  (xanthelasma  tuberosum). 
These  new  growths  of  tissue  are  found  to  contain  cells  with  granules  or  glob- 
ules of  oil.    Brown  or  yellow   molecules  ofpigmenl  lie  singly  or  in  clusters  in 

the  cells  and  walls  of  the  lymphatic  vessels.  Ablation  may  be  practised  on 
account  of  the  disfiguremenl   they  produce. 

Chalazion  (Meibomian  cyst,  tarsal  tumor,  cystic  tumor,  tarsal  cyst)  occurs 
as  a  round  tumor  of  variable  size,  giving  the  feeling  of  a  shot  beneath  the 
finger.  The  skin  over  it  is  freely  movable,  but  the  growth  has  a  firm  attach- 
ment to  the  tarsus  beneath. 

Etiology. — The  cause  of  chalazion  is  not  well  understood.  Generally  it 
occurs  in  persons  subject  to  inflammatory  disturbances  of  the  lid-margins, 
frequently  successive  glands  being  attacked,  one  alter  another,  until  most  of 
the  Meibomian  glands  of  one  or  more  lids  have  been  involved.  Refractive 
errors  seem  to  be  an  important  element  in  many  bad  cases  of  chalazion, 
especially  of  the  recurring  type. 


Fig.  172.-Vertical  section  of  chalazion  (Meibomian  cyst);  X  10,  glycerin:  1,  stratified  epithelium 
•continued  over  the  surface  :  2,  connective  tissue  outside  tumor ;  3,  capsule  of  fibrous  tissue  from  which 
septa  pass  inward,  dividing  the  cyst  into  lobules  :  4.  epithelial  cells  inside  capsule  :  5,  fatty  material  occu- 
pying center  of  lobules,  the  (Alter  layers  being  more  opaque  pollock). 

Pathology. — Chalazion  may  be  solitary  or  several  chalazia  may  occur  in 
the  lid,  and  the  lower  and  upper  lids  of  both  eyes  may  be  the  seat  of  the  growths. 
They  originate  in  the  Meibomian  glands,  and  develop  from  an  obstructive 
inflammation  of  the  duct  of  these  glands,  which  prevents  the  excretion  of  the 
sebaceous  material.  This  accumulation  aids  in  the  development  of  an  inflam- 
matory action  involving  the  gland  and  its  surrounding  tissue.  The  result  is 
a  tumor  of  considerable  size,  the  contents  of  which,  undergoing  a  fatty  de- 
generation, become  soft,  and  till  the  sac  with  a  gelatinous  mass  of  granulation 
tissue  containing  giant-cells  or  with  pus  (Fig.  172).  The  process  is  very  sim- 
ilar to  the  formation  of  an  atheroma,  except  that  the  inflammatory  changes 
are  more  marked.  Then-  i<  no  true  cyst-wall.  If  allowed  to  take  its 
course,  the  chalazion  develops  outward,  toward  the  -kin  (external  chalai 
or  involves  the  conjunctiva  (internal  chalazion).  It  frequently  perforate-  the 
latter,  extensive  granulations  springing  up  on  the  under  surface  of  the  lid, 
often  resembling  a  neoplasm.  Usually  a  catarrhal  conjunctivitis,  which 
infect-  the   Meibomian  glands,   precede-   the  chalazion. 

Symptoms. — These  vary  somewhal   in  the  acuti   and  chronic  vari 
In   the  former  the  tumor  may  develop   rapidly,   with    indications   of   much 
inflammation   and    with    - •    pain    and    tenderness.      It    resembl  - 


2.-.I » 


DISEASES  OF  THE   EYELIDS. 


except  that  the  tumor  is  more  circumscribed  and  does  not  "  point."  The 
chronic  variety  grows  slowly  and  causes  no  uneasiness,  to  the  patient,  except 
the  feeling  of  weight  in  the  lid  which  it  gives  (Fig.  17.°>).  Should  the  growth 
perforate  the  conjunctiva,  there  may  result  some  conjunctival  and  corneal  irri- 
tation, due  to  the  rubbing  of  the  granulations  upon  these  membranes.  An 
acute  chalazion  is  liable  to  be  confounded  with  a  stye,  the  diffuse  appearance 
and  "pointing"  of  the  latter,  however,  serving  to  distinguish  it.  The  chronic 
variety  has  been  mistaken  for  small  malignant  growths  and  sebaceous  cysts. 
The  firm  attachment  of  the  chalazion  to  the  tarsus  should  serve  to  differentiate 
it  from  a  cyst.  Sarcomata,  when  small,  are  difficult  to  diagnose,  and  some- 
times a  microscopic  examination  becomes  necessary  to  determine  the  true 
nature  of  the  growth. 


PlG.  17U. —Chalazion.    (From  a  patient  in  the  out-patient  department  of  the  Western  Reserve  University, 

Medical  Department.) 

Treatment. — The  only  satisfactory  treatment  for  chalazion  is  surgical. 
Some  relief,  perhaps,  may  be  afforded  in  the  acute  variety  by  frequent  hot 
pack-,  followed  by  the  use  of  the  yellow-oxid-of-mercury  ointment.  The 
proper  surgical  procedure  for  its  removal  is  described  on  page  546. 

Sarcoma,  as  a  primary  growth,  develops  in  the  connective  tissue  of  the 
lid-,  ami  occur-  usually  in  children.  In  the  early  stage  of  its  growth  the 
skin  moves  freely  over  the  tumor,  but  this  rapidly  invades  the  overlying 
tissues,  which  break  down  and  become  ulcerated.  Sarcoma  of  the  eyelids, of 
the  small  spindle-celled  variety,  may  resull  from  traumatism.  It  sometimes 
resembles  a  chalazion,  but  careful  examination  is  likely  to  show  a  deeper 
coloring,  with  diffuse  swelling.  Microscopical  examination  alone  will  some- 
times determine  the  true  nature  of  the  trouble. 

Primary  sarcoma  of  the  eyelid  may  arise  from  any  of  the  subepithelial 


CARCINOMA    OF  THE  LIDS. 


25  1 


tissues,  and  may  be  of  the  spindle-,  large  <>r  small  round-,  or  mixed-celled 
variety.  Pigmentation  (({'cells  or  cells  and  stroma  is  sometimes  seen  (melano- 
sarcoma).  W.  II.  Wilmer,  who  has  described  a  melanotic  giant-celled 
sarcoma,  has  analyzed  •">•">  eases,  and  finds  that  4<>  per  cent,  were  spindle- 
celled,  43  per  cent,  round-celled,  17  percent,  mixed,  and  11  per  cent,  pre- 
sented myxomatous  element.-. 

An  early  excision  of  the  growth  alone  offers  any  hope  of  protection  against 
a  fatal  outcome  of  the  trouble.  Even  after  thorough  removal  return  of  the 
growth  occurs  in  40  per  cent,  of  the  cases   (Wilmer). 

Carcinoma. — The  most  usual  type  of  carcinoma  of  the  lid  is  the  epitheli- 
omatous  ulcer,  commonly  called  "rodent  or  Jacob's  ulcer."  The  border  of 
the  lid  is  the  favorite  starting-point  for  the  growth,  which  occurs  in  elderly 
persons.     It  usually  begins  as  a  small   pimple  covered  with  a  crust,  and  its 


Fig.  174.— Rodent  nicer  besinninqr  in  the  left  lower  eyelid.    (From  a  patient  in 
land,  Ohio,  under  the  eare  of  Dr.  Dudley  1'.  Allen.) 


'harity  Hospital,  Cleve- 


growth  i-  often  exceedingly  slow.  As  time  goes  on  it  gradually  develops 
into  a  flat  ulcer,  with  indurated,  ragged,  and  elevated  edges,  attended  with 
only  a  -light  secretion.  Eventually  it  may  involve  the  lid-,  eyeball,  and  adja- 
cent structures  (Fig.  171).  Rodent  ulcer  may  he  mi-taken  for  a  syphilitic 
ulcer,  l>ut  generally  the  age  of  the  patient,  the  -low  growth  of  the  tumor, 
and  the  therapeutic  test  with  iodid  of  potassium,  which  rapidly  relieves  a 
syphilitic  ulcer,  suffices  to  differentiate  the  epithelial  growth  from  the  latter 
affection.      It   i-  distinguished  from  lupus,  because  this  disease  occurs  usually 

in  young  subjects,  because  of  the  greater  inflai atory  action  of  lupus,  and 

because  other  portions  of  the  body  are  at   the  same  time  similarly  affected. 

Pathology. — Ordinary  epithelioma  of  the  eyelid  presents  no  diff! 
from  epithelioma  of  the  -kin  elsewhere.     From  the  greatly  thickened  epider- 
mis irregular  outgrowths  penetrate  into  the  subepithelial  structures.     Epithelial 


DISEASES  OF   THE  EYELIDS. 

cell-nests  may  also  lie  in  this  layer,  together  with  "  epithelial  pearls."  The 
surrounding  tissue  is  usually  very  vascular  and  infiltrated  with  round  and 
epithelial  cells.  The  growth  may  originate  from  the  epidermis  or  from  the 
epithelial  lining  of  the  sebaceous  or  sweat-glands;  rarely  from  Meibomian 
glands.  At  times  it  appears  as  a  raised  ulcer  with  infiltrated  edges.  The 
growth  may  be  ver^  -low,  and  cicatrization  take  place  in  the  center  a>  the 
ulceration  progresses  at  the  edges.  It'  the  ulcerative  process  is  an  elaborate 
one  and  extends  into  the  deeper  as  well  as  surrounding  tissues,  a  "rodent 
ulcer*'  results.  The  stroma  of  these  epitheliomata  is  always  more  or  less 
infiltrated  with  round-cell-  and  presents  the  appearance  of  granulation-tissue. 

Rare  forms  of  cancer  of  the  lid-structures  having  their  point  of  origin  in 
the  Meibomian  or  in  Krause's  glands  may  be  denominated  glandular  carci- 
nomata,  in  contradistinction  to  the  ordinary  epitheliomata  and  rodent  ulcers. 

Treatment. —  Radical  measures  alone  give  any  promise  of  permanent 
relict'  in  carcipomata.  An  early  operation  for  their  removal  should  be  per- 
formed and  the  exposed  surface  covered  with  suitable  skin-flaps.  In  the 
later  stages  palliative  measures  to  aid  in  limiting  the  rapidity  of  the  growth 
may  he  used.  To  further  this  end  caustic,  chloracetic  acid,  scraping  with  a 
curette,  or  the  actual  cautery  may  be  employed.  As  milder  measures  aristol, 
chlorate  of  potassium,  and  injections  of  pyoktanin  have  been  recommended. 
Not  infrequently  in  the  advanced  cases  it  may  be  necessary  to  remove  the 
eyeball,  together  with  the  orbital  and  periorbital  tissues. 

I^upus  Vulgaris. — Associated  with  lupus  of  the  lace  or  nose  the  eyelids 

may    beco the   seat   of  this  affection.      The   ulcers  are  formed   by   several 

points  of  infection  coalescing  and  producing  ragged,  soft  edges,  which  exude 
an  offensive  secretion.  The  disease  frequently  inflicts  much  damage  to  the 
lid-tissue,  eventuating  in  marked  cicatricial  contraction  and  deformity.  The 
history  of  the  case,  together  with  the  fact  that  the  face  and  nose  are  involved 
in  the  same  disease,  will  serve  to  distinguish  lupus  from  the  syphilitic  ulcer, 
for  which    it    is   likely  to  be   mistaken. 

Treatment. — ( lauterization  by  means  of  caustic  paste  or  the  actual  cautery 
gives  the  1m  -t  results  in  the  early  stage  of  the  disease.  The  ulcers  may  also 
be  curetted.  When  the  ulcers  arc  large  sxcision  may  be  practised,  with  the 
proper    plastic   operation    for  covering   the  denuded    surface  of  the   eyelids. 

I^epra. — Leprosy  of  the  eyelids  is  very  frequent  in  countries  where  the 
general  disease  is  prevalent.     Tubercular  growths  form  in  the  region  of  the 

brows    and     cilia,    producing    loss   of    the    lashes    and    eyebrows.       Anesthetic 

patches  of  a  color  slightly  different  from  the  surrounding  skin,  with  entropion 
and  ectropion,  are  frequently  developed. 

Elephantiasis  Arabum  i-  characterized  by  a  chronic  hypertrophy  of 
the  skin  and  subcutaneous  tissue.  The  lids  reach  enormous  proportions, 
and  from  their  mere  weight  prevent  the  patient  from  opening  the  eyes. 
The  upper  Md-  .lie  the  ones  usually  affected.  Elephantiasis  occurs  congen- 
itally  or  may  result  from  an  injury.  According  as  the  hypertrophy  affects 
the  lymphatics  or  the  blood-vessels  the  name- of  elephantiasis  lymphangiec- 
imlis  ;md  elephantiasis  telangiectodes  have  been  assigned.  Removal  of  the 
excessive  growth  of  tissue  sufficient  to  enable  the  patient  to  open  the  eyes 
offers  the  most    hope  of  relief. 

Tarsitis  is  usually  a  chronic  inflammation  of  the  tarsus  characterized  by 
thickening  of  tin-  body.  Acute  tarsitis,  with  sloughing  of  the  tissues,  has 
been  described.  There  is  often  found  associated  with  conjunctivitis  ami 
blepharitis  a  thickening  of  the  tarsus,  especially  in  scrofulous  subjects. 
Syphilitic  tarsitis   is  the  mosl    frequent    variety  of   the  disease,  and   in  this 


/;/. /,77/. I  ROSPASM. 


253 


affection  the  thickening  of  the  lids  is  often  very  marked,  giving  rise  to  much 
deformity.  It  usually  occurs  in  the  third  stage  of  syphilis,  and  assumes  the 
gummatous  type  of  the  disease;   more  rarely  an  acute  form  appear-. 

The  symptoms  of  tarsi  tis  are  gradual  thickening  of  the  lid,  without  marked 
inflammatory  disturbance,  and  the  consequent  inconvenience  to  the  patient 
of  the  bulk  of  the  eyelid,  which  may  droop  over  the  globe.  If  the  lower  lid 
is  the  seat  of  the  disease,  the  weight  of  the  lid  sometime-  pulls  it  away  from 
the  eyeball,  producing  an  ectropion.  In  severe  eases  an  atrophy  of  the  tarsus 
may  ensue  after  the  subsidence  of  the  inflammation  (Fig.  175). 


Fig.  175.— Syphilitic  tarsitis. 


patient  undei  the 
Hospital.) 


•initz  in  the  Philadelphia 


Treatment. — The  remedies  appropriate  to  blepharitis  should  be  used 
locally, and  any  constitutional  disturbance  corrected  by  proper  means.  In 
tarsitis  syphilitica  treatment  suitable  for  the  specific  disease  should  be  insti- 
tuted.     Recovery  i-  -low,  but  generally  perfect. 

Blepharospasm  i-  characterized  by  a  cramp-like  contraction  of  some  or 
of  all  of  the  tibei'-  of  the  orbicularis  muscle. 

A  frequent  condition  in  many  persons  is  the  contraction  of  a  few  fibers  "t 
the  orbicularis  muscle  in  either  the  upper  or  lower  lid,  which  is  very  annoy- 
ing.    The  twitching  of  the  muscle  may    readily    be   seen    by   an   observer. 
This  condition  i-  usually  indicative  of  some  local  irritation  of  the  eye-  or  the 
lid.-,  and  i-  of  do  great   import. 

A  more  serious  and  uncomfortable  phase  of  the  difficulty  is  cramp  o\  the 
entire  muscle,  when  the  eyelids  close  tightly  and  violently.     There  are  two 


254  DISEASES  OF  THE  EYELIDS. 

varieties  <>t'  blepharospasm — the  clonic  and  the  tonic  spasms.  In  the  former 
the  spasm  is  of  momentary  duration,  and  consists  of  a  series  of  forcible  uncon- 
trollable "Winkings;"  in  the  latter  there  is  a  violent  closure  of  the  lids, 
which  remain  tightly  shut  for  some  minutes  or  for  days  or  months,  and  the 
patienl  i-  rendered  practically  blind  by  the  inability  to  use  the  eyes.  Blind- 
in--  has  occasionally  resulted,  manifest  when  the  patient  has  become  able  to 
open  the  eyes,  either  with  or  without  grave  ophthalmoscopic  changes. 

Blepharospasm  may  be  either  a  symptomatic  condition  or  an  essential 
disease.  Children  especially  are  prone  to  have  slight  more  or  less  frequent 
"blinking"  attacks  or  nictitation,  especially  when  using  their  eyes  in  school- 
work.  They  are  generally  found  to  have  slight  conjunctivitis  or  an  asthe- 
nopic  condition  due  to  refractive  error.  Not  infrequently  associated  with 
this  i-  a  choreic  or  spasmodic  affection  of  the  facial  muscles.  Blepharospasm 
i-  essentially  due  to  reflex  irritation  of  the  fibers  of  the  trigeminus,  and  hence 
occurs  in  follicular  conjunctivitis,  with  foreign  bodies  in  the  eye  ( when  the 
spasms  may  be  mine),  with  blepharitis,  refractive  errors,  and  muscular  insuf- 
ficiencies. Depending  upon  the  cause,  the  attacks  are  monocular  or  binocular, 
the  latter  form  prevailing  in  all  severe  cases,  the  attacks  being  usually  more 
severe  on  one  side.  In  hysterical  subjects  the  attacks  come  on  without  any 
known  cause,  the  eyes  close  tightly,  the  spasm  is  persistent,  and  the  patient  is 
rendered  helpless.  In  adults  as  well  as  in  children  the  facial  muscles  may 
twitch  as  actively  as  the  orbicularis.  In  elderly  people  the  spasm  is  often 
associated  with  tie  or  with  chronic  conjunctivitis. 

Treatment. — The  treatment  of  blepharospasm  depends  upon  the  cause. 
In  case  of  local  irritation  removal  of  the  foreign  body,  relief  of  conjunc- 
tivitis, blepharitis,  or  other  local  inflammation,  correction  of  refractive  errors, 
and  gymnastic  exercise  for  insufficiency  of  the  eye-muscles  are  the  essen- 
tial point-  to  be  considered.  The  general  health  should  be  looked  into,  and 
tonics,  especially  iron,  quinin,  and  strychnin,  should  be  exhibited,  care 
being  taken  that  the  latter  does  not  aggravate  the  trouble.  Antispasmodics, 
as  conium  and  gelsemium,  pushed  to  their  physiological  tolerance,  may  be  of 
benefit. 

In  many  cases  medication  seems  to  have  no  beneficial  effect.  In  some 
patients  pressure  on  certain  points  seems  to  relieve  temporarily  the  difficulty. 
The  patient  discovers  these  and  learns  to  control,  in  a  measure,  the  orbicularis 
spasm  by  pressing  upon  the  point.  This  point  may  be  situated  on  the  fore- 
head or  in  some  other  portion  of  the  head.  In  such  cases  galvanism,  or,  in 
very  bad  cases,  hypodermic  injections  of  morphin  in  these  regions,  may  be 
tried.  Complete  rest  from  work,  with  change  of  climate,  sea-bathing,  or 
mountain-climbing,  have  sometimes  proved  efficacious  when  other  means  have 
failed. 

Ptosis  (blepharoptosis,  blcpharoplegia)  i>  a  term  properly  applied  to  a 
drooping  of  the  eyelid  due  to  paralysis  of  the  levator  palpebrarum  muscle. 
In  addition  t"  true  ptosis  there  i-  a  more  or  less  marked  degree  of  drooping 
of  the  lid  <liie  to  its  increased  weighl  or  bulk,  which  prevents  the  levator 
from  sufficiently  raising  the  lid  t<>  expose  the  eyeball.  This  often  is  the  case 
in  tarsitis,  hypertrophic  blepharitis,  granular  conjunctivitis,  ami  tumors  of 
various  sorts  occurring  in  the  substance  of  the  lid.  Bu1  ptosis  proper  is 
due  either  to  paralysis  <>f  the  oculo-motor  nerve  or  to  a  fault  in  the  develop- 
ment of  the  levator  muscle  it-elf. 

The  affection  may  be  a  congenital  or  an  acquired  one.     In  the  congenital 

cases  the  ptosis  may   be  associated   with  other  congenital  malformations  of  the 

lid-,  eye,  or  orbit.     In  some  cases  of  unilateral  congenital  ptosis,  usually  on 


LAGOPHTHALMOS. 


255 


the  left  side,  while  the  eyelid  cannol  be  raised  voluntarily,  it  is  raised  when 
the  jaw  is  moved  during  eating,  or  there  i>  contraction  of  the  levator  in  asso- 
ciation with  the  external  pterygoid.  Not  infrequently  ptosis  is  the  result  of 
injury  to  the  muscle-fibers  or  to  the  supraorbital  branch  of  the  oculo-motor 
(Fig.  176).  Paralysis  of  the  eye-muscles  is  frequently  associated  with  ptosis, 
and  it  may  be  found  in  certain  eases  of  hemiplegia  or  from  lesion  of  the 
cortical  center.  In  bilateral  ptosis  the  peculiar  pose  of  the  head,  which  is 
thrown  back  to  enable  the  patient  to  look  under  the  drooping  lids,  is  strikingly 
characteristic. 

Treatment. — The  cause  must  determine  the  proper  procedure.      Medicinal 
measures  must  be  instituted  if  the   palsies  are  of  syphilitic,  rheumatic,  or  of 


Fig.  176.— Traumatic  ptosis  with  cystic  tumor  of  orbit.     (Western  Reserve  University,  Medical  Depart- 
ment.) 

other  origin  which  is  amenable  to  medicinal  agents.  The  surgical  treatment 
is  described  elsewhere  (see  page  557). 

I,agOphthalmos  manifests  itself  by  an  inability  of  the  eyelids  to  do-,.. 
the  degree  of  this  immobility  varying  as  the  cause  is  a  paralytic  or  a  non- 
paralytic one.  The  non-paralytic  causes  art — shortening  of  the  eyelids, 
which  may  be  congenital  or  due  to  loss  of  tissue  of  the  lids  from  burn-, 
ulceration,  gangrene,  etc.  ;  ectropion  ;  loss  of  reflex  sensibility  in  the  eyeball 
and  protrusion  of  the  globes,  so  that  the  lids  are  unable  to  cover  them,  as  in 
exophthalmic  goiter,  orbital  tumors,  etc. 

The  most  marked  cases  are  caused   by  paralysis  of  the  orbicularis  muscle, 

usually  associated  with  facial  paralysis.     The  distressing  symp< -  of  lagoph- 

thalmos  arise  in  connection  with  the  cornea,  which  i-  exposed  to  external 
irritations  and  suffers  the  loss  of  the  lubricating  and  protecting  action  <>f  the 
lids.  The  exposed  portions  of  the  cornea  and  conjunctiva  become  chronically 
inflamed,  and  ulceration  and  even  blindness  may  be  the  result. 

Treatment  should  have  in  view,  primarily,  the  protection  of  the  eyeball 
from  external  irritation.  Patients  are  likely  to  suffer  most  while  isleep  from 
inability  to  close  the  lids  bv  voluntary  action.      Hence  in  bad        es  the  lids 


256 


DISEASES   OF  THE  EYELIDS. 


should  be  closed  with  adhesive  plaster,  a  compress  and  bandage,  <>r  by  other 
suitable  mean-.  Relief  should  be  directed  to  the  cause  of  the  affection  in  the 
paralytic  variety,  and  the  operation  of  tarsorrhaphy  (page  547)  may  be  re- 
quired. 

Symblepharon  is  an  abnormal  adhesion  of  the  eyelid  to  the  eyeball. 
It  may  be  congenital,  but  is  usually  the  result  of  injuries,  especially  burns 
from  acid-,  lime,  or  hot  metal  (Fig.  177).  It  occurs  always  when  the  con- 
junctival structure  is  destroyed  in  its  sulcus  and  when  the  palpebral  and 
bulbar  conjunctiva'  are  cauterized  in  approximate  positions.  It  also  results 
from  purulent  and  granular  conjunctivitis,  pemphigus,  etc.  Not  infrequently 
the  lid-margins  become  strongly  adherent  to  the  cornea  by  cicatricial  bands  or 
the  entire  body  of  the  lid  may  be  adherent  i  Fig.   17.S). 


Fig.  177.— Symblepharon  due  to  burn    hot  metal.    (Prom  a  patient  in  Western  Reserve  t'niversity,  Medical 

Department,  i 

Ankyloblepharon  has  the  same  causes  as  symblepharon,  and  likewise 
may  be  congenital  or  acquired.  It  consists  of  a  union  between  the  margins 
of  the  upper  and  lower  lid-,  and  may  be  'partial  or  complete.  In  the  acquired 
variety  burn-  are  the  most  common  cause. 

Biepharophimosis  is  an  agglutination  of  the  eyelid-  at  the  outer  angle 

of  the  eye.  ean-cd  usually  by  eliroiiie  eoiijti net ivi t i-  or  ulceration  at  the  com- 
missure.    The  adhesions  cause  shorteningof  the  palpebral  opening. 

Treatment. — These  condition-,  generally  due  to  a  similar  cause,  require 
like  treatment.  In  case  of  injury,  burn-,  etc.  care  should  be  exercised  to 
keep  tin'  lid-  well  separated  from  each  other  a-  well  a-  from  the  eyeball.  In 
case  of  extensive  burn-  of  both  the  bulbar  and  palpebral  conjunctiva  no 
method  will  prevenl  the  lid  and  the  eyeball  from  becoming  adherent,  with  the 
formation  of  a  more  or  less  complete  symblepharon.  When  the  deformity 
has  occurred  suitable  Burgical  measures  should  lie  employed  for  its  correction 
(see  page  5  18). 


ENTROPION. 


257 


Trichiasis  is  a  term  used  to  describe  thai  condition  of  the  lids  where  the 
eyelashes  are  turned  backward  so  as  to  rub  against  the  eyeball.  A  single 
cilium  or  the  entire  row  of  lashes  may  be  inverted. 

The  most  frequent  cause  of  trichiasis  is  trachoma.  The  entire  conjunctiva] 
surface  being,  as  a  rule,  involved  in  chronic  trachoma,  the  resulting  cicatricial 
contraction  affects  the  entire  border  of  the  lid  and  occasionally  develops  more 
or  less  complete  trichiasis.  The  more  localized  affection  i-  likely  to  be  due 
to  burns,  blepharitis,  injuries,  operation-,  etc.  The  result  of  the  lashes  turn- 
ing in  is  marked  irritation  of  the  cornea,  which  often  results  in  ulcers  :  thick- 
ening of  the  epithelial  covering,  somewhat  simulating  pannus  ;  constant  lach- 
rymation  ;  and,  in  long-continued  cases,  permanent  impairment  of  vision. 

Distichiasis  is  a  term  applied  to  that  affection  where  there  arc  double 


Fig.  178. — Complete  symblepharon  due  to  burn.    (From  a  case  in  Western  Reserve  University,  Medical 

Department. 

rows  of  lashes,  one  row  being  directed  properly,  while  the  other  is  turned 
backward  against  the  eyeball.  Some  authors  consider  distichiasis  -imply  one 
step  in  the  development  of  trichiasis  and  assign  the  term  to  the  congenital 
affection  alone.     The  causes  of  the  two  affections  are  the  same. 

Treatment. — Should  a  single  lash  or  a  small  number  of  lashes  turn  in, 
temporary  relief  i>  afforded  by  ( pilation  of  the  cilia  which  are  at  fault.  The 
lashes  grow  again,  however,  and  this  operation  must  be  frequently  repeated. 
Patient-  can  often  remove  the  lashes  themselves  with  a  pair  of  cilium  fore 
For  permanent  relief  electrolysis  or  some  other  operative  procedure  must  be 
employed  i  see  page  5  16). 

Entropion  is  a  turning  inward  against  the  eyeball  of  the  external  lid- 
margin.  Not  only  the  lashes  bul  the  skin  of  the  palpebral  margin  is  rolled 
back  againsl  the  eye.  Two  varieties  of  this  affection  have  been  described, 
the  spasmodic  and  the  organic.     The  former  results  from  the  over-acti  m  of 

the  orbicularis  muscle  due  to  the  reflex  irritati f  conjunctivitis,  kerat 

etc.     En  elderly  people  it   not   infrequently  results  from  operations  when 
eye  ha- Keen  kept  bandaged  too  long.     The  organic  type  results  from  chronic 

17 


258 


DISEASES   OF    THE   EYELIDS. 


trachoma,  diphtheritic  conjunctivitis,  burns,  injuries,  etc.,  which  lead  to  cica- 
tricial contraction  of  the  conjunctiva.  The  effecl  upon  the  cornea  may  be 
serious  on  account  of  the  production  of  ulcers,  opacities,  etc. 

Treatment. — Spasmodic  entropion  is  generally  relieved  by  the  disappear- 
ance of  the  conjunctivitis,  keratitis,  or  foreign  substance  which  has  caused  it. 
Early  removal  of  the  bandage  is  necessary  when  the  entropion  occurs  after 
cataract  operation.-.  Strips  of  adhesive  plaster  applied  to  the  lid-margin  by 
one  extremity  and  by  the  other  to  the  cheek,  or  collodion  painted  over  the 
lid.  or  strips  of  gauze  fixed  with  collodion  applied  in  the  same  manner  as  the 
adhesive  strip-,  serve  a  most  useful  purpose  in  case  of  spasmodic  ectropion. 
The  s<  rr<-fim  has  been  used  with  advantage  by  fixing  a  fold  of  the  skin,  thus 
pulling  the  lid-margin  away  from  the  eyeball.  The  chronic  types  of  entropion 
require  careful  surgical  treatment.  The  operations  are  described  on  page  548. 
Ectropion  i-  a  rolling  outward  of  the  eyelids,  so  that  the  conjunctival 
portion  is  exposed  to  view.     This  eversion  may  be  partial  or  complete.     It 

may  also  be  spasmodic  or 
muscular  and  chronic  or  or- 
ganic.  In  the  former  case 
it  is  due  to  the  over-action 
of  the  peripheral  fibers  of 
the  orbicularis  muscle.  The 
lower  lid  sometimes  shows  a 
tendency  to  droop,  particu- 
larly in  elderly  people  and  in 
persons  affected  with  facial 
palsy.  The  tears  thus  run 
over  the  cheeks  and  occasion 
additional  irritation. 

The  causes  of  organic 
ectropion  are  those  which 
produce  a  cicatricial  shorten- 
ing in  the  length  of  the  eye- 
lids, as  chronic  blepharitis, 
lupus,  necrosis  of  the  orbit 
or  malar  hone,  abscesses, 
burns,  and  injuries  (  Fig. 
1  79).     The  eve  beinir  more  or 

less  exposed,  the  cornea  suf- 
fers from  external  irritant-. 

Treatment. — No1  infrequently  the  excessive  lachrymation  which  occurs 
in  ectropion  may  be  cured  by  slitting  up  the  canaliculus  and  passing  probes 
through  the  naso-lachrymal  duet.  Associated  inflammation  of  the  cornea  and 
conjunctiva  should  receive  attention.  The  severer  chronic  forms  of  the  affec- 
tion require  operative  measures  for  their  relief  (see  page  551  ). 

Seborrhea  is  characterized  by  a  secretion  on  the  margin  of  the  lids 
cither  of  an  oily  fluid  or  of  :i  sebaceous  material,  which  dries,  forming  crusts 
or  scales  along  the  cilia.  Generally,  seborrhea  of  the  face,  scalp,  or  other 
portions  of  the  body  i-  an  accompanying  affection.  It  not  infrequently  occurs 
in  young  persons  about  the  age  >>\'  puberty.  Conjunctivitis  and  marginal 
blepharitis  are  frequenl  concomitants. 

Treatment  mu-t  be  directed  to  the  improvement  of  the  general  health. 
Removal  of  the  crusts  and  the  application  of  mercurial  or  sulphur  ointments, 
together  with  measures  suited  to  conj stivitis  and  blepharitis,  are  required. 


Fig.  179.— Case 


■  !  ectropion     (From  a  patient  in  On-  Charity 
Hospital.) 


CHBOMIDBOSIS. 

Milium. — Milia  arc  accumulations  of  sebum  in  closed  sebaceous  glands. 
These  growths  arc  about  the  size  of  a  milletseed,  from  which  they  take  their 
name.  They  present  a  yellowish-white  appearance,  and  are  slightly  elevated 
above  the  surrounding  skin,  giving  the  feeling  of  a  pinhead  under  the  finger. 

They  usually  indicate  improper  care  of  the  skin,  and  occur  in  persons  with 
some  disturbance  of  digestion,  constipation,  etc. 

Treatment. — Hot  applications,  frequently  repeated,  together  with  suitable 
remedies  for  indigestion  or  constipation,  will  prove  beneficial.  After  removal 
of  the  milium  with  a  knife-point  or  needle,  hot  packs  and  mild  ointment-,  well 
rubbed  in,  will  afford  relief. 

Molluscum  contagiosum  (molluscum  sebaceum)  occurs  in  the  lids  in 
the  form  of  small  rounded  tumors  which  originate  from  the  sebaceous  glands. 
They  attain  the  size  of  a  pea,  have  an  umbilicated  appearance  due  to  the  ori- 
fice of  the  gland  on  the  summit  of  the  growth,  and  have  a  wax-like  color. 
The  material  from  the  growths  is  contagious.  The  disease  not  infrequently 
occurs  among  children  in  asylums  and  schools  in  the  nature  of  an  epidemic. 
The  contagious  nature  of  the  disease  is  supposed  to  be  due  to  a  parasite,  and 
the  aifection  is  allied  in  character  to  contagious  epitheliomata.  The  parasite 
is  believed  by  some  author-  to  belong  to  the  class  Coccidia,  and  to  inhabit 
the  epithelial  cells  and  cause  the  formation  of  these  small  prominent  epi- 
thelial growths.  The  coccidia  multiply  in  the  cells  of  the  epithelial  pro- 
jections; these  are  then  cast  off  and  accumulate  as  a  mass  of  epithelial 
detritus.  According  to  H.  Muetze,  the  molluscum  corpuscles  are  the  prod- 
uct of  a  degeneration  of  the  epithelial  cells  caused  by  the  contagium,  the 
nature  of  which  is  uncertain ;  but  the  corpuscles  themselves  are  not 
parasites. 

Treatment  consists  of  opening  each  molluscum  and  scraping  out  it.-  con- 
tents.    Cauterizing  the  sac  with  nitrate  of  silver  may  also  be  employed. 

Hphidrosis  (hyperidrosis)  is  a  rare  affection  of  the  lid-  characterized  by 
profuse  secretion  from  the  sweat-glands.  It  is  associated  with  excessive 
sweating  of  other  portions  of  the  lace  or  body,  and  has  been  noticed  in  cases 
of  unilateral  facial  sweating.  Its  cause  is  not  understood.  It  may  produce 
excoriations,  especially  at  the  angles  of  the  eyes  and  in  the  skin-fold-. 

Treatment  must  be  directed  to  the  excoriations  of  the  -kin  and  to  the 
cause  if  it  can  be  discovered. 

Chromidrosis  I  sometimes  called  seborrhcea  nigricans1)  is  the  formation 
of  various  colored  secretions  on  the  eyelids,  the  oily-like  fluid  giving  a  bluish 
or  blackish  color  to  the  affected  skin.  It  usually  occurs  on  the  lower  lid. 
The  discoloration  can  readily  be  removed  by  wiping.  Some  author-  believe 
that  it  i-  always  an  evidence  of  malingering,  as  it  most  frequently  occur-  in 
hysterical  patients,  particularly  young  women.  In  rare  instances  it  i-  genuine. 
It  may  be  caused  bv  a  deposit  of  dust  upon  a  cutaneous  surface  affected  with 
seborrhea. 

Treatment  should  be  directed  toward  the  relief  of  any  general  disturb- 
ance of  the  health.  The  discoloration  may  be  removed  with  some  oily  sub- 
stance; lead-water  and  glycerin  have  been  recommended. 

Sebaceous  cysts  arc  small  rounded  bodies  of  the  size  of  a  pea  or  of  a 
hazelnut   which   occur   in   the   thicker  portion-  of  the  skin  of  the  eyelids, 
especially  in  the  superior  or  external  orbital   portion  of  the  lid  |  Fig. 
They  develop  from  the  sebaceous  follicles  of  the  skin,  and  contain 
(•eon-,  oily- like  material,  and  frequently  fine  hairs.     They  have  well-formed 

1  For  ;i  full  account  of  thi>  affection  see  a  paper  by  I>r.  .1.  K.  Mitchell  in  the  Phila. 
Jwrn.,  1898,  L  117-119. 


260 


/>/,v/;j.s/;,s  OF  THE  EYELIDS. 


cyst-walls,  which  enables  the  surgeon  to  dissect  them  out  without  great  diffi- 
culty, this  being  the  proper  method  of  treatment. 


JF'     ^ 

^^                          *% 

Fig.  180.— Sebaceous  tumor  of  the  eyelid.    (From  a  patient  in  the  Western  Reserve  University, 

"  Medical  Department.) 

Dermoid  cysts  likewise  occur  in  the  same  region  and  should  be  removed 
in  like  manner. 

Cysticercus  has  been  observed  a  few  times  under  the  skin  of  the  eye- 
lid-, having  the  appearance  of  a  sebaceous  cyst,  only  the  contents  are  fluid. 
On  opening  the  tumor  the  remains  of  the  parasite  are  discovered. 


THE  EYEBROWS. 

The  eyebrows  may  he  the  seat  of  eczema  or  of  seborrhea,  and  are  a  favorite 
situation  for  the  developmenl  of  sebaceous  and  dermoid  cysts.  Occasionally 
these  growths  extend  some  distance  into  the  orbit,  where  by  pressure  they 
may  produce  a  depression  in  the  underlying  hone. 


DISEASES   OF   THE   LACHRYMAL   APPARATUS. 

By   SAMUEL  THEOBALD,   M.  1)., 

OF    BALTIMORE. 


In  treating  of  diseases  of  the  lachrymal  apparatus  it  is  convenient  to  con- 
sider, first,  those  affections  which  have  to  do  with  the  lachrymal  gland  and  its 
ducts,  and,  second,  those  of  the  drainage  apparatus,  including  the  puncta,  the 
canaliculi,  the  lachrymal  sac,  and  the  nasal  duct.  The  lachrymal  gland,  prob- 
ably owing  to  its  protected  position  and  its  multiple  ducts,  is,  comparatively 
speaking,  rarely  the  seat  of  disease,  while,  on  the  other  hand,  disease  of  the 
drainage  apparatus,  doubtless  because  of  its  intimate  anatomical  and  patho- 
logical relationship  to  the  nasal  passages,  is  of  very  frequent  occurrence. 

DISEASES  OF  THE  LACHRYMAL  GLAND. 

Dacryoadenitis,  or  inflammation  of  the  lachrymal  gland,  occurs  as  an 
acute  and  as  a  chronic  affection.  Both  varieties  are  rare,  though  it  seems  not 
improbable  that  acute  inflammation  of  the  gland  is  sometimes  mistaken  for 
cellulitis  of  the  orbit,  from  which  it  is  not  always  easy  to  differentiate  it. 

Etiology. — It  occurs  more  frequently  in  children  than  in  adults,  and 
oftener  in  women  than  in  men.  It  has  been  known  to  assume  an  epidemic 
character,  and  Galezowski  reports  having  met  with  an  unusual  number  of 
cases  during  an  epidemic  of  mumps.  Other  causes  to  which  it  has  been 
ascribed  are  traumatism,  "  cold,"  rheumatism,  gout,  struma,  syphilis,  septic 
absorption,  and  the  extension  of  inflammation  from  the  conjunctiva  and  cornea. 
It  is  usually  unilateral,  but  not  infrequently  both  glands  arc  involved. 

Symptoms. — Acute  dacryoadenitis  gives  rise  to  severe  pain,  which  may 
be  accompanied  by  elevation  of  temperature,  cerebral  excitement,  sleepless- 
ness, and  delirium.  The  lids,  especially  the  upper  lid,  are  greatly  swollen, 
and  there  is  marked  chemosLs  of  the  conjunctiva.  The  eyeball  may  be  dis- 
placed and  its  movements  restricted  and  rendered  painful  through  the  enlarge- 
ment of  the  gland.  Palpation  of  the  exquisitely  sensitive  gland  is  difficult 
because  of  the  edema  of  the  lids,  and  eversion  of  the  lid,  to  permit  of  it- 
inspection,  is  out  of  the  question.  The  general  appearance  of  the  eye  is  not 
unlike  that  which  characterizes  purulent  conjunctivitis  (S.  ( '.  Ayres).  Suppu- 
ration may  supervene  within  a  few  days,  the  pus  making  its  way  through  the 
integument  of  the  lid  or  into  the  conjunctival  cul-de-sac,  or  the  inflammation 
may  subside  without  the  formation  of  pus. 

in  chronic  dacryoadenitis  the  characteristic  enlargement  of  the  gland  may 
be  recognized  by  palpation,  and  sometimes  by  simple  inspection.      By  everting 
the  upper  lid  the  swollen  gland   may  be  brought  into  view  as  a  red,  tongue- 
shaped,  nodular  mass  (  Hirschberg).    The  gland  Is  usually  sensitive  to  pre* 
but   the  pain,  swelling  of  the  lids,  and  conjunctival  chemosis  are  much 
pronounced  than  in  the  acute  variety  of  the  disease.     A.s  in  the  latter,  there 

may  be  marked  displacement  of  the   eyeball,  usually  downward   and    inward, 

261 


262  DISEASES  OF  Till-:  LACHRYMAL   APPARATUS. 

;iii<1  this  may  give  rise  to  diplopia.  In  rare  instances  non-suppurative  dacryo- 
adenitis  {mumps  of  the  lachrymal  gland,  Hirschberg)  is  bilateral. 

Treatment. — The  treatmenl  of  acute  dacryoadenftis,  if  the  ease  is  seen  at 
the  outsel  of  the  attack,  should  consist  in  Leeching,  the  application  to  the  lid 
an<l  brow  ot*  an  ointment  of  mercury  with  opium  or  belladonna  (ext.  opii 
vel  ext.  belladonna  .~j  ;  ung.  hydrarg.  j§j),  and  the  administration  of  an  ener- 
getic mercurial  purgative,  to  be  followed  by  liberal  doses  of  quinin,  sodium 
salicylate,  or  sodium  pyrophosphate  (the  last-named  drug  in  twenty-grain  doses 
every  two  hours)  ;  or,  instead,  small  and  frequently  repeated  doses  of  calomel 
may  be  administered.  Should  these  measures  fail  to  cut  short  the  attack, 
warm  fomentations,  containing  opium  or  belladonna,  should  be  employed,  and 
as  soon  n>  the  presence  of  pus  can  be  detected  it  should  be  evacuated  by  an 
incision  either  through  the  integument  of  the  lid  or  through  the  conjunctival 
cul-de-sac  as  may  seem  to  be  indicated. 

In  chronic  inflammation  of  the  gland  the  local  application  of  mercurial  or 
compound  iodin  ointment,  and  the  administration  of  alteratives  and  tonics, 
an-  indicated.  Extirpation  of  the  gland  (see  page  596)  may  be  necessary 
should  it  become  so  enlarged  as  to  endanger  the  integrity  of  the  eyeball. 

Fistula  of  the  lachrymal  Gland. — This  troublesome  variety  of 
lachrymal  fistula  may  be  a  consequence  of  dacryoadenitis  or  may  he  of  trau- 
matic origin.  Cases  of  congenital  fistula  of  the  lachrymal  gland  have  also 
keen  observed. 

Idie  fistulous  opening  is  usually  at  some  point  in  the  upper  lid,  and  the 
constant  flow  of  tears,  which  prevents  its  closure,  gives  rise  to  much  annoy- 
ance. 

It  is  not  easy  to  bring  about  a  healing  of  the  fistula,  and  if  this  is  accom- 
plished, it  is  at  the  risk  of  precipitating  a  fresh  attack  of  inflammation  of  the 
gland.  The  operative  procedure  which  has  proved  most  effectual  is  that 
proposed  by  Sir  William  Bowman  (see  page  596). 

Dacryops,  or  cyst  of  the  lachrymal  gland,  is  a  rare  condition  due  to  occlu- 
sion of  one  or  more  of  the  efferent  ducts  of  the  gland.  It  has  also  keen  met 
with  as  a  congenital  affection. 

I  pon  eversion  of  the  upper  lid  the  cyst  may  be  brought  into  view  as  a 
semi-transparent,  elastic  swelling,  consisting,  perhaps,  of  several  nodules. 
I  tilling  a   spell  of  crying  the  cyst    may  become   markedly  increased    in   size. 

Treatment. — This  consists  in  establishing  a  permanent  opening  between 
the  cyst  and  the  conjunctival  sac.  This  may  be  done  by  removing  a  portion 
ot'  the  cyst-wall  and  preventing  the  closure  of  the  wound  by  the  repeated 
introduction  of  a  prokc,  or,  as  suggested  by  von  Graefe,  a  silk  thread  may 
be  passed  through  the  wall  of  the  cyst,  tied  in  a  Loop,  and  left  to  cut  its  way 

Ollt.1 

Dacryoliths  (Lachrymal  <'<ilnili). — Chalky  concretions,  known  as 
dacryoliths,  occasionally  form  in  the  lachrymal  gland.  As  they  are  apt  to 
cause  mechanical  irritation,  their  early  removal  (through  a  conjunctival  in- 
cision)  is   indicated. 

Dislocation  of  the  lachrymal  Gland. — This  affection,  s etimes 

described  a-  hernia  or  prolapse  ';/'  the  gland,  ha-  keen  met  with  as  a  sponta- 
neous condition,  and  also  a-  a  consequence  of  injury  involving  the  neigh- 
boring pail-. 

( lases  of  spontant  ous  dislocation  ot'  the  gland  have  keen  reported  by  Snell, 
Noyes,  Mauthner,  and   Brifcre.     In   Briere's  case  the  luxation  of  the  gland 

1  An  interesting  paper  upon  fistulse  and  cysts  of  the  lachrymal  gland,  by  Mr.  rlulke,  may 
be  found  in  the  Royal  London  < )phihal.  Hosp.  Reps.,  voL  i.  p.  285. 


TUMORS  OF  THE  LACHRYMAL   GLAND. 


263 


was  due  to  caries  of  the  orbit,  and  was  accompanied  by  ectropion  of  the 
upper  lid. 

Yon  Graefe  and  Rampoldi  have  reported  cases  of  traumatic  dislocation  of 
the  gland. 

If  possible  the  gland  should  be  restored  to  its  normal  position,  a~  was 
done  successfully  in  von  Graefe's  and  in  Snell's  cases,  and  a  compress 
bandage  should  be  applied  and  worn  for  a  time  to  prevent  a  redislocation. 
If  this  cannot  be  accomplished,  removal  of  the  gland  may  become  necessary 
(see  page  596). 

Hypertrophy  of  the  lachrymal  Gland. — This  condition  occurs 
more  frequently  in  children  than  in  adults,  and  has  been  known  to  be  of  con- 
genital origin.  The  enlargement 
of  the  gland  may  become  so  great 
as  to  force  the  eyeball  from  the 
orbit,  and  destroy  the  sight  through 
stretching  and  compression  of  the 
optic  nerve. 

The  accompanying  illustration 
(Fig.  1X1)  represents  a  striking 
example  of  a  case  of  this  character 
which  occurred  in  the  practice  of 
the  late  Prof.  Christopher  John- 
ston of  Baltimore.  The  hyper- 
trophied  gland,  which  was  about 
the  si/.e  of  a  lien's  egrgr  and  con- 
tained  numerous  dacryoliths,  was 
removed  through  an  incision  made 
parallel  with  the  orbital  margin. 
The  eye  subsequently  resumed 
nearly  its  normal  position,  and 
retained  vision  equal  at  least  to 
counting  lingers. 

If  the  enlargement  of  the  gland  is  so  great  as  to  endanger  the  integrity  ..1" 
the  eye,  it  should  be  removed  without  unnecessary  delay  (see  page  596) ;  but 
if  it  is  not  so  great  as  to  interfere  with  vision,  less  radical  measures,  such  as 
the  local  application  of  iodin  or  mercury  and  the  administration  of  the 
iodides,  may  be  tried.  The  fact  that  the  hypertrophic  process  may  be  of 
syphilitic  origin  (syphilis  of  the  lachrymal  gland)  should  not  be  lost  sight  of 
in  considering  the  treatment  to  be  adopted. 

Atrophy  of  the  I,achrymal  Gland. — This  has  been  observed  in 
xerophthalmia  (see  page  296).  Arlt  has  described  a  case  of  this  character 
in  which  the  gland  was  reduced  to  one-third  its  normal  size  and  its  efferent 
ducts  obliterated.  In  paralysis  of  the  trigeminus  the  functional  activity  of 
the  lachrymal  gland  may  be  abolished. 

Tumors  of  the  lachrymal  Gland. — These  are  rare,  and,  not  infre- 
quently, are  traceable  to  some  previously  received  injury.  They  are  usually 
of  slow  growth  and  occur  oftenesi  in  advanced  life  As  they  increase  insize 
they  interfere  with  the  movements  of  the  eyeball,  giving  rise  to  diplopia. 

Later  they  produce  exophthal s,  and  eventually  may  not  only  destroy  sight 

by  the  pre—ure  whieh  they  exert  upon  the  optic  nerve      but  which  they  rarely 
invade — but  may  cause  death  by  the  involvement  of  the  brain. 

The  following  varieties  of  tumors  believed  to  have  had  their  origin  in  the 
lachrymal   eland    have   been   observed  :   adenoma,    myxoma,  myxo-sarcoma, 


^m 

:M*i    '  M^k 

vggdj 

Mf. 

k                s     V       \i 

5C\ } 

^iiiiiBft 

i  iirT  fi  \  1 

■rl\ 

;1\  ml     i&\   V     II 

Fig.  181.— Hypertrophy  of  the  lachrymal  gland. 


264  DISEASES  OP  THE  LACHRYMAL   APPARATUS. 

lympho-sarcoma,  spindle-cell    sarcoma,   epithelioma,    cylindroma,    chloroma, 

and   carcinoma. 

Early  and  complete  removal  of  the  growth  is  of  course  indicated. 
Whether  this  can  be  accomplished  successfully  without  sacrifice  of  the  eve 
will  depend  upon  the  size  of  the  tumor  and  the  extent  to  which  it  has  invaded 
the  deeper  portion-  of  the  orbit.  (See  page  596  tor  description  of  operation 
for  removal  of  lachrymal  gland.) 

DISEASES  OF  THE  DRAINAGE  APPARATUS. 

All  parts  of  the  drainage  apparatus  are  liable  to  pathological  changes, 
and,  whether  these  changes atl'ect  thepuncta,  the  canalieuli,  the  lachrymal  sac, 
or  the  nasal  duct,  a  common  symptom  characterizes  them  all  :  the  tears  are  no 
longer  carried  from  the  conjunctival  sac  to  the  nasal  cavity,  as  in  the  normal 
state,  hut,  instead,  overflow  the  lids,  giving  rise  to  the  annoying  condition 
known  as  epiphora  or  stillicidium  lacrymarum.  Not  only  is  this  condition, 
in  itself,  very  annoying,  hut  it  leads  to  chronic  conjunctivitis,  blepharitis,  and 
not   infrequently  to  eczema  of  the  lids  and  cheek. 

Atresia  of  the  lachrymal  Puncta. — This  condition  is  met  with  as 
a  congenital,  and  as  an  acquired  anomaly. 

Congenital  atresia  of  the  puncta,  of  which  not  many  authentic  eases  have 
been  reported,  may  be  attended  by  absence  of  the  corresponding  canalieuli. 
The  writer  has  encountered  one  case  of  this  character,  in  which,  however, 
only  one  punctum   with   its  canaliculus  was  absent. 

Complete  obliteration  of  the  puncta  as  an  acquired  condition  seldom 
occurs,  except  as  the  result  of  destruction  of  neighboring  tissue,  such  as 
happen-,  for  example,  from  burns  of  the  eye  by  lime,  etc.  It  has  also  been 
known  to  follow  the  cicatrization  of  a  small-pox  pustule  and  of  a  chancre  of 
the  lid. 

A  superficial  occlusion  of  the  lower  punctum,  which  is  easily  overcome, 
and  which  is  chiefly  due  to  desiccation  of  the  parts,  is  often  observed  in 
blepharitis  marginalis  complicated  by  ectropion. 

Treatment. — Whether  the  occlusion  be  congenital  or  acquired,  it  is,  as  a 
rule,  overcome  without  much  difficulty,  provided  the  canaliculus  is  not  in- 
volved. A  slight  depression  usually  indicates  the  site  of  the  occluded  punctum, 
and  with  a  straight,  moderately  sharp-pointed  probe,  such  a-  i-  represented 
in  Fig.  182,  an  opening  may  be  drilled  into  the  canaliculus  at  this  point  and 


Pig.  182  -Sharp-pointed  lachrymal  probe. 

kepi  from  reclosing  by  the  occasional  introduction  of  a  somewhat  larger 
probe.  If.  however,  the  canaliculus  as  well  as  the  punctum  be  occluded,  or 
if  the  Latter  be  everted,  the  caualiculus  will  require  to  be  slit  up  to  it>  point 
of  juncture  with  the  lachrymal  sac.  (For  description  of  this  operation  see 
page  596.) 

A-  congenital  anomalies  doubh  puncta  and  double  canalieuli  have  been 
observed,  and  in  connection  with  absence  of  the  puncta  the  canalieuli  have 
been  represented  by  slighl   furrow-  alone   the  lid-margin. 

Malpositions  of  the  Puncta. -In  their  normal   position  the  puncta 

lie    in     contact    with     the    eyeball.        Mai  posit  ions   of    the    upper    puncta    are 

not  common,  bul  faulty  positions  of  the  lower  puncta  arc  frequently  met 
with. 


DACRYOCYSTITIS.  265 

Emersion  of  the  puncta  i-  present  in  nearly  all  cases  of  ectropion  ;  it  also 
occurs  in  inflammatory  thickening  of  the  lid-margin,  in  senile  relaxation  of 
the  palpebral  tissue,  and  in  facial  paralysis. 

Inversion  of  the  puncta  is  met  with  in  entropion.     Occasionally,  owing  to 

the  small  size  or  deeply-set  position  of  the  eyeball,  the  puncta  are  not  in 
apposition  with  it,  and  epiphora  results,  as  i1  does  when  the  puncta  are 
everted,  through  failure  of  the  tears  to  find  their  way  into  the  canaliculi. 

Treatment. — The  efficient  remedy  in  all  malpositions  of  the  puncta  is 
division  of  the  canaliculus.  It  not  only  relieves  the  epiphora,  but  usually 
leads  to  the  rapid  disappearance  of  the  conjunctivitis  and  blepharitis  which 
are  its  common  accompaniments. 

Atresia  of  the  Canaliculi  may  occur  as  a  congenital  defect  in  con- 
nection with  absence  of  the  puncta,  as  has  already  been  mentioned  ;  it  may 
also  be  of  traumatic  origin. 

(  ircumscribed  strictures  of  the  canaliculi,  located  usually  near  the  juncture 
of  the  canaliculi  and  the  lachrymal  sac,  are  of  frequent  occurrence,  especially 
in  association  with  stenosis  of  the  nasal  duet. 

When  the  canaliculi  are  completely  obliterated  their  restoration  by  opera- 
tive procedure  is  impracticable  ;  but  it  may  be  possible  to  make  a  passage- 
way directly  into  the  lachrymal  sac,  and  by  repeated  probings  cause  it  to 
remain  patulous,  as  was  done  in  the  case  to  which  allusion  ha-  been  made 
under  the  head  of  Atresia  of  the  Puncta.  The  circumscribed  strictures  may 
usually  be  overcome  by  the  passage  of  a  small  lachrymal  probe  or  of  the 
straight  probe  shown  in  Fig.  182.  Division  of  the  canaliculus  may  be  called 
for  if  the  stricture  is  difficult  to  overcome  or  is  disposed  to  recur. 

Dacryoliths  occasionally  form  in  the  canaliculi.  They  were  formerly  sup- 
posed to  be  simply  concretions  of  lime,  but  are  now  known  to  be  composed 
in  great  part  of  a  fungus  believed  by  some  investigators  to  be  identical  with 
the  leptothrix  buccalis.  Colin,  however,  denies  this,  and  suggests  the  name 
streptothrix  Forsteri.  Goldzieher  has  met  with  eases  in  which  a  cilium  occu- 
pied the  center  of  the  dacryolith,  and  was  probably  the  exciting  cause  of  its 
development.  The  presence  of  dacryoliths  in  the  canaliculus,  which  may  be 
detected  by  the  circumscribed  swelling  to  which  they  give  rise,  causes  epiphora 
and  may  excite  conjunctivitis.  Their  early  removal,  which  may  necessitate 
division  of  the  canaliculus,  is  indicated. 

Polypi  have  been  known  to  form  in  the  canaliculi,  and  may  project 
through  the  puncta.  They  should  be  removed,  the  canaliculus,  if  necessary, 
being  divided,  as  soon  as  their  presence  is  recognized. 

Foreign  bodies,  such  as  eyelashes,  bits  of  the  beard  of  wheat  and  barley, 
occasionally  find  their  way  into  the  canaliculi,  where  they  may  remain  for  a 
long  time,  causing  considerable  annoyance.  If  they  project  through  the 
puncta,  they  may  be  seized  with  forceps  and  easily  withdrawn  ;  otherwise 
division  of  the  canaliculus  may  be  necessary  to  effect  their  removal.  In  one 
instance  (reported  by  Haflher)  an  ascaris  lumbricoides  was  removed  from  the 
lower  canaliculus. 

Dacryocystitis.— Inflammation  of  the  lachrymal  sac,  or  dacryocystitis, 
occur-  as  a  chronic  and  as  an  acute  affection.  The  former  is  usually  denomi- 
nated blennorrhea  of  tfo  lachrymal  sac,  while  the  latter  is  often  spoken  of  as 
abscess  of  the  sac. 

Etiology  and  Symptoms.— Primary  inflammation  of  the  lachrymal  sac 
i-  of  rare  occurrence.  It  i-  oftenest  met  with  in  the  new-born,  usually  in  the 
form  of  a  mild  blennorrhea  :  ii  is  said  to  occur  in  strumous  children,  and  it 
may  be  excited  by  external  violence  or  the  entrance  into  the  sac  oi  an  irr 


266  DISEASES  OF  THE  LACHRYMAL   APPARATUS. 

fluid.  In  the  large  majority  of  cases  dacryocystitis  is  secondary  to,  and 
dependent    upon,  stricture  of  the  nasal   duet. 

Although  inflammation  of  the  lachrymal  sac  frequently  gives  rise  to  con- 
junctivitis and  keratitis,  the  reverse  rarely  happens.  The  truth  of  this  state- 
ment is  strikingly  illustrated  in  gonorrheal  conjunctivitis.  Although  the 
gonococci  doubtless  find  their  way  in  greal  numbers  into  the  lachrymal  sac, 
dacryocystitis  as  a  complication  of  gonorrheal  conjunctivitis  is,  so  far  as  the 
writer  can  learn,  practically  unknown. 

On  the  other  hand,  there  is  the  closesl  pathological  sympathy  between  the 
lachrymal  sac  and  duet  and  the  nasal  passages,  and  doubtless  in  a  majority 
of  cases  dacryocystitis  is  traceable,  directly  or  indirectly,  to  nasal  disease. 
Such  being  the  ease,  it  is  not  surprising,  when  one  hears  in  mind  how  almost 
universally  prevalent  catarrhal  affections  of  the  nasal  mucous  membrane  are, 
that  inflammation  of  the  lachrymal  sac  and  nasal  duct  should  he  of  compara- 
tively frequent  occurrence. 

Watering  of  the  eyes  is  a  usual  symptom  of  acute  rhinitis,  and  probably 
in  most  pronounced  eases  of  this  affection  the  mucous  membrane  lining  the 
lachrymal  drainage  apparatus  participates  to  a  greater  or  less  extent  in  the 
general  nasal  catarrh.  With  the  subsidence  of  the  rhinitis  the  lachrymal 
catarrh  and  the  transient  occlusion  of  the  nasal  duct  which  has  probably 
accompanied  it  usually  disappear,  and  the  parts  return  to  a  healthy  con- 
dition. 

Exceptionally,  however,  because  of  the  severity  of  the  inflammation,  the 
occurrence  of  a  second  or  third  attack  before  the  first  has  been  recovered 
from,  a  congenita]  narrowness  of  the  nasal  duct,  or  a  peculiar  susceptibility 
of  the  lachrymal  passages  to  disease  (a  susceptibility  which  is  not  infrequently 
inherited),  the  inflammation  of  the  walls  of  the  duct  does  not  subside  with 
the   nasal   affection,  and   presently  assumes  a   more  serious  character. 

Under  such  circumstances  the  inflammation,  which  at  first  was  simply  a 
catarrh  of  the  mucous  membrane,  invades  the  underlying  periosteum,  and  the 
temporary  occlusion  of  the  duct  from  engorgement  of  the  submucous  plexus 
of  veins  give.-  place  in  time  to  a  permanent  stenosis  from  periosteal  and  osteal 
thickening.  In  this  way — and,  perhaps,  still  more  frequently  from  the  ex- 
tension of  chronic  inflammatory  affections  of  the  nose  to  the  lachrymal 
passages  -stricture  <>/  the  nasal  duct,  which,  as  has  been  said,  is  the  usual 
forerunner  of  dacryocystitis,  commonly  arises. 

The  chronic  nasal  affections  of  inherited  and  acquired  syphilis,  it  may  be 
remarked,  are  especially  liable  to  involve  the  lachrymal  apparatus.  Blows 
upon  the  bridge  of  the  nose  <>r  about  the  inner  angle  of  the  eye  may  not  only 
cause  inflammation  of  the  lachrymal  sac,  as  has  been  indicated,  but  may  lead 
to  the  development  of  stricture  of  the  nasal  duct. 

When  once  the  occlusion  of  ilir  duet  is  complete,  the  tears,  mucus,  and 
epithelial  d6bris  which  collect  in  the  lachrymal  sac  are  invaded  by  bacteria 
and  undergo  putrefactive  change-.  This  soon  leads  to  inflammation  of  the 
lining  membrane  of  the  sac,  and  the  condition  known  aschronic  dacryocystitis 
or  blennorrhea  of  tin-  lachrymal  sac  bee -  established. 

This  condition  does  nol  give  rise  to  pain,  but  the  attendant  epiphora  and 
regurgitation  of  mucus  and  muco-pus  through  the  puncta  into  the  conjunc- 
tival sac  not  only  cause    greal    annoyance,  but,  as  ha-  been   stated,  may  bring 

on  chronic  conjunctivitis  and  blepharitis,  and  even  corneal   inflammation. 

The  accumulation  of  tear-  and  mucus  frequently  Leads  to  a  perceptible 
distention  of  the  sac  (mucoceh  (,  which  disappears  under  slight  pressure  with 
the  tip  of  the  finger,  the  contents  of  the  sac  usually  regurgitating  through  the 


a  err/:  dacryocystitis. 


267 


puncta,   but   exceptionally,   when    the   stenosis  of  the   duct   is   incomplete, 
escaping  into  the  nose  |  Fig.  183). 


Fig.  183. — Mucocele :   fracture  of  superior  maxilla  :  exostoses  of  nasal  bones.    (Case  under  care  of  Dr. 
de  Schweinitz  in  the  Philadelphia  Hospital.) 

In  some  instances  this  state  of  chronic  catarrhal  inflammation  lasts  indef- 
initely, without  undergoing  appreciable  change;  but  in  others,  through  the 
influence  of  cold,  a  slight  traumatism, 
the  entrance  into  the  lachrymal  sac  of 
pyogenic  organisms  of  unusual  viru- 
lence/ some  constitutional  disorder  or, 
as  seems  to  happen  not  infrequently, 
the  sudden  occlusion  of  the  canaliculi 
at  their  point  of  junction  with  the  sac, 
the  inflammation  undergoes  a  sudden 
and  acute  aggravation. 

Severe  pain,  accompanied  by  great 
distention  of  the  sac  and  marked  edema 
of  the  lids  and  surrounding  parts,  comes 
on,  and  decided  evidences  of  consti- 
tutional disturbance,  such  as  fever,  loss 
of  ajtpetite,  sleeplessness,  etc.,  manifest 
themselves.  These  are  the  symptoms 
which  characterize  acute  dacryocystitis 
or  abscess  of  the  lachrymal  sa&  (Fig. 
I84),and  which  in  many  cases  of  stric- 
ture of  the  nasal  duct  recur  from  time 
to  time  so  long  as  the  occlusion  of  the 
duct  i>  permitted  to  remain. 

After   several    days  of  intense   suf- 
fering the  integumenl  over  the  sac  assumes  a  yellowish  appearance,  becomes 
thinned,  and,  if  left  to  itself,  usually  gives  way  al   a   point   ju-t   below  the 

1  Besides  the  commoner  pyogenic  organisms,  the  streptococcus  pyogenes  lias  been  found  in 
dacryocystitis,  especially,  it  is  claimed,  in  the  acute  exacerbations. 


Pig.  184      v.titt-  dacryocystitis. 


268  DISEASES  OF  THE  LACHRYMAL   APPARATUS. 

internal  palpebral  ligament,  permitting  the  purulent  contents  of  the  sac  to 
escape,  and  affording  the  individual  immediate  and  almost  complete  relief  from 
his  sufferings.  Exceptionally,  the  inflammation  subsides  without  perforation  of* 
the  sac,  and  the  pus  ultimately  escapes  through  the  canal iculi  and  puncta. 

It  is  a  fact  worthy  of  remark  that  during  an  attack  of  acute  dacryocystitis 
it  i-  scarcely  ever  possible  to  empty  the  distended  sac  by  external  pressure, 
although  alter  the  subsidence  of  the  acute  inflammation  pressure  will  usually 
cause  the  contents  of  the  sac  t<>  regurgitate  through  the  canaliculi  and  puncta, 
as,  in  all  probability,  was  the  ease  before  its  onset.  From  this  it  would  seem 
probable  that  when  the  sac  is  unduly  distended  a  valve-like  closure  of  the 
canaliculi  at  their  point  of  juncture  with  the  sac  occurs;  and  it  may  he  that 
this  i-  often  a  potent  factor  in  the  causation  of  acute  dacryocystitis. 

After  the  content-  of  the  acutely  inflamed  lachrymal  sac  have  been 
evacuated,  either  spontaneously  or  by  an  incision,  the  inflammation  rapidly 
subsides,  and  within  ten  days  or  two  weeks  the  opening  through  which  the 
discharge  has  occurred  usually  closes,  and  the  sac  resumes  its  previous 
condition  of  chronic  blennorrhea. 

Exceptionally,  however,  the  cicatrization  of  the  opening  is  prevented  by 
the  continual  discharge  through  it  of  tears  and  muco-pus,  and  the  condition 
known  as  lachrymal  fistula  becomes  established — to  remain,  perhaps,  for  an 
indefinite  period. 

Treatment  of  Dacryocystitis. — There  is  but  one  effectual  and  rational 
way  of  curing  dacryocystitis,  and  that  is  by  eradicating  the  stenosis  of  the 
nasal  duet  upon  which,  a.-  has  been  stated,  it  almost  invariably  depends. 

During  an  attack  of  acute  inflammation  of  the  sac,  and  for  some  days 
after  its  subsidence,  operative  interference  with  the  strictured  duct  is  out  of 
the  question,  and  we  must,  for  the  time  being,  content  ourselves  with  the 
administration  of  anodynes  and  such  other  constitutional  remedies  as  the 
condition  of  the  patient  may  seem  to  call  for,  and  the  local  application  of 
soothing  fomentations,  to  be  followed,  in  all  probability,  by  an  early  incision 
through  the  anterior  wall  of  the  sac,  below  the  internal  palpebral  ligament. 
Such  ;in  incision,  if  made  in  the  direction  in  which  the  skin  tends  to  wrinkle 
— that  is,  from  above  and  toward  the  nose  downward  and  outward — does  not 
leave  :i  perceptible  scar,  and  gives  a  freer  exit  to  the  retained  pus  than  docs 
an  incision  into  the  sac  along  the  canaliculus. 

A  pad  of  gauze  wet  with  a  lotion  of  opium  and  boric  acid  (ext.  opii, 
gr.  x-xv,  acid,  boric,  gr.  lx,  aq.  de-til.,  §iv),  and  covered  with  a  piece  of 
rubber  ••protective"  to  prevent  evaporation,  forms  a  cleanly  and  convenient 
substitute  for  q  poultice,  and  will  be  found  a  very  useful  application  in  these 
cases. 

In  chronic  blennorrhea  of  the  sac,  if  for  any  reason  it  is  not  practicable  to 
treat  the  strictured  nasal  duet,  a  considerable  measure  of  relief  may  he  obtained 
from  slitting  the  lower  canaliculus  and  prescribing  a  collyrium,  either  of 
bichlorid   of  mercury  (1  :  12,000)  or  of  alum   (gr.  ij)   and   boric  acid   (gr.  x- 

xv  to  s unce),  to  be  dropped  into  the  eye  two  or  three  times  a  day,  explicit 

instructions  being  given  to  empty  the  sac  of  it-  contents  b)  pressure  \\  ith  the 
finger-tip  before  each  instillation  of  the  drops. 

It  i-  well  to  bear  in  mind  that  abscesses  occasionally  occur  in  the  neigh- 
borhood of  the  lachrymal  sac  (prelachrymal  abscess),  which,  from  their 
appearance  only,  cannot  always  be  distinguished  from  dacryocystitis.  The 
history  of  the  case,  however,  ahowing  the  absence  of  pre-existing  symptoms 
of  lachrymal  disease,  will  usually  make  the  diagnosis  plain. 

Stricture  of  the  Nasal  Duct. — A-  to  the  etiology  of  obstructions  of 


STRICTURE  OF  THE  NASAL   DUCT.  269 

the  nasal  duct,  little  need  be  added  to  what  has  already  Keen  said  upon  this 
subject  in  treating  <>t'  Dacryocystitis.  How  often  syphilis,  both  inherited 
and  acquired,  is  a  factor  in  their  causation,  especially  when  it  has  invaded 
the  nasal  passages,  has  already  been  pointed  out.1  Syphilitic  gummata  have 
Keen  met  with  in  the  lachrymal  sac,  as  well  as  in  the  duct.  Tuberculosis  of 
the  nose,  through  extension  to  the  lachrymal  passages,  has  been  known  to 
cause  stenosis  of  the  duct,  and  polypi  of  the  lachrymal  sac  to  produce  a  like 
effect.  The  exanthematous  fevers — measles,  scarlel  fever,  and  small-pox — 
also  may  lead  to  occlusion  of  the  duct  through  the  inflammation  of  the  nasal 
mucous  membrane  which  attends  them. 

As  to  the  location  of  the  strictures,  there  is  no  part  of  the  duct  in  which 
they  are  not  frequently  encountered,  although  their  most  common  situation 
is  at  its  upper  extremity.  Multiple  stricture,  at  least  in  cases  of  long  stand- 
ing, is  the  rule. 

As  the  strictures  are  the  outcome  of  periosteal  inflammation,  they  are  almost 
invariably,  in  part  at  least,  of  bony  structure.  They  may  be  circumscribed 
and  annular  in  form  (a  thin  bony  septum  being  sometimes  encountered),  or  ill 
defined  and  of  wide  extent,  involving  a  considerable  part  of  the  length  of  the 
duct.  When  situated  at  the  lower  extremity  of  the  duct  their  existence  is 
not  so  easily  recognized,  and  it  may  happen  that  a  mistake  of  this  kind  will 
render  the  treatment  of  no  avail. 

The  stenosis  of  the  lachrymal  duct  which  occur-  in  the  new-born  is  usually 
of  an  entirely  different  character,  being  due  simply  to  tumefaction  of  the  mem- 
branous walls  of  the  canal,  and  in  consequence  it  generally  yield-  readily  to 
treatment,  operative  interference  being  only  exceptionally  called  for.  A  sim- 
ilar condition  is  occasionally  met  with  in  adults,  and  may  be  suspected  if  the 
symptoms  of  occlusion  of  the  duct  are  of  but  short  duration. 

Prognosis  and  Treatment. — The  confessedly  poor  results  which,  in  the 
main,  have  been  obtained  in  the  treatment  of  strictures  of  the  nasal  duct  are, 
in  the  writer's  opinion,  attributable  chiefly  to  the  inadequate  size  of  the 
probes  which  are  commonly  employed  to  overcome  the  stenosis.  The  great 
merit  of  the  invaluable  operation  devised  by  Bowman  of  slitting  the  cana- 
liculus as  a  preliminary  step  in  the  treatment  of  lachrymal  strictures  (see  page 
596)  is  that  it  permits  the  passage  of  probes  sufficiently  large  to  overcome 
entirely  the  stenosis  and  restore  completely  the  normal  caliber  of  the  canal. 
Nevertheless,  Bowman  himself  fell  far  short  of  appreciating  this  fact,  as  is 
shown  by  the  small  size  of  the  probe-  which  he  employed,-'  and,  owing  to  an 
unreasoning  conservatism,  which  those  who  have  emancipated  themselves 
from  its  influence  can  scarcely  comprehend,  the  same  may  be  said,  even  at 
the  present  day,  of  the  greal  majority  of  those  who  have  followed  his  plan  of 
treatment.  The  absurdity  of  attempting  with  a  probe  of  [.50  mm.  diameter 
to  restore  to  it-  normal  dimensions  an  occluded  canal  which  in  health  has  an 
average  diameter  (measured  in  it-  shortest  axis)  of  somewhal  more  than  -1  mm., 
it  would  seem  should  be  evident  to  all  ;  but  experience  -how-  that  such  is  far 
from  being  the  case. 

1  Seventeen  em  of  two  hundred  and  forty  cases  of  stricture  of  the  nasal  duel   in  <  •• 
>ki's  clinic  were  found  to  be  of  syphilitic  origin. 

•  The  largesl  of  Bowman's  probes,  No.  6,  had  a  diameter  of  aboul  L.3  mm.,  or,  according  to 
Soelberg  Wells,  about  .'.  of  an  inch.  Dr.  hsaac  Hays  of  Philadelphia,  ii  may  be  remarked,  had 
previously  used  a  slightly  larger  probe  than  this    1.50  nun.    without  dividing  the  canaliculus. 

paper  by  the  writer  upon  "The  1  se  of  Large  Probes  in  the  Treatmi  nl  ol  Stri 
of  the  Nasal  Duct,"  Tran  .  \Ieduxd  and  Chirurg.  Faculty  of  Maryland,  1877,  p. 
ments  of  the  nasal  duel  given  by   Mr.  Henry  Power  in  " Lectures  upon   I  'he  Lach- 

rymal Apparatus,"  published  in  the  London  Lancet,  ls-,;.  vol.  ii. 


270  DISEASES  OF   THE  LACHRYMAL   APPARATUS. 

The  accompanying  illustration  (Fig.  185),  which  represents  graphically 
the  results  of  measurements  of  the  nasal  duct  made  by  the  writer,  and  de- 
scribed in  the  paper  to  which  reference  has  been  given,  is  in  this  connection 
instructive  : 

•       Bowman's  No.  6  probe  ;  diameter  =  1.50  mm. 

^k     Theobald's  No.  1(1  probe;  diameter        1  nun. 

^fc     Average  size  of    10  adult  nasal    ducts,  cadaver;  diameter  = 
^^  4.47  —  mm. 

^^     Largest  of  Id  adult  nasal  ducts,  cadaver  ;  diameter       5.25  mm. 

Largest  of  70  bony  nasal  ducts  ;  diameter  =  7  mm. 
Pig.  185. — Diameters  of  probes  and  nasal  ducts. 

Besides  the  treatment  by  means  of  probes,  there  are  other  methods  of 
dealing  with  stenosis  of  the  duct  and  its  accompanying  dacryocystitis  which 
have  their  advocates.  Although  the  gold  canula  of  Wathen  and  Dupuytren 
i-  probably  scarcely  ever  used  at  the  present  day,  there  are  many  who  still 
employ  styles  of  different  patterns  made  of  lead,  silver,  or  aluminum,  and 
others  who  practise  division  of  the  strictures  as  recommended  by  Stilling,  to 
whom  the  credit  of  having  originated  this  method  of  treatment  is  usually 
given.  The  interesting  fact,  however,  has  recently  come  to  the  writer's 
knowledge  that  a-  early  as  1846  the  late  Prof.  Xathan  \l.  Smith  of  lialtimore 
dealt  with  lachrymal  strictures  in  this  manner,  and  devised  a  knife  of  peculiar 
pattern  for  this  especial  purpose.1 

In  intractable  cases  of  dacryocystitis  dependent  upon  occlusion  of  t he 
nasal  duct,  which  have  failed  to  yield  to  less  radical  measure-:,  removal  of 
the  lachrymal  gland  (see  page  596),  and  also  excision  of  the  lachrymal  sac 
page  597)  or  its  destruction  by  means  of  caustics  or  the  galvano- or 
thermo-cautery  (see  page  597),  arc  practised  by  some  ophthalmic  surgeons. 
and.  it  is  claimed,  with  excellent  results.  The  writer  has  had  no  experience 
with  these  last-mentioned  procedures,  not  having  encountered  cases  in  which 
such  radical  measures  seemed  to  be  indicated.  As  to  the  employment  of 
styles,  lu~  experience  with  them  has  not  been  satisfactory,  and  leads  him  to 
regard  them  as  of  limited  applicability,  being  useful  only  when  time  will  not 
permit  of  the  proper  carrying  out  of  the  probing  treatment. 

Briefly  described,  the  writer's  method  of  dealing  with  strictures  of  the 
nasal  duct,  which  he  has  employed  almost  without  exception  in  all  cases  that 
have  come  into  hi-  hands  during  the  past  twenty  year-,  and  which  has  yielded, 
as  a  rule,  mo-i  gratifying  results,  is  as  follows  j 

The  lower 2  canaliculus,  after  having  been  slightly  dilated  by  the  passage 
of  a  No.  1  or  No.  2  probe  cocain  having  been  previously  instilled  into  the 
conjunctiva]  sac),  is  divided  well  up  to  its  juncture  with  the  lachrymal  sac 
with  Weber'-  beak-pointed  canaliculus  knife  (Fig.  415),  or,  preferably,  with 

the   writer's  article  upon  "Diseases  of  the  Lachrymal   Apparatus,"  in  a  System  of 
1 1  •  ■  ■     i  (ht   /.</•,  edited  by  Nbrris  and  Oliver,  vol.  iii. 

'-'  Some  Burgeons  prefer  to  divide  the  upper  canaliculus  and  i"  introduce  the  probes  through 
it.  Inn  this  -•■•■in-  to  the  writer  a  mimic  difficult  and  comparatively  awkward  procedure. 


STRICTURE  OF  THE  NASAL   DUCT.  271 

tlif  modification  of  the  knife  represented  in  Fig.  410.  An  effort  is 
then  made  to  pass  into  the  sac  and  through  the  duct  a  No.  5  or  No.  n' 
of  the  writer's  series  of  lachrymal  probes  (usually  the  former)1  (see  Fig. 
11!',  page  598).  It'  the  probe  enters  fairly  into  the  lachrymal  sac,  any 
reasonable  amount  of  force  which  may  be  necessary  to  pass  it  through  the 
occluded  duet  to  the  Moor  of  the  nose  is  employed  without  hesitation,  care 
being  exercised  that  it  does  not  take  a  wrong  course.  If,  owing  to  a  con- 
striction at  the  juncture  of  the  canaliculus  and  the  sac  (a  condition  which 
is  not  infrequently  met  with,  and  which  occasionally  greatly  complicates  the 
treatment),  the  point  of  the  probe  is  arrested  and  prevented  from  entering 
the  sac.  a  smaller  probe,  No.  4  or  No.  3,  is  tried.  If  neither  of  these  can  he 
introduced,  it  is  best  to  desist  from  further  efforts  and  to  wait  for  forty-eight 
hours,  when  very  often  the  difficulty  previously  experienced  in  entering  the 
sac  will  he  found  to  have  disappeared.  If  this  does  not  prove  to  he  the  case, 
an  opening  is  drilled  through  the  constriction  with  the  sharp-pointed,  straight 
probe  (Fig,  182),  or,  the  lid  being  kept  well  upon  the  stretch,  a  No.  5  probe 
is  passed  along  the  canaliculus  to  the  point  of  resistance  and  is  then  turned 
vertically  and  forced  into  the  sac — a  procedure  which,  if  possible,  should  he 
avoided,  as  it  may  result  in  the  making  of  a  false  passage  directly  from  the 
canaliculus  into  the  duct.  Exceptionally,  the  constriction  must  he  divided 
with  a  sharp-pointed  knife,  the  old-fashioned  cataract  knife  of  Sichel  being 
especially  convenient  for  this  purpose. 

The  probe,  after  being  passed  entirely  through  the  duct  to  the  floor  of  the 
nose,  is  allowed  to  remain  /'//  situ  for  from  ten  to  twenty  minutes.  The  probing 
is  repeated  during  the  early  stages  of  the  treatment  every  other  day,  usually 
a  .-ize  larger  probe  being  passed  each  time.  The  size  of  the  largest  probe 
which  it  is  desirable  to  use  will  of  course  vary  in  different  cases,  but  there  are 
very  few  in  which  it  is  well  to  stop  short  of  No.  14,  for  it  is  to  be  borne  in 
mind  that  our  purpose  is  to  obliterate  the  stricture  completely  (not  simply  to 
make  a  small  opening  through  it)  and  to  restore  the  normal  caliber  of  the 
duct.  In  about  two-thirds  of  all  his  cases  (including  children  as  well  as 
adults)  the  writer  introduces  Xo.  16.  In  passing  the  larger  probes  consider- 
able force  is  sometimes  employed.  This  has  been  found  not  only  to  be  per- 
missible, but.  instead  of  doing  harm,  as  many  maintain  must  necessarily  be 
the  case,  its  effect  upon  the  carious  walls  of  the  duct  is  distinctly  curative,  the 
result  being  not  unlike  that  produced  by  the  curetting  of  diseased  hone  in 
other  parts  of  the  body. 

When  as  large  a  probe  has  been  introduced  as  is  deemed  necessary,  the 
interval  between  the  probings  is  gradually  increased,  first  to  three  or  four 
days,  then  to  a  week,  a  fortnight,  and  finally  to  a  month  or  two  months;  and 
when  several  of  these  longer  intervals  have  elapsed  without  any  tendency  to 
recontraction  having  manifested  itself,  the  case  is  dismissed  with  full  assurance 
that  a  permanent  cure  has  been  effected.  Including  these  longer  intervals 
the  treatment  frequently  extends  over  a  period  of  eight  or  ten  months  :  but 
the  active  treatment,  involving  the  frequent  probings,  is  comprised  within  as 
many  weeks. 

Electrolysis  has  been  tried  by  the  writer  to  a  limited  extent,  to  promote 
the  more  rapid  absorption  of  lachrymal  strictures;  but,  so  far  as  could  be 
judged,    its   effect   was    inappreciable.      The   chloride-of-silver,  "dry-cell/ 

1  The  series  comprises  sixteen  sizes.     No.  1  has  a  diameter  of  0.25  mm.,  and  the  sizes  in- 
crease by  0.25  nun.,  the  Largest  of  the  series,  No.  16,  having  a  diameter  of  1  mm.     The  smaller 
sizes,  from  No.  1  to  No.  •;,  are   made  of  coin-silver:  the  larger  Bizes,  from  No. 
aluminium  or  of  copper,  nickel-plated. 


272  DISEASES  OF  THE  LACHRYMAL   APPARATUS. 

battery  is  convenient  for  this  purpose.  From  eight  t<>  twelve  cells  may  bo 
used,  the  negative  pole  being  connected  with  a  probe  which  has  Keen  intro- 
duced into  the  duct,  while  a  moist  sponge  connected  with  the  positive  pole  is 

held  iu  contact  with  the  cheek. 

NO  attempt  is  made  by  means  of  syringes  to  inject  antiseptic  or  other 
solution  into  the  lachrymal  sac,  hut,  instead,  a  collyrium  is  prescribed,  which 
the  patient  is  instructed  to  drop  into  the  inner  corner  of  the  eye  three  times  a 
dav,  after  having  pressed  out  the  contents  of  the  sic  with  the  finger-tip.  The 
collyria  which  have  been  found  most  useful  are  a  solution  of  bichlorid  of 
mercury  (1  :  L2,000)  and  one  of  alum  and  boric  acid,  containing  2  per  cent. 
of  boric  acid  and  one-half  of  1  per  cent,  of  alum.  Formaldehyd  (1  :  2000) 
i~  much  employed  by  some  surgeons,  as  are  all  of  the  usual  antiseptic  and 
astringent  collyria. 

The  presence  of  a  lachrymal  fistula,  even  when  accompanied  by  caries  of 
the  underlying  bone,  has  not  seemed  to  call  for  especial  treatment.  The  fis- 
tula has  been  found  to  heal  promptly,  and  the  carious  bone  to  become  re-cov- 
ered with  periosteum  as  soon  as  the  stenosis  of  the  duct  has  been  overcome 
by  the  passage  of  the  large  probes. 

The  frequent  dependence  of  lachrymal  disease  upon  nasal  catarrh  is  kept 
constantly  in  mind,  and  treatment  is  directed  to  the  nasal  passages  whenever 
it  seems  to  he  indicated.  For  tin-  purpose  a  weak  solution  of  bichlorid  of 
mercury  (1  :  5000),  to  which  is  added  a  small  quantity  of  chlorid  of  sodium 
and  glycerin,  applied  to  the  nose  several  times  a  day  by  means  of  a  hand- 
atomizer,  has  been  found  especially  efficacious.  (For  full  particulars  in  refer- 
ence to  measures  suited  to  such  conditions  see  seetions  devoted  to  diseases  of 
the  rhino-pharynx.) 

'Idie  length  of  time  during  which  the  probing  must  be  kept  up  varies  con- 
siderably in  different  cases  :  hut  it  i-  a  sale  rule  not  to  discontinue  the  use  of 
the  probe  altogether  as  long  as  there  is  any  evidence  of  dacryocystitis  or  any 
roughness  of  the  wall-  of  the  duet  noticeable  on  passing  the  probe.  In  obsti- 
nate cases,  however,  it  is  well  to  lengthen  the  interval  between  the  probings, 
as  it  sometimes  happens  that  the  inflammation  is  kept  up  by  the  too  frequent 
introduction  of  the  probe.  In  several  instances,  when  patients  from  a  distance 
could  not  remain  under  treatment  as  long  as  was  thoughl  desirable,  it  has  been 
found  practicable  to  teach  them  to  probe  their  own  nasal  ducts  with  the  large 
probes  which  had  been  previously  introduced,  cocain  being  first  instilled 
to  minimize  the  pain.  In  this  way  relapses,  which  otherwise  might  have 
occurred   from    the   too  early  discontinuance  of  the   treatment,  have  been 


I  ig  186     Modified  form  "f  lachrymal  probe  for  use  by  j >; 1 1 1 . ■  1 1 1 -  (actual  size). 

avoided.     The  probe  represented  in   Fig.  186  was  devised  by  the  writer  for 
this  purpose,  and  has  been  found  very  useful. 

In  the  transient  occlusion  of  the  nasal  duel  which  occur-  in  the  new-born 
operative  interference,  as  has  been  stated,  is  seldom  called  fur:  nevertheless, 
if  the  collyria  of  bichlorid  of  mercury,  of  alum  ami  boric  acid,  and,  per- 
haps, a  weak  solution  (gr.  |  to  §j)  of  nitrate  of  silver,  have  been  tried  per- 
Beveringly  without  effect,  it  may  become  necessary  to  divide  the  canaliculus 
and  introduce  a  probe.      The  outcome  of  this  treatment  is  usually  very  Batis- 


sri:i<rri;i:  <>r  the  NASAL  DUCT.  273 

factory,  and  it  is  seldom  necessary  t<»  repeal  the  probing  oftener  than  four  or 
five  times.  In  a  ease  of  this  character  in  ;i  child  fifteen  months  old  recently 
under  treatment,  and  in  which  a  complete  cure  was  effected,  the  duet  was 
probed  in  all  ten  times,  No.  12,  the  largest  probe  used,  being  introduced  upon 
five  successive  occasions. 

The  writer's  experience  with  the  radical  treatment  of  strictures  of  the 
nasal  duet  by  the  use  of  large  probes  now  extends  over  a  period  of  nearly 
twenty  years,  during  which  time  he  has  employed  it  in  a  large  number  of 
cases,  and  has  had  the  opportunity  of  seeing  many  of  them,  from  time  to 
time,  fur  lung  periods  after  the  discontinuance  of  the  probing;  and  his  obser- 
vation is  that  the  eases  in  which  the  treatment  is  systematically  carried  out 
in  tlu'  manner  which  has  been  described  arc,  with  comparatively  i'vw  excep- 
tions, completely  and  permanently  cured. 

18 


DISEASES   OF   THE    CONJUNCTIVA. 

By  MHl^    E.    WEEKS,  M.  D., 

OF    NEW    YORK    (I  I  \  . 


Congenital  Anomalies  of  the  Conjunctiva. — Pigment-patches, 
like  moles,  sometimes  appear  on  the  conjunctiva,  accompanying;  moles  of  the 
lace 

Dermoid  tumors  develop  on  the  ocular  conjunctiva  (often  extending; 
on  to  the  cornea),  at  the  caruncle,  and  at  the  upper  outer  quadrant  of  the 
globe  (see  page  329).  They  are  at  times  associated  with  coloboma  oi'  the 
lids.      They  may  be  pigmented.      Dermoid  cysts  have  also  been  observed. 

Telangiectatic  patches  may  appear  on  the  caruncle  and  also  on  the 
palpebral  conjunctiva.  They  are  flat,  slightly  elevated,  bright  red  in  color, 
and  often  accompany  telangiectatic   patches  on   the  litis  and    face. 

Cavernoma  of  the  conjunctiva  also  exists  as  a  congenital  growth.  The 
color  is  dark  blue,  and  the  conjunctiva  is  bulged  forward  at  the  affected  part. 
When  the  head  is  lowered  or  the  child  eric-  or  coughs  the  tumor  increases 
in  si/e. 

Small  subconjunctival  lipomata  may  accompany  congenital  coloboma  of 
the  lids  or  may  exisl  alone. 

Well-developed  bone-tissue  has  been  observed  situated  beneath  the  ocular 
conjunctiva,  between  the  margin  of  the  cornea  and  the  outer  commissure. 

The  caruncle  may  present  an  abnormal  development  of  hair  (trichosis 
caruneulce).  Congenital  duplication  <>/  tin-  caruncle  has  been  reported  by 
Stephenson. 

Hyperemia  of  the  Conjunctiva  (Dry  Catarrh). — This  condition 
usually  affects  the  palpebral  conjunctiva,  and  is  manifested  by  a  persistent 
redness  with  no  appreciable  thickening.  The  posterior  system  of  conjunctival 
vessels  is  involved. 

Etiology. — The  causes  of  this  affection  are  numerous,  and  comprise  the 
entrance  of  minute  irritating  particles  into  the  conjunctival  sac,  exposure  to 
strong  winds,  cold,  heat,  and  glare  of  light.  Conjunctival  hyperemia  may  be 
produced  by  use  of  the  eves  with  poor  illumination,  eye-strain  from  errors 
of  refraction  or  muscular  irregularities,  by  too  continuous  use  of  the  eyes  on 
line  work,  by  indigestion,  alcoholic  beverages,  rheumatic  gout,  vaso-motor 
disturbances,  nasal  catarrh,  lachrymal  disease,  blepharitis  marginalis,  acute 
exanthematous  fevers,  etc. 

Pathology. — There  i-  little  change  in  the  tissues ;  the  blood-vessels  are 
enlarged  ami  overfull,  and  there  isa  scanty  -mall  cell-in61tration  and  increase 
in  nuclei. 

Symptoms. — The  lid-  feel  heavy  and  hot  ;  movements  of  the  eye  are 
painful  ;  there  are  increased  lachrymation  and  slight  photophobia.  Attempts 
to  use  the  eyes  by  artificial  lighl  are  accompanied  by  distress. 

Diagnosis  and  Prognosis. —  Redness  of  the  conjunctiva  without  discharge 

L'7I 


CONJUNCTIVITIS.  275 

other  than  increased  lachrymation,  and  without  other  appreciable  change  in 
the  conjunctiva,  suffices  to  establish  a  diagnosis.  The  prognosis  is  favorable, 
provided  the  cause  can  be  removed. 

Treatment. — This  should  include  the  prevention  of  the  entrance  of  for- 
eign substances  into  the  eye,  and  the  correction  of  habits  and  systemic  con- 
ditions that  contribute  to  the  continuation  of  the  hyperemia.  Errors  of 
refraction  and  muscular  defects  should  be  corrected.  Bathing  the  conjunc- 
tiva with  a  solution  of  boric  acid,  '2  or  •">  per  cent.,  three  or  four  times  a  day, 
usually  suffices  for  the  local  treatment.     Strong  astringents  are  not  advisable. 

Conjunctivitis  (Ophthalmia). — This  term  embracesa  number  of  diseases 
of  the  conjunctiva  characterized  by  increased  altered  secretion  from  the  sur- 
face of  the  conjunctiva,  pronounced  distressing  symptoms,  and  transient  or 
permanent  pathological  changes  in  the  membrane. 

Simple  Conjunctivitis  (Catarrhal  Ophthalmia). — There  is  a  relatively 
large  number  of  forms  of  conjunctivitis  which  are  mild  in  character  and  tend 
to  spontaneous  recovery,  without  serious  complications,  which  may  be  placed 
in  this  class.  They  are  characterized  by  slight  swelling  of  the  lids  and  con- 
junctiva and  the  presence  of  a  muco-purulent  secretion.  The  specific  disease 
known  as  acute  contagious  conjunctivitis,  usually  considered  under  this  head, 
will  be  described  separately. 

Etiology. — (a)  Mechanical  <<r  traumatic  varieties  are  caused  by  the  pres- 
ence of  dust  or  other  irritating  substances,  as  certain  kinds  of  pollen,  fish- 
scales,  foreign  bodies  of  any  description,  insects  and  parts  of  insects. 

(6)  Associati  varieties  accompany  the  eruptive  fevers  (measles,  scarlet 
fever,  small-pox),  influenza,  acute  coryza,  laeial  erysipelas,  eczema,  and  bleph- 
aritis marginalis.  The  pneumococcus  of  Frankel(Fig.  IV.,  Plate  2) has  been 
described  by  Morax,  Parinaud,  and  others  as  an  infrequent,  and  by  Gifford1 
as  a  frequent,  cause  of  simple  conjunctivitis." 

Symptoms. — The  development  of  muco-purulent  secretion  is  preceded 
by  burning  sensations,  increased  lachrymation,  hyperemia,  and  slight  swell- 
ing of  the  palpebral  conjunctiva  and  transition  ibid.  More  or  less  marked 
swelling  of  the  lids  occurs,  movements  of  the  lids  are  painful,  and  photo- 
phobia with  inability  to  use  the  eyes  develops.  Frequently  one  eye  alone 
is  affected,  particularly  in  those  cases  having  a  mechanical  origin. 

Diagnosis  and  Prognosis.- — Often  the  history  of  the  case  is  all-sufficient. 
Examination  of  the  conjunctival  sac  may  disclose  the  presence  of  an  irritating 
substance  in  addition  to  the  muco-purulent  secretion.  In  doubtful  cases  a 
microscopical  examination  of  the  secretion  will  serve  to  decide  its  character. 
The  prognosis  as  to  duration  is  favorable  in  all  cases  where  the  cause  can  be 
discovered  and  removed.     No  serious  impairment  of  vision  occurs. 

Treatment. — The  causes  that  produce  (lie  disease  should  be  sought  for 
and  removed,  when  rapid  recovery  even  without  local  medication  often  will 
take  place.  However,  a  cleansing  wash,  as  a  solution  of  boric  acid,  or  of 
sublimate  1  :  15,000,  may  be  used  every  two  or  three  hour-  to  advantage. 

1  Archives  of  Ophthalmology,  veil,  xxv.,  1896,  p.  314. 

2  The  affections  of  the  conjunctiva  which  are  due  to  a  known  specific  micro-organism  are: 
Acute  conjunctivitis  described  by  Morax — pneumococcus ;  acute  contagious  conjunctivitis — 
small  bacillus, first  Been  by  Koch  in  1883,  and  cultivated  and  proved  t"  lie  the  specific  micro- 
organism by  Weeks  in  1886,  without  knowledge  of  Koch's  observation;  gonorrheal  conjunc- 
tivitis— diplococcus  of  tseisser;  diphtheritic  conjunctivitis  Klebs-Loffler  bacillus;  tubercular 
conjunctivitis— tubercle  bacillus  "I  Koch  :  and  leprosy  of  the  conjunctiva — leprosy  bacillus. 

There  are  a  number  of  affections  of  the  conjunctiva  in  which  a  specific  micro-organism 
probably  exists,  but  which  has  not  yet  been  positively  identified;  of  these  may  he  mentioned 
phlyctenular  conjunctivitis,  trachoma,  membranous  conjunctivitis,  and  xerosis  epilheliahs. 


276  Dls/:.\s/,s  OF  THE  CONJUNCTIVA. 

After  the  acute  stage  is  passed  an  astringent  stimulating  collyriuni  of  zinc 
sulphate,  alum,  or  nitrate  of  silver,  in  the  strength  of  one  grain  to  the  ounce, 
may  be  instilled  once  daily  until  all  secretion  has  disappeared. 

Acute  Contagious  Conjunctivitis  (Acute  or  Epidemic  Catarrhal 
Conjunctivitis;  Muco-puruhnt  Conjunctivitis;  "Pink  Eye"  (vulgarly)). — 
This  is  an  acute,  highly  contagious,  muco-purulent  inflammation  of  the  con- 
junctiva, accompanied  by  some  swelling  of  the  lids.  A  period  of  incuba- 
tion precedes  the  acute  stage;  both  eyes  are  usually  affected.  Xo  age  is  ex- 
empt, except  perhaps  the  first  ten  days  of  life.  The  affection  is  met  with 
most  frequently  in  the  spring  and  fall  months,  often  becoming  epidemic. 
So  far  as  is  known  it  is  prevalent  throughout  almost  if  not  quite  the  entire 
world. 

Etiology. — This  disease  is  due  to  the  presence  of  a  specific  micro- 
organism, a  bacillus,  in  the  conjunctival  sac.  A  careful  study  of  this  micro- 
organism  was  first  made  by  the  writer  '  in  1886,  and  his  work  has  since  been 
confirmed  by  Kartulis,2  Morax,3  and  others.  The  bacillus  resembles  that  of 
mouse-septicemia,  measuring  0.25  micro-millimeters  in  thickness  (Figs.  II. 
and  III.,  Plate  2). 

Pathology  and  Pathological  Anatomy. — The  posterior  and  anterior 
systems  of  blood-vessels  are  congested,  and  there  is  apparently  an  increase  in 
the  number  of  capillaries  and  arterioles.  The  conjunctiva  at  the  transition 
folds  becomes  thickened  through  the  medium  of  the  enlarged  vessels,  slight 
serous  effusion,  and  the  presence  of  leukocytes  in  moderate  number  in  the 
conjunctival  tissue.  Small  transfusions  of  blood  occur  in  the  ocular  con- 
junctiva from  the  smaller  vessels  of  the  anterior  vascular  system. 

Microscopical  examination  of  the  conjunctiva  at  the  fornix  discovers  a 
slight  infiltration  of  leukocytes  at  the  base  of  the  epithelial  layer  and  between 
the  epithelial  cells,  a  moderate  edematous  condition  of  the  tissue,  and  the 
presence  of  a  few  bacilli  disposed  in  small  groups  in  the  epithelial  and  very 
superficial  conjunctival  layers.  The  secretion  contains  many  bacilli,  free  and 
aggregated,  on  or  in  the  leukoevtes. 

Symptoms. — About  thirty-six  hours  after  the  inception  of  the  con- 
tagium  the  patient  experiences  a  mild  burning  sensation  in  the  lids,  which 
are  stuck  together  on  waking  in  the  morning;  lachrymation  is  slightly 
increased.  On  the  morning  of  the  third  day  the  lids  are  glued  together  with 
a  thick  layer  of  muco-pus.  They  are  swollen,  sometimes  intensely  so,  and 
the  patient  suffers  from  a  sensation  as  of  a  foreign  body  in  the  eye.  Some 
photophobia  is  experienced.  Use  of  the  eyes  is  accompanied  by  pain  ;  vision 
is  blurred  by  the  presence  of  the  secretion.  The  palpebral  conjunctiva  is 
deeply  injected,  the  transition  fold  thickened,  and  the  ocular  conjunctiva 
presents  a  bright-red  appearace,  a  peculiarity  which  has  given  the  disease  the 
popular  name  of  "  pink  eye."  At  the  end  of  the  third  day  the  affection  is 
usually  at    its  height. 

In  the  greater  number  of  cases  the  swelling  of  the  lids  does  not  become 
intense,  but  in  ;i  few  tin-  symptom  is  pronounced,  and  when  accompanied  by 
pseudo-membrane  the  disease  may  be  mistaken  for  diphtheria. 

The  secretion  seldom  loses  its  ropy  character,  due  to  the  presence  of 
mucin,  but  in  some  cases  it  becomes  quite  purulent,  resembling  the  discharge 
of  gonorrhea]  conjunctivitis.  There  is  seldom  any  chemosis,  although  the 
ocular  conjunctiva  is  intensely  injected,     (lose  inspection   will   disclose  the 

'    i  Ophthalmology,  vol.  xv.  No.   I.  1886;  .V  )'.  M></.  Rec.,May  21,  1887. 

dralbl.f.  Bakt.u.  Paraailmk.,  1887 ,  p  289, 

/  .,,.,/.;,,;,,,  r Etiologie  des  Conjunctivitis  aiffries,  etc.,  Paris,  1894. 


Plate  2. 


fig.i 


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FiG.m 


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// 


PlG.   I.  —  Discharge  from  right  rye  in  a  case  of  purulent  conjunctivitis;  gouococci  numerous 
in  cells  (Stephenson  . 

Fig.  II.     Bacillus  of  Weeks  in  pure  culture  (from  a  photograph  . 

Fig.  III.     Conjunctiva]  secretion  from  acute  contagious  conjunctivitis;  polyuuclear  leuko- 
cytes with  the  bacillus  of  Weeks;  /'.  phagocyte  containing  bacillus  of  Weeks;  i ers.  ,'_..  >><•.  iii. 

Moras  . 

Fig.  IV.     Secretion  from  a  case  of  conjunctivitis,  showing   \ imococci ;   immcrs 

iii.  (Moras). 


ACUTE  CONTAGIOUS  CONJUNCTIVITIS.  -Ill 

presence  of  many  small  transfusions  of  blood  in  the  ocular  conjunctiva:  this 
is  such  a  common  symptom  thai  Nettleship  has  given  the  affection  the  name 
of  "hemorrhagic  catarrhal  conjunctivitis." 

The  acute  stage,  which  is  often  accompanied  by  slighl  rise  of  temperature 
and  frontal  headache,  lasts  from  four  to  ten  days.  The  discharge  gradually 
diminishes  in  quantity,  becomes  thicker,  and  collect-  in  little  yellow  masses 
at  the  inner  canthi.  The  swelling  of  the  lids  and  conjunctiva  and  the  pain- 
ful symptoms  gradually  subside,  and  recovery  usually  occurs  in  from  two  to 
three  weeks,  in  the  subacute  stage  the  conjunctiva  at  the  transition  folds 
presents  a  swollen,  succulent  condition,  with  enlargement  of  the  papillary 
body  and  some  follicular  hypertrophy. 

Diagnosis  and  Prognosis. — A  history  of  the  presence  of  the  affect  inn  in 
all  or  a  number  of  the  members  of  a  family,  or  of  its  epidemic  character  in 
institutions,  will  aid  much  in  establishing  a  diagnosis.  The  very  yellow 
mass  of  secretion  at  the  inner  canthus  is  quite  characteristic.  Acute  con- 
tagious conjunctivitis  may  be  mistaken  for  purulent  conjunctivitis,  and,  when 
a  pseudo-membrane  forms,  as  it  does  in  about  4  per  cent,  of  the  cases,  for 
diphtheritic  conjunctivitis.  The  microscope  may  be  depended  on  to  make 
the  diagnosis  clear  in  doubtful  cases. 

In  the  greater  number  of  eases  recovery  ensues  without  leaving  a  trace 
of  the  disease;  relapses  and  recurrences  are  frequently  observed.  Qne  attack 
does  not  ensure  immunity.  Phlyctenule  may  develop  in  the  later  stages  or 
trachoma  may  follow,  but  these  conditions  must  be  regarded  as  secondary 
diseases  grafted  on  the  primary  disease  by  added  infection.  The  cornea  is 
rarely  affected.  In  adults  the  attack  is  more  severe  than  in  children.  The 
disease  is  contagious  as  long  as  secretion  is  present. 

Treatment. — As  the  disease  is  very  contagious,  isolation  should  be 
resorted  to  if  possible.  Bathing  appliances  should  be  separate.  In  all  cases 
wrhere  large  numbers  of  individuals  are  aggregated  quarantine  should  be 
rigidlv  enforced,  and  persevered  in  until  all  traces  of  secretion  have  disap- 
peared, and  even  for  a  few  days  after  that  period. 

For  the  first  three  to  five  days  of  the  acute  stage  cold  application-  arc 
indicated.  These  may  be  applied  as  follows  :  Thin  pads  of  absorbent  cotton, 
H  inches  in  diameter,  or  pieces  of  linen,  1^  inches  square  and  two  or  three 
layers  in  thickness,  to  the  number  of  ten  or  twelve,  should  be  placed  on  a 
cake  of  ice  over  which  a  thin  napkin  is  spread,  and  a  pad  transferred  to  and 
from  the  eye  sufficiently  often  to  keep  the  lids  cool — every  two  minutes. 
In  severe  cases  the  cold  applications  should  be  continuous ;  in  mild  cases  it 
will   suffice  to  keep  up  the  applications  through  the  daytime. 

While  this  is  being  done  the  eye  should  be  cleansed  every  half  hour  if 
the  secretion  is  profuse,  less  often  if  the  secretion  is  scanty,  with  some  bland 
antiseptic  solution.  Boric  acid.  2  or  :;  per  cent.,  or  the  bichlorid  of  mer- 
cury, 1  :15,000,  may  be  employed.  When  the  acute  stage  is  subsiding  the 
cold  applications  should  lie  discontinued,  the  bathing  continued,  and  in  addi- 
tion a  more  energetic  germicidal  astringent  may  be  employed.  Nitrate  <>t 
silver,  in  the  solution  of  0.5  to  1  per  cent.,  is  excellently  adapted  for  t hi- 
purpose.  The  application  may  be  made  once  in  twenty-four  hours,  and  may 
be  continued  with  less  frequency  until  the  secretion  ceases.  Other  topical 
applications  an — alum  (gr.  1-f.SJ),  acetate  of  lead  i'j;w  l-f3j),  sulphate  ol 
zinc  (gr.  1-f.Vp,  peroxid  of  hydrogen,  formalin  (Schering's  solution — 1  : 
to  1  :  500), 

Bandaging  the  eye-  and  the  application  of  poultices  of  tea-leaves,  oysters, 
scraped  potato.-,  bread  and  milk,  and  other  domestic  concoctions  should  be 


278 


DISEASES  OF  THE  CONJUNCTIVA. 


avoided.  These  only  serve  to  retard  recovery,  and  in  many  cases  increase 
the  inflammation. 

Purulent  Conjunctivitis  (Acute  Blennorrhea  of  the  Conjunctiva). — The 
term  purulent  conjunctivitis  properly  applies  to  all  forms  of  conjunctivitis 
in  which  the  discharge  is  more  or  less  copious  and  comparatively  free  from 
mucin.  This  condition  obtains  in  certain  cases  of  acute  contagious  conjunc- 
tivitis in  some  cases  of  traumatic  conjunctivitis,  in  the  forms  induced  by  the 
application  of  a  poultice  of  tea-leaves  in  simple  conjunctivitis  (tea-leaf  con- 
junctivitis), and  in  the  later  stages  of  diphtheritic  conjunctivitis.  As  cora- 
monlv  employed,  it  refers  to  the  conjunctivitis  induced  by  the  presence  of  the 
gonococcal  of  Neisser,  and  is  usually  considered  under  the  terms  gonorrheal 
conjunctivitis  and  conjunctivitis  neonatorum. 

Gonorrheal  Conjunctivitis. — This  disease  occurs  in  men  much  more 
frequently  than  in  women.  It  is  characterized  by  marked  swelling  of  the 
lids  and  copious  discharge  of  purulent  secretion  from  the  conjunctiva. 

Etiology. — The  gonococcus  of  Neisser  (see  Fig.  I.,  Plate  2)  in  secretion 
from  a  diseased  mucous  membrane  is  brought  in  contact  with  the  conjunc- 
tiva. Probably  the  nm-i  frequent  manner  of  its  conveyance  is  by  means  of 
the  finger  from  a  urethral  or  vaginal  gonorrhea.  The  use  of  a  common 
washing-bowl,  towels,  etc.  may  serve  to  communicate  t'iie  disease.  It  is  not 
probable  that  the  contagium  can  be  carried  through  the  air.  The  discharge 
in  gleet,  as  well  as  in  pronounced  gonorrhea,  may  serve  to  set  up  the  affec- 
tion, but  it  is  supposed  to  lie  less  severe  when  arising  from  gleet. 

Pathology  and  Pathological  Anatomy. — Engorgement  of  the  vessels 
<>t'  the  palpebral  and  ocular  conjunctiva  rapidly  develops.  An  infiltration 
of  leukocytes  into  the  superficial  layers  of  the  entire  conjunctiva  and  edema 
induced  by  a  serous  and  in  some  cases  a  fibrinous  exudation  occur  early.  The 
conjunctival  epithelial  layer  h  swollen  and  uneven.  The  pathogenic  micro- 
organism grouped  in  or  on  the  leukocytes  in  the  characteristic  manner  is  seen 


-Gonococci  in  the  tissu  mjunctiva  i  Bumm). 


W 


Pig.  188     Gonoci  icci  free  and 
mi  the  cells  I  liumm). 


in  the  superficial  layers  of  the  conjunctiva  (Fig.  187).      The  secretion  con- 
tain- the  gonococci,  which  are  found  free  and  on  the  pus-cells  (Fig.  188). 

Symptoms. — The  stage  of  incubation,  which  la<ts  from  twelve  to  forty- 
eight  hours,  is  succeeded  by  the  acute  stage.  The  lids  swell  rapidly,  and 
sometimes  enormously,  taking  on  a  dark-red  hue.  The  vessels  of  the  con- 
junctiva become  deeply  congested,  the  conjunctiva  red  and  swollen.  There 
are  a  gritty  sensation  and  smarting  and  burning  of  the  lid-.  The  increased 
weighi  of  the  lid-  produces  a  continuous  dull  pain  in  the  eye-.  The  acvJU 
stage  reaches  its  heighl  in  two  or  three  days,  at  which  time  the  swelling 
of  th<'  lids  in  typical  cases  is  intense.  The  upper  overlap  the  lower  lids; 
from  beneath  the  margins  of  the  upper  lids  the  secretion,  which  at  lir-t  is 
watery  and  flaked  with  pus,  and  later  becomes  thick  and  creamy,  oozes  oul 
on  to  and  flows  down  the  cheek.  At  times  the  secretion  is  retained  in  the 
conjunctival   sac,  producing   much   pain  by  pressure  on  the  globe. 


GONOlilillEAL   COXJl  \<  TIVITIS.  279 

The  conjunctiva  of  the  tarsus  and  transition  fold  becomes  much  thickened 
and  presents  a  deep-red,  velvety  appearance.  The  ocular  conjunctiva  becomes 
very  edematous,  marked  chemosis  develops,  and  extravasations  of  blood  are 
observed  in  this  part  of  the  conjunctiva.  The  chemotic  tissue  may  overlap 
the  cornea,  giving  lodgement  to  secretion  in  the  sulcus  thus  formed,  which  is 
difficult  to  remove,  and  which  serves  to  macerate  and  destroy  the  corneal  epi- 
thelium, establishing  an  ulcer  of  the  eornea.  The  chemotic  tissue  may  pro- 
trude between  the  lids. 

The  acute  stage  continues  from  four  days  to  two  weeks,  and  gradually 
merges  into  the  subacute  stage.  The  thickening  of  the  lids  is  now  much  less; 
they  are  pale,  soft,  and  flabby.  The  conjunctiva  presents  a  velvety  appear- 
ance, and  is  still  much  hypertrophied ;  the  chemosis  is  less  marked  and  the 
secretion  less  profuse. 

What  might  be  termed  the  atonic  stage  succeeds  the  subacute  stage.  The 
swelling  of  the  lids  has  subsided,  but  the  conjunctiva  of  the  tarsus  and  tran- 
sition folds  is  left  rough,  rugose,  and  presents  many  papilliform  elevations. 
The  secretion  is  thinner  and  not  so  profuse.  Use  of  the  eye  is  difficult.  This 
stage  may  drift  into  a  chronic  condition  if  not  treated  properly,  in  which  cor- 
neal ulcer,  trichiasis,  entropion,  etc.  may  develop. 

Of  the  complications  that  develop,  corneal  involvement  is  most  dreaded. 
Total  destruction  of  the  cornea  may  occur  early  from  interference  with  the 
nutrition  of  that  membrane  ;  the  cornea  loses  its  luster,  becomes  gray,  and 
disappears.  Loss  of  the  crystalline  lens  and  panophthalmitis  may  follow. 
Involvement  of  the  cornea  is  most  frequent  in  the  second  week  of  the 
disease,  the  ulcer  commencing  at  the  margin  of  the  cornea  as  a  grayish, 
uneven  defect  which  increases  in  depth  and  area.  Pseudo-membrane  occurs 
in  a  small  percentage  of  the  cases.  It  appears  on  the  palpebral  conjunctiva 
as  a  result  of  the  deposition  of  fibrin  on  a  surface  from  which  the  superficial 
epithelial  cells  have  been  lost.  Gonorrheal  rheumatism  is  an  infrequent  con- 
sequence of  gonorrheal  conjunctivitis. 

Diagnosis. — Gonorrheal  conjunctivitis  presents  many  degrees  of  severity. 
It  may  be  so  mild  that  it  readily  passes  for  simple  conjunctivitis  ;  or  so  severe 
that  diphtheria  is  suspected.  The  history  of  the  case  will  assist  in  making  a 
diagnosis,  and  microscopical  examination  will  absolutely  establish  it.  The 
conjunctivitis  occurring  in  young  girls  with  leukorrhea,  which  is  observed 
from  time  to  time,  is  often  gonorrheal,  but,  according  to  some  authors,  may 
have  other  causes. 

Prognosis. —  In  spite  of  all  treatment,  a  large  percentage  of  cases  result 
in  impairment  of  vision,  to  a  greater  or  less  degree,  from  corneal  complica- 
tions. If  an  ulcer  appears  at  the  margin  of  the  cornea,  and  the  cornea  at 
this  point  becomes  vascular,  recovery  without  perforation  may  be  looked  for. 
Partial  ulceration  of  the  cornea,  with  or  without  perforation,  may  be  followed 
by  partial  staphyloma  after  the  ulcer  has  healed.  Adherent  leukoma  follow-; 
perforating  ulcer  of  the  cornea,  and  in  rare  cases  the  lens  may  become  adherent 
to  the  seai'.     Panophthalmitis,  ;i<  already  stated,  may  be  the  result. 

Treatment. — Prophylaxis  :i-  regards  other  individuals  and  in  regard  to 
the  fellow-eye  must  be  firsl  considered.  The  disease,  through  the  secretion, 
i-  extremely  contagious;  hence  immediate  isolation  should  be  secured,  and 
should  be  persisted  in  until  all  secretion  has  disappeared.  All  dressings  and 
appliances  with  which  the  secretion  come-  in  contacl  should  be  dest 
thoroughly  sterilized.  To  protect  the  fellow-eye  a  Buller's  shield,  which  con- 
sists of  a  watch-crystal  held  over  the  eye  by  mean-  of  strips  of  rubber  plas- 
ter, should  be  applied. 


280  DISEASES  OF   THE  CONJUNCTIVA. 

L,,rdl  Treatment. —  In  the  acute  stage  cold  applications  should  be  em- 
ployed day  and  night,  after  the  method  described  on  page  277,  and  the  con- 
junctiva freed  from  secretion  as  often  as  is  necessary — every  thirty  to  sixty 
minutes,  with  a  bland  aseptic  solution — boric  acid  •">  per  cent,  or  bichlorid  of 
mercury  (1  :  15,000).  For  the  carrying  oul  of  this  treatment  two  nurse-,  a 
day  ami  a  night  nurse,  are  required.  It*  the  lids  become  .-ore  and  erosion  of 
the  epithelium  is  threatened,  some  borated  vaselin  may  be  applied  after  each 
bathing. 

There  are  many  ways  of  eleansinf;  the  eye.  The  lids  may  be  held 
gently  apart  and  the  warm  solution  be  permitted  to  run  into  the  conjunc- 
tival sac  from  a  piece  of  absorbent  cotton.  A  pipette  may  lie  used  to  force  a 
stream  beneath  the  lid-  after  they  have  been  gently  opened.  A  speculum 
with  perforated  Made-  has  been  devised  (Andrews)  for  cleansing  the  con- 
junctival sacs,  and  a  lid-retractor  which  permits  the  solution  to  How  through 
thehandle  and  into  the  blade,  escaping  at  openings  at  the  margin  of  the 
I. lade,  has  been  made  for  the  same  purpose.  Except  in  very  skilful  hands 
the  instruments  devised  for  cleansing  the  eyes  are  dangerous,  as  they  are  apt 
to  injure  the  cornea  and  induce  corneal  ulceration. 

Applications  of  cold,  which  are  generally  made  inadequately,  may  he 
made  too  assiduously  and  the  vitality  of  the  cornea  threatened.  When  too 
much  cold  is  applied  the  cornea  takes  on  a  steamy  appearance  and  breaks 
down  more  easily.  If  corneal  luster  fails  without  evidence  of  loss  of  sub- 
stance, the  applications  of  cold  should  be  intermittent. 

//"/  applications  in  the  acute  stage  are  contraindicated ;  they  serve  to 
increase  exudation  and  the  growth  of  the  gonococcus.  In  the  subacute  and 
atonic  stages  they  may  he  resorted  to  with   benefit. 

A-  - a-   the  discharge  lake- on  a  purulent  character  and  the  lids  are 

less  rigid,  local  application-  to  the  conjunctiva  may  he  made.  For  this  pur- 
pose a  solution  «»f  the  nitrate  of  silver,  1  or  2  per  cent.,  is  probably  the  best. 
The  lids  are  carefully  everted,  the  secretion  removed,  and.  by  means  of  a 
piece  of  absorbent  cotton  wound  around  the  end  of  a  small  applicator  the 
solution  i-  applied  to  the  entire  surface  of  the  conjunctiva.  This  should  he 
followed  by  application-  of  cold  for  one  or  two  hour.-.  The  treatment  out- 
lined above  will  suffice  to  effect  a  cure  in  the  greater  number  of  eases. 

Finely  pulverized  iodoform  i-  sometimes  employed  by  dusting  it  into  the 
conjunctival  surface  two  or  three  time-  daily.  Peroxid  of  hydrogen  has  been 
advocated  by  Landolt  :  it  i-  of  value  as  a  cleansing  and  germicidal  agent. 
Sublimate  solution,  1  :  500,  ha-  been  employed  recently  by  applying  it  to  the 
conjunctiva  sufficiently  often  to  hold  the  secretion  in  check.  Aqua  chlorini, 
formalin  (1  :3000),  permanganate  of  potassium  in  copious  irrigations  (1  :500 
or  1  :  looo).  are  used  to  irrigate  the  eye.  \)\\  Wilson  of  Bridgeport  advocates 
filling  the  conjunctival  sac  with  a  boric-acid  ointment  (boric  acid  gr.  xlviij, 
vaselin  3j)  every  one  to  two  hour-  after  cleansing,  continuing  this  treatment 
until  the  acute  stage  ha-  pa—  ed  ;  he  claim- excellent  results.  In  some  severe 
cases  Nov,-  ha-  resorted  to  scarifying  the  conjunctiva  and  brushing  in  a  solu- 
tion of  corrosive  sublimate,  I  :  500,  repeating  the  operation  in  two  or  three 
days  if  the  discharge  return-. 

[f  corneal  ulcer  develops,  atropin  (gr.  ij  to  sj)  should  be  instilled  two  or 
three  times  daily.  Ehrenthaler1  recommends  eserin  (gr.  ij  to  Ij)  in  those 
cases  of  corneal  ulcer  where  congestion  of  the  iria  is  nol  present,  alternating 
with  atropin  in  other  cases  unless  perforation  is  imminent.  He  avers  that 
the  circulation  is  improved  and  recovery  more  certain. 

1  Munch,  med.   Wochemschrift,  No  38,  1892. 


CONJUNCTIVITIS  NEONA  TOBUM. 


•J>1 


When  the  lids  arc  greatly  swollen  and  tense  a  free  canthotomy  may  be 
done.  This  relieves  the  pressure  on  the  cornea,  unloads  t h<-  blood-vessels, 
and  prevents  spasmodic  contraction  of  the  orbicularis  palpebrarum  muscle. 
In  the  la-t  stage  hot-water  bathing,  the  sulphate  of  copper  or  alum-crystal, 
and  tannin  may  be  employed. 

Systemic  Treatment. — The  bowels  should  be  kept  free  by  use  of  calomel 
and  a  saline  Rich  food  and  alcoholic  beverages  should  be  forbidden.  ( )pium 
may  be  administered  if  there  is  much  pain. 

Conjunctivitis  Neonatorum  (Ophthalmia  Neonatorum). — This  is  a 
purulent  affection  of  the  conjunctiva,  accompanied  by  great  swelling  of  the 
lids  and  thick  purulent  secretion,  occurring  within  a  few  day-  after  the  birth 
of  the  child. 

Etiology. — That  form  of  the  affection  which  develops  within  three  days 
after  the  birth  of  the  child  is  undoubtedly  produced  by  gonorrheal  infection 
from  the  vaginal  secretions  of  the  mother  at  the  time  of  birth.  In  cases  that 
have  developed  ten  days  to  three  weeks  after  birth  other  causes  are  found: 
the  small  bacillus  of  acute  contagious  conjunctivitis,  the  pneumo-bacillus,  and 
the  Klebs-Lofrler  bacillus  have  been  observed.  The  use  of  -oiled  towels  or 
napkins  about  the  infant  or  the  unclean  hands  of  mother  or  attendant  may 
serve  as  a  means  of  carrying  infectious  material  to  the  infant's  eve.  Ex- 
ceptionally, inoculation  in  utero  may  occur  (ante-partum  conjunctivitis). 

Pathology. — The  pathology  of  ophthalmia  neonatorum  resembles  that  of 
purulent  conjunctivitis  in  the  adult,  so  far  as  the  tissue-changes  arc  concerned. 

Symptoms. — Slight  puffiness  of  the  lids  and  a  tendency  to  .-tick  together 
will  be  noticed  twenty-four  or  thirty-six   hours  after  birth,  and  on  inspec- 


Fig.  189.— Conjunctivitis  n< atorum  (from  a  patient  in  the  Philadelphia  Hospital  under  the  .'are  of 

I»r.  ilij  Schweinitz). 

tion  the  palpebral  conjunctiva  will  be  found  to  be  congested.  A-  a  rule, 
the  change  in  the  lids  and  the  presence  of  secretion  are  not  sufficient  to  at- 
tract attention  until  the  third  day.  when  the  secretion  ha-  become  distinctly 
purulent  and  the  lids  somewhat  swollen.  At  the  end  of  the  fourth  or  fifth 
dav  the  lids  are  greatly  thickened  and  of  a  dusky-red  color;  the  secretion  is 
purulent  and  quite  copious.  It  either  flows  out  on  to  the  cheek  <>r  i<  retained 
in  greater  part  by  the  lid-  and  bursts  forth  on  attempts  t"  separate  the  lid-. 


282  DISEASES  OF   THE  (OXJ LXVTIVA. 

The  swelling  of  the  conjunctiva  is  so  intense  in  some  cases  that  ectropion 
of  the  upper  lid  is  produced.  Chemosia  is  not  so  marked  as  in  purulent  con- 
junctivitis occurring  in  adults,  and  involvement  of  the  cornea  occurs  in  a 
smaller  proportion  of  eases.  What  has  been  stated  in  regard  to  the  symptoms 
in  gonorrhea]  conjunctivitis  of  the  adult,  excepl  as  indicated  above,  applies  to 
conjunctivitis  neonatorum. 

Diagnosis. — The  history  of  the  case  and  the  age  of  the  child  will  suffice 
to  establish  a  diagnosis. 

Prognosis. — If  not  properly  treated  the  prognosis  is  grave,  but  not  to 
such  a  degree  as  in  the  adult.  Properly  treated,  the  prognosis  is  good. 
Careful  observation  of  many  eases  has  taught  the  writer  that  if  the  patient  is 
seen  while  tin1  cornea  is  still  dear  impairment  of  vision  need  not  occur,  except 
in  the  eases  in  which  the  affection  is  very  severe  and  the  patient's  vitality 
much  impaired.  Since  the  retention  of  vision  depends  so  much  on  careful 
and  proper  treatment,  it  is  of  the  greatest  importance  that  the  infant  should 
be  seen  by  a  competent  physician  as  early  as  possible.  Neglected  cases  have 
contributed  20  per  cent,  to  the  number  of  the  blind. 

Prophylaxis. — The  great  work  done  by  Crede  in  Leipzig  in  reducing  the 
number  of  cases  of  conjunctivitis  neonatorum  from  10.8  to  0.2  per  cent,  in 
the  infants  born  at  the  Lying-in  Asylum  under  his  charge  shows  what  may 
be  accomplished  by  prophylaxis,  ('rede's  method  was  to  drop  two  drops  of 
;i  "_'  per  cent,  solution  of  nitrate  of  silver  into  the  conjunctival  sac  of  the 
infant'-  rye-  very  shortly  after  its  birth,  having  first  wiped  the  lids  clean. 
The  reaction   is  quite  severe  in  some  cases. 

It  has  been  found  that  equally  good  results  may  be  obtained  with  a  1 
per  cent,  solution  of  nitrate  of  silver,  also  with  a  solution  of  bichlorid  of 
mercury  (1  :  4000)  dropped  into  the  eye  in  the  same  manner.  Normal  saline 
solution,  used  a  little  more  freely,  is  excellent,  but  not  quite  as  efficacious 
a-  either  the  silver  or  sublimate  solution.  Aqua  chlorini  and  carbolic  acid 
(1  :  100)  have  been  advocated. 

Those  in  charge  of  a  case  of  conjunctivitis  neonatorum  should  be  cau- 
tioned regarding  it-  contagious  nature,  and  should  be  instructed  to  destroy  or 
to  disinfect  all  appliance-;  thai  come  in  contact  with  the  secretion.  The  in- 
fant should  be  removed  from  the  presence  of  all  persons  except  those  in  im- 
mediate attendance.  A  protective  shield  for  the  unaffected  eye  i>  not  easily 
made  efficienl  ;  more  reliance  may  be  placed  in  the  ability  of  the  nurse  to  keep 
the  fellow-eye  disinfected.     A.lmos1  always,  however,  the  affection  i-  bilateral. 

Treatment. —  If  the  lid-  arc  at  all  swollen,  cold  applications,  made  as 
described  on  page  '277.  and  continued  until  the  swelling  of  the  lids  partly 
subsides,  are  valuable.  Three  hours  of  the  applications  and  one  hour  of 
intermission  i-  an  excellent  way  of  applying  cold.  After  the  -welling  has 
markedly  diminished  applications  of  cold  for  one  hour,  three  times  daily,  may 
be  kept  up  until  little  swelling  remains. 

The  pus  should  be  gently  removed  by  lavage  with  a  2  or  .">  percent. 
solution  of  boric  acid  every  half  hour  or  every  hour,  as  long  as  the  secretion 

i-  ab lam.     After  the  first  two  or  three  days  applications  of  a   1   percent. 

solution  of  nitrate  of  silver  may  be  made  by  the  surgeon  to  the  palpebral 
conjunctiva,  either  employing  a  bit  of  absorbenl  cotton  on  a  -mall  applicator 
or  a  camel's-hair  bru-li.on.-i'  in  twenty-four  hours.  As  the  secretion  and 
swelling  diminish  the  silver  solution  may  be  weaker  and  may  be  applied  less 
frequently.  Should  the  integumenl  of  the  lid-  lose  some  of  it~  epithelium  or 
become  roughened,  some  borated  vaselin  may  be  applied  after  each  cleansing 

if    the   c\ 


CROri'OUS  (OXJIWCTIVITIS.  283 

When  ulcer  of  the  cornea  occurs,  atropin  in  weak  solution  (gr.  ij  to  51) 
should  he  instilled  twice  daily  if  the  ulcer  is  central  ;  if  marginal,  eserin 
(gr.  j  to  gj)  may  be  alternated  with  the  atropin.  The  treatment  may  he 
varied  as  indicated  w  hen  considering  the  treatment  of  gonorrheal  conjunctivitis 
of  adults  (page  280). 

Croupous  Conjunctivitis  {Membranous  Conjunctivitis). — There  is  a 
class  of  cases  characterized  by  a  slight  swelling  of  the  lids,  by  a  flaky  serous 
discharge,  and  by  the  deposit  of  a  fibrinous  pseudo-membrane  on  the  surface 
of  the  palpebral  conjunctiva,  extending  in  some  cases  on  to  the  ocular  con- 
junctiva, which  from  a  bacteriological  or  clinical  standpoint  cannot  be 
included  with  any  other  form  of  conjunctivitis.  Graefe  '  terms  the  disease 
pseudo-membranous  or  croupous,  in  contradistinction  to  the  diphtheritic  form. 
The  cases  are  comparatively  rare. 

Etiology. — No  exact  cause  is  known.  The  affection  is  regarded  as  a 
mild  diphtheria  by   some  authors. 

Pathology  and  Pathological  Anatomy. — The  conjunctiva  is  thickened, 
and  shows  on  section  the  presence  of  leukocytes  and  an  increase  in  nuclei. 
The  epithelial  layer  is  reduced  in  thickness  ;  blood-vessels  are  numerous  and 
are  enlarged.  The  pseudo-membrane  consists  of  fibrin,  which  includes  in 
its  meshwork  epithelial  cells  from  the  conjunctiva,  leukocytes,  red  blood- 
corpuscles,  and  various  forms  of  micro-organisms.  The  pseudo-membranes 
found  in  epidemic  conjunctivitis,  gonorrheal  conjunctivitis,  diphtheritic  con- 
junctivitis, and  those  that  cover  the  surface  of  the  conjunctiva  after  burns 
with  acids,  steam,  or  after  scarifying  the  conjunctiva,  differ  from  each  other 
microscopically  only  in  their  bacterial  contents  and  the  products  of  the  bac- 
terial growth.  Thus  membranous  conjunctivitis  has  been  ascribed  to  staphylo- 
cocci, streptococci,  Loffler-bacilli,  and  diplococci.2 

Symptoms. — The  symptoms  are  not  severe.  The  patient  complains  of 
ob-euration  of  vision,  slight  itching,  and  some  burning  pain.  There  is  some 
photophobia.  The  lids  are  slightly  swollen  and  somewhat  hyperemic.  On 
everting  the  lids  a  grayish  pseudo-membrane  is  found.  It  can  be  separated 
from  the  conjunctiva  with  comparative  ease,  but  leaves  a  slightly  bleeding 
surface.  The  fibrin  filaments  do  not  appear  to  be  so  numerous  or  to  pene- 
trate so  far  into  the  conjunctiva  as  is  the  case  in  diphtheritic  conjunctivitis. 
Removal  i-  followed  by  rapid  regeneration  of  the  membrane,  and  this  tend- 
ency may  continue  for  from  ten  days  to  many  months  or  even  longer. 

Diagnosis. — The  diagnosis  is  arrived  at  largely  by  exclusion.  The  sub- 
acute nature  of  the  disease,  the  absence  of  any  known  specific  micro-organism, 
and  the  persistence  of  the  affection  serve  to  establish  a  diagnosis. 

Prognosis. — The  prognosis  is  good  in  perhaps  50  per  cent,  of  the  cases. 
Although  the  disease  persists  for  a  long  time,  appropriate  treatment  will  often 
produce  a  gradual  diminution  in  the  tendency  to  reproduce  the  membrane  ami 
the  patient  will  recover,  d'he  cornea  remains  clear  for  a  long  tinn — ten  days 
or  perhaps  as  many  week-.  It  may  finally  become  the  -eat  of  ulcerative  pro- 
cesses and  be  partly  or  totally  destroyed. 

Treatment. — Unfortunately,  treatment  appear-  to  be  of  little  avail  in 
some  cases  ;  in  other-  a  tardy  response  is  secured.  It  appears  to  be  almost 
useless  to  remove  the  membrane.  Frequent  and  prolonged  bathing  with 
3ome  mild  antiseptic  solution,  as  carbolized  water,  corrosive  sublimate  (1  : 
10,000),  chlorin-water,  or  a    I   per  cent,  solution  of  boric  acid,  is  indicated. 

1  Arehivf.  Ophtk,  1854,  I    V.bth.,  i.  168. 
For  .'in  article  on  "  Pathology  of  <  Ihronic  Membranous  <  kmjunctivitis  "  b  i  [owe, 

consult  Trans.  Ann,.  Ophth.  Sac.,  1  -- '. ♦  "7 .  mi.  :;<i    11. 


284 


DISEASES  OF  THE  CONJUNCTIVA. 


Some  writers  believe  thai  it  i-  best  to  remove  the  membrane  and  to  treat  the 
surface  with  the  mitigated  stick  of  nitrate  of  silver:  but  this  measure  is  of 
doubtful  value  A  solution  of  chlorate  of  potassium  has  been  suggested;  as 
have  also  applications  of  iodoform  and  quinin. 

Diphtheritic  Conjunctivitis  [Membranous  Conjunctivitis). — This  is  a 
severe,  acute  affection  of  the  conjunctiva,  characterized  by  intense  swelling 
of  the  lids,  which  become  thick,  hard,  and  smooth,  and  by  the  presence  of  a 
pseudo-membrane  on  the  surface  of  the  ocular  and  palpebral  conjunctivae. 
It  attacks  individuals  of  all  ages  except  the  new-horn  (von  Grraefe),  but  is 
mosl  frequent  in  children.     Both  eve-  are  generally  involved. 

Etiology. — The  direct  cause  is  without  doubl  a  specific  micro-organism 
known  as  the  diphtheritic  or  Klebs-Loffler-bacilhs  (  Fig.  1  90),  which  develops 
on  the  conjunctiva  only  when  that  membrane  is  in  a  suitable  condition  to 
receive  it.  A  depreciation  of  the  resisting  power  of  the  conjunctiva  to  the 
inroads  of  bacteria,  the  result  of  malnutrition  or  an  acute  illness,  as  scarlet  fever 
or  measles,  will  favor  an  attack.  The  affection  i<  more  frequent  during  the 
climatic  changes  of  fall  and  spring  and  when  epidemics  of  diphtheria  of  the 
air-passages  occur.  Many  cases  accompany  and  are  secondary  to  faucial  and 
nasal  diphtheria,  but  the  disease  may  occur  primarily  in  the  eye.  To  pro- 
duce the  disease  direct  infection  of  the  conjunctiva  with  secretion  containing 
the  bacilli  is  uecessary.  Von  Graefe1  states  that  simple  conjunctivitis  ren- 
der- the  conjunctiva  susceptible  to  the  diphtheritic  poison. 

Pathology  and  Pathological  Anatomy. — A  congestion  of  the  blood- 
vessels of  the  conjunctiva  and  lids  first  occurs,  which  is  soon  followed  by  the 

transudation  of  leukocytes  and 
plastic  material  into  the  tissue  of 
the  lids  and  on  to  the  surface  of  the 
conjunctiva.  A  partial  destruction 
of  the  epithelial  layer  of  a  portion 
of  the  conjunctiva  is  probably 
necessary  before  the  plastic  exuda- 
tion can  find  its  way  to  the  surface 
of  the  conjunctiva.  The  circula- 
tion is  greatly  impeded  by  the 
presence  of  the  exudation.  Tin' 
pseudo-membrane  i-  composed  of 
layers  of  fibrin  which  enclose 
leukocytes,  degenerating  epithelial 
cells.  vrt\  blood-corpuscles,  and  va- 
rious forms  of  bacteria,  prominent 
among  which  are  the  diphtheritic 
bacilli.  At  the  baseofthe  pseudo- 
membrane  fibrillae  of  fibrin  em- 
brace the  Superficial   epithelial   cells 

membrane   to  adhere  closely  during 


* 


>. 

v 


•vr-  Jat-'«V 


Fig.  190     Bacillus  diphtherial,  from  a  culture  upon 
blood-serum;      1000 (Frankel and  Pfeifl 


and  extend  between  them,  causing   the 
the  time  of  its  formation. 

Diagnosis. —  In  some  cases  it  is  difficult  to  discriminate  between  mem- 
branous conjunctivitis  due  to  diphtheria  and  that  due  to  other  forms  of 
inflammation.  Caustic  applications  in  mild  forms  of  conjunctivitis  in  in- 
fant-  and    children    may  produce   a    p-eiido-ineinhrane  and   an   intense   plastic 

infiltration  of  the  lid  that  may  be  mi-taken  for  diphtheria.     Severe  cases  of 

gonorrheal  and  of  epidemic  conjunctivitis  may  assume  a  diphtheritic  aspect, 

1  Arehivf.  Ophth.,  1854,  I  Al.ili..  p.  168. 


DIPHTHERITIC  CONJUNCTIVITIS. 

The  history  will  aid  in  eliminating  error,  bul   the  most  conclusive  method  is 
that  of  bacteriological  examination.     Should  the  examination  of  a  cover-e 
specimen  fail  to  afford  positive  results,  cultivation  experiments  may  be  tried. 

Symptoms. — In  a  typical  case  the  onsel  is  sudden.  Slight  discomfort  in 
the  lids,  increased  lachrymation,  and  congestion  of  the  conjunctiva  precede 
the  severer  symptoms  by  a  few  hours.  Swelling  of  the  lid-  take-  place 
rapidly:  at  the  end  of  twenty-four  hours  the  upper  lid  may  have  attained 
four  or  five  times  its  normal  thickness.  The  folds  of  the  skin  of  the  lid  are 
obliterated;  it  becomes  shiny  and  assumes  a  dusky-red  hue.  The  lid  is  hard 
to  the  touch,  slightly  elastic,  closes  the  eye  completely,  and  cannot  be  easily 
raised  or  exerted.  A  little  flaky  serous  secretion,  sometimes  tinged  with 
blood,  ooze-  from  between  the  lids  at  this  stage.  Attempts  to  open  the  eye 
on  the  part  of  the  patient  arc  futile,  and  the  surgeon  will  only  partly  succeed. 
A  sensation  of  weight  and  tension  on  the  globe  is  experienced,  but  aside  from 
this  there  is  little  pain. 

On  raising  the  lid  from  the  globe  the  palpebral  and  often  the  ocular  con- 
junctival surface  will  be  found  to  be  covered  with  a  gray  membrane,  which, 
in  the  average  ease,  is  about  one  millimeter  in  thickness.  <  hi  attempts  to 
remove  this  membrane  shortly  after  it  has  formed,  it  will  he  found  to  be 
closely  adherent  :  forcible  removal  leaves  a  raw,  bleeding  surface,  which  is 
soon  covered  again  by  new-formed  membrane. 

The  acute  stage,  which  may  last  three  to  seven  days,  is  accompanied  by 
slight  rise  of  bodily  temperature,  and  sometimes  by  cephalalgia.  Gradually 
the  lids  become  less  rigid,  the  secretion  morepuriform  ;  the  pseudo-membrane 
comes  away  in  lai'ge  or  small  plaques,  and  finally  disappears.  Corneal  com- 
plications in  the  form  of  ulcers  and  extensive  sloughing  frequently  develop, 
not  only  when  the  membranous  deposit  is  extensive,  but  also  when  it  is  mod- 
erate in  amount.  There  is  great  variation  in  the  degree  of  severity,  rapid 
destruction  of  the  eye  occurring  in  some  cases,  while  others  are  so  mild  that 
the  nature  of  the  disease  is  not  recognized. 

Prognosis. — Diphtheritic  conjunctivitis  i-  probably  the  most  destructive 
disease  that  affects  the  conjunctiva.  The  nutrition  of  the  cornea  is  often 
interfered  with  at  an  early  stage,  and  the  membrane  slough-.  Of  40  cases 
reported  by  von  Graefe  occurring  in  children,  9  eyes  were  destroyed,  in  3 
there  were  adherent  leukomata,  in  7  simple  leukomata,  and  in  '1\  the  cornea 
remained  unaffected.  Of  8  cases  in  adults,  5  sustained  perforation  of  the 
cornea,  and  3  presented  marked  simple  leukomata  after  t  he  disease  had  passed. 
Symblepharon  of  varying  degree-  may  result  from  adhesion  of  opposing  raw- 
surfaces.  Tendinous  cicatricial  bands  may  form  in  the  conjunctiva.  Great 
changes  in  the  lid  may  ensue  as  a  result  of  the  formation  of  cicatricial  tissue. 

Treatment. — The  indication-  are  to  prevent  the  communication  of  the 
disease  to  the  fellow-eye  ami  to  the  eyes  of  other  individual.-,  to  limit  the 
infiltration  of  the  lids,  to  prevent  destruction  of  the  cornea  by  pressure  or 
by  infection,  and  to  check  the  extension  of  the  diphtheritic  process  to  other 
mucous  membranes.  Aseptic  or  antiseptic  solutions  may  he  employed  to 
cleanse  the  unaffected  eye  ;n  stated  intervals,  or.  better  still,  Bullets  shield 
may  be  applied  to  the  sound  eye.  The  patient  should  !><•  isolated,  dressings 
and  secretion-  from  the  eye  destroyed,  and  towels,  linen,  etc.  disinfected  after 
use.  ('old  applications  should  lie  made  a-  advised  on  page  277,  until  the 
lids  are  less  tense.  A  free  canthotomy  will  cause  desired  depletion  and 
relieve  the  pressure  on  the  eyeball  exerted  by  the  tense  lid-.  The  conjuncti- 
val sac  should  1m-  carefully  cleansed  at  frequent  intervals  with  a  solution  oi 
boric  acid,  bichlorid  of  mercury  (1  :  5000  or  10,( or  chlorin-water  (one- 


2s. i 


DISEASES  OF  THE  CONJUNCTIVA. 


half  the  U.  S.  P.  strength).  To  prevent  extension  to  the  mucous  membrane 
of  the  air-passages  mercury  to  saturation  has  been  advised.  The  usual  con- 
stitutional treatment  of  diphtheria  is  indicated. 

Recently,  serv/m-therapy  has  been  resorted  to  with  results  which,  if  uni- 
formlv  as  brilliant  as  in  the  eases  reported,  will  rob  the  disease  of  its  terrors.1 
A-  soon  as  the  diagnosis  is  made,  10  cgm.  of  Behring's  diphtheria-antitoxin 
is  injected  into  the  abdominal  wall,  and  the  injection  is  repeated  after  forty- 
eighl  hours  it*  there  is  doI  a  marked  recession  of  the  disease.  In  many  cases 
improvement  is  noted  before  the  end  of  the  first  twenty-tour  hours,  and  the 
membrane  disappears  before  the  expiration  of  forty-eight  hours.  Antitoxin 
is  said  to  modify  favorably  the  necrotic-  process  in  the  cornea. 

Phlyctenular  Conjunctivitis  ( Lymphatic  <  'onjunctivitis  (  Fuchs) ;  Scrof- 
ulous Ophthalmia  ;  Eczema  of  the  Conjunctival — This  disease  is  characterized 
by  the  appearance  of  one  or  more  small  translucent  elevations  at  the  limbus 
or  at  some  point  on  the  ocular  conjunctiva,  accompanied  by  an  increased  local 
vascularization  ( Fig.  191  .      [fa  single  nodule  appears,  it  is  situated  at  the 


Fig.  191.— Phlyctenular  conjunctivitis 
I  De  Schweinitz). 


Pig.  192.—  Pus  with  staphylococci;  X 
800  (Flugge). 


apex  of  a  triangular  patch  of  injected  vessels,  the  base  of  the  triangle  being 
directed  toward  the  equator  of  the  globe.  The  affection  is  common  in  chil- 
dren, never  affects  the  new-born,  and  is  rarely  seen  in  adults. 

Etiology. — A    depraved    c lition    of  the   system    induced   by   inherited 

taints,  malnutrition,  tilth,  and  bad  hygienic  surroundings  predisposes  to  this 
affection.  Although  most  frequently  met  with  among  the  children  of  the 
poor,  the  children  of  the  rich  are  not  exempt.  Experiments  that  have  been 
conducted  with  cultivations  made  from  the  content-  of  the  vesicles  permit  of 
but  little  doubt  that  the  immediate  cause  is  the  presence  of  the  staphylococcus 
pyogenes  aureus. or  aibus  beneath  the  epithelium  of  the  affected  portion  of 
the  conjunctiva  (see  Fig.  192).  This  affection  is  frequently  associated  with 
moist  eczema  of  the  lids,  face,  scalp,  ears,  or  other  parts.  The  nodules  of 
eczema  closely  resemble  those  of  phlyctenular  conjunctivitis,  from  which  the 
same  micro-organism  may  be  cultivated.  It  is  undoubtedly  from  the  eczema- 
tons  process  that  the  infectious  principle  is  derived  in   many  cases. 

Pustular  blepharitis  marginalis  supplies  the  necessary  bacterium  in  some 
cases.  Phlyctenular  conjunctivitis  frequently  follows  the  exanthemata,  as 
measles  and  scarlel  fever.  Simple  and  epidemic  catarrh  of  the  conjunctiva 
encourage  to  the  development  of  phlyctenular  which  appear  six  or  seven  days 
after  the  onset  of  the  acute  conjunctivitis  due  to  a  secondary  infection.  Xaso- 
pharyngeal  disease  always  accompanies  the  affection. 

'Hamilton  ami  Jones:    Brit.   Med.  Journ.,  1895,  p.    1419;  Morax:   Annul,  d1  Oculistique, 
cxiii.  j>  360;  Coppez:  Bevtu  gin.  d' Ophthcd.,  Feb.,  1896,  p.  51  ;  Standish:   Trans.  Atner.  Ophth. 
iii.  11  50. 


VERNAL   CONJUNCTIVITIS  OR   CATARRH.  287 

Patholog-y. — Apparently  as  a  result  of  the  depreciation  of  the  resisting 

powers  of  the  tissues  of  the  body,  the  surface  cells  do  not  prevent  the  entrance 
and  development  of  the  pathogenic  micro-organisms.  The  contents  of  the 
nodule  in  the  early  stage  is  a  thickened  fluid  containing  many  leukocytes  and 
some  granules  ;  later  the  contents  resemble  pus.  A  section  of  a  nodule  -hows 
it  to  be  formed  by  the  elevation  of  the  epithelial  layer  from  the  underlying 
basement-membrane ;  the  vessels  in  the  vicinity  are  congested,  and  there  i-  an 
increased  number  of  leukocytes  in  the  adjacent  tissue. 

Symptoms. — The  palpebral  conjunctiva  is  congested  ;  this  is  also  the 
condition  of  the  ocular  conjunctiva  in  the  affected  portion.  There  are  -light 
stinging  pain,  laehryniation,  photophobia,  ami  annoyance  on  use  of  the  eye-. 
'Idie  photophobia  in  phlyctenular  conjunctivitis  is  slight  compared  with  that 
accompanying  phlyctenular  keratitis  (see  page  305).  In  almost  all  cases  the 
preauricular  glands  are  enlarged.  Frequently  there  i-  marked  coryza,  the 
upper  lip  becoming  thickened  by  the  flow  of  irritating  secretions  over  it. 

Diagnosis. — Herpes  conjunctivae,  vernal  catarrh,  and  trachoma  affecting 
the  ocular  conjunctiva  may  be  mistaken  for  phlyctenular  conjunctivitis.  In 
herpes  the  vesicles  which  spring  from  the  injected  conjunctiva  are  transpa- 
rent and  appear  in  clusters.  They  do  not  select  the  limbus,  and  are  much 
more  transient.  In  vernal  catarrh  the  elevations  are  larger  and  do  not 
ulcerate.  Trachoma  of  the  ocular  conjunctiva  is  associated  with  trachoma  of 
the  palpebral  conjunctiva,  and  seldom  affects  the  limbus  conjunctivae. 

Prognosis. — When  the  conjunctiva  only  is  affected  the  prognosis  i-  favor- 
able, as  recovery  occurs  without  leaving  a  trace  of  the  disease.  The  duration 
is  variable,  from  a  few  days  to  a  number  of  month-,  successive  phlyctenular 
appearing.     Recurrences  are  frequently  observed. 

Treatment. — This  should  be  local  and  constitutional.  The  local  treat- 
ment consists  in  keeping  the  eyes  clean  by  the  use  of  some  antiseptic  lotion. 
Bathing  with  a  saturated  solution  of  boric  acid  in  water  three  or  four  times  a 
day  gives  good  results.  An  ointment  of  the  yellow  oxid  of  mercury  (1—1.5 
per  cent.),  introduced  into  the  conjunctival  sac  twice  daily  after  the  phlyc- 
tenule has  broken  down,  is  of  much  value.  Calomel  may  be  dusted  on  the 
conjunctiva  once  daily  if  the  patient  is  not  taking  iodin.  A  mild  altera- 
tive in  the  shape  of  small  doses  of  •calomel  may  be  continued  for  some  weeks 
with  benefit.  Nourishing  food  and  general  tonic  treatment  —  iron,  quinin, 
cod-liver  oil,  and  perhaps  strychnin—  may  be  given.  The  naso-pharynx 
should  receive  appropriate  treatment.  (Consult  also  Phlyctenular  Kerato- 
conjunctivitis, page  -'107. ) 

Herpes  Conjunctivae. — This  occurs  ;it  time-  in  connection  with  herpes 
febrilis  or  herpes  zoster  affecting  the  lids  and  face.  It  is  seldom  that  the 
complete  vesicles  are  found,  as  they  rupture  early,  and  their  site  is  marked 
by  shreds  of  epithelium  which  remain  attached  to  the  conjunctiva  at  the 
margins  of  the  preceding  vesicles. 

The  condition  is  accompanied  by  irritation  and  increased  laehryniation. 
Herpes  of  the  cornea  may  accompany  herpes  conjunctivae.  The  affection  is 
extremely  rare.  It  call-  for  no  treatment  other  than  that  given  for  the 
affection  which  it  accompanies  (see  also  page  309). 

Vernal  Conjunctivitis  or  Catarrh  (Fruehjahr's  Catarrh  (Saemisch  ; 
Spring  Catarrh;  Phlyctama  Pallida  (Hirschberg)). — This  i-  a  chronic  form 
of  conjunctivitis  which  presents  peculiar  feature-;.  The  tarsal  conjunctiva  is 
covered  by  -mall,  closely-placed,  flattened,  papilliform  excrescences,  which 
appear  to  be  covered  by  a  delicate  grayish  film.  At  the  margin  of  the  cornea 
the  conjunctiva  is  thickened  and  unequally  raised,  forming  pale,  translucent, 


L>ss  DISEASES  OF  THE  CONJUNCTIVA. 

or  waxy  nodules,  which  arc  largesl  opposite  the  palpebral  fissure,  encroach  a 
little  on  the  cornea,  hut  extend  to  a  greater  distance  outward  into  the  ocular 
conjunctiva. 

Etiology. — Nothing  definite  is  known  of  the  cause  of  the  affection.  Some 
writers  believe  it  to  he  a  form  of  trachoma,  and  so  classify  it.  Fuchs  is  of 
the  opinion  that  it  is  a  specific  disease,  and  that,  although  no  specific  micro- 
organism has  been  discovered,  it  i-  produced  by  such  a  micro-organism. 
Both  eye-  are  affected.  'The  male  sex  suffers  most,  the  attacks  being  expe- 
rienced  between   the  ages  of  one  and   thirty-five  years. 

Pathology. —  Little  is  known  regarding  the  development  of  the  papillae 
of  the  tarsal  conjunctiva.  The  elevations  about  the  cornea  are  preceded  by 
local  injection  of  the  vessels ;  the  thickening  develops  slowly.  The  papilla? 
of  the  tarsal  conjunctiva  are  composed  of  a  central  cylinder  or  cone,  made  up 
of  connective  tissue  and  a  few  small  blood-vessels,  which  is  covered  by  a 
thickened  layer  of  epithelium.  Over  the  nodules,  at  the  limbus,  the  epithelial 
layer  is  uneven,  and  is  thicker  than  normal. 

Symptoms. — The  ropy  nature  of  the  secretion  produces  a  sensation  as 
of  a  foreign  body  in  the  eye.  There  are  photophobia,  burning  of  the  lids, 
and  blurring  of  vision,  principally  due  to  the  presence  of  secretion  on  the 
cornea.  I  %-c  of  the  eyes  by  artificial  light  increases  the  irritation  and  lachry- 
mation  ;  the  redness  of  the  ocular  conjunctiva  about  the  cornea  and  the  nodules 
at  the  limbus  are  apparent  on  inspection.  On  everting  the  lid  the  fine  fissures 
of  the  tarsal  conjunctiva  due  to  separation  of  the  papillae  are  recognized.  The 
disease  gives  but  little  annoyance  during  winter  months,  but  is  very  trouble- 
some during  the  summer  months,  at  which  time  there  is  more  or  less  stringy 
discharge  and  the  eyes  are  painful.  When  cold  weather  comes  on  the  eleva- 
tions at  the  margin  of  the  cornea  become  much  smaller,  some  disappearing 
entirely  ;  the  tarsal  conjunctiva  is  less  thickened,  but  the  papilliform  eleva- 
tions still  remain.  Burnett  -tates  that  in  the  colored  race  the  bases  of  the 
nodules  are  pigmented. 

Diagnosis. — The  history  of  the  case  is  of  great  value  in  making  a  diag- 
nosis.  Xo  other  form  of  conjunctivitis  recurs  and  persists  to  the  same  extent 
during  the  warm  weather.  The  conjunctivitis  that  accompanies  hay  fever 
has  none  of  the  anatomical  and  few  of  the  symptomatic  characteristics  of 
this  disease. 

Vernal  catarrh  may  be  confounded  with  trachoma  and  with  phlyctenular 
conjunctivitis.  The  elevations  on  the  tarsal  conjunctiva  do  not  have  the 
appearance  of  the  follicles  of  trachoma,  nor  do  they  have  the  same  anatomical 
structure.  The  pericorneal  elevations  differ  from  those  of  phlyctenular  con- 
junctivitis in  that  they  are  not  so  transient  and  do  not  break  down  and  form 
ulcers. 

Prognosis. — The  disease  recurs  for  a  number  of  years,  and  may  then  dis- 
appear entirely.  In  the  greater  number  of  cases  no  injury  is  done  to  the 
central  area  of  the  cornea  :  however,  the  nodule-  may  advance  for  a  consider- 
able distance,  and  in  rare  cases  may  cover  the  cornea,  abolishing  useful 
vision. 

Treatment. — -A  complete  cure  by  means  of  treatment  must  not  be  expected, 
but  much  can  be  done  to  relieve  distressing  symptoms,  and  the  advance  of  i  he 
uodules  on  to  the  cornea   maybe  checked.     Bathing  the  eye-  with  ;i  warm 

solution   of  boric  acid    three    time-  daily   will    serve  to  keep    them   fairly  clear 

of  secretion.  This,  with  the  application  of  a  smooth  ointment  of  the  yellow 
oxid  of  mercury  i  I .',  percent.)  in  the  conjunctival  sac  twice  daily,  will  pro 
due.'  very  favorable  results.     Calomel  and  solutions  of  bichlorid  of  mercury 


GRANl  LAB   <  'ONJUNl  "JTVITIS. 

arc  useful.  It'  the  nodules  arc  large,  they  may  be  reduced  and  their  advance 
checked  by  destroying  them  with  the  cautery  ;  electrolysis  has  been  recom- 
mended. Randolph  advises  salicylic  acid  applied  to  the  conjunctiva  in  the 
form  «>t'  an  ointment  (gr.  iij— 3iv)  and  as  a  collyrium  (gr.  v-f.^j). 

Follicular  Conjunctivitis  (Conjunctivitis  FolUculains  Simplex). — This 
inflammation  of  the  conjunctiva  is  characterized  by  the  occurrence  of  -mall, 
oval,  pale  or  light-red  elevations  in  the  transition  folds  of  the  conjunctiva. 
A  tew  follicles  the  size  of  a  pinhead  are  often  observed  in  the  tarsal  con- 
junctiva. 

Etiology. —  Follicular  conjunctivitis  occurs  among  persons  inhabiting 
crowded  quarters  and  among  those  whose  habits  and  surroundings  are  not 
cleanly.  Soelberg  Well-  states  that  he  thinks  that  there  can  be  no  doubt  that 
the  disease  i-  contagious.  It  is  often  met  with  in  the  young,  ami  i-  of  fre- 
quent occurrence  in  inmates  of  residential  schools. 

Pathology. — The  follicles  are  due,  according-  to  Krause  and  Schmidt,  to 
an  abnormal  enlargement  of  the  lymphatic  follicles  of  Krause,  which  are  not 
visible  to  the  unaided  eye  in  the  normal  state,  but  which  are  situated  imme- 
diately beneath  the  epithelium  of  the  conjunctiva.  They  are  supposed  to  be 
neoplastic  growths.  The  follicles  are  composed  of  a  ma—  of  lymphoid  cells 
contained  in  a  delicate  network  of  connective  tissue  having  an  incomplete 
capsule  in  which  a  few  small  vessels  ramify. 

Symptoms. — These  are  few  and  not  pronounced;  indeed,  follicular  con- 
junctivitis may  exist  for  months  without  the  knowledge  of  the  individual 
affected.  On  inspection  the  lower  lid  appears  to  be  slightly  thickened  ;  there 
may  be  increased  Iachrymation,  some  mucoid  secretion,  and  the  ocular  con- 
junctiva may  be  injected.  On  everting  the  lower  lid  the  transition  fold  is 
found  to  be  reddened,  and  may  be  swollen  to  such  an  extent  that  the  follicles 
will  not  be  visible  ;  however,  in  the  greater  number  of  cases  the  follicles 
appear  as  small,  oval,  translucent  nodules,  arranged  in  row-,  lying  in  the 
transition  fold.  They  may  be  few  or  numerous.  Although  ordinarily  con- 
fined to  the  lower,  they  may  be  found  in  large  numbers  in  the  upper,  transition 

fold. 

Diagnosis  and  Prognosis. — If  the  conjunctiva  is  not  greatly  swollen, 
the  diagnosis  is  easy.  Follicular  conjunctivitis  differ-  from  typical  trachoma 
in  that  it  is  more  transient,  is  more  amenable  to  treatment,  ami  is  not  followed 
by  cicatricial  changes.  The  -prognosis  i-  favorable  for  a  return  to  the  nor- 
mal condition  of  health  in  a  number  of  month-  if  medicinal  measures  are 
adopted,  and  in  two  or  three  week-  if  surgical  measures  arc  employed.  There 
is  no  tendency  to  involvement  of  the  cornea. 

Treatment. — The  patient  should  not  be  allowed  to  use  the  same  bathing 
appliances  with  other-,  and  should  be  isolated  when  practicable.  The  hygienic 
condition-  should  be  made  a-  good  a-  possible3  and  cleanliness  should  be 
insisted  upon.  ( lonstitutional  treatment  in  the  form  of  tonic-,  iron,  strychnin, 
or  (jui niii  should  lie  employed.  Locally,  a  mild  astringent  collyrium  of  zinc 
sulphate  (gr.  j  to  ^j),  alum  (gr.j  to  §j),  tannic  acid,  and  glycerin  (gr.  30—60 
to  §j)  may  lie  employed.  The  sulphate  of  cupper  or  alum-crystal  may  be 
lightly  applied  to  the  follicle-  every  forty-eighl   hour-. 

For  the  surgical  tri atm<  nt  of  this  affection  see  Surgical  Treatment  for 
Trachoma,  page  563.  Expression  of  the  follicle-  with  suitable  forceps  is  the 
nio-t  efficienl  measure  to  destroy  them. 

Granular  Conjunctivitis  i  Trachoma  ;  Granular  Ophthalmia  ;  Mill 
Ophthalmia). — This  disease  of  the   conjunctiva    presents  as    it.*-   dist  active 
feature  iii  its  early  or  first  stage  numerous  discrete,  oval   bodies  in   the  tarsal 

19 


290 


DISEASES  OF  THE  CONJUNCTIVA, 


conjunctiva  :m<l  transition  fold  {trachoma  bodies).  When  the  conjunctiva  is 
net  hypertrophied  these  granules  arc  prominent,  translucent,  and  resemble 
frog-spawn,  to  which  they  have  been  compared.  Granular  conjunctivitis  is 
most  common  in  youth  ;  however,  individuals  at  all  ages  arc  affected,  excepl 
perhaps  those  in  the  first  year  of  life. 

Description. —  In  describing  the  clinical  features  of  granular  conjunctivitis 
it  is  convenient  to  divide  it  into  three  stages. 

The  first  stage  i-  that  in  which  the  granulations  are  discrete,  in  which  the 
cicatricial  contraction  has  not  occurred]  and  may  he  termed  the  stage  of 
hypertrophy.  It  manifests  itself  in  a  number  of  distinct  phases  which  we 
will   consider  separately. 

1.  Cases  appear  sporadically  in  which,  with  little  or  no  previous  indi- 
cation, no  secretion,  hut  with  perhaps  a  little  thickening  of  the  lids,  the 
granules  develop,  and  the  physician  is  surprised  on  everting  the  lid  to  find 
the  palpebral  conjunctiva  completely  studded  with  well-formed  granulations 

(Fig.  193).  There  is  scarcely  any  injection 
of  the  conjunctiva  and  no  marked  discomfort 
to  the  individual.  Only  one  member  of  a 
family  may  he  affected  or  only  one  or  two 
pupils  in  a  school  may  show  this  condition. 
If  this  form  of  granular  conjunctivitis  is  at  all 
contagious,  it  is  only  very  slightly  so,  prob- 
ably   because  of  the   very   scanty   secretion. 

2.  The  clinical  picture  presented  by  this 
phase  of  the  disease  is  the  most  common. 
The  onsel  is  not  very  acute,  hut  there  is  red- 
ness of  the  conjunctiva  and  of  the  margins  of 
the  lids,  accompanied  by  increased  lachryma- 
tion,  scanty  mucoid  secretion,  and  a  sensation 
of  burning  and  itching.  In  the  morning  the 
lid-  are  stuck  together,  hut  can  he  opened  without  much  difficulty.  At  the 
(iid  of  a  week  the  conjunctiva  at  the  transition  folds  is  thickened,  injected, 
and  presents  a  few  shreds  of  mucoid  secretion  in  its  folds.  The  pain  and 
irritation  have  increased.  There  may  he  some  photophobia.  The  irritation 
i-  aggravated  by  use  of  the  eyes. 

At  the  end  of  two  weeks,  if  the  hypertrophy  of  the  conjunctiva  is  not  too 
great,  numerous  slight  elevations  which  have  much  the  color  of  the  con- 
junctiva, can  he  made  out.  situated  in  the  transition  folds  and  frequently  in 
the  tarsal  conjunctiva.  The  conjunctiva  is  much  hypertrophied,  and  in  a 
small  percentage  of  the  ease-  the  granules  arc  so  hidden  that  they  arc  seen 
only  when  the  hypertrophy  subsides.  In  from  three  to  six  weeks  the  hyper- 
trophied condition  of  the  conjunctiva  lessens;  a  hyperemic  condition  prevails 
and  becomes  chronic.  The  cases  are  contagious  from  the  time  that  the  secre- 
tion appeal-  until  it  disappears.  The  disease  often  appears  in  epidemic  form. 
Corneal  complications  may  occur  during  the  second  stage,  and  are  not  un- 
common. 

.;.  'flic  third  form  of  onset  i-.  so  far  as  the  writer  knows,  confined  to 
adult-,  ami  begins  much  the  same  a-  an  acute  conjunctivitis  of  not  a  very 
severe  type.  The  eyelids  are  considerably  swollen;  the  secretion,  which  is 
muco-purulent,  is  accompanied  by  much  lachrymation ;  the  hypertrophy  <;/ 
tlu  conjunctiva  is  excessive,  causing  it  to  lie  in  large  folds  in  the  upper  and 
lower  cul-de-sacs.  The  ocular  conjunctiva  is  injected,  hut  not  much  hyper 
trophied  :  the  caruncle  ami  semilunar  fold  freguently  take  part  in  the  general 


Fig.  193.-  Follicular  trachoma  (John- 
son i. 


G /.'. I ZV ULA  B   ( 'ONJ t  X<  II 1 7 TIS. 


291 


Fig.  194.— Typical    granular  lid  anil  beginning 
cicatrization,  with  pannus  (Berry). 


thickening.     None  of  the  ordinary  forms  of  treatment   have  much  effecl  in 
reducing  the  hypertrophy,  and  at  the  end  of  two  to  four  week-  it   becomes 

evident   that   the  large  rigid   folds   represent  one  mass  of  lymphoid  or  tra- 
chomatous tissue. 

Cornea]  irritation  is  experienced  relatively  soon  in  this  form  of  the  dis- 
ease, and  quite  marked  pannus  may  also  occur  early.  This  variety  is  emi- 
nently contagious,  the  type  produced  corresponding  with  this  or  with  the 
second  described. 

The  first  stage  of  granular  conjunctivitis,  as  described  in  the  three  types 
of  onset,  merges  gradually  into  the  second  stage,  which  is  one  of  commencing 
atrophy  with  the  persistence  of  granulation  tissue. 

The  hypertrophy  of  the  conjunctival  tissue  has  passed  away,  and  bands 
of  cicatricial  tissue  begin  to  appear  (Fig.  194).  The  individual  follicle-  have 
lost  their  character  and  have  coalesced, 
forming  larger  or  smaller  masses  ;  not 
infrequently  the  upper  tarsus  of  the 
upper  lid  is  one  continuous  plaque  of 
lymphoid  tissue.  The  area  of  the  con- 
junctiva is  considerably  lessened  by 
cicatricial  contraction.  The  tarsus  is 
not  so  wide,  and  is  more  sharply  curved 
from  above  downward.  The  margins 
of  the  lids  arc  thickened,  the  palpebral 
fissure  narrowed  (partial  ptosis)  and 
shortened.  Lymphoid  tissue  may  ap- 
pear on  the  ocular  conjunctiva  or  even 
on  the  cornea. 

From  irritation  by  the  rubbing  of  the  roughened  lids  the  corneal  epithelium 
is  disturbed,  and  in  the  effort  on  the  part  of  nature  to  protect  this  membrane 
vascular  pannus  appears  over  the  parts  most  seriously  menaced  (Fig.  194). 
When  the  corneal  epithelium  is  disturbed  and  superficial  ulcers  are  estab- 
lished, the  irritation  to  the  eye  when  exposed  to  light  is  intense,  and  marked 
photophobia  is  experienced.  This  brings  on  contraction  of  the  orbicularis 
palpebrarum  muscle  and  clonic  or  tonic  spasms,  with  a  forward  bending  of 
the  head. 

With  a  cicatricial  contraction  of  the  inner  or  posterior  surface  of  the 
tarsus,  which  increases  the  curvature  and  thickens  its  lower  half,  and  the  for- 
cing down  of  the  marginal  fibers  of  the  orbicularis  palpebrarum  muscle,  the 
eyelashes  arc  made  to  impinge  upon  the  cornea  and  entropion  is  established. 
Slight  mucoid  secretion  and  profuse  lachrymation  accompany  this  stage;  fre- 
quently the  teaiv-  and  secretion  flow  on  to  the  cheeks,  causing  more  or  less 
erosion   of  the  epithelium   of  the   lower   lid   and   face. 

The  third  sfd</<  i-  essentially  one  of  atrophy.  All  lymphoid  tissue  has 
disappeared,  the  cicatricial  contraction  has  partly  or  wholly  abolished  the 
retrotarsal  fold-,  and  the  conjunctival  sacs  arc  rendered  very  shallow.  There 
may  remain  some  islets  of  fairly  good  conjunctiva  and  sufficient  moisture  to 
lubricate  the  lids.  The  cornea  is  partly  or  wholly  opaque.  In  some  < 
tin'  eye  becomes  opaque  and  dry  (xerosis).  Vision  is  greatly  impaired  or 
wholly  abolished. 

Although  granular  conjunctivitis  in  not  a  few  cases  pursues  the  eours< 
outlined  above,  it   may  also  assume  a   much   more  benign  type. 

Duration. — There  i-  greal  variation  in  the  duration  of  all  the  stag 
granular  conjunctivitis.     The  first  stage  may  give  way  to  the  second  stage  in 


292  Dfx/-: asks  or  the  roxJUNCTlVA. 

the  course  of  three  or  tour  months;  it  may  last  six  mouths  or  a  year.  The 
second  stage  is  much  more  prolonged  ;  it  may  never  pass  into  the  third  stage. 
Seldom  fewer  than  ten  years  are  required  to  bring  the  patient  to  the  stage  of 
atrophy,  and  in  most  cases  the  individual  has  reached  middle  age  before  com- 
plete atrophy  is  established. 

Etiology. —  Bad  air,  overcrowding,  poor  and  scanty  food,  and  filth  con- 
tribute largely  to  the  development  of  granular  conjunctivitis.  It  is  very 
probable  that  a  contagium  musi  be  added  to  produce  the  disease.  It  becomes 
epidemic  in  residential  schools,  barracks,  almshouses,  prisons,  etc. 

A  micro-organism  supposed  to  be  specific  has  been  described  by  Sattler 

and  Michel.     It  is  a  small  double  coccus,  and  may  be  cultivated  from  the 

contents  of  a  trachoma  follicle  (see  Fig.  195).      Xo  satisfactory  results  have 

been    reached    by    inoculation-experiments.       Mutermilch1 

,s,  #.#  has  described  a  fungus  which  he  terms  mierosporon  tra- 

«.hi  *"•  chomatosum,  with  pure  cultures  of  which  he  claims  to  have 

vHi  "*  produced   trachoma   in    calves   and   rabbits.     Other   micro- 

organisms have  been  mentioned  as  probable  causative  fac- 
coccuTfmchei)!"  tors.  Although  it  is  thought  by  all  who  have  studied  the 
disease  that  it  is  mierophytic  in  origin,  sufficient  evidence  is 
not  as  yet  at  hand  to  make  the  belief  indisputable.  Parasitic  protozoa  have 
been  described  (Pfeiffer,  Ridley). 

So  far  as  is  known,  there  is  no  constitutional  condition  that  predisposes  to 
the  development  of  granular  lids.  Individuals  of  a  lymphatic  condition  are 
-aid  to  be  especially  prone  to  trachoma,  but  there  is  no  good  evidence  upon 
which  to  base  this  assertion.  Among  certain  peoples,  as  the  Jews,  Italians, 
Egyptians,  and  other  inhabitants  of  the  East,  trachoma  is  prevalent.  Accord- 
ing to  Burnett,  the  negro  of  pure  blood  is  immune  to  trachoma  ;  but  his 
observations  have  apparently  been  confined  to  the  negroes  of  our  Southern 
States.  The  geographical  distribution  of  granular  lids  has  attracted  much 
attention.  In  certain  regions  of  the  inhabited  portions  of  the  earth  the  dis- 
ease i-  of  extremely  rare  occurrence.  This  is  true  of  the  Scandinavian  penin- 
sula and  of  the  southern  part  of  California. 

Pathology  and  Pathological  Anatomy. — In  the  inflammatory  cases  the 
blood-vessels  become  enlarged,  and  apparently  increase  in  number,  accom- 
panied by  an  increase  in  the  nuclei  and  in  the  cellular  elements  of  the  con- 
junctiva. The  papillary  body  becomes  enlarged,  the  lymphoid  tissue  is 
greatly  increased,  and  numerous  small  lymphoid  follicles  develop  in  the 
palpebral  conjunctiva. 

An  attempt  has  been  made  to  separate  foUieulosis  from  trachoma  on 
histological  ground-,  the  claim  being  made  that  in  foUieulosis  there  is  an 
enlargement  of  the  lymph-follicles  of  Krause,  which  normally  reside  in  the 
conjunctiva.  It  is  affirmed  that  the  follicles  in  granular  conjunctivitis  are 
neoplasms,  and,  although  anatomically  identical  with  the  follicles  in  folllCU- 
losis,  have  no  connection  with  it.  In  careful  studies  made  by  the  writer  no 
such  distinction  has  appeared  to  be  possible.  The  follicle  consists  of  aggre- 
gations of  lymph-corpuscles  situated  immediately  beneath  the  epithelium, 
having  a  more  or  less  marked  fibro-vascular  capsule  and  traversed  by  very 
fine  trabecular  of  connective-tissue  fibers;  some  capillaries  may  be  traced 
into  them.  The  epithelium  over  the  follicle  is  irregular  and  slightly  thick- 
ened in  some  pari-.  After  the  granules  have  coalesced  the  mass  resembles 
a   flattened  lymphoma  (  Fig.  1 96 1. 

The  cicatricial  tissue  is  made  up  of  fine  connective-tissue  fibrillar  closely 
1  Annal.  <T  Oculixtique,  <  >ct,  L891    May,  L892. 


GBANULA  /,'   COXJlXCTlViriS. 


293 


associated,  which  contract  as  they  mature.  Small  cysts  develop  in  the  con- 
junctiva   in   the  second   stage   in   sonic  cases   of  granular  conjunctivitis. 

Diagnosis. — Granular  conjunctivitis  may  lie  confounded  with  the  papilli- 
form  swellings  of  the  transition  fold  which  occur  in  acute  muco-purulent 
and  in  purulent  conjunctivitis,  with  vernal  catarrh,  and  with  the  ease-  of 
fibroid  or  fungoid  excrescences  of  the  conjunctiva. 

In  the  first  a  further  observation  of  the  case  will  serve  to  decide  it- 
nature.  Vernal  catarrh  affords  by  its  history,  by  the  fact  that  the  transition 
folds  are  relatively  free,  and  by  the  peculiar  character  and  arrangement  of 
the  elevations  about  the  cornea  sufficient  data  to  relegate  it  to  another  class. 
Fibrous  or  horny  granulations  may  require  careful  study — microscopically 
perhaps — to  enable  one  who  has  not  observed  other  cases  to  determine  their 
nature.  The  masses  are  not  lymphomata,  but  are  fibromata  with  a  much- 
thickened  epithelial  layer. 

Prognosis. — This  is  favorable  if  the  case  is  seen  before  much  permanent 
impairment  of  vision  has  resulted.     If  seen   in  the  first  stage,  a  cure  may  be 


Fig.  196.— Section  of  a  trachoma  follicle,  showing  an  ill-defined  capsule  containing  vessels,  small 
blood-vessels  in  the  body  of  the  follicle,  and  the  immediate  proximity  of  the  epithelial  cells  to  the 
lymphoid  cells  of  the  follicle  (camera  lucida). 


effected  with  but  little  damage  to  any  of  the  tissue  involved.  Some  cicatri- 
cial tissue  will  develop  in  the  conjunctiva  at  the  site  of  the  follicles,  but  the 
function  of  the  eye  will  be  but  little  interfered  with. 

In  the  second  stage  much  can  be  done  to  improve  the  condition  if  treat- 
ment is  instituted.  If  the  disease  is  permitted  to  take  its  course,  spontane- 
ous recovery  will  occur  in  some  cases,  but  in  many  corneal  ulcer,  pannus, 
trichiasis,  and  entropion  will  develop. 

When  the  third  stage  is  reached  little  can  be  done  to  improve  the  condi- 
tion of  the  eye. 

Treatment. — This  is  prophylactic,  medicinal,  and  surgical. 

I-olation  should  be  practised,  if  possible,  so  long  as  discharge  persists. 
Cleanliness  by  irrigating  the  eye  with  some  bland,  antiseptic,  or  mild  germi- 
cidal solution  is  first  to  he  observed,  care  being  taken  that  bathing  appliances 
used  by  the  patient  shall  not  be  used  by  others.  A  solution  of  horic  acid 
or  a  solution  of  bichlorid  of  mercury  (1  :  10,000  <>r  I  :  15,000)  or  formalin 
(1  :3000)  may  We  employed  three  or  four  times  daily,  bathing  ten  or  twenty 
minutes  each  time.  A  solution  of  bichlorid  of  mercury  |  I  :  -5000  or  1  :  S1  H  I 
which  contains  a  few  grains  of  -odium  chlorid,  or  chlorin-water,  50  per  cent., 
officinal,  may  lie  dropped  freely  into  the  eye  after  each  bathing.     A  pplications 


294  DISEASES  OF  THE  CONJUNCTIVA. 

of  nitrate  of  silver  (gr.  iij  to  ,^j)  once  daily  will  be  of  much  value  if  there  is 
secretion. 

When  the  acute  syra  ptoms  have  subsided  stimulating  astringent  applica- 
tion may  be  made.  Alum-crystal,  sulphate-of-copper  crystal,  or  the  miti- 
gated -tick  of  nitrate  of  silver  may  be  employed  to  lightly  touch  the  granula- 
tions once  every  second  day.  Sulphate  of  copper  is  most  generally  used  and 
gives  greatest  satisfaction.  Not  all  conjunctiva?  will  tolerate  these  applica- 
tions; trial  will  enable  one  to  decide  in  which  cases  to  employ  them.  In  the 
intervals  between  the  applications  the  patient  should  continue  with  the  bathing 
and  drops,  using  them  at  least  three  times  daily.  Corneal  complications 
usually  require  atropin,  hut  nothing  additional.  With  an  improvement  in 
the   lids  the  corneal   ulcers  will   disappear. 

Surgical  treatment  is  of  the  greatest  value  in  the  early  stage,  and  is 
described  on  page  563. 

Chronic  Conjunctivitis  {Chronic  Ophthalmia). — A  thickened,  con- 
ire-ted.  irritable  condition  of  the  palpebral  conjunctiva  sometimes  persists 
\'"\-  months  after  an  acute  conjunctivitis,  accompanied  by  redness  of  the 
margins  of  the  lids.  A  similar  condition  may  accompany  blepharitis  margin- 
alis,  concretions  in  the  lachrymal  canals, atrophic  or  hypertrophic  rhinitis,  and 
eye— train  from  errors  of  refraction  or  muscular  abnormalities.  The  affection 
i-  more  than  a  simple  congestion,  being  accompanied  by  a  scanty  muco-puru- 
bnt  secretion. 

In  old  people  a  flabby,  slightly  congested  condition  of  the  conjunctiva 
sometimes  exists,  also  accompanied  by  a  scanty  discharge.  Swelling  or 
hypertrophy  *>/  the  caruncle  is  found  in  almost  all  cases  of  chronic  conjunc- 
tivitis. 

Treatment. — The  lachrymal  and  nasal  passages  should  be  carefully  ex- 
amined and  any  abnormal  condition  properly  treated.  Errors  of  refraction 
should  be  corrected,  and  the  condition  of  the  margins  of  the  lids  made  favor- 
able by  proper  treatment.  The  conjunctivitis  may  subside  spontaneously 
after  the  successful  treatment  of  the  source  of  irritation,  but  in  many  cases 
stimulating  and  astringent  measure-  must  be  resorted  to.  Applications  may 
be  made  with  a  solution  of  nitrate  of  silver  (1  percent.)  once  in  forty-eight 
hours  until  the  secretion  ceases,  or  with  glycerol  of  tannin  (3ss  to  .sij)  sprayed 
on  the  conjunctiva  once  daily.  Extremely  lighl  applications  of  sulphate  of 
copper  nr  alum-crystal  may  be  made  every  second  day.  These  measures, 
with  careful  cleansing  two  or  three  times  daily  with  a  solution  of  boric  acid 
(•'!  per  cent.),  will  in  many  cases  effect  a  cure. 

Egyptian  and  Military  Ophthalmia. — These  terms  are  used  without 
discrimination  to  indicate  acute  or  subacute  inflammations  of  the  conjunctiva 
which  appear  in  Egypt  or  may  affect  an  army.  They  comprise  at  least  three 
distinct  form- — namely,  epidemic  acute  contagious  conjunctivitis,  gonorrheal 
conjunctivitis,1  and  acute  trachoma.  The  consideration  of  these  diseases  is 
found   under  their  appropriate  headings. 

Lachrymal  conjunctivitis  i-  an  inflammation  of  the  conjunctiva 
accompanying  dacryocystitis,  and  due  to  the  presence  of  the  irritating  puru- 
lent -eeretion  f V < nn  the  lachrymal  sac,  which  contains  streptococci  (Fig.  1!'7). 
The  inner  third  of  the  palpebral  ami  ocular  conjunctiva  is  mosl  congested, 

bllt      the     whole     |o\\e|-    <-|||-de--ae     j,      f|e(  1 1  |e||  t  1  V      involved.        The    eye     is    often 

suffused  with  tear- and  muco-purulenl  -eeretion-,  which,  failing  to  escape  by 
the  tear-passages,  flow  over  on  to  the  cheek. 

I  he  presence  of  a  dacryocystitis  determines  the  diagnosis.     It   is  easy, 
1  Koch  :    Weiner  med.   II'- A..  1883,  L550. 


TOXIC  CONJUNCTIVITIS. 


295 


The  treat- 


however,  to  overlook  this  cause,  and  it  is  therefore  advisable  to  examine  the 
condition  of  the  lachrymal  sac  in  all  cases  of  conjunctivitis. 

The  prognosis  is  favorable   it'  the  dacryocystitis  can  be  corrected.     In 

sonic  cases  an  nicer  of  the  cornea 
f'onns,  becomes  infected,  and  perfo- 
ration follows,  with  greater  or  less 
impairment  ot'  vision. 

An  early  correction  of  the  da- 
cryocystitis is  advisable  in  all  cases. 

I/ithiasis     conjunctivae     is 

characterized  by  the  formation  of 
white  calcareous  concretions  in  the 
acini  of  the  Meibomian  glands. 
These  concretions  penetrate  the 
epithelial  layer  and  produce  great 
irritation  by  friction  on  the  cornea 
and  conjunctiva.  They  usually  ac- 
company a  gouty  diathesis,  and  are 
apparently  of  the  nature  of  tophi. 
On  everting  the  lids  the  white 
concretions    are     readily     seen     and    frG.  197.— Streptococci  pyogenes  (Fraenkel  and  Pfeiffer). 

recognized.     The  prognosis  is  good  ; 

however,  new  formations  of  similar  deposits  must  be  expected. 

meni  consists  of  liberation  of  the  concretions  by  incision. 

Toxic  conjunctivitis  is  a  term  employed  to  designate  those  form-  of 
conjunctivitis  that  are  due  to  the  chemical  action  of  certain  substances.  The 
following  substances  may  be  mentioned  as  acting  in  this  manner  :  Atropin  and 
other  mydriatics,  the  myotics,  chrysarobin,  calomel,  the  dust  from  anilin  dyes, 
fumes  from  menthol  and  formalin,  and  virus  introduced  by  the  bites  of  insects. 

The  conjunctiva?  of  some  individuals  do  not  tolerate  atropin  even  in 
very  weak  solutions.  When  a  few  drops  of  a  solution  r>f  atropin  are  intro- 
duced into  the  conjunctival  sac  of  such  individuals,  a  smarting  and  pricking 
sensation  is  soon  experienced ;  the  conjunctiva  and  lids  become  slightly 
swollen  and  congested.  The  congestion  of  the  lid  is  confined  to  the  palpe- 
bral portion,  imparting  a  peculiar  and  quite  characteristic  appearance.  .More 
or  less  dryness  of  the  throat  and  irritation  of  the  nasal  mucous  membrane 
may  accompany  the  conjunctivitis.  If  no  more  atropin  i-  instilled,  the  smart- 
ing and  swelling  subside  in  twenty-four  to  forty-eight  hours,  and  recovery 
ensue.-.  A  similar  condition  may  follow  the  use  of  hyoscyamin,  duboisin, 
cocain,  and  homatropin,  but  is  much  less  apt  to  occur.  Kserin  sometimes 
produce-  congestion  of  the  conjunctiva.  If  a  non-sterile  solution  of  atropin 
be  used  daily  for  some  time.  ;i  follicular  conjunctivitis,  in  which  the  follicles 
arc  largely  confined  to  the  lower  cul-de-sac,  may  be  produced.  The  condition 
responds  readily  to  treatment  after  the  atropin  is  discontinued. 

Chrysarobin,  when  n>c<\  in  the  form  of  an  ointment,  may  produce  a 
violent  non-suppurative  conjunctivitis  which  gradually  subsides  on  the  dis- 
continuance of  the  drug. 

( 'aloinel  when  du-ted  into  the  eye,  a-  in  the  treatment  of  cornea]  affections 
in  one  who  is  taking  iodin  in  any  form,  undergoes  a  rapid  change  into  an 
iodid  through   the  action   of  the  lachrymal   fluid,  and   may   produce  marked 

inflammation  of  the  < junctiva  with  superficial  ulcers  (calomel  eonjuncti 

If  the  calomel  treatment  is  withdrawn  and  the  conjunctival  sac  thoroughly 
cleansed,  recovery   will   rapidly  occur. 


296  DISEASES  OF  THE  CONJUNCTIVA. 

The  irritation  occasioned  by  the  dust  from  anilin  dyes  and  the  fumes 
from   menthol  and  formalin  will  subside  when  the  cause  is  removed. 

The  sting  of  the  fly  produces  intense  edematous  swelling  of  the  conjunc- 
tiva and  lids,  accompanied  with  but  little  secretion.  Bathing  with  hoi  water 
t,,  which  ;i  little  biborate  of  sodium,  bicarbonate  of  sodium,  boric  acid,  or 
sodium  chlorid  is  added  will  aid  in  causing  the  tissues  to  resume  their  normal 
condition.  The  irritation  caused  by  caterpillar  hairs  produces  a  form  of  con- 
junctivitis to  which  the  name  ophthalmia  nodosa  has  been  applied  (see  also 
page  327). 

Xerosis  (xerophthahnos)  of  the  conjunctiva  is  a  condition  in  which  the 
surface  of  the  conjunctiva  appears  to  he  dry.     Two  forms  are  recognized  : 

{a)  Xerosis  due  to  cicatricial  degeneration  of  the  conjunctiva  (X.  paren- 
chyrnatosa,  essential  atrophy  of  the  conjunctiva). 

(/>)  Xerosis  accompanying  a  general  disease  ( X.  superfidalis,  X.  epithelialis, 
X.  triangularis,  X.  infantilis). 

Xerosis  due  to  cicatricial  degeneration  of  the  conjunctiva  is  most  fre- 
quently  caused  by  trachoma.  Pemphigus,  burns,  and  exposure  of  the  con- 
junctiva to  the  atmosphere,  as  in  ectropion  and  lagophthalmos,  may  produce 
it.  Xerosis  maybe  partial  or.  complete.  In  xerosis  the  conjunctiva  is  luster- 
less  :  the  dryness  is  due  to  cicatricial  obliteration  of  secreting  tissues  in  or 
connected  with  the  conjunctiva.  This  affection  is  seldom  met  with  in  indi- 
viduals who   have   not    reached   mature  years.      It    is   incurable. 

Xerosis  due  to  general  disease  appears  both  in  a  mild  and  in  a  severe 
form.  The  mild  form  is  characterized  by  the  appearance  of  triangular  masses 
of  a  foamy,  lardaceous  secretion,  not  moistened  by  the  tears,  which  are  located 
:it  the  ma  ruins  of  the  cornea  in  the  horizontal  meridian.  The  bases  of  the 
triangles  are  placed  next  to  the  cornea.  Nyctalopia  (night-blindness)  accom- 
panies  this  condition.  It  appears  in  children  and  adults,  and  is  the  result  of 
malnutrition.  Inmates  of  prisons,  soldiers  in  barracks  or  field,  railroad 
laborers,  sailors  on  long  voyages,  and  those  who  eat  a  poor  quality  of  food 
with  but   little  variety  for  long  periods  of  time,  suffer  from  this  affection. 

A  severer  form,  which  attacks  infants  and  very  young  children  only,  is 
often  associated  with  kerato-malacia  (see  page  318).  The  disease  extends 
from  the  conjunctiva  to  the  cornea,  producing  complete  destruction  of  that 
membrane.  The  secretion,  which  is  of  the  same  nature  as  that  which  appears 
in  the  mild  form,  first  develops  in  the  conjunctival  sac  and  extends  over  the 
eye. 

Prognosis. — The  prognosis  in  the  mild  form  is  favorable.  Infants  and 
young  children  suffering  from  the  severe  form  seldom   recover. 

Microscopical  examination  of  the  secretion  in  these  eases  discloses  the 
presence  in  almost  pure  culture  of  a  plump,  short  bacillus,  which  usually 
appears  in  pairs.  This  bacillus  has  been  fully  described  by  Leber,  and  was 
thoughl  by  him  to  be  the  pathogenic  factor  in  the  disease.  Other  observers 
have    not    been   able   to   supporl    this    view. 

Treatment. — Improvement  in  the  nutrition  of  the  individual  is  the 
essential   measure  to  promote  recovery. 

Amyloid  Disease  of  the  Conjunctiva. —  This  disease  is  rarely  met 
with  in  the  United  Stntc-.  It  is  characterized  by  the  appearance  of  yellow- 
ish, waxy,  translucenl  masses  in  the  conjunctival  sac,  taking  their  origin  most 
frequently  from  the  retrotarsal  Ibid.  The  entire  conjunctiva  may  participate 
in  the  change,  the  greal  thickening  converting  it  into  large  folds  which  may 
overlap  the  cornea  and  serioush  obstrucl  vision.  The  tissue  is  very  friable 
and   is  almosl   devoid  of  blood-vessels. 


PTERYGIUM. 


297 


il 


Pathology. — The  tissue  is  largely  made  up  of  lymphoid  cells  which  in 
certain  places,  notably  near  the  surface,  have  lost  their  distinctive  character- 
istics and  have  undergone  a  hyalin  degeneration,  contributing  to  the  formation 
dt'  a  homogeneous  mass.  The  hyalin  stage  passes  into  an  amyloid  stage 
(Kaehlmann),  when  fresh  sections  give  the  starch-reaction  in  the  presence  of 
the  iodin  test.  Sarcomatous  tissue  may  he  an  element  in  these  growths,1 
and  osseous  deposits  may  occur  in   the  mass. 

The  diagnosis  is  easy,  no  other  growth  possessing  the  same  appearance, 
and  the  prognosis  is  favorable  if  no  malignant  element  is  present.  The  de- 
velopment is  slow.  The  treatment  should  consist  of  thorough  removal  of  the 
diseased  tissue.2 

Pterygium  is  a  peculiar  fleshy  mass  of  hypertrophied  conjunctiva  which 
develops  most  frequently  at  the  inner,  but  occasionally  at  the  outer,  side  of 
the  eyeball.  It  is  wedge-shaped,  the  base 
lying  at  the  caruncle  ;  its  upper  and  lower 
borders  overlap  the  conjunctiva,  permitting 
of  the  introduction  of  a  probe.  The  apex 
of  the  pterygium  advances  on  to  the  cornea 
in  the  horizontal  meridian,  rarely  passing 
the  center  of  the  pupil  (Fig.  198).  Pterygia 
are  most  frequently  met  with  in  men,  and 
are  peculiar  to  adult  life. 

Etiology. — Irritating  particles  that  pass 
the  margins  of  the  lids  and  impinge  upon 
the  ocular  conjunctiva  first  produce  Pinguec- 
ulae (Fuchs),  and  later  pterygia.  Miners, 
stone-masons,  laborers, and  those  who  inhabit 
countries  where  there  is  much  alkali  dust 
present  the  condition  most  frequently. 

A  form  of  pterygium  known  as  jiseudo- 
pterygium  is  also  recognized.  This  is  an 
irregular  growth  which  may  encroach  upon 
the  cornea  from  any  direction.  It  follows 
burns,  ulcerative   processes,  and   injuries  to  the  margin   of  the  cornea. 

Pathology. — A  transverse  section  through  the  body  of  a  pterygium  show- 
it  to  be  composed  of  loose  connective  tissue,  rich  in  blood-vessels,  and  with 
more  or  less  small-cell  infiltration  according  to  the  degree  of  irritation.  'Hie 
epithelial  layer  is  thickened.  The  tissue  of  the  preceding  pinguecula  i-  em- 
bodied in  that  of  the  pterygium.  At  the  apex  of  the  pterygium  an  infiltration 
of  small  cells  is  found  which  extends  for  a  short  distance  into  the  superficial 
lamellae  of  the  cornea.  A  very  few  line  blood-vessels  also  precede  the  advance 
of  the  growth.  Micro-organisms  find  suitable  lodgement  in  the  folds  of  the 
tissue  of  the  pterygium. 

Pain  is  experienced  only  when  the  pterygium  becomes  inflamed.     Dis- 
turbances of  vision   resull    from  acquired  astigmatism  and   from   invasion  oi 
the  pupillary  area.    The  condition  can  scarcely  be  confounded  with  any  other 
disease.      If  curly  operation  is  resorted  to,  the  prognosis  is  good,  bul  recur- 
rence i-  not  uncoi After  the  pupillary  area  is  invaded  slighl  nebulous 

opacities  and  irregular  astigmatism  are  presenl  after  the  pterygium  is  removed. 

1  Prout  .-mil  Bull:  Archives  of  Ophthalmology,  vol.  viii.  p.  7:;. 
Leber  has  described  a  recurring  and  spreading  form  of  conjunctival  disease,  character! 
by  tin-  appearance  of  raised  whitish  patches,  in  the  center  of  which  is  found  a  deposit  ol  lime, 
to  which  be  gives  tin-  name  conjundivUia  petrifica 


Fig.  198.- 


-Pterygium:  1' 
(Michel) 


apex ;  /■'.  base 


298  DISEASES  OF  THE  CONJUNCTIVA. 

Treatment. — This  is  always  surgical — divulsion,  excision,  or  transplanta- 
tion.    Early  operation  is  advised.     (See  page  "»'»1  for  technique.) 

Pinguecula. —  This  is  a  small  yellowish  elevation  in  the  ocular  conjunc- 
tiva, situated  near  the  inner  margin  of  the  cornea  in  the  horizontal  meridian  ; 
the  growth  may  also  occur  near  the  outer  margin  of  the  cornea.  Fuchs  is 
of  the  opinion  that  pinguecula  should  he  regarded  as  the  early  stage  of 
pterygium. 

The  condition  is  apparently  due  to  irritation  produced  by  the  presence  on 
the  ocular  conjunctiva  of  particles  of  dust  and  small  foreign  bodies,  and  is 
most  frequently  observed  in  those  whose  occupation  brings  them  in  contact 
with  much  dust.  Formerly  supposed  to  owe  its  yellow  color  to  the  presence 
of  fat-cells,  it  is  now  known  to  he  a  hyperplasia  of  the  white  and  elastic 
connective-tissue  fibers  of  the  conjunctiva,  together  with  a  colloid  substance. 
Its  epithelial  layer  is  considerably  thickened. 

The  diagnosis  is  made  without  difficulty,  as  there  is  nothing  for  which  it 
can  he  mistaken.  Pinguecula  may  degenerate  into  pterygium,  hut  in  many 
cases  remains  practically  without  change. 

Treatment. — The  growth  may  be  excised  or  destroyed  by  the  cautery. 
It   is   not   necessary   to   interfere   in   ordinary   cases. 

Abscess  of  the  conjunctiva  is  an  extremely  rare  condition.  As  a  con- 
sequence of  traumatism  small  abscesses  may  develop.  A  suppurating  Meibo- 
mian gland  may  produce  an  abscess  that  opens  on  the  conjunctival  surface. 
Pus  from  a  suppurative  process,  taking  place  in  the  orbital  tissue,  may  bulge 
the  conjunctiva  forward  and  form  a  fluctuating  tumor.  These  conditions, 
however,  belong  properly  to  other  tissues.  The  abscess  should  be  opened 
in  the  ordinary  manner. 

Ecchymosis  of  the  Conjunctiva  (Subconjunctival  Hemorrhage). — This 
is  a  condition  due  to  the  exudation  of  blood  beneath  the  conjunctiva,  and  pre- 
sents the  appearance  of  a  bright-red  or  dark-red  spot  of  varying  dimensions 
with  rather  sharply-defined  margins.  The  ecchymosis  may  affect  the  loose 
conjunctiva  of  the  globe  or  lids.  The  conjunctiva  tarsi,  because  of  its  close 
connection  with  the  tarsus,  does  not  permit  the  blood  to  pass  beneath  it. 

Etiology  and  Patholog-y. — The  ecchymosis  may  be  traumatic  in  origin, 
following  squint  or  other  operations,  blows,  the  entrance  of  a  foreign  body, 
or  it  may  be  due  to  the  spontaneous  rupture  of  a  small  subconjunctival  blood- 
vessel (see  also  page  •"><>••).  The  spontaneous  exudation  of  blood  usually  occurs 
in  elderly  individuals,  in  whom  the  walls  of  blood-vessels  are  undoubtedly 
weakened  by  atheromatous  processes  and  give  way,  and  may  indicate  nephri- 
tis, but  is  sometimes  seen  in  children  as  a  result  of  violent  coughing,  vomit- 
ing, etc.  In  certain  cases  of  fracture  of  the  skull  through  the  orbit  conjunc- 
tival ecchymosis  occurs  in  the  outer  lower  quadrant  of  the  ocular  conjunctiva. 
Very  small  ecchymotic  spots  accompany  acute  forms  of  conjunctivitis.  The 
blood  gradually  becomes  absorbed  and  the  natural  color  of  the  tis>ue>  i> 
restored. 

Treatment. —  Left    to    itself,    the    hi 1    will     be    gradually    absorbed. 

Absorption  may  !><•  hastened  by  bathing  the  eye  with  water,  at  as  high  a 
temperature  as  the  individual  can  bear,  three  or  four  time-  daily,  for  twenty 
or  thirty  minutes  each   time. 

Chemosis  of  the  conjunctiva  may  be  active  (inflammatory)  or  passive 
(non-inflammato7'y).  It  is  a  condition  in  which  the  ocular  conjunctiva  becomes 
thickened  and  raised  around  the  margin  of  the  cornea,  forming  a  uniform 
shallow  pit  of  which  the  cornea  constitutes  the  floor. 

Etiology  and  Pathology. —  [nflammatory  chemosis  is  rarely  absent    in 


/.  YMPHAXlil EVTASIS  COX.I  (WCTI  WE. 


299 


purulent  conjunctivitis,  and  often  accompanies  pronounced  keratitis.  When 
the  interior  of  the  eye  is  the  seal  of  :m  inflammatory  process,  as  in  certain 
forms  <>t"  iridocyclitis  and  infection  after  cataract  operations,  chemosis  is  some- 
times produced.  It  may  follow  the  administration  of  potassium  iodic!  or  suc- 
ceed an  attack  of  urticaria.      It  is  an  occasional   accompaniment  of  nephritis. 

Passive  chemosis  is  sometimes  observed  in  alcoholic  and  gouty  indi- 
viduals. 

A  section  of  the  tissue  in  inflammatory  chemosis  presents  an  intense  infil- 
tration of  leukocytes  into  the  subconjunctival  tissue  at  the  margin  of  the 
cornea,  some  thin-walled,  newly-formed  blood-vessels,  transuded  blood,  and 
fibrin  (Fig.  L99).  In  the  passive  variety  the  leukocytes  are  very  much  less 
numerous,  there  are  no  newly-formed  blood-vessels,  and  the  condition  is 
more  nearly  one  of  simple  edema.. 

The  chemosis  is  so  great  in  some  cases  that  the  swollen  conjunctiva  over- 
hangs the  cornea  and  obstructs  the  vision  ;  it  may  even  protrude  between  the 
lids.     There  are  no  other  symptoms  added  to  those  accompanying  the  con- 


Fig.  199. — Section  of  the  globe,  showing  chemosis  of  tin-  conjunctiva  (camera  lucida).    i  Extensive  small- 
cell  infiltration.)    l.  thin-walled  blood-vessels;  2,  cornea. 

dition  which  has  produced  the  chemosis.  The  chemosis  subsides  on  subsid- 
ence of  the  accompanying  inflammation;  if  it  is  intense,  scarification  may  be 
resorted  to. 

Emphysema  of  the  Conjunctiva. — Subconjunctival  emphysema  is 
characterized  by  a  non-inflammatory  lobulated  swelling  of  the  conjunctiva, 
which  emits  a  peculiar  fine  crackling  sound  on  pressure.  It  is  due  to  the 
entrance  of  air  beneath  the  conjunctiva  from  injuries  to  the  lids,  fracture  of 
the  margin  of  the  orbit  extending  into  the  frontal  sinus,  ethmoid  nuns,  or 
nasal  cavity.     The  air  is  absorbed  and  the  condition  disappears  spontaneously. 

I^ymphangiectasis  conjunctivae  is  a  benign  condition  which  affects 
the  ocular  conjunctiva,  and  is  of  much  more  frequenl  occurrence  in  it-  outer 
half  than  in  any  other  part.  It  consists  of  a  small  chain  or  cluster  of  vesi- 
cles, which  vary  in  size  from  very  minute  one-  to  those  the  size  of  a  grain  of 
wheat.  They  are  transparent,  and  are  freely  movable  over  the  subconjunctival 
tissue.  The  cause  is  not  known.  The  disease  i<  found  mosl  frequentl; 
those  who  suffer  from  chronic  conjunctivitis.     The  condition  is  one  of  di la- 


300  DISEASES  OF  THE  CONJUNCTIVA. 

tation  of  the  lymph-channels,  the  small  pockets  containing  a  clear  fluid.  The 
diagnosis  is  not  difficult,  as  there  is  nothing  else  with  which  it  may  be  con- 
founded.    The  vesicles  may  be  excised. 

Syphilis  of  the  Conjunctiva. — Chancre,  papular  syphilides,  copper- 
colored  spots,  mucous  patches,  gummata,  aodular  syphilides,  and  syphilitic 
ulcer  may  affeel   the  conjunctiva. 

Chancre  appears  most  frequently  on  the  palpebral  conjunctiva  near  the 
margin  of  the  lid,  where  it  presents  an  indurated  circular  red  elevation  of 
perhaps  1  centimeter  in  diameter,  usually  with  a  shallow  nicer  at  the  top, 
having  a  gray  base.  Occurring  in  the  transition  fold  or  in  the  ocular  con- 
junctiva, the  base  of  the  mass  is  distinctly  indurated,  and  when  grasped  by 
the  forceps  is  much  like  a  piece  of  parchment  lying  in  the  mucous  membrane. 

Grouped  papular  syphilides  are  of  rare  occurrence;  they  accompany  the 
same  form  of  syphilide  on  the  face  and  lids;  the  same  may  be  said  of  the 
copper-colored   spots,    which   are   rarely    seen. 

Mucous  patches  are  more  common;  they  resemble  the  mucous  patches  as 
they  appear  on  other  mucous  surfaces,  are  slightly  raised,  with  a  gray,  even 
surface,  and   have  a   border  of  injected    mucous   membrane  around   them. 

Gummata  of  the  conjunctiva  arc  extremely  rare.  .Morrow  states  that  they 
appear  as  small  discrete  tumors  of  the  conjunctiva  the  size  of  a  pea  or  bean. 

Gummy  tumor  of  the  episcleral  tissue  and  of  the  lids,  affecting  the  con- 
junctiva, is  met  with.  The  growth  is  elevated  and  is  soft.  It  may  cause 
extensive  destruction  of  tissue.  It  is  differentiated  from  sarcoma  by  the 
effect  produced  on  it  by  antisyphilitic   treatment. 

Nodular  syphilides,  manifestations  of  the  later  stages  of  syphilis,  some- 
time- occur  in  the  lids  and  produce  conjunctival  ulcers.  Sloughs  of  large 
extenl  may  result.  In  all  of  the  conjunctival  manifestations  of  syphilis  the 
preauricular  and  cervical  glands  are  more  or  less  enlarged.  Pain  is  not  a 
prominent  feature. 

If  recognized  early,  the  prognosis  in  all  eases  of  syphilitic  affections  of 
tin'  conjunctiva   i-  favorable.      The  condition   responds  readily  to  treatment. 

Treatment. —  If  an  ulcerated  surface  exists,  it  may  be  cleansed  with  a 
weak  bichlorid  solution  (1  :  3000  or  1  :  5000),  and  calomel  dusted  on  after- 
ward. Vigorous  antisyphilitic  constitutional  treatment  should  he  given  as 
early  a-  possible. 

Tumors  and  Cysts  of  the  Conjunctiva. — Congenital. — Dermoid 
Tumors. — These  usually  develop  near  or  at  the  sclero-corneal  margin  ;  they 
may  he  small,  slightly  elevated,  and  have  a  very  few  tine  hairs  projecting  from 
them.  They  may  cover  a  large  part  of  the  ocular  conjunctiva,  lie  markedly 
elevated,  pigmented,  covered  with  coarse  hair,  and  contain  numerous  sebaceous 
glands.  A  dermoid  growth  sometimes  develops  in  the  conjunctiva  and  pre- 
sents between  globe  and  lid  at  the  upper  outer  quadrant  of  the  globe.  It  has 
much  the  appearance  of  a  thickened  nictitating  membrane,  is  Hat,  has  a 
rounded  border,  is  pale,  ami  often  hear-  a  few  very  line  hairs:  movements 
of  the  cm-  downward  and  inward  bring  it  readily  into  view.  Dermoid 
tumor-  may  he  cystic  ;  they  may  also  contain  much  lipomatous  tissue — 
lipomatosis  dermoids. 

Vascular  Tumors. —  Telangiectatic  tumors  and  caveimomata  arc  observed. 
The  former  are  often  associated  with  similar  growths  on  the  lid-.  Both  are 
benign,  bul  tend  to  increase  in  size. 

Benig-n  Tumors. — Those  thai  are  not  congenital  are  fibroma,  lipoma, 
myxoma,  osteoma,  granuloma,  papilloma,  simple  cystic  tumors,  ami  cysts 
due  t"  evsticerei  and  echinococci. 


TUMORS  AND   CYSTS  OF  THE  CONJJJNCTIVA.  303 

Fibromata  develop  most  frequently  on  the  tarsal  conjunctiva  of  the  upper 

lid  as  a  result  of  a  chronic  conjunctivitis  ;  they  arc  multiple,  Hat,  and  elevated 
one  to  two  millimeters.  TApoma  appears  as  a  yellowish  soft  mass,  usually  in 
the  retrotarsal  folds.  Myxoma  appears  in  the  form  of  polypoid  masses 
developing  from  the  margin  ot'a  wound  or  sinus,  rarely  from  the  conjunctival 

surface  itself.  Osteoma  is  a  Hat  tumor  developing  in  the  ocular  conjunctiva. 
Granuloma  develops  from  wounds  and  from  ulcerating  surfaces.  Papilloma 
is  most  frequently  met  with  at  the  caruncle  as  a  soft,  villous  ma>s.  It  may 
appear  on  any  part  of  the  ocular  or  palpebral  conjunctiva,  and  is  often  mis- 
taken for  granulation-tissue.  It  is  very  prone  to  recur  after  removal,  pro- 
vided the  removal  is  not  complete.  There  is  no  tendency  to  the  destruction 
of  tissue.  Oystic  tumors  are  observed  near  the  openings  of  the  lachrymal 
ducts,  in  the  retrotarsal  fold,  and  at  the  caruncle.  They  are  often  due  to 
chronic  conjunctivitis.  Oysticercus  cysts  are  large,  and  usually  present  a 
white  spot  on  the  outer  wall.  Fj-hinococcus  cysts  may  he  very  large  and 
extend  far  back  into  the  orbit.  Daughter  cysts  and  hooklets  may  he  found 
as  part  of  the  contents. 

Treatment. — The  most  satisfactory  treatment  is  excision.     The  vascular 
tumors  should  be  removed  as  early  as  possible — the  cavernomata  especiallv — 


Fig.  200.    Bacillus  Leprae,  seen  in  a  section  through  a  subcutaneous  node;  X  500  (Fraenkel  ami  Pfeiffer). 

as  they  may  reach  such  enormous  proportions  if  neglected  that  subsequenl 
removal  is  impossible. 

Malignant  Tumors. —  Epithelioma  and  sire a  are  the  mosi   common. 

A  peculiar  tumor,  known  as  cylindroma,  has  been  described  by  Hensel  :  it  is 
probably  a  form  of  sarcoma. 

Epithelioma  of  the  conjunctiva  accompanies  epithelioma  of  the  lid. 
although  it  may  develop  spontaneously  from  any  part  of  the  ocular  conjunc- 
tiva. It  appears  as  a  small  reddish  elevation  which  s i  presents  an  irregu- 
lar, grayish,  ulcerated  patch  with  slightly  raised  borders  and  a  congested  b 

Suramin  may  develop  in  the  shape  of  pigmented  or  non-pigmented  poly- 
poid  masses  springing  from   the  retrotarsal   fold  and  growing   rapidly.      It 


302  />/\/:as/;s  OF  THE  CONJUNCTIVA. 

may  also  develop  at  the  limbus  conjunctivae.  It  appears  in  this  location 
as  a  small  red  or  pigmented  spot  :  it  may  develop  rapidly,  bul  may  also 
remain  in  a  quiet  state  for  a  long  period.  Metastasis  to  the  cervical  glands 
or  to   remote   part-  of  the  body   may  occur. 

Treatment. — Thorough  removal  of  all  diseased  tissue  by  knife  or  cautery 
is  the  only  way  to  make  a  favorable  issue  possible. 

leprosy  of  the  conjunctiva  occurs  in  connection  with  leprosy  of 
the  genera]  system  in  nearly  all  case-;  however,  it  may  begin  primarily  in 
the  conjunctiva.  Morrow'  cites  one  case  in  which  a  leprous  tubercle  ap- 
peared on  the  eve  and  was  mi-taken  for  sarcoma.  Cutaneous  tubercles  fol- 
lowed. Nodular  masses  may  form  in  the  conjunctiva  which  may  persist  for 
•a  long  time,  and  may  finally  disappear,  leaving  non-vascular  cicatricial  tissue. 
The  bacillus  leprae,  to  which  the  disease  is  due.  is  represented  in  Fig.  200. 
The  writer  has  observed  a  mild  persistent  irritation  of  the  conjunctiva  accom- 
panying leprosy,  producing  slight  redness  of  the  palpebral  conjunctiva  and 
increased  lachrymation.     Treatment  is  of  little  avail. 

I/Upus  erythematosus  is  mentioned  by  Bowen  z  as  attacking  the  con- 
junctiva. It  appears  as  irregular  plaques  which  are  covered  with  small 
punctate  excoriations  or  with  grayish  masses  of  exudation  and  superficial 
cicatrices.  The  condition  is  accompanied  by  lupus  erythematosus  of  the  face. 
The  etiology  is  obscure.  The  disease  progresses  extremely  slowly,  and  i* 
accompanied  by  slight  irritation  and  increased  lachrymation.  When  accom- 
panied by  the  same  disease  on  the  face  the  diagnosis  is  easy.  Treatment  is 
of  little  avail. 

Tuberculosis  of  the  Conjunctiva. — This  affection  presents  two  quite 
distincl  clinical  pictures,  which  will  be  considered  separately  : 

First.  When  tuberculosis  of  the  conjunctiva  appears  as  an  extension  from 
adjacent  mucous  or  cutaneous  surfaces  [lupus  vulgaris)  it  presents  slightly  ele- 
vated, irregular  patches  having  uneven,  ulcerated  surfaces,  from  which  small 
granulations   project  ;  the   patches   may   be  small   or  large,  and  may  appear 

on  the  palpebral  (where they  are  most 

frequently  met  with)  or  on  the  ocular 

conjunctiva. 

"vfV  r,N  \t  A  *\       \  Pathology. — The  tissue  of  the  neo- 

-^  *  ,  1\\/X':vnY'*'"        ' mjS  plasm  shows  loss  of  epithelium  at  the 

£f*;    '  V  C-*  it  \  •  ^l    tr-^l  "  s',<>    °f   ,U('   nicer,   <ri'anulation-tissue, 

'^ff/^V    'C    w    *^\\    '  ^j. ,       "V1      uramdar  detritus,  new-formed  connec- 

>V  1^^/     '■      \W       Ufa       tive-tissue    elements,    giant-cells,    and 

'f\i  >}       \*      ■     •    /A'i*'    >   '     HI    numerous  leukocytes,  which  gradually 

£*         >kl//.     '      b»      •', *\  \  diminish  as  the   normal   tissue  is  en- 

't    ti&Mj     *    f>  '.-,.-'     /'     tered.     A  few  tubercle  bacilli  are  found 

-lH         *\V      tilfw'-M  in  the  tissue  (see  Fin-.  -JO  1).      The  in- 

V"'J  ^     « V        *\  *S^/J  fection   is  most   frequently  by  way  of 

the  lachrymal  canals. 

Symptoms. — There  is  slighl 
irritation  of  the  eye,  accompanied 
by    a    scanty     muco-purulenl    secre- 

Fig  201.— Tubercle  bacillus  in  sputum  (Fraenkel      ,  •'  i  •   i    *  •   .      c 

and  i'ii ij  tion     which     may    persisl    ror    many 

month-.     Enlargement  of  the  preau- 
ricular  gland    on    the   affected    -i<le    i-    present. 

Diagnosis    and    Prognosis. — The    coexistence    of   lupus   on    the    nasal 

1  System  of  Ih  .,,  .    of  tht  Skin     Dermatology,  vol.  iii.  |>  587. 
twentieth  Century  Practia  of  ,1A</.   vol,  \.  p.  698, 


PEMPHIGUS. 

mucous  membrane  or  on  the  integument  of  face  or  lids,  with  a  history  of 
long  duration,  is  usually  sufficient.  In  a  large  percentage  of  the  cases  the 
mucous  membrane  at  the  inner  canthus  will  be  involved  as  a  result  of  the 
continuation  of  the  disease  from  the  lachrymal  passages.  The  condition  may 
be  confounded  with  epithelioma.  It'  doubt  exists,  a  piece  of  the  tissue  may 
be  excised  and  examined  microscopically,  or  the  iris  of  a  rabbil  may  !»■  inocu- 
lated with  the  tissue.     The  prognosis  is  favorable  in  nearly  all  cases. 

Treatment. — Excision  of  the  diseased  parts  or  destruction  l>v  means  of 
the  cautery  is   indicated. 

Second.  When  tuberculosis  of  the  conjunctiva  i-  the  resull  of  direct 
inoculation  the  early  stage  is  marked  by  a  distinct  congestion  of  the  con- 
junctiva and  the  appearance  of  numerous  small,  discrete,  grayish  nodules  in 
the  ocular  or  palpebral  conjunctiva  which  do  not  present  an  ulcerated  sur- 
face. The  tubercle  bacilli  are  commonly  introduced  through  wounds  in 
the  conjunctiva,  made  either  accidentally  or  during  operation  involving  the 
conjunctiva.  The  nodular  masses  present  all  the  characteristics  of  miliary 
tubercles. 

Symptoms. — Marked  irritation  of  the  eye,  redness  of  the  conjunctiva, 
increased  lachrymation,  and  a  muco-purulent  secretion  are  present.  The  dis- 
ease  advances  quite  rapidly,  producing  hypertrophy  of  the  conjunctiva  and 
superficial  ulcers.  The  preauricular  and  cervical  eland-  on  the  affected  side 
enlarge  and  break  down.     Ulceration  of  the  cornea  may  develop. 

Diagnosis  and  Prognosis. — Acute  trachoma  and  syphilis  are  the  only 
diseases  with  which  tins  form  of  tuberculosis  may  be  confounded.  A  section 
of  a  nodule,  stained  for  tubercle  bacilli  and  examined  microscopically,  will 
settle  the  question  beyond  doubt.  The  disease  runs  a  very  long  and  per- 
sistent course,  and  may  involve  other  parts  of  the  system.  The  eye  may 
lie  completely  destroyed. 

Treatment. —  It  is  doubtful  if  anything  short  of  early  removal  of  the 
affected  conjunctiva  will  have  any  effect.  After  the  active  enlargement  of  the 
cervical  glands  has  been  established  appropriate  constitutional  treatment,  with 
attention  to  local  symptoms  as  they  arise,  is  all  that  can  be  done. 

Pemphigus. — -This  disease  of  the  conjunctiva  is  characterized  by  the 
appearance  of  very  transient  bulla?,  followed  by  red.  and  later  by  grayish, 
areas  on  the  conjunctiva  of  the  lids  and  of  the  o;lol>e.  A-  these  areas  heal 
the  conjunctiva  becomes  atrophic,  other  patches  appear,  and  further  atrophy 
takes  place;  soon  meridional  band-  between  lids  and  globe  are  formed,  and 
the  condition  known  as  symblepharon  posterius  is  the  result.  The  conjunctival 
surface  becomes  dry  and  shiny,  the  cornea  opaque,  and  vision  is  lost.  The 
condition  is  very  rare  :    Horner  observed  it  but  ■">  time-  in  70,000  eye  cases. 

Etiology. —  Pemphigus  usually  accompanies  pemphigus  vulgaris  or  pem- 
phigus foliaceus,  and  depends  on  a  dyscrasia  of  the  system.  Individual-  of 
all  ages  are  attacked.  A  history  of  syphilis  was  obtained  in  only  1  of  the  28 
cases  reported  by  Morris  and  Roberts.1 

Pathology. — The  red  raw  surface-  evidently  follow  destruction  of  the 
upper  layer  of  the  epithelium  due  to  a  process  which  on  the  skin  would  pro- 
duce blebs.  The  conjunctival  epithelium,  being  thinner  ami  much  weaker,  i- 
cast  off  early.  A  deposil  of  fibrin  soon  form-  over  the  affected  area,  and  the 
grayish  patch  i-  the  result.  Section-  of  the  atrophied  conjunctiva  -how  cica- 
tricial connective  tissue  containing  a  few  blood-vessels.  The  epithelium  i- 
thin  ami  irregular. 

Symptoms. — The  progress  of  the  affection  i-  extremely  -low;  there 

1  Brit.  Journ.  of  Dermatol.,  1889,  p.  175. 


304  DISEASES  OF  Till'.   CONJUNCTIVA. 

little  secretion.      With  the  advance  in  the  atrophy  of  the  conjunctiva  dimness 
of  vision  increases.      Both  eyes  arc  attacked. 

Prognosis. — This  is  very  unfavorable.  The  disease  lasts  for  years,  and 
usually  results  in   loss  of  vision. 

Treatment  i-  of  little  avail.  Arsenic  may  be  given  internally.  Oint- 
ments and  mucilaginous  remedies  may  be  employed  to  relieve  the  dryness  of 
the  conjunctiva.     Surgical  interference  is  seldom  satisfactory. 

Argyria  Conjunctivae  (Argyrosis). — Long-continued  use  of  nitrate  of 
silver  on  the  conjunctiva,  particularly  of  a  solution  dropped  into  the  eye,  pro- 
duces a  discoloration  which  affects  the  ocular  and  palpebral  conjunctiva,  most 
marked  in  its  'lower  half.  The  color  varies  from  a  light  ochre  hue  to  a  deep 
brown.  In  some  cases  slight  hypertrophy  of  the  conjunctiva,  with  slight 
irritation,  results.  In  one  case  observed  by  the  writer  the  hypertrophied,  non- 
inflamed  conjunctiva  formed  a  fold  which  projected  into  the  palpebral  fissure. 
At  the  request  of  the  patient  this  fold  was  excised  and  the  condition  corrected. 
The  stain  formed  is  indelible.  A  solution  of  hyposulphit  of  sodium  or  of 
iodid  of  potassium  in  the  strength  of  1  :  10  of  water  has  been  suggested 
for  the  removal   of  these  stains. 

Affections  of  the  Caruncle  and  Semilunar  Membrane. — Inflam- 
mation of  the  caruncle  is  sometimes  observed  as  a  result  of  infection  of  one 
or  more  of  its  sebaceous  glands.  When  this  occurs  the  caruncle  swells, 
becomes  enlarged,  and  is  much  congested.  The  abscess  opens  spontaneously 
or  may  be  opened  with  the  knife  ;   recovery  will  follow. 

The  hairs  of  the  caruncle  may  become  unusually  large  and  numerous 
(trichosis  caruncidce)  and  produce  more  or  less  irritation.  Epilationjor  excis- 
ion of  the  hair-bulb  will  give  relief. 

Papilloma  of  the  caruncle  and  semilunar  fold,  occurs  as  a  pink,  soft,  villous 
mass,  with  numerous  papillae,  which  are  bathed  in  muco-pus.  The  mass 
bleed-  easily  and  tends  to  increase  in  size.  It  is  attended  by  a  slight  sensa- 
tion a-  of  a  foreign  body  at  the  inner  canthus,  but  gives  little  or  no  pain. 
Papilloma  is  prone  to  recur,  and  will  do  so  unless  thoroughly  and  completely 
removed.     The  knife  or  cautery   should   be  employed. 

Congenital  telangiectasia  of  the  caruncle  has  been  observed. 

The  term  encanthis  is  applied  to  an  enlargement  of  the  caruncle  and  semi- 
lunar  fold  from  any  cause.  Enlargement  of  the  caruncle  accompanies  all 
forms  of  conjunctivitis,  and  sub-ides  with  the  subsidence  of  the  conjunc- 
tivitis. Cystoid  enlargement  is  at  times  seen.  Adenoma  may  develop. 
Chalky  deposits  may  form  in  the  glands  of  the  caruncle,  "which  may  cause 
it  to  become  enlarged.  Carcinoma  and  sarcoma  (encanthis  maligna)  may 
develop   primarily   at    the  caruncle. 

Treatment. —  In  the  case  of  tumors  at  the  caruncle  and  semilunar  fold 
early  operative  procedure  should  lie  resorted  to. 


DISEASES  OF  THE  CORNEA  AND  SCLERA. 

By  SWAN   M.  BURNETT,  M.  I).,  Pn.  T)., 

OF   W  iSHINGTON,    I).   ('. 


Inflammation  of  the  Cornea  (Keratitis). — The  cornea,  having  no 
vascularization  of  its  own,  depends  for  its  nutritive  supply  on  the  blood- 
vessels of  the  conjunctiva,  sclera,  iris,  and  ciliary  body.  From  tins  it 
happens — first,  that  inflammations  of  these  tissues  are  nearly  always  accom- 
panied by  some  change  in  the  nutrition  of  the  cornea;  and.  second,  that 
defective  general  nutrition  is  apt  to  be  felt  early  in  the  cornea  as  a  tissue  far 
from  the  base  of  supplies.  Keratitis,  therefore,  when  not  the  direct  resull 
of  a  traumatism,  is  in  the  vast  majority  of  cases  the  expression  of  some 
depres.-ed  general  vitality  or  is  the  effect  or  accompaniment  of  an  inflam- 
mation in  the  adjacent  parts.  A  primary  and  isolated  keratitis  is  a  rare  affec- 
tion, though  the  participation  of  other  tissues  may  be  so  slight  as  to  escape 
detection   or  be  veiled  by  the  intensity  of  the  corneal  affection. 

( 'orneal  inflammations  may  be  studied  clinically  from  the  standpoint  either 
of  their  supposed  etiology  or  by  following  the  anatomical  divisions  of  the 
affected  part.  For  practical  purposes  sometimes  the  one  method  and  some- 
times the  other   has  been  found  the  more  convenient. 

Anatomically,  the  cornea  is  a  direct  continuation  of  other  coats  of  the  eye- 
ball— of  the  conjunctiva,  through  its  epithelial  layer;  of  the  sclera,  through 
the  substantia  propria  ;  and  of  the  uveal  tract,  through  the  endothelial  layer 
of  Descemet's  membrane.  The  pathological  importance  of  this  connection 
will  be  apparent  when  we  come  to  consider  the  various  individual  forms  of 
keratitis. 

Superficial  Keratitis. — The  most  common  form  of  this  affection  is  that 
known  as  phlyctenular  conjvmctivitis,  phlych  nular  herato-conjv/nctivitis,  <  >r  ht  rp<  s 
corneal,  but  more  properly  as  strumous  or  scrofulous  ophthalmia,  because  it  is 
usually  limited  to  the  conjunctival  or  epithelial  layer  of  the  cornea,  and  is 
always  associated  with  the  strumous  diathesis  or  some  form  of  defective 
assimilation. 

Etiology. — The  disease  is  confined  almost   entirely  to  childl I.     One 

eye  or  both  may  be  affected  at  the  same  time,  and  a  recurrence  of  the  affec- 
tion from  time  to  time  is  the  rule.  Evidences  of  a  strumous  diathesis  are 
seldom  lacking  in  its  subjects.  There  is  often  swelling  of  the  preauricular 
and  submaxillary  glands ;  the  patients  are  badly  nourished,  even  when  not 
positively  anemic,  and  the  appetite  i~  bad  or  capricious.  In  the  worst  i 
the  scrofulous  cachexia  i-  very  pronounced.  Running  from  the  nostrils, 
which  are  clogged  up  with  dried  secretions,  swollen  alas  nasi,  thick  upper  lip, 
and   excoriated   cheeks   make  the  diagnosis  before   the  eyes   are   insp< 

NTaso-pharyngeal  disease,  infla latory  or  obstructive,  which  most  frequently 

accompanies  the  affection,  is  the  etiological  factor  in  many  instances.  Phlyc- 
tenular disease  often  follows  in  the  wake  of  measles  and  other  exanthemata. 
It  is  more  aggravated  in  warm  and  moisl  weather. 

20 


306 


DISEASES  OF  THE  CORNEA    AND  SCLERA, 


Micro-organisms  have  been  described,  but  their  etiological  relationship 
to  this  disease   has  not   been  established  (compare  with   page  286). 

Objective  Symptoms. — The  disease  manifests  itself  by  a  small  yellow- 
ish-white elevation  (the  phlyctenule)  on  the  surface  of  the  cornea,  varying  in 
size  from  1  to  2  or  •">  mm.  in  diameter.  It  may  occur  at  any  place  on  the 
corneal  surface,  bul  its  usual  seat  is  near  the  scleral  edge,  and  commonly  on 
the  limbus  itself.  It  is  not  uncommon  for  two  or  more  of  these  phlyctenules 
to  appear  at  the  same  time,  and  on  rare  occasions  they  are  so  numerous  as  to 
form  a  circlel  around  the  corneal  base  (marginal phlyctenular  keratitis).  The 
accompanying  injection  of  the  conjunctiva]  vessels  may  he  very  slight,  and  is 
commonly  limited  to  a  leash  of  vessels  running  up  to  and  ending  in  the  phlyc- 
tenule I  Fig.  202). 

On  the  other  hand,  and  especially  when  the  spot  is  farther  in  on  the 
cornea]  surface  and  the  deeper  structures  are  involved,  the  conjunctiva]  con- 
gestion is  more  general.     Oftentimes  the  accompanying  conjunctivitis  assumes 


Fig.  202. — Scrofulous  ophthalmia  (phlyctenula  cornese). 


the  form  of  a  more  or  less  muco-purulent  type.  The  intensity  of  the  accom- 
panying conjunctiva]  participation,  however,  hears,  as  a  rule,  no  proportion  to 
the  local  lesion  on  the  cornea. 

Subjective  Symptoms. — The  subjective  symptoms  vary  greatly  in  inten- 
sity. In  the  milder  cases  there  is  little  or  no  pain,  and  a  feeling  of  discom- 
fort and  an  inability  to  use  the  eyes  as  much  as  customary  arc  about  all  that 
is  complained  of. 

In  severe  cases,  which  occur  especially  in  children,  the  symptoms  arc  of 
the  most  intense  kind.  There  is  a  photophobia  which  makes  the  child  keep  the 
eyes  tightly  shut  [blepharospasm),  and  which  may  persist  for  weeks,  render- 
ing even  forcible  separation  of  the  lids  difficult  (see  also  page  253).  The 
child  seeks  the  darkest  cornel- of  the  room,  buries  its  head  deep  in  the  pillow, 
and  violently  resists  every  effort  to  bring  it  into  the  light.  The  lachrymation 
i-  profuse,  and  the  cheek-  arc  excoriated  with  the  constant  overflow  of  irri- 
tating  tears. 

Between  this  and  the  mildest  form  there  is  every  gradation ;  moreover, 
the  intensity  of  the  symptoms  does  not  bear  any  proportion  to  the  extent  of 
the  pathological  change.  A  single  phlyctenule  may  he  attended  with  more 
pronounced  subjective  symptoms  than  three  or  four,  and  the  severity  differs 
in  different  attacks  in  the  same  person.  This  can  he  accounted  for  partly,  no 
doubt,  by  the  fact  that  in  the  one  case  the  exudate  presses  on  the  terminal 
filaments  of  t  he  nerve  distributed  among  the  cell-  of  t  he  epithelial  layer,  caus- 
ing these  intense  reflex  phenomena,  and  in  the  other  it  doe-  not.  Another 
important  fetor,  too,  is  the  generally  hyperesthetic  condition  of  the  patient, 
due.  most    likely,  to  defective  nutrition  of  the  nerve-centers. 


SI  rPEBFICIAL   KERA  Tills. 


307 


Pathology.  Pathologically,  the  phlyctenule  is  qoI  a  vesicle  with  fluid 
contents,  as  its  appearance  would  indicate.  Under  the  epithelium  there  is 
Pound  a  collection  of  small  round  lymphoid  cell-,  as  shown  in  Fig.  3)'-\. 
The  anterior  epithelial  wall  of  the  phlyctenule  breaks  down;  the  cell-  are 
discharged,  leaving  a  small,  superficial  ulcer  [phlyctenular  ulcer),  which  is 
generally  rapidly  covered  over  by  a  fresh  layer  of  epithelium,  and  the  dis- 
eased process  i-  ended  for  the  time,  usually  leaving  no  trace  unless  the  deeper 


Fig.  203. — Phlyctenule :  6, Bowman's  layer:  ?,  corneal  substance;  d,  Descemet's  membrane;  e,  epi- 
thelium; f,  phlyctenule,  consisting  of  a  deposit  of  round-cells  in  the  epithelial  layer  and  along  the 
course  of  the  nerve:   »,  twig  of  nerve  ending    in  epithelium  (modified  from  Iwanoflf). 

structures  of  the  cornea  are  involved,  when  there  is  likely  to  be  more  or  less 
opacity  remaining  for  a  time  or,  it  may  be,  permanently. 

Diagnosis  and  Prognosis. — Direct  inspection  reveals  the  nature  of  the 
disease.  The  prognosis  depends  on  the  type.  It  is  essentially  a  relapsing 
disease;  repeated  attacks  may  leave  the  corneal  epithelium  roughened  and 
scarred,  and  sometimes  covered  with  vessels,  the  so-called  phyctenular pannus. 

Treatment. — In  the  treatment  of  the  affection  attention  to  the  general 
condition  is  of  greatest  importance.  A  persistent  and  long-continued  use  of 
tonics  and  nutrients — among  which  iron  (syrup  of  the  iodid)  and  cod-liver 
oil  are  perhaps  the  best — is  the  first  requisite  as  regards  medication.  But 
most  important  is  the  regulation  of  the  diet  and  habits  of  the  child.  Only 
nutritious  food  should  be  allowed — milk,  meat  (except  pork  and  veal)  in 
moderate  quantity,  vegetables  (except  potatoes  in  excess),  with  abstinence 
from  sweets  and  pastries.     Good  fruit  may  be  allowed  in  proper  quantities. 

The  child  should  live  out  of  doors  as  much  as  possible  in  spite  of  the 
photophobia,  and  the  function  of  the  skin  should  be  kept  in  proper  order  by 
frequent  bathing.  Any  associated  nasal  affection  should  receive  prompt  and 
thorough  attention,  and  the  naso-lachrymal  passages  should  be  kept  patulous. 

Locally,  in  the  first  or  acute  stage,  atropin  drops  (gr.  iv-.Vp  arc  to  be 
used,  and  where  there  is  much  photophobia  an  equal  amount  of  muriate  oi 
cocain  can  be  added.  A  drop  of  this  solution  is  to  be  put  in  the  eye  three 
times  a  day  or  every  four  hours  according  to  the  intensity  of  the  symptoms. 
The  eye  should  be  bathed  in  water  as  hot  a<  can  be  borne  for  five  minutes 
every    tour   hours. 

In  the  second  stage,  after  the  rupture  of  the  phlyctenule  and  the  pr 
of  restoration  has  begun,  the  insufflation  of  finely-powdered  calomel  is  a  time- 
honored   remedy,  as  is  also   Pagenstecher's  salve  (hydrarg.  oxid.  flav.,  gr.j, 
petrolat.  gj  or  ij)  put  under  the  eyelid   and    rubbed  over  the  ball.      In  very 
mild    cases,    where   there    i-    no    photophobia,    lachrymal ion.  or  other 
irritation,  a  simple  antiseptic  collyrium,  such  as  boric  acid  or  biborat 
sodium,  gr.  x  to  §j,  will  suffice,  with  care  in  the  use  of  the  eyes.      I  h 

should  never  be  bandaged,  protection  fr the  excessive  lighl  being  secured 

by  colored  glasses  or  a  shade. 


308  DISEASES  OF  THE  CORNEA    AND  SCLERA. 

In  the  severest  cases  the  blepharospasm  is  so  intense  as  to  require  especial 

attention.  When  it  has  once  become  a  fixed  habit  it  is  difficult  to  break  up, 
and  its  presence  undoubtedly  prolongs  the  disease.  It  sometimes  yields  to  the 
instillation  of  cocain,  hnt  in  long-standing  eases  this  will  not  suffice.  In 
these  instances  the  mosi  efficient  means  is  to  plunge  the  face  in  a  basin  of 
eold  water  and  hold  it  there  a  few  moments.  The  shock  of  this  violent  pro- 
cedure will  usually  relieve  the  spasm, and  the  child  will,  on  removal  from  the 
water,  open  its  eyes  widely.  Forcible  dilatation  of  the  eyelids  by  an  eye- 
speculum  for  a  short  period  each  day  has  been  recommended.  The  excoria- 
tion-at  the  angles  of  the  lid-  no  doubt  keep  up  the  blepharospasm  through 
reflex  action,  and  should  be  cured  as  promptly  as  possible.  After  the  disease 
has  subsided  any  refractive  error  should  he  corrected,  as  eye-strain  may  excite 
an  attack  in  an  eye  predisposed  to  this  disorder. 

Pannus. — Vascularity  of  the  superficial  layers  of  the  cornea  is  often  an 
accompaniment  of  trachoma  or  of  one  of  its  sequels — cicatricial  entropion  or 
trichiasis. 

When  the  vascularity  and  thickening  accompany  the  first  stages  of  the 
disease,  before  the  period  of  cicatrization  has  arrived,  there  are  grounds  for 
believing  that  the  pannus  is  but  an  expression  of  the  trachomatous  process 
itself — i.  e.  a  true  trachoma  of  the  conjunctival  layer  of  the  cornea — and  not 
a  secondary  effect.     In  such  cases  the  thickening-  is  much  greater  than  when 


— b 


Fig.  J04.— I'annus  (after  [wanoff):  c,  the  cornea;  h.  Bowman's  membrane;  a,  thickened  layer  of  epi- 
thelium: d,  blood-vessels ;  e,  infiltration  of  round-cells. 

it  i-  due  to  mechanical  irritation  by  trichiasis  or  the  rough  cicatricial  con- 
junctiva (see  also  page  291  i. 

The  denser  form-  of  pannus  have  been  called  pannus  crassus — the  thinner, 
pannus  tenuis.  In  pannus  tenuis  the  blood-vessels  are  con  fund  to  the  super- 
ficial layers,  and  there  is  not  much  infiltration  or  thickening  of  the  epithelial 
layer;  bul  in  the  denser  form  the  infiltration  may  involve  the  deeper  layers 
of  the  substantia  propria  (Fig.  204).  The  entire  surface  of  the  cornea  may 
be  covered,  ami  the  thickening  so  dense  that  the  iris  can  no  longer  he  distin- 
guished.  In  the  lighter  form-  only  a  part  of  the  cornea  may  he  involved, 
and    in    1  li.it    case    it    is    usually    the    upper   portion. 

It  i-  seldom  that  a  case  of  pannus  runs  its  course  without  more  or  less  loss 
of  tissue,  or  ulceration.     Occasionally,  however,  the  pathological  condition  is 

one  only  of  hypemutrition,  characterized  by  the   formation   of  new   hi I- 

vessels  and  connective  tissue,  and  if  there  is  no  destruction  of  the  substantia 
propria,  the  process  may  end  with  a  complete  absorption  of  the  foreign  mate- 
rial, leaving  the  cornea  quite  clear. 

Treatment. — A.S  the  condition   is  usually  secondary  to  some  other  patho- 


HERPES  COB, \  /:./:. 

logical  process — trachoma,  trichiasis,  tic. — the  treatment  musl  be  mainly 
directed  against  these  affections.  The  existence  of  a  pannus  is  no  bar  to 
the  prompt  and  energetic  treatment  of  these  conditions ;  on  the  contrary,  it 
improves  pari  passu  with  the  amelioration  of  the  original  cause.  A.tropin, 
with  cocain  sometimes  added  (atrop.  sulph.  cocain.  mur.,  aa.gr.  iv— §j),  and 
hot  applications  are  the  remedies  proper  to  the  relief  of  the  symptoms  of 
pain  and  photophobia,  of  which  the  corneal  trouble  is  the  immediate 
cause. 

When  the  vascularization  and  opacity  persist  in  any  degree  alter  the 
removal  of  the  original  cause,  remedial  measure-  addressed  to  the  condition 
itself  become  necessary.  These  consist  in  diminishing,  or  in  some  manner 
cutting  off,  the  blood-supply  to  the  newly-formed  tissue  in  the  cornea  or 
assisting  in  its  absorption  by  the  natural  processes.  The  former  may  be 
accomplished  directly  by  dissecting  a  narrow  band  of  conjunctival  tissue, 
2  mm.  wide,  from  around  the  base  of  the  cornea  (  peritomy),  or,  as  has 
been  suggested,  by  cauterizing  the  tissues  deeply  with  the  actual  or  galvano- 
cautery. 

The  production  of  a  violent  inflammation  of  the  conjunctiva  by  means 
of  an  infusion  of  or  the  powder  of  the  jequirity  bean  had  at  one  time  quite  a 
vogue  in  the  treatment  of  pannus,  but  some  unfortunate  cases  of  total  destruc- 
tion of  the  cornea  from  its  excessive  action  have  caused  it  to  fall  into  disuse 
except  among  a  very  few  surgeons.  The  same  may  be  said  of  inoculations 
with  gonorrheal  matter,  which  at  one  time  were  used,  particularly  in  Belgium. 

Curetting  the  surface  of  the  cornea,  especially  in  the  earlier  stages  and 
before  entropion  or  trichiasis  has  set  in,  can  be  practised  with  great  benefit. 
For  the  less  serious  cases  the  ointment  of  the  yellow  amorphous  oxid  of 
mercury  (gr.  j-.^ij ),  rubbed  under  the  lids  once  or  twice  a  day,  assists  in 
the  process  of  absorption.  For  the  same  purpose  insufflation  of  finely- 
powdered  calomel  is  a  remedy  of  old  and  established   value. 

Resorption  or  Transparent  Ulcer  of  the  Cornea. — A  loss  of  tissue 
on  the  corneal  surface,  usually  not  very  deep  nor  extensive,  and  not  associated 
with  any  opacity  of  the  corneal  substance,  is  known  as  a  "  resorption  nicer." 

The  distinguishing  characteristics  are  its  transparency  and  the  smoothness 
of  its  surface,  which  is  covered  by  normal  epithelium. 

The  usual  seat  of  the  ulcer  is  near  the  center  of  the  cornea.  There  i- 
commonly  but  little  lachrymation  or  photophobia,  and  there  is  scarcely  any 
increased  vascularization  of  the  conjunctiva.  An  ulcer  of  this  character  is 
most  common  among  the  old  and  enfeebled,  and  is  usually  slow  in  healing. 
A   slight   traumatism   is  most    probably   the  originating  cause. 

The  ulcer  usually  heals  without  other  interference  than  protection — with 
atropin  and  hot  applications  when  the  subjective  symptoms  are  more  pro- 
nounced than  usual.  In  the  chronic  cases  eserin  has  been  found  useful. 
The  lesion  may  become  converted  into  a  true  nicer,  with  a  tendency  to 
spread  through  necrosis  of  the  tissue. 

When  situated  over  the  pupil  a  transparent  nicer  gives  rise  to  greal  dis- 
turbance of  vision,  quite  as  much  so  as  an  opacity  of  the  same  size,  on  account 
of  the  diffraction  and  diffusion  of  light  through  its  irregular  surface. 

Herpes  Corneas  i  Vesicular  Keratitis). —  In  those  cases  of  herpes 
talis  where  the  nasal  twig  of  the  fifth  pair  is  affected  and  a  vesicle  is  formed 
along  the  side  of  the  nose,  it  is  rare  to  have  the  cornea  unaffected. 

A    vesicle   containing  a   clear  fluid    form-    on    the    surface    of   the    cornea, 
ruptures  early,  and    leaves  a  superficial  nicer  or  epithelial  denudation,  wit 
infiltration  and  opacity  of  the  surrounding  part-.     It   i-  accompanied   with 


:;m 


DISEASES  OF   THE  CORNEA    AND  SCLERA. 


much  pain  of  a  neuralgic  character,  photophobia,  and  lachrymation.  Occa- 
sionally, however,  these  violent  symptoms  are  absent.  The  cornea  itself  is 
usually  more  or  less  anesthetic  to  touch,  and  the  tension  of  the  eyeball  is 
diminished. 

The  vesicle  differs  from  a  phlyctenule  of  scrofulous  conjunctivitis,  with 
which  it  is  sometimes  confounded  on  account  of  the  name  herpes  conjunctivae 
by  which  the  latter  was  formerly  known,  in  that  it  is  larger  and  its  contents 
are  fluid.  Some  opacity  of  the  cornea  nearly  always  remains  (see  also  page 
287). 

Treatment. — The  treatment  is  palliative — atropin  alone  or  combined 
with  coeain,  hot  applications,  and  an  anodyne  internally  when  the  pain  is 
exhausting.  The  general  condition  usually  requires  tonics  and  a  sustaining 
nourishment.  The  author  has  found  the  salicylate  of  sodium  in  large  doses 
useful  in  controlling  pain  and  mitigating  the  severity  of  the  disease.  It  has 
been  suggested  to  scrape  the  ulcers  and  cauterize  them,  but  unless  they  show 
a  marked  tendency  to  spread  this  course  is  not  advisable. 

Vesicles  on  the  cornea  have  sometimes  been  found  associated  with  herpes 
labialis  or  nasalis, especially  in  children,  to  which  the  name  herpes  febrilis  has 
been  given.  The  symptoms  exhibit  less  intensity  than  those  just  described  ; 
there  is  little  or  no  anesthesia  of  the  cornea,  and  the  globe-tension  is  not 
changed.  These  vesicles  have  been  seen  during  malarial  levers.  They  all, 
however,  seem  to  depend  on  some  derangement  of  the  central  nervous  system. 

Dendritic  Keratitis. — This  name  has  been  given  to  a  species  of  super- 
ficial keratitis  of  a  peculiar  arborescent  form  (Fig.  205). 


pIGi  205.— Dendritiform  keratitis  (after  oalenga) :  a,  first  stage;  !>,  seventeen  days  after. 

It  ben-ins  as  a  small  vesicle,  and  continues  its  growth  by  a  series  of  newly- 
formed  contiguous  vesicles  which  break  down  into  small  ulcers,  forming  irreg- 
ular lines  which  give  the  distinctive  name  to  the  disease  (Galenga,  Horner). 

Etiology. — Some  authors  regard  the  affection  as  mycotic,  and  no  doubt 
micro-organisms  are  found  in  it,  but  none  that  are  peculiar  to  it.     It  has  been 

found  associated  wit  I ilaria  (Kipp  and  others),  and  syphilis  has  been  assigned 

as  a  cause  by  some  writers.  It  seems  most  probable  that  the  disease  i>  the 
expression  of  a  dyscrasia  of  some  kind. 

The  ulceration  occupies  by  preference  the  central  portion  of  the  cornea. 
The  course  of  the  disease  is  usually  -low,  and  though,  for  (he  most  part,  not 
very  annoying,  is  occasionally  very  painful  and  associated  with  severe  supra- 
orbital neuralgia  ami  tenderness,  depending  on  the  depth  of  the  ulceration 
and  the  amount   of  involvement  of  the  terminal   filaments  of  the  nerves. 

Treatment. — This  consists  in  rest,  protective  spectacles,  atropin,  and  hot 
applications.  Should  there  be  a  marked  tendency  to  spread  or  an  obstinacy 
in  healing  under  the  above  treatment,  the  ulcer  should  be  -craped  and  1  :  ii<» 
formalin  solution  applied,  or  in  severe  cases  the  actual  cautery.  Quinin  and 
arsenic  internally  are  useful.  Galvanism  alone-  the  supraorbital  nerve  has 
been  suggested. 


BULLOUS  KEBA  Tills. 


311 


Filamentous  Keratitis. — <  >n  rare  occasions,  after  rupture  of  corneal 
vesicles,  a  rope-like  body  is  seen  attached  to  the  sur- 
face of  the  ulcer,  its  free  end  being  frayed  I  Fig.  'JOG). 
This  is  the  filamentous  keratitis  of  Leber  and  Nuel. 
It  consists  of  epithelial  cells  and  coagulated  fibrin 
twisted  into  the  form   of  a  cord. 

Superficial  Punctate  Keratitis. — ruder  the 
head  of  superficial  keratitis  must  also  he  admitted  a 
form  of  corneal  inflammation  called  by  Fuchs  keratitis 
punctata  superficialis  (Syns. :  Keratitis  subepithelialis 
centralis;  Keratitis  maculosa  ;  Noduli  cornece  ;  J!< .laps- 
ing herpes  cornea  ). 

The  alterations  in  the  cornea  consist  of  small  gray 
dots  arranged  in  groups  or  short  rows  in  the  super- 
ficial layers,  mostly  near  the  center.  The  disease 
begins  with  a  rather  pronounced  catarrhal  conjunctivitis,  and  i-  usually  asso- 
ciated with  catarrhal  disease  of  the  respiratory  tract.  The  dots  remain  some- 
times for  weeks.  Stellwag  has  described  a  similar  affection,  the  foci  of  larger 
size  being  found  in  the  periphery  of  the  cornea.  There  is  much  pain,  and 
iritis  may  develop  (nummular  keratitis). 

Treatment. — Hot  applications,  atropin,  and  protection  of  the  eye  with 
dark  glasses. 

Fascicular  Keratitis  (Keratitis  in  Bandelette). — This  affection,  which 
bears  a  resemblance  to  the  phlyctenular  form  of  keratitis,  and  of  which  it 
may  he  a  modified  form,  is  characterized  by  a  hand  or  leash  of  vessels,  with 
a  narrow  border  of  opaque  corneal  tissue,  which  traverses  the  surface  of  the 
cornea  to  end  near  the  center  in  a  small  round  whitish-yellow  head  (Fig.  207). 


I'h..  206.— Filamentous  kera- 
titis (after  Panas). 


Fig.  207.— Fascicular  keratitis. 

On  disappearance  of  the  vessels  a  more  or  less  opaque  hand  or  streak'  i- 
usually  left  on  the  cornea.  More  than  one  of  these  hand-  may  appear  at  the 
same  time  or  develop  consecutively.  The  treatment  i-  the  same  a-  that  suited 
to  keratitis  in  general. 

Bullous  Keratitis. —In  eyes  whose  nutrition  has  been  seriously  inter- 
fered with,  a-  it  i-  likely  to  he  in  glaucoma,  irido-cyclitis,  or  choroiditis,  an 
extensive  elevation  of  the  epithelium  is  sometime-  observed  at  or  near  the 
center  of  the  cornea.  The  bleb,  thus  formed,  i-  usually  partially  tilled  with  a 
clear  fluid  which  gravitates  to  the  bottom,  giving  it  a  baggy  appearance.    The 

-a phenomenon  ha-  also  been  observed  a  few  time-  in  eyes  that  are  not  thus 

disorganized.  There  i>  slight  pericorneal  injection,  but  the  pain  i-  usually 
quite  severe  and  of  a  more  or  less  intermittent  character.  The  anterior  layers 
of  the  cornea  are  seldom  exempt   from  implication. 

The  disease  seems  to  be  purely  local  in  character,  nol  depending  upon  the 
general  condition,  a-  doc-,  for  instance,  vesicular  keratitis. 

A    recurrent  form   following   injuries  ha-  been   noted   by    Hansen  Grut. 


312  DISEASES  OF  THE  CORNEA    AND  SCLERA. 

Fuchs  :iik1  some  others  seem  to  think  thai  the  elevation  of  the  epithelium  is 
due  to  an  obstruction  in  the  Lymph-circulation. 

Treatment. — The  disease  is  to  be  treated  by  instillations  of  atropin,  except 
where  glaucoma  is  present  or  feared,  when  eserin  (\  to  \  gr.— 3j)  can  be  \\>vd 
instead,  and  by  hoi  applications  for  the  mitigation  of  pain,  with  an  opiate  or 
other  anodyne  it'  it  do(-  no1  yield  to  these  mild  measures.  Should  an  ulcer 
form  with  a  tendency  to  spread,  it  can  be  touched  with  formalin,  1  :60,  or 
with  the  actual  cautery,  tn  the  milder  forms  insufflations  of  iodoform  acl 
with  good  effect  on  the  ulcer  and  the  pain.  Cocain  can  be  used  in  mode- 
ration.    A   protective  bandage  is  usually  beneficial. 

Suppurative  Inflammations  of  the  Cornea  or  Suppurative  Kera- 
titis.—  Purulent  inflammations  of  the  cornea  form  the  mosl  important  cate- 
gory of  it-  diseases,  because  of  their  immediate  and  remote  dangers. 

Suppuration  of  the  corneal  tissue  is  always  followed  by  ulceration  or 
destruction  of  the  substance,  leaving  invariably  an  opaque  cicatrix  as  a  sequel, 
thus  annulling  one  of  its  most  accessary  qualities — it  >  transparency. 

These  inflammations  may  not  only  eventuate  in  a  total  destruction  of  the 

cornea   itself,  but   i ccasion   lead  to  an  involvement  of  the  whole  eyeball, 

ending  in  its  disorganization.  They  demand  our  most  earnest  attention,  more- 
over, from  the  fact  that  they  are  truly  infectious  in  their  nature,  and  are, 
thus  far,  to  be  classed  among  the  preventable  diseases 

Etiology  and  Pathology. — We  know,  since  the  great  work  of  Leber,1  that 
for  the  genuine  infecting  process  we  must  have  a  micro-organism,  and  that 
usually  it  is  introduced  from  without.  For  this  reason  these  infectious  affec- 
tions of  the  cornea  are  common  among  those  working  out  of  doors  and  in  the 
dust,  a-  laborers,  harvesters,  etc.  But  not  only  musl  we  have  the  organism, 
but  also  the  soil  made  ready  for  the  >vv(\,  and  the  tissue  must  he  in  a  con- 
dition to  serve  as  a  proper  nidus  for  the  growth  and  development  of  the 
particular  micro-organism   present. 

Few  organisms  are  able  to  obtain  a  foothold  upon  a  perfectly  healthy 
tissue,  with  the  power  to  throw  out  white  blood-corpuscles  to  acl  as  phagocytes. 
'fhc  wounded  normal  cornea!  tissue  always  heals  without  suppuration  when 
free  from  any  infecting  organism.  The  epithelium  of  the  cornea,  when 
intact,  interposes  an  almosl  insuperable  harrier  to  the  entrance  of  germs,  and 
when  we  find  an  infection  we  may  be  almost  certain  that  a  destruction  of 
epithelium  has  preceded  it.  The  important  practical  lesson  to  he  learned 
from  this  is,  that  with  proper  precaution  and  early  attention  many,  if  not 
most,  of  these  destructive  suppurations  can  he  avoided. 

All  injuries  and  wound-  to  the  cornea  should  he  promptly  treated  by 
disinfection,  or  at  leasl  by  thorough  and  frequent  cleansing  with  an  asep- 
tic liquid,  as  boric  acid  or  mild  bichlorid  or  weak  formalin  solutions. 
Bandaging  the  eye  closely  under  these  conditions  is  of  doubtful  wisdom. 
The  heal  of  the  bandage  hastens  the  developmenl  of  what  germs  may  yet 
remain  in  the  conjunctival  sac  or  on  the  lid-margins.  An  absolute  disin- 
fecti >f  these  part-  ha-  not    vet   been  found  possible  by  any  safe  procedure. 

For  clinical  purposes  suppurative  diseases  of  the  cornea  can  he  considered 
under  several  head-,  based  on  their  etiology,  course,  particular  complications, 
and  special  features;  hut  the  general  characteristics  are  the  same  in  all,  and 
all  begin  in  essentially  the  3ame  manner. 

There  is  firsl  noted  at  the  place  of  infection  an  infiltration  of  a  pearly- 
gray  color  which  rapidly  nun-  to  a  creamy  yellow.  This  infiltration  spreads 
to  a  greater  or  less  extent,  remaining  circumscribed  only  in  a  genuine  "ab- 

1  lu>  Entstehuny  der  Entziindung,  Leipzig,  1891. 


ULCERATION  OF  THE  CORNEA.  313 

scess.5  In  tlu'  eroding  or  serpiginous  forms  tin-  extension  is  sometimes  very 
rapid.  ( >n  the  other  hand,  it  may  be  slow,  !>ut  steady  in  it-  progress.  The  pari 
of  the  cornea  affected  loses  its  vitality,  sloughs  off,  and  an  ulcer  is  formed. 
This  destructive  action  of  the  micro-organism  is  arrested,  it  i-  claimed,  by 
the  phagocytic  power  of  the  white  blood-corpuscles.  A  limit  is  thus  sel  to 
the  invasion  of  sound  tissue,  and  the  healing  begins  by  the  re-formation  of 
epithelium  at  the  edge  of  the  nicer.  The  process  of  reparation  goeson,  when 
the  loss  of  tissue  is  not  extensive,  to  a  complete  restoration  of  the  original 
form,  but  usually  with  a  substance  not  of  the  nature  of  the  true  corneal 
tissue.  It  is  cicatricial  in  character,  ami  not  transparent, except  perhaps  in 
those  cases  where  the  destruction  is  very  limited  in  extent.  The  membrane 
of  Bowman  is  never  re-formed  when  it  is  once  destroyed,  bul  the  epithelium 
i-  very  readily  re-established.  While  the  pathological  processes  in  all  cases 
of  suppuration  are  essentially  those  just  recited,  for  the  purposes  of  clinical 
study  and  treatment  they  have  been  classified  under  several  distinct  varieties. 

.Abscess  of  the  Cornea. — This  is  a  simple  circumscribed  collection  of 
pus  in  the  corneal  substance,  usually  some  distance  from  the  scleral  edges. 

It  is  most  commonly  -ecu  as  a  sequel  or  continuation  of  a  phlyctenule 
•on  the  surface,  the  throwing  off  of  the  epithelium  opening  up  the  way  to  an 
infection  of  the  deeper  parts.  The  subjective  symptoms  are  the  same  as  in 
other  forms  of  keratitis.  It  terminates  by  a  breaking  down  of  its  anterior 
wall  and  a  discharge  of  its  content-,  becoming  thereby  an  open  ulcer,  which 
under  favorable  circumstances  heals  in  a  few  days,  and,  if  the  loss  of  tissue  i> 
not  great,  leaving  little  opacity.  It  may  be  induced  by  any  other  mean-  that 
destroy  the  epithelial  layer,  such  as  small  wounds,  foreign  bodies,  etc.  The 
so-called  ring  abscess,  where  the  suppuration  extend-  around  the  base  of  the 
•cornea,  is  seen  mostly  after  cataract  operation-. 

Treatment. — The  proper  treatment  is  hot  applications,  atropin  solution 
(gr.  iv-.5J),  a  drop  three  times  a  day,  with  rest  and  protection  of  the  eye-. 
A  spontaneous  rupture  is  usually  allowed.  When  the  ulcer  i-  formed  it-  heal- 
ing is  expedited  by  aseptic  applications  of  weak  formalin  solution,  ^  :  2000,  or 
boric-acid  solution,  or  other  means  to  be  mentioned  in  succeeding  paragraphs. 

Ulceration  of  the  cornea,  or  destruction  of  the  corneal  substance,  is 
the  essential  feature  of  all  forms  of  suppurativi    keratitis. 

Varieties. — The  form-  of  corneal  ulceration,  from  a  clinical  standpoint, 
depend  upon  its  seat,  its  cause,  it-  course,  and  its  association  with  other 
pathological  conditions.  Thus  we  have  the  sthenic  and  asthenic  ulceration, 
according  a-  the  accompanying  vascularization  and  other  symptoms  of  irri- 
tation are  considerable  or  mild  ;  marginal  ulceration,  when  it  i-  seated  near 
the  margin  of  the  cornea  ;  serpiginous  ulceration,  when  it  creeps  over  the  sur- 
face  of  the  cornea,  invading  successively  the  adjoining  area-;  keratitis  witii 
hypopyon,  when  associated  with  the  presence  of  pus  in  the  anterior  chamber ; 
and  other  distinctive  title-.  Moreover,  all  these  varieties,  or  any  number  of 
them,  may  be  only  different  or  successive  phases  of  the  same  attack.  In  all, 
the  essential  clinical  features  are  the  same,  modified,  however,  by  the  par- 
ticular circumstances  of  individual  cases. 

Under  tin-  head  may  be  mentioned  a  rare  form  of  chronic  era //in;/  ulcer, 
which  begins  near  the  margin  of  the  cornea  and  progresses  in  :i  cr<  scentic 
form  without  any  pronounced  suppuration  or  hypopyon,  never  Leading  to 
perforation,  but  followed  by  dense  cicatricial  opacities.  To  this  the  name 
rodent  ulcer  ha-  been  given. 

A  form  of  spreading  keratitis  is  observed  very  often   in  tho;  d  in 

shucking  oyster — the  so-called  oyster-shucker's  keratitis.     It  was  thought  to 


314  DISEASES  OF   THE  COL'XEA    A.\/>  SCLERA. 

be  a  purely  infectious  disease  until  Randolph  of  Baltimore  demonstrated 
that  it  was  not,  bui  a  mechanical  keratitis  caused  l>y  the  fine  particles  of 
lime  of  the  oyster-shell.  The  harvester's  keratitis  is  probably  iirst  mechanical 
and  afterward  microbic. 

Etiology. — The  immediate  causes  of  destructive  ulcers  of  the  cornea  are 
usually  infecting  wounds  or  injuries  of  some  kind,  including  operations,  such 
as  cataract  extraction,  iridectomy,  and  other  operations  involving  the  cornea. 
Anything  that  destroys  the  epithelium  opens  up  the  way  to  the  entrance  of 
infecting  micro-organisms.  These  germs  maybe  introduced  at  the  time  of 
injury  or  they  may  enter  later.  Two  factors  are  necessary  for  development 
of  the  process — the  germ  and  the  soil.  As  there  are  always  germs  in  the  con- 
junctival sac,  or  as  they  can  easily  get  entrance  there,  some  of  which  may  be 
pyogenic,  any  injury  of  the  cornea  is  liable  to  take  on  an  ulcerative  action  if 
the  tissue  is  in  a  condition  of  non-resistance,  as,  for  instance,  in  the  case  of 
weak,  poorly-nourished  people.  The  progress  of  the  ulceration  may  he  very 
brief,  the  reparative  process  setting  in  in  a  few  days,  or  it  may  continue  for 
weeks  without  showing  any  tendency  to  heal,  or  may  extend  itself  slowly, 
hut   persistently,   into  the  sound   tissue. 

The  germs  most  commonly  found  as  the  active  agents  primary  in  corneal 
ulcerations  are  the  usual  pyogenic  forms — principally  staphylococcus  and 
streptococcus  (see  Figs.  192  and  11)7) — butUhthoff,  Axenfeld,  and  others  have 
recently  (1896)  found  the  pneumococcus  in  great  abundance  in  serpent  ulcers 
(Plate  2,  Fig.  IV.),  and  Leber  has  found  a  form  of  aspergillus  in  some  cases. 
Probably  the  most  frequent  cause  of  large  destruction  of  the  cornea  is  the 
gonococcus  of  Neisser  found  in  purulent  ophthalmia  of  gonorrheal  origin  (see 
article  on  the  Conjunctiva). 

Symptoms  and  Course. — An  ulcer  begins  with  a  focus  of  infection, 
noticeable  as  a  superficial  defect  with  ragged  edges  of  a  yellow  color  and  sur- 
rounded by  a  zone  of  infiltrated  cornea.  Its  sides  and  bottom  are  covered  by 
a  detritus  of  dead  corneal  tissue,  having  a  yellow  pultaceous  appearance.  The 
accompanying  vascularization  of  the  conjunctiva  varies  greatly.  In  some 
instances  it  is  pronounced,  the  swelling  of  the  tissue  around  the  base  of  the 
cornea    in    the   vicinity   of  the   ulcer   being   very   marked. 

There  are  at  times  greal  photophobia  and  much  lachrymation  and  pain, 
which,  however,  in   the   indolent    forms  may  be  lacking  almost  entirely. 

In  the  serpiginous  form  the  ulceration  spreads  gradually  over  the  surface, 
and  usually  with  increasing  depth.  Then  some  time  during  its  course  there 
is  .-in  appearance  of  pus  in  the  bottom  of  the  anterior  chamber — hypopyon 
Fig.  208).  This  may  occur  while  the  ulcer  is  still  central  and  there  is  yet 
clear  cornea  between  it  and  the  scleral  margin.  It  was  held  at  one  time  that 
it    was   necessary  to   have  a    perforation   of  the  posterior  wall   of  the   ulcer 

through  the  membrane  of  Descemet   in  order  that 

^V%(>  x^V  pus  might  Hud  its  way  into  the  anterior  chamber. 

j~sy. -       The  researches  of  Leber  have  shown,  however,  that 

•^-nSs, jifc.,  \-j &0C^      'he    pus-cells    may    gravitate   down    through    the 

^'^z^'\      -oiind    corneal     tissue    and     pa--     into    the   anterior 

/^>vf-;      ■•hiiinlier   ;it    the    iris   angle,  or   thev    may    originate 

/  . •■-..        ,^--_/-v— 5*  al   this  point  from  a  participation  of  the  uveal  tract 

f  y.\'\ ■J^'\i -,S^^%        in   the  inflammatory  process.      In  certain  cases  no 

*     '    \         \  doiihl    there    is    a    -mall    perforation    of    Descemet's 

Fig  piginous       membrane. 

"icer  with  hypopyon  T|)),  destruction  0f  tissue  may  be  very  exten- 

sive,  covering   the   entire   anterior   surface,    leaving   the    posterior   layers  and 


ULCERATION  OF  THE  CORNEA.  315 

the  membrane  of  Descemet  intact;  in  which  case  there  will  be  no  perfora- 
tion. In  most  cases,  however,  this  is  the  event,  and  we  have  as  a  conse- 
quence a  new  set  of  phenomena  and  complications. 

With  the  opening  of  the  anterior  chamber  the  aqueous  humor  escapes; 
the  iris  falls  forward  against  the  posterior  wall  of  the  cornea,  plugs  up  the 
opening,  and  in  course  of  time  may  become  united  to  it  by  adhesive  inflam- 
mation (anterior  synechia).  The  anterior  chamber  then  refill-,  leaving  this 
portion  of  the  iris  in  front  of  the  mass  of  aqueous  humor.  It'  the  opening 
is  la r<ie  enough,  the  pressure  from  behind  is  sufficient  to  push  the  iris  through 
the  opening  and  form  a  bag  of  greater  or  less  size  in  the  site  of  the  ulcer.  We 
then  have  perforation  with  prolapse  oj  the  iris. 

It  may  happen  that  the  pyogenic  germs  entering  the  anterior  chamber 
find  a  suitable  nidus  for  their  development  in  the  iris,  ciliary  body,  and 
choroid,  and,  setting  up  a  purulent  inflammation  in  these  tissues,  bring  about 
the  condition  of  panophthalmitis,  leading  to  final  atrophy  of  the  eyeball.  There 
is  no  case  of  hypopyon  probably  in  which  the  iris  is  not  more  or  less  aifeeted. 

Prognosis. — From  what  has  been  said  it  may  be  inferred  that  the  prog- 
nosis depends  upon  the  activity  of  the  morbific  agent  and  the  ability  of  the 
tissues  to  resist  its  encroachment.  In  the  old  and  feeble  it  is  much  more 
serious  than  in  the  young  and  strong. 

Treatment. — Suppurative  keratitis  being  an  infectious  disease,  the  treat- 
ment should  be  both  preventive  and  therapeutic.  Every  injury  of  the 
cornea  should  be  considered  as  if  it  were  infected.  'Phe  conjunctival  sac 
should  be  thoroughly  cleansed  with  an  aseptic  liquid,  as  a  saturated  boric-arid 
solution  or  formalin  1  :  2000,  and  kept  as  aseptic  as  possible.  The  scat  of 
injury  itself  should  be  touched  with  a  1  :  60  formalin  solution,  or  nitrate  of 
silver  (gr.  xx-sj),  or  tincture  of  iodin,  when  there  is  strong  suspicion  of  infec- 
tion, and,  where  it  is  reasonably  certain,  with  the  actual  cautery.  The  treat- 
ment of  the  ulcer  when  it  has  declared  itself  should  be  antiseptic  and 
palliative.  The  surface  of  the  ulcer  should  be  touched  with  a  1  :  60  formalin 
solution  once  a  day  so  long  as  there  seems  to  be  any  tendency  to  spread. 
Formerly  the  author  was  accustomed  to  use  full-strength  carbolic  acid  for  this 
purpose  with  good  effect.  Mules  recommends  iodoform  applied  on  a  water  of 
gelatin  directly  to  the  ulcer,  bandaging  the  eye  to  keep  it  in  place.  The  iodo- 
form may  be  dusted  directly  on  the  ulcer,  but  this  is  less  efficacious.  When 
the  serpiginous  character  becomes  pronounced,  the  actual  cautery  applied  to 
the  edges  and  bottom  of  the  ulcer  becomes  necessary.  This  must  be  done  under 
cocain.  It  is  well  to  scrape  away  as  much  dead  tissue  as  possible  with  a  sharp 
spoon  before  applying  either  the  cautery  or  the  formalin  caustic  solution. 
Tincture  of  iodin  and  nitrate  of  silver  (gr.  xx-f gj)  are  also  applied  to  the 
curetted  area.  The  cauterization  maybe  repeated  every  two  or  three  days, 
according  to  the  urgency  of  the  symptoms.  Curetting  of  the  ulcer  while  a 
fine  spray  of  a  2  percent,  solution  of  boric  acid  is  directed  againsl  its  surface 
has  been  recommended.  Samisch  recommended  an  incision  into  the  anterior 
chamber  through  the  sides  and  bottom  of  the  ulcer  in  the  serpiginous  form,  ami 
this  operation  is  still  performed  by  many  surgeons.  Its  performance  before  a 
hypopyon  is  formed  is  in  the  majority  of  cases  uoi  advisable,  since  it  makes  ear 
the  entrance  of  germs  into  the  interior  of  the  eye.  In  cases  of  hypopyon  tins 
objection  doe-  not  hold  to  the  same  extent.  It  i-  often  necessary  to  let  out 
the  pus  when  present  in  large  quantity,  and  in  these  cases  the  incision 

lie  made  as  low  down  a-  possible  ( -ee  also  p.  567). 

Quite  recently  the  subconjunctival  injections  of  bichlorid  of  mercti 
had  many  advocates.     A   few   drops  of  I  :2000  solution  are  injected  under 


316  DISEASES  OF  THE  CORNEA    AND  SCLERA. 

the  conjunctiva  once  a  day  or  every  other  day.  The  operation  is  generally 
very  painful,  even  under  cocain.  Others  have  found  the  injection  of  a 
normal  sail  solution  quite  as  effective.  A-  palliatives  atropin  and  cocain 
are  the  main  reliance.  The  latter  should  be  used  only  for  the  temporary 
reliefofpain  and  the  lowering  of  intraocular  tension.  Eserin  in  weak  solu- 
tion (4  to  .',  gr.  ad  sj)  is  used  for  the  same  purpose  it'  iritis  is  not  a  com- 
plication. 

A-  a  palliative  and  curative  agent  heal  ismosl  valuable.  As  the  morbific 
process  is  to  be  stopped,  or  at  leasl  retarded,  !>y  the  phagocytic  action  of  the 
while  blood-corpuscles,  a  determination  of  fresh  Mood  to  the  part,  with  dila- 
tation of  the  vessels,  is  all  important.  Heat  accomplishes  this,  and  the  best 
form  of  application  is  fomentation  with  water  as  hot  as  it  can  be  borne  for 
five  minutes  every  three  or  four  hours.    The  immersion  of  the  eye  in  a  goblet 

or  glass  of  hot  water,  as  recommended  by  Leartus  C ler  of   Detroit,  is  an 

elegant  and  most  efficient  way  of  administering  heat. 

The  eye  should  not  be  bandaged,  except  when  the  ulcer  is  very  deep  and 
there  i-  danger  of  spontaneous  rupture,  under  which  circumstances  the  dry 
antiseptic  'pressure  bandage  is  effective. 

In  cases  of  perforation  the  management  is  little  different,  except  as  to  the 
treatment  of  the  prolapse  of  the  iris.  When  the  prolapse  is  not  large  and  is 
situated  peripherally,  and  does  not  involve  the  sphincter,  eserin  should  be  sub- 
stituted for  atropin.  Its  myotic  action  tends  to  draw  the  iris  out  of  the 
wound,  and  often  quite  successfully.  If  the  condition  of  the  conjunctiva 
warrants  it,  a  pressure  bandage  aid-  in  reducing  a  henna  of  the  iris.  The 
prolapsed  iris  should  not  be  excised  or  punctured,  certainly  not  until  the  sup- 
purative process  has  ended,  and  then  only  under  strictest  asepsis.  Even  very 
large  prolapses  smoothe  down  in  time. 

Careful  attention  must  be  paid  to  the  general  condition  of  the  patient, 
particularly  in  the  old  and  feeble.  Tonics,  and  even  stimulants,  with  the 
most    nutritious  diet,  are   indicated. 

There  are  two  forms  of  secondary  purulent  keratitis  which  require  a  brief 
separate  mention  : 

( 1  i  Ulcerations  following  Purulent  Conjunctivitis. — ruder  these 
circumstances  the  two  most  potent  factors  are  united  in  the  development  of  the 
disease  in  its  most  destructive  form — namely,  the  presence  of  an  infecting  germ 
and  a  denuded  and  macerated  condition  of  the  epithelium,  with  diminished 
nutrition  of  the  cornea  from  the  pressure  of  the  chemosis  on  the  surrounding 
nutritive  vessels.  The  ulceration  usually  begins  at  the  periphery  of  the  cornea 
under  a  fold  of  overlapping  chemosis.  Quite  often,  however,  it  commences 
near  tin-  center,  and  occasionally  there  is  a  necrosis  of  the  whole  cornea  at 
once  from  the  cutting  off  of  its  nutritive  supply  by  pressun — a  true  sphacelus 
cornea — when  the  entire  tissue  becomes  yellow  and  breaks  down  into  a  pul- 
taceous  mass.  The  presence  of  the  corneal  ulcer,  however  great  its  extent,  is 
1 1 « - t  ;i  bar  to  the  mosl  energetic  treatment  of  the  conjunctival  disease  (see  also 
page  '_'7 '.i  i.  The  ulceration  is  apt  to  be  deeper  than  in  other  forms,  especially 
at  the  periphery, and  there  is  an  earlier  prolapse  of  the  iris.    (  M'ten  the  whole 

iris  seems  to  bulge  forward  either  a-  a  ma h  rat (><■</<■ — or  through  numerous 

perforations  in  the  apparently  clear  cornea — the  so-called  mulberry  appear- 
and— and  the  eye  seems  doomed  to  destruction.  There  i-.  however,  in  many 
of  these  cases  quite  a  quantity  of  Bound  corneal  tissue  remaining.  The  mem- 
brane of  Descemel  resists  destruction  fora  long  while,  and  eyes  that  seemed 
losl   regain  their  form  and  some  part  of  their  function. 

In   cases  of  peripheral   perforation  eserin   is  to   he  used,  while  in   other 


CORNEAL    ULCERS  TN  SMALL-POX.  317 

forms  atropin  and    antisepsis,   with   hot    applications,   should   constitute   the 

main    local    treatment. 

(2)  Neuroparalytic  Keratitis. — The  other  form  of  secondary  kera- 
tin- is  that  associated  with  paralysis  of  the  fifth  pair  of  cranial  nerves,  the 
so-called  neuro-paralytic  keratitis.  When  the  fifth  nerve,  particularly  the 
part  containing  fibers  of  the  sympathetic,  is  divided  in  animals,  in  a  short 
time  the  cornea  on  that  side  begins  to  ulcerate,  and  soon  passes  on  to  total 
destruction.  The  same  thing  is  likely  to  occur  in  man  when  the  tilth  nerve 
is  from  any  cause  paralyzed,  and  particularly  when  the  branch  of  the  seventh 
going  to  the  orbicularis  is  at  the  same  time  involved. 

It  has  been  a  point  in  dispute  whether  the  ulceration  is  due  to  interference 
with  nutrition  from  injury  to  the  trophic  filaments  in  the  fifth  pair,  or  is 
simply  the  result  of  the  traumatic  injuries  inflicted  on  the  insensitive  cornea 
on  account  of  its  constant  exposure  from  the  paralysis  of  the  orbicularis.  It 
would  seem  from  a  careful  sifting  of  the  evidence  that  both  factor-  play  a 
part.  Injury  to  the  trophic  nerves  seriously  impairs  the  resisting  power  of 
the  corneal  tissue,  and.  it  may  he  in  some  instances,  is  of  itself  sufficient 
to  bring  about  destructive  inflammation,  independent  of  serious  injury, 
for  we  see  the  ulceration  sometimes  when  the  orbicularis  i<  intact.  On 
the  other  hand,  we  have  paralysis  of  the  orbicularis  without  corneal  ulcer- 
ation. 

The  process  usually  begins  as  a  marginal  ulcer,  with  deep  injection  of  the 
conjunctiva,  and  spreads  gradually  over  the  whole  cornea,  the  tissue  breaking 
down  into  a  soft  yellow  mass.  On  occasion  the  process  seems  to  arrest  itself, 
and  a  small  amount  of  clear  cornea  is  left.  It  is  usually  painless,  and  not 
accompanied  by  photophobia   or  lachrvmation. 

The  course  is  slow  and  prognosis  serious,  a  total  destruction  of  the  cornea 
being  the  result  to  be  expected. 

Treatment  is  wholly  palliative,  protection  of  the  eyes  by  bandage  or 
stitching  the  lids  and  cleanliness  being  the  main  features  in  the  therapeutics. 
Tonics  and  a  nutritious  diet  are  nearly  always  demanded. 

After  removal  of  the  Gasserian  ganglion  Dr.  W.  W.  Keen  and  Dr.  de 
Schweinitz  recommend  primarily  stitching  of  the  lids,  and  when  the  first 
dressing  is  made  the  application  of  a  Buller's  shield,  which  remains  for  a 
week  or  more.  With  these  precautions  they  have  prevented  corneal  ulcer 
after  complete  excision  of  the  ganglion.  Destructive  ulceration  of  the  cornea 
is  the  result  most  to  be  feared  in  diphtheria  of  the  conjunctiva  (page  28  I  \. 

Keratitis  e  I/agophthalmo. — When  the  cornea  i-  continuously  ex- 
posed from  any  cause  its  epithelium  desiccates  and  falls  off,  and  there  i-  a 
liability  to  the  entrance  of  germs  with  an   infective   keratitis  as  a   result. 

The  affection  has  been  observed  in  excessive  exophthalmos,  destruction 
of,  or  cicatricial  contraction  of  the  eyelids,  paralysis  of  the  orbicularis,  etc. 

due  keratitis  pursues  practically  the  same  course  as  neuro-paralytic 
ophthalmia,  though  not  usually  with  the  same  rapidity  or  malignancy,  and 
responds  more   promptly   to  treatment. 

Treatment. — This  consists    in    removing  the  cause  when    possible,  and 
usually  by  some  operation  on   the  lid-.      In  case  this  cannot  be  done  a   pro- 
tective  bandage   musl   be  constantly  used.       In    the   -lighter  form-  of  lag- 
ophthalmos  the   bandage    should    always    be  applied   at    night,  and  all 
eve-   should    be   protected   against    dust,  wind,   smoke,   and   other   it 
influences.     The  treatment  of  the  keratitis  itself  is  the  same  a-  that  indii 
for  keratitis  in  general. 

Corneal  Ulcers   in   Small-pox. — In   the  days   prior  to 


318  DISEASES  OF  THE  CORNEA    AND  SCLERA. 

destruction  of  ili<'  cornea  from  small-pox  was  one  of  the  most  common  forms 
of  blindness.      Happily,  it  is  not  often  encountered  now. 

True  vaccinal  abscess  differs  from  ordinary  abscess  in  that  it  is  generally 
endogenous,  being  simply  the  appearance  of  a  variolous  pustule  on  the  cornea 
itself.  Thai  it  may  be  due  to  secondary  infection  is,  however,  possible, 
especially  it'  the  cornea  becomes  involved  after  the  stage  of  eruption  i.> 
passed. 

The  treatment  is  the  same  as  that  for  other  forms  of  purulent  keratitis. 

Keratomalacia.  —  This  is  a  form  of  destructive  corneal  trouble  met 
with  mostly  in  badly-nourished  infants  and  children,  though  adults  with 
vital  powers  greatly  reduced  by  lack  of  proper  food  are  also  liable  to  be 
attacked,  it  is  seen  accompanying  meningitis,  variola,  measles,  and  severe 
diarrhea  or  dysentery. 

Symptoms. —  It  is  always  associated  with  xerosis  of  the  conjunctiva 
(page  296).  There  is  great  dryness  of  the  conjunctiva,  which  is  covered  in 
spots  with  a  froth-like  material  that  is  found  upon  examination  to  consist  of 
fatty  matter  and  epithelial  cells.  The  lachrymal  secretion  is  deficient  or 
entirely  Lacking.  The  cornea  becomes  dry  and  cloudy  from  a  drying  of  its 
epithelium,  and  soon  shows  evidences  of  breaking  down  at  the  center.  This 
disintegration  is  of  the  color  of  pus,  and  sometimes  extends  very  rapidly, 
destroying  the  cornea  in  the  course  of  a  few  hours.  Sometimes,  however,  it 
requires  several  days  to  accomplish  this.  It  may  even  happen  in  mild  cases 
that  the  whole  tissue  is  not  destroyed.  There  is,  in  those  who  are  old  enough 
to  express  themselves,  a  pronounced  night-blindness  at  the  beginning  of  the 
affection.  This,  as  well  as  the  other  characteristic  symptoms,  gives  evidence 
of  a  lack  of  nutrition  at  the  nerve-centers. 

Microbes  of  various  kinds  have  been  found  in  the  secretions,  but  they 
are  probably  not  the  essential  cause  of  the  disease,  but  only  find  in  it  a  nidus 
for  growth.  The  one  most  frequently  found  is  a  small  bacillus,  the  so-called 
pseudo-diphtheria  bacillus,  and  is  often  present  in  large  numbers. 

The  prognosis  is  most  unfavorable  ;  the  patients  frequently  succumb  to 
the  disease  which  has  caused  the  keratitis  or  to  an  intercurrent  pneumonia. 

Treatment. — The  first  object  in  treatment  is  to  improve  the  nutrition  as 
rapidly  as  possible  by  the  most  nourishing  foods,  tonics,  etc  The  eye  itself 
should  be  treated  with  hoi  fomentations,  mild  aseptic  washes.  Caustics  are 
seldom  called  for.  On  account  of  the  insensitiveness  of  the  eyes  and  the 
tendency  of  the   lids  to   remain   open,  a   bandage   is   necessary  for   protection. 

Tuberculosis  of  the  Cornea. — Primary  tuberculosis  of  the  cornea  is 
a  rare  affection.  The  cornea,  however,  usually  participates  more  or  less  in 
the  conjunctiva]  form  of  that  affection  (page  302). 

Symptoms. — In  the  lew  cases  that  have  been  reported  it  has  begun  as 
an  interstitial  opacification,  commencing  at  the  edge  and  progressing  toward 
the  center  of  the  cornea.  Ill  this  affected  area  there  are  to  be  seen  small 
yellowish-white  granules  like  miliary  tubercle.-,  which  coalesce  and  finally 
break  down,  and  are  thrown  oil',  leaving  an  ulcer  usually  without  hypopyon. 
A  bacteriological  examination  or  experimental  inoculation  will  usually  demon- 
strate the  character  of  t In-  disease. 

The  treatment  is  the  same  as  that  for  other  ulcer-,  only  demanding  an 
early  scraping  or  destruction  by  caustics  of  the  affected  tissues. 

interstitial  or  Parenchymatous  Keratitis  (Syphilitic,  Inherited, 
Specific,  Diffuse  Interstitial  Keratitis).  In  contradistinction  to  the  destructive 
forms  of  corneal  inflammation  we  have  been  considering,  tin-  form  does  not 
lea. I.  a-  a  rule,  to  .i  loss  of  corneal  tissue.     Moreover,  it  i-  always  the  man- 


INTERSTITIAL    OR   PARENCHYMATOUS  KERATITIS.       319 

iiestatioii  of  a  systemic  derangement,  and  usually  some  form  of  dyscrasia, 
hereditary  syphilis  being  the  must  common.  Its  association  with  acquired 
syphilis  is  uncommon,  nor  does  scrofula  usually  manifesl  itself  by  this  form 
<il'  cornea]   inflammation. 

Etiology. — We  owe  to  Hutchinson  the  discovery  of  the  intimate  connec- 
tion of  keratitis  parenchymatosa  with  inherited  syphilis.  The  ground  taken 
by  him  nearly  forty  years  ago  is  still  maintained  by  a  large  part  of  the  ablest 
clinicians. 

Still,  it  may  be  questioned  whether  all  eases  of  interstitial  keratitis  are 
syphilitic.  Von  Hippel  has  found  the  disease  xcvy  frequent  in  people  of  a  tuber- 
culous taint  with  no  history  of  inherited  syphilis.  Of  87"  cases,  23  were  syph- 
ilitic and  15  doubtful ;  IS  tuberculous  and  8  doubtful— other  cases  uncertain. 
Parinaud  found  96  per  cent,  of  his  eases  syphilitic  ;  Despagnet,  14  per  cent. ; 
Seklassy,  30  per  cent.  ;   Bosse,  44  cases  in  54. 

The  syphilitic  cases  are  generally  marked  by  definite  and  peculiar  features. 
As  regards  the  mother,  there  arc  rarely  absent  histories  of  abortions  or  early 
death  of  other  children,  and  those  now  living  show  more  or  less  evidence  of 
being  affected.  Probably  the  most  characteristic  appearance  is  on  the  part 
of  the  permanent  teeth.  The  central  upper  incisors  have  notched  rd<r^>  and 
arc  peg-shaped,  the  so-called  "  Hutchinson's  teeth."  This  shape  is  due  to 
defective  nutrition  and  the  breaking  away  of  the  enamel.  There  are  often 
nodosities  on  the  tibia,  and  the  frontal  tuber- 
osities are  unusually  prominent.  There  are 
often  deep  scars  around  the  angles  of  the  mouth 
and  the  alae  nasi.  It  is  usual  to  describe  the  skin 
as  being  coarse,  but  the  author's  observation  is 

that  it  is  commonly  unusually  fine  and  velvety  Fig.  209.— Form  of  the  upper  teeth 

In  t„,4nm  Tl,;t.  ;  .  ™«ri/ii.ln»ln  .,,.<-;^™Ul^  :.-.  in  keratitis  parenchymatosa  lafter 
in  texture.      1  his  is  particularly  noticeable  in     Hutchinson). 

the  negro  race.    A  less  common  accompaniment 

is  that  of  deafness.     Synovitis  of  the  knee-joint  may  be  a  complication,  and 

there  are  likely  to  be  other  evidences  of  faulty  nutrition.     The  disease  is 

commonest  between  the  ages  of  five  and  fifteen,  occurring  occasionally  as 

early  as  the  third  year  and  rarely  as  late  as  the  sixtieth  year.      A  congenital 

form  has  been  described.     In   female  children   it   is  apt  to  appear  about  the 

supervention  of  menstruation. 

Cases  occurring  in  persons  above  thirty  years  of  age  are  not,  as  a  rule, 
due  to  syphilis,  but  to  some  other  dyscrasia,  as  rheumatism,  gout,  and 
possibly  tuberculosis,  or  the  climacteric. 

Symptoms. — The  disease  begins  as  a  grayish  opacity  in  the  substance  of 
the  cornea,  sometimes  at  more  than  one  place,  and  gradually  extends  in 
typical  cases  until  the  whole  of  the  tissue  is  involved.  This  opacity  is  so 
dense  in  fully-developed  cases  as  to  entirely  veil  the  iris  from  view,  and  is 
generally  quite  uniform,  though  a  close  inspection  will  reveal  foci  of  more 
intense  infiltration. 

At  the  beginning  the  epithelium  is  intact  and  I  lie  surface  of  the  cornea 
has  its  normal  glistening  look,  but  later  it  becomes  rough  like  ground  glass, 
showing  a  disturbance  in  the  arrangement  of  its  epithelial  cells. 

In  a  form  to  which  the  name  circumscript  <>v  discrete  has  been  given  there 
may  be  several  -pots  at  some  distance  from  each  other  and  apparently  uncon- 
nected.     An  examination  with  oblique  illumination  and  a  magnifier,  how. 
will  nearly  always  show  some  fine  streak-  of  opacity  connecting  them. 

In  this  discrete  form,  which  is  more  frequently  found  in  the  rheumatic 
diathesis  and   in  women  about  the  climacteric,  there  is  nearly  always  a  per- 


320 


DISEASES  OF   THE  CORNEA    A  XI)  SCLERA. 


manent  opacity   remaining  after  the  disease    has  subsided,  more   especially 
when  the  spots  are  near  the  scleral  border  (Fig.  '21  h. 

During  the   very  early  stage  of  the  infiltration   there  is  no  great   increase 


X-,  \ 


-    ■o-  ■ 


-V 


~ 
1 


SB 


r^- 


v-- 


Fig.  210.— Interstitial  keratitis,  with  commen- 
cing vascularization. 


Fig.  211.— Circumscribed  interstitial  keratitis 

author's  case). 


in  the  vascularization  of  the  conjunctiva,  nor  are  photophobia  and  lachryma- 
tion  very  pronounced. 

The  second  stage,  that  of  vascularization,  is  almost  always  attended  with 
symptoms  of  irritation.  This  vascularization  of  the  infiltration  is  the  nat- 
ural process  for  it-  absorption.  Its  manner  of  invasion  is  characteristic  and 
distinctive.  The  vessels,  which  are  very  fine  and  delicate,  are  seen  to  pen- 
etrate deeply  into  the  substance  of  the  cornea  at  its  periphery.     On  account 

of  their  fineness  and  compactness  they 
seem,  as  seen  through  the  hazy  cor- 
neal tissue,  almost  like  an  extrava- 
sation of  blood  into  its  substance — 
the  "salmon  patch "  of  Hutchinson. 
The  vascularization  usually  ad- 
vances pari  passu  with  the  progress 
of  the  infiltration  across  the  cornea, 
and  that  is  usually  from  above  down- 
ward, so  that  by  the  time  the  in  tilt  ra- 
tion reaches  the  opposite  side  the 
cornea  look-  like  a  piece  of  raw- 
beef — the  vascular  keratitis  of  some 
writer-.  This  may  have  required 
weeks  or  even  months,  for  tedious- 
ness  is  a  prime  characteristic  of  the 
affection  (Fig.  210). 

The  accompanying  symptoms  may 
be  mild,  giving  rise  to  but  little 
pain.  In  most  cases,  however,  there 
arc  considerable  pain  of  a  neuralgic 
character  and  lachr}  mation,  and 
there  are  generally  indications  of  the 
involvement  of  the  uveal  tract.  In  fact,  few  cases  run  their  eoiir-e  without 
an  implication  of  the  ii'i-,  ciliary  body,  or  choroid,  or  all  three.  Stellwair 
designated  the  disease  as  "anterior  uveitis."  We  musl  remember  that  the 
cornea   is  <•<> -ted  directly   with    the   uveal   tract   through   the  endothelial 


I  Section  of  the  cornea  in  parenchyma- 

tous keratitis :  a,  epithelial  layer;  b,  Bowman's  mem- 
brane; ''.  membrane  "i    Descemel    with  deposit  of 

round-cells,  c,  on  its  posterior  surface    • .  bl 1  ves 

f,  infiltration  and  dislocation  "t  the  corneal 
layers   lifted  from  S'ordensen  i. 


INTERSTITIAL   OR   PARENCHYMATOUS  KERATITIS.       321 


layer  <>t"  Descemet's  membrane.  Unfortunately,  the  condition  of  the  cornea 
does  not  allow  us  to  examine  carefully  into  the  state  of  the  hi-,  bul  after  the 

opacity  lias  cleared  up  we  are  apt  to  find  evidence  of  iritis.  Retinitis  aii<l 
optic   neuritis  may  occur,  and   secondary  glaucoma  is   not    uncommon. 

All  eases,  however,  do  not  run  such  a  typical  course.  A  part  of  the 
cornea  may  be  attacked,  vascularize,  and  clear  up,  and  then  another  and 
another,  until  the  whole  tissue  has  been  successively  affected.  The  process 
may  occasionally  stop  after  an  attack  on  a  limited  portion.  A  number  of 
eases  of  an  atypical  form,  which  are  not  properly  form-  of  interstitial  kera- 
titis, have  been  reported  in  which  the  opacities  are  stripe-like  or  ring-like. 
These  present  the  appearance  of  pus  in  the  corneal  layers,  the  so-called 
abscess-forms,  or  they  may  appeal-  as  a  central  annular  lesion.  On  rare 
occasions  ulceration  and  hypopyon  are  accompanying  conditions,  but  should 
be  regarded  as  incidental  complications. 

Prognosis. — The  course  of  the  disease  is  invariably  slow,  and,  as  the  eyes 
are  liable  to  be  affected  in  succession  and  the  same  eye  experience  more  than 
one  attack,  many  months  or  even  years  may  not  see  the  end.  And  yet  the 
prognosis  quoad  visum  is  generally  good,  and  particularly  is  this  so  when  the 
uveal  tract  is  not  seriously  involved.  In  many  cases  the  cornea  clear-  up 
almost  perfectly,  though  an  examination  with  oblique  illumination  and  cor- 
neal loup  will  reveal  some  faint  streaks  of  opacity  ;  indeed,  years  after  an 
attack  of  interstitial  keratitis  minute  vessel-channels,  nearly  straight,  branch- 
ing at  acute  angles  and  short  bends,  may  be  detected  in  the  cornea.  These  are 
best  studied  with  the  ophthalmoscope,  after  dilating  the  pupil,  through  a  strong 
convex  glass  (+  16  D.)  (Fig.  213).  The  process  of  resolution  always  begins 
at  the  periphery  of  the  cornea. 

Treatment. — The  disease  is  essentially  self-limited,  and  we  can  do  but- 
little  to  shorten  its  course.     Yet  we  are  not  without  resource  for  the  allevia- 


Fig.  213. — Vessel-formation  in  the  cornea  after  interstitial  keratitis  (Hirschberg). 

tion  of  it-  uncomfortable  symptoms  and  measures  to  encourage  a  favorable 
issue  of  the  disease.  As  resolution  takes  place  through  vascularization,  means 
which  increase  this  are  in  order,  and  chief  among  them  are  hot  applications. 
The  eye  should  be  bathed  in  water  as  hot  as  can  be  borne  for  five  minutes 
every  four  hours.  This  also  assists  in  relieving  any  pain  that  may  be  present. 
Atropin,  1  per  cent,  solution,  dropped  in  the  eye  three  time-  a  day  i-  ben- 
eficial, not  only  for  the  corneal  affection,  bul  also  for  the  iritis  which  may  be 
present.  When  the  long-continued  use  of  atropin  sets  up  a  papillary  inflam- 
mation of  the  conjunctiva — which  it  may  do  on  very  ran casions — hyoscya- 

min,  scopolamin,  or  daturin  may  be  substituted  for  it.  Being  a  diathetic  dis- 
ease, general  treatment  is  all-important,  especially  iron,  arsenic,  and  cod-liver 
oil.     Tonics  and  good  nourishment  are  called  for  in  cases  of  debility,  while 

21 


322  DISEASES  OF  THE  CORNEA    AND  SCLERA. 

rheumatism  and  gout  and  tuberculosis  require  their  appropriate  treatment. 
In  those  cases  where  hereditary  syphilis  is  evident  or  suspected,  specific  treat- 
ment is  demanded,  bul  nol  of  a  vigorous  kind.  The  simplest  form  of  admin- 
istration is  bichlorid  <>t'  mercury  gr.  ,;'(l  and  iodid  of  potassium  gr.  ij,  after 
each  meal.  These  remedies  are  well  borne  for  many  months.  Inunctions 
of  mercury  arc  not  usually  called  for  except  in  very  severe  and  well-pro- 
nounced cases.  In  the  practice  of  some  surgeons  they  constitute  the  basis  of 
treatment  in  the  majority  of  ease-.  The  patient  should  be  encouraged  to  go 
out  of  doors  as  much  as  possible,  protecting  the  eyes  with  blue  or  gray  glasses. 
Recently  subconjunctival  injection-  of  bichlorid  of  mercury  have  been  advo- 
cated quite  strongly  in  certain  quarters,  a-  have  tho.se  of  normal  salt  solution, 
u>vd  in  the  same  manner.  The  severe  pain  which  has  been  found  to  accom- 
pany their  employment  is  a  great  bar  to  their  general  use. 

Results  of  Corneal  Inflammation. — Opacities  <>/  flu  Cornea. — The 
outcome  of  an  inflammation  of  the  cornea  as  regards  its  restitutio  ad  integrum 
of  transparency  depend-  largely  upon  whether  it  is  of  the  destructive  form  or 
not.  A  pannus  or  interstitial  keratitis  can  continue  for  months  or  even 
year-,  ami  yet  the  cornea  clear  tip  almost  perfectly,  provided  there  has  been 
no  loss  of  substance  replaced  by  cicatricial  tissue.  But  even  in  the  inter- 
stitial form  there  can  be  an  organization  of  the  effused  material,  taking  on  the 
character  of  connective  tissue,  which  does  not  become  transparent.  Indeed, 
in  the  most  favorable  cases  there  arc  always  line  streaks  of  opacity  to  he  dis- 
covered by  oblique  illumination  and  the  magnifier  (see  page  146). 

Where  there  has  been  any  considerable  loss  of  tissue  the  rule  is  for  an 
opacity  to  remain,  the  cicatricial  material  which  replaces  the  lost  corneal 
tissue  never  becoming  transparent.  The  presence  or  activity  of  the  corneal 
epithelium  seems  to  exercise  a  favorable  influence  on  the  reproduction  of  the 
clear  corneal  substance.  The  clearing  up  of  the  opacity  proceeds  from  the 
periphery   toward   the  center. 

Opacities  have  always  been  classified,  according  to  their  intensities,  into 
nebula  or  in<<cnl<< ,  the  slighter  forms,  and  leukomata,  the  denser  forms.  When 
after  a  perforation  of  the  cornea  there  is  prolapse  of  the  iris,  with  adhesion  to 
the  wound,  we  have  the  condition  known  as  adherent  leukoma. 

The  amount  of  damage  to  perfect  vision  caused  by  an  opacity  depends 
largely  upon  it-  situation,  and  to  some  extent  upon  its  density.  A  small, 
sharply-defined,  dense  opacity  over  the  pupil,  however,  will  disturb  vision 
less  than  a  thinner  one.  which  allows  a  greater  amount  of  light  to  go  through, 
hut  diffuses  it  more. 

The  course  and  final  condition  of  a  corneal  opacity  depend  largely  upon 
the  age  of  the  patient  and  the  depth  of  the  destructive  process.  In  young 
people  the  chance-  of  a  clearing  up  are  much  better  than  ill  elderly  ones,  and 
the  smaller  and  more  superficial  the  nicer  the  greater  the  probability  of  an 
ultimate  clarification. 

Treatment. — The  treatment  of  corneal  opacities  is  directed  to  an  as-i-t- 
ance  in  the  absorption  of  the  effused  material.  This  requires  usually  some 
mean-  which  increases  temporarily  the  vascularization  of  the  part  and  stimu- 
lates the  absorbents,  [nsuffiation  of  finely-powdered  calomel  once  a  day  i-  an 
old  remedy.  Another  form  of  mercury  much  used  i-  the  yellow  amorphous 
oxid,  gr.  j  ad  -j  of  cosmolin — " Pagenstecher,8  ointment"  -a  -mall  hit  to 
he  rubbed  under  the  lid-  once  a  day  or  every  other  day  (massage  of  tlf 
cornea).  Turpentine  oil  moderated  with  sweet  oil  has  been  used  for  the 
same  purpose.  In  fact,  everything  which  increases  the  blood-supply  of  the 
conjunctiva  has  been  used,  and  with  some  -how  of  success.      The  value  ol 


CHANGES  IX   THE  FORM   OF   THE  CORNEA. 


323 


the  constant  current  of  electricity  applied  to  the  cornea  for  this  purpose  has 
doubtless  it-  basis  in  the  same  quality. 

The  attempt  to  remove  opacities  by  operation  is  of  course  futile,  since 
the  removed  tissue  will  be  replaced  by  cicatricial  tissue,  excepl  in  those  cases 
where  the  trouble  is  limited  to  the  epithelial  layer,  as  where  there  are  deposits 
of  lime,  lead,  etc.,  and  in  some  eases  of  superficial  pannus. 

For  cases  of  total  leukoma  of  the  cornea  or  large  central  opacities  covering 
th.'  pupil,  with  no  room  tor  an  artificial  pupil  at  the  periphery,  transplanta- 
tion of  a  portion  <>J  the  cornea  of  rabbits  or  other  animals  was  first  suggested 
by  Reissinger  in  1824,  and  revived  by  von  Hippel  in  187(i.  It  cannot  lie 
said,  however,  that  any  brilliant  permanent  success  has  followed  the  attempts 
made  thus  far. 

In  case  of  leukoma  adherens  it  may  be  necessary  to  loosen  the  iris  from 
its  adhesion  to  the  cicatrix  for  optical  purposes,  or  to  free  the  eye  from  a 
source  of  constant  irritation.  An  iridectomy  is  often  called  for  when  the 
opacity  covers  the  pupil,  even  when  there  is  no  incarceration  of  the  iris,  for 
optical   purposes. 

In  permanent  opacity  the  disfiguring  appearance  can  be  much  mitigated 
by  the  process  of  tattooing  the  white  spot  with  India  ink. 

Changes  in  the  Form  of  the  Cornea. — While  inflammations  of  the 
cornea  may  subside  without  any  change  in  the  form  of  the  cornea,  even  when 
a  considerable  opacity  remains,  in  a  large  number  of  cases,  and  especially  in 
those  where  there  has  been  a  considerable  loss  of  tissue  or  even  long-continued 
infiltration,  the  original  shape  is  seldom  retained,  and  sometimes  the  change 
is  enormous.  This  alteration  may  be  in  the  manner  of  flattening — or  of 
bulging — staphyloma. 

(1)  Flattening  of  the  cornea  most  frequently  follows  upon  total  destruction 
or  large  losses  of  the  corneal  tissue,  and  especially  in  those  cases  where  the 
uveal  tract  has  been  involved  and  the  nutrition  of  the  eye  interfered  with, 
accompanied  by  reduced  tension  of  the  eyeball.  The  iris  is  found  in  such 
cases  plastered  against  the  posterior  wall  of  the  remnant  of  the  cornea, 
some  portion  of  which  may  still  be  transparent.  The  flattening  may  be  of 
any  grade,  from  that  discernible  only  by  means  of  the  ophthalmometer  to 
that  associated  with  a  more  or  less  complete  atrophy  of  the  eyeball. 

(2)  Bulging  of  the  Cornea. — Staphyloma  has  various  qualifying  terms, 
denoting  special  characteristics.  It  may  be  partial  or  complete,  conical, 
globose,  or  racemose,  the  latter  name  sig- 
nifying a  number  of  small  protrusions 
linked  together  around  the  periphery  of 
the  cornea.  A  general  enlargement  of 
the  eyeball  (hydrophthalmos)  (Fig.  214) 
i-  very  often  associated  with  these  condi- 
tion- and  always  indicates  the  participa- 
tion of  the  iris  and  choroid  in  the  inflam- 
matory process.  The  iris  may  be  attached 
to  it  cither  partially,  as  in  adherent  leu- 
koma, or  completely,  as  in  some  forms 
of  keratoglobus. 

All    staphylomata    indicate    an    in- 
creased ten-ion  of  the  eyeball  at  some  tim 
is  by  no  means  uniform.     Its  wails  may 
times  the  apex  undergoes  ulceration  or  degeneration  of  the  calcareous  or  col- 
loid form  ;  and  it  is  always  liable  to  attacks  of  inflammation. 


214.— Hydrophthalmos  after  ophthal- 
mia ne<  inatorum  :  •  ■.  cornea  ;  "  ».  op)  i< 
(From  a  patient  in  the  Children's  H 
Washington,  i 


The  structure  of  a  staphyloma 
be  thin  or  very  thick,  and   some- 


324  DISEASES  OF  THE  CORNEA    AND  SCLERA. 

Treatment. — The  therapeutics  of  staphylomata  is  preventive' and  surgical. 

The  former  is  applicable  only  during  its  stage  of  formation,  when  a 
pressure  bandage  should  he  applied  tosupporl  the  weak  tissue.  Paracentesis, 
sometimes  repeated,  by  lessening  the  intraocular  tension,  removes  an  important 
factor  in  its  production.      Eserin  can  be  used  for  the  same  end. 

When  a  staphyloma  has  become  so  large  as  to  be  unsightly,  or  is  a  source 
of  annoyance  or  pain,  surgical  interference  of  some  kind  is  the  only  remedy  : 
enucleation  of  the  eye,  abscission  of  the  staphyloma,  or  evisceration. 

Enucleation  should  be  avoided  when  possible  in  children,  among  whom 
staphyloma  so  frequently  occurs  as  a  consequence  of  conjunctivitis  neona- 
torum. The  presence  of  the  eyeball  seems  to  be  necessary  to  the  proper 
development  of  the  orbit,  and  an  artificial  eye  is  difficult  to  adapt  to  very 
voung  children.  In  cases  of  excessive  hydrophthalmos  the  operation  of 
evisceration  finds  its  best  held  of  application.  Evisceration,  with  the  intro- 
duction of  a  glass  ball  within  the  sclera  (Mules's  operation),  gives  an  excellent 
support  for  an  artificial  eye  (see  page  072). 

(3)  Oystoid  Cicatrix. — The  condition  of  union  between  the  tissues  at  the 
scleral  border  in  some  cases  of  adherent  leukoma  can  be  such  as  to  form  a 
circumscribed  cystic  elevation  the  walls  of  which  may  give  way  at  times,  dis- 
charging the  contents  of  the  aqueous  chamber — the  so-called  cystoideieatrixj  or 
the  opening  may  not  close  at  all,  constituting  a  fistula,  through  which  the  aque- 
ous humor  constantly  leaks,  sometimes  under  the  conjunctiva,  causing  a  chemosis 
•pallida.     Similar  phenomena  may  arise  after  the  operation  of  iridectomy. 

These  conditions  are  usually  very  rebellious  to  treatment,  which  is  for  the 
most  part  surgical,  consisting  in  cauterization,  the  formation  of  conjunctival 
Haps  over  the  parts,  or  cutting  away  a  part  of  the  walls  of  the  cyst  and  pro- 
curing a  firm  adhesion  between  the  edges  of  the  wound.  An  iridectomy 
sometimes  helps  much. 

i  1)  Astigmatism. — The  changes  in  the  form  of  the  cornea  arc  commonly  so 
irregular  (irregtdar  adigmatism) that  it  is  not  possible  to  correct  the  optical 
defect  by  any  form  of  lens  in  such  manner  as  to  improve  vision  materially. 
Changes  are  occasionally  so  regular,  however,  as  to  allow  this  to  he  done,  and 
here  the  ophthalmometer  becomes  a  valuable  aid  in  diagnosis.  With  the  sug- 
gestion afforded  by  this  examination  it  is  often  possible  to  double  or  treble  the 
visual  acuteness  (see  a  bo  page  231). 

When  the  intraocular  pressure  is  reduced  to  any  considerable  degree  the 
cornea  feels  the  diminished  tension,  and  manifests  it  by  an  altered  curvature, 
sometimes  in  the  nature  of  wrinkling.  This  is  very  apparent  in  many  forms 
of  atrophy.  In  cyclitis  associated  with  reduced  eye-tension  it  is  nearly  always 
demonstrable  by  the  ophthalmometer,  or  Placido's  disk.  Fig.  215  gives  the 
corneal  reflection  of  Placido's  disk  in  such  a  case.  The  cornea  resumed  its 
normal  shape  when   the  tension  was  restored. 

Sclerosing  Keratitis. — A  special  form  of  corneal  opacity  i-  associated 
with  long-continued  scleritis  and  irido-choroiditis. 

It  begins  in  the  former  case  a-  a  triangular  bit  of  bluish-white  tint,  with 
it-  base  on  the  sclera,  it-  apes  toward  the  center  of  the  cornea.  The  change 
b  interstitial,  the  epithelium  seldom  undergoing  any  alteration.  When  fol- 
lowing Ion- -eon  tin  i  led  inflammation  of  the  uveal  tract,  with  depressed  nutrition 
of  the  eyes,  the  opacity  sometimes  extend-  a-  a  band  wholly  or  partially 
around  the  corneal  circumference,  as  shown  in  Fig.  216,  taken  from  a  case 
under  the  author's  own  observation.     Baumgartner  and    Berlin   have  found 

thai    the  corneal   tissue  has   underg i  fatty  and   hyalin  degeneration  with 

what  appears  to  be  in  some  instances  adenoid  tissue. 


STRIPED   KEBA  TITIS. 


325 


Treatment  is  of  no  avail,  though  the  galvano-cautery  applied  to  the  base 
of  the  lesion  has  been  recommended. 


Pig.  215.— Wrinkling  of  the  cornea  ; 

reflection  of  Placido's  disk. 


Fig.  216.— Sclerosing  keratitis  in  both  eyes  from  irido- 
choroidil  is  (aul  hor's  i 


Ribbon-shaped  Keratitis  {Primary  Transverse  Opacity  of  Cornea; 
Zonular  Opacity;  Keratitis  Bandelette). — This  is  a  rare  form  of  corneal 
opacity,  not  due  to  an  inflammation  of  the  cornea  itself,  but  associated  with 
or  following  some  kind  of  ocular  malnutrition,  caused  by  irido-choroiditis, 
glaucoma,  or  a  gouty  tendency. 

The  lesion  is  situated  directly  in  the  palpebral  aperture,  where  the  cornea 
is  most  exposed,  and  consists  of  finely  punctiform  opacities  under  the  epithe- 


Fig.  217.— Keratitis  bandelette  (after  von  Graefe). 

Hum  of  the  cornea.  It  begins  sometimes  on  one  side,  sometimes  on  the  other, 
leaving  a  small  area  of  clear  tissue  at  the  periphery,  and  progresses  steadily 
toward  the  pupil,  over  which  the  two  bands  usually  meet  in  time  I  Fig.  217). 
Some  cases  have  been  observed  in  which  it  began  in  the  center.  Both  cornese 
are  liable  to  be  affected  in  time.  It  occurs  mostly  in  men.  After  the  epithe- 
lium is  removed  the  deposit  can  be  flaked  off, 
leaving,  as  a  rule,  clear  cornea  beneath.  The 
deposit  is  either  the  phosphate  or  carbonate  of 
lime,  its  removal  in  this  manner  is  the  only 
treatment.  Airopin  should  be  avoided  in  such 
eyes,  on   account  of  their  tendency  to  glaucoma. 

Striped  Keratitis. — A  peculiar  form  of 
opacity  of  the  cornea  is  sometimes  noticed  after 
cataract  extraction,  but  has  been  observed  also 
after  other  forms  of  injury  or  inflammal  ion  of  the 
cornea.  It  consists  of  fine,  straighl  stripes  .',  to 
1  iniii.  in  width,  focussing  toward  the  scat  of  in- 
jury. The  intervening  corneal  tissue  may  be 
comparatively  clear,  in  which  case  the  Lines  will 
appear  as  grayish  .-tripe-  againsl  the  darker  back- 
ground of  the  iris  (  Fig.  218).  There  may  be  two  or  more  set*  of  lin 
ing  each  other,  making  a  sorl  of  panel  figure  (Fig.  219). 

They  were  once  thought  to  be  dilated  by  lymph-chann  r,  Eteck- 


Fig.  218.— Striped  keratitis 
and  hypopyon  (afti  i  Schin 


326 


DISEASES  OF  THE  CORNEA    AND  SCLERA. 


linghausen)  or  infiltration  of  the  large  nerve-canals  (Alt).  They  are  caused, 
however,  by  a  folding  of  the  membrane  of  Descemetj  due  to  a  shrinking  of 
the  corneal  ti->ue  in  cicatrization  or  its  unequal  swelling  in  infiltration  (Mull, 
Bess,  Schirmer)  (Fig.  220).     They  usually  disappear,  but  traces  of  them  may 


Fig.  219.— Panel-like  opacities  of 
the  cornea  (after  Schirmer). 


Fig.  220.— Section  of  the  cornea  showing  the  folds  of  the 
membrane  of  Descemet  in  panel-like  opacity  of  the  cornea 
(after  Schii  mi 


remain  in  the  form  of  geometrical  figures  (Fridenberg).  The  folding  of 
Bowman's  membrane  may  give  the  same  appearance. 

Corneal  Opacities  due  to  Metallic  Deposits. — The  salts  of  lead 
coming  in  contact  with  the  albumin  of  the  cornea  denuded  of  its  epithelium 
are  sublimated  in  the  form  of  an  opaque  albuminate.  Such  deposits  were  of 
much  more  frequent  occurrence  when  lead  lotion-  were  used  more  commonly 
than  now  in  corneal  ulcers.  The  epithelium  usually  forms  over  it.  The 
deposit  can  be  scraped  off  alter  the  epithelium  is  removed,  leaving  usually  a 
moderately  clear  cornea  beneath. 

Nitrate  of  silver  also  leaves  a  stain  when  applied  to  the  substantia  propria 
for  :i  long  while.  A  brilliant  metallic  luster  has  also  been  observed  in 
opacities  of  the  cornea  the  results  of  injuries. 

Arcus  Senilis. — An  arc  of  opacity  1  to  1.5  mm.  in  width  is  very  com- 
monly seen  at  the  base  of  the  cornea  in  old  people.  It  may  entirely  circle 
the  cornea.  There  i-  usually  a  narrow  strip  of  clear  cornea  between  it  and  the 
sclera.  It  i-  sometimes  met  with  in  comparatively  young  persons.  In  the 
negro  race  it  is  usually  very  pronounced.  It  is  a  colloid  degeneration  of  the 
superficial  layers  of  the  cornea.  When  incised  it  heals  as  readily  ;i>  normal 
corneal  tissue. 

Transient  Corneal  Opacities. — Sudden  and  severe  pressure  on  the 
eonxa  causes  a  derangement  of  its  fibers  which  impair-  its  transparency. 
This  is  observed  in  severe  blows  directly  on  the  cornea  and  in  acute  attacks 
of  glaucoma.     This  disappears  in  a  short  time  when  the  pressure  is  relieved. 

Rampoldi  (1881)  has  described  a  temporary  form  of  opacity  due  to  infil- 
tration of  i/k  corneal  tissue  with  lymph.  It  occurs  in  anemic  persons  or  those 
affected  with  lymphatism.  It  may  extend  to  the  anterior  chamber,  forming 
hypopyon,  <>r  into  Tenon'-  capsule.  It  may  be  called  up  or  increased  by  a 
dependent   position  of  the  head. 

Cocain  causes  a  dryness  and  opacity  of  the  epithelium,  and  even  its 
detachment  from  Bowman's  membrane,  when  applied  too  long  with  exposure 
of  the  cornea  to  air.  The  corneal  epithelium  in  old  glaucoma  is  nearly 
always  dull  and   irregular. 

Blood-staining  of  the  Cornea. — A  number  of  cases  have  been 
observed  after  traumatism  in  which  the  cornea  has  been  infiltrated  with  blood; 
it  is  of  a  chocolate  or  greenish-brown  color  at  the  central  part-,  passing  off 
into  ;i  reddish  tinge  at  the  periphery.  The  appearances  closely  resemble  those 
of  an  amber-colored   lens  dislocated  into  the  anterior  chamber.     The  hema- 


NON-INFLAMMATORY  CHANGES  TN  FORM  OF  CORNEA.    327 


toidin  deposited  in  the  substantia  propria,  which  gives  this  color,  i-  absorbed 
very  slowly,  at  least  two  years  elapsing  before  its  entire  disappearance. 

Keratitis  Nodosa. — When  the  poisonous  spines  of  certain  caterpillars 
gel  into  the  eye,  they  set  up  an  inflammation  which  is  peculiar  in  thai  it 
is  in  the  Conn  of  nodules  which  very  much  resemble  tubercles.  While 
more  commonly  found  in  the  conjunctiva,  the  nodules  occur  also  in  the 
cornea,  and  pass  sometimes  into  the  iris.  They  never  break  down  and 
discharge,  but  in  time  disappear  by  absorption  (see  also  page  296). 

No  attempt  should  be  made  to  excise  the  node-  from  the  cornea.  They 
should   be  treated  as  secondary   keratitis  with   heat  and  atropin. 

Keratitis  Punctata  (A quo-capsulitis,  Desce,metitis). — Small  whitish  de- 
posits are  observed  on  the  posterior  surface  of  the  cornea  in  that  form 
of  iritis  known  as  serous  iritis,  and  have  been  considered  by  some  authors  as  a 
form  of  iritis  or  irido-cyclitis.  As  the  anterior  surface  of  the  iris  and  the 
posterior  surface  of  the  cornea  are  lined  by  a  continuous  layer  of  endothelial 
cells,  converting,  in  fact,  the  anterior  chamber  into  a  closed  or  serous  sac, 
there  i-  some  ground  tor  this  view  ;  and  in  these  cases,  almost  without  excep- 
tion, both  cornea  and  iris  are  involved,  sometimes,  however,  one  more  than 
the  other.  In  some  instances  there  is  a  marked  plastic  iritis  accompanying 
or  following  the  appearance  of  the  dots  in  the  cornea.  Though  the  dot-  are 
usually  arranged  in  a  pyramidal  shape,  base  down,  they  are  often  irregularly 
placed  (Fig.  221).  The  deposits  vary  in  size  from  a  millimeter  or  so  in  diam- 
eter to  a  microscopic  point.  They  consist  of  inflammatory  exudate  with  a  quan- 
tity of  endothelial  cells  (Fig.  222).  Snellen,  Jr.,  is  reported  to  have  found  a 
microbe  in  the  deposits,  but  this  observation  has  not  been  confirmed  by  others. 
The  exudate  is  sometimes  found  in  the  iris  angle  and  in  the  choroid.     Oblique 

illumination  and  a  magnifier  are  often 
necessary  to  determine  its  presence  in 
the  cornea.     A  general  haziness  of  the 


Fig.  --1.— Descemetitis  or  keratitis  punctata. 


Fig.  222.— Deposit  on  the  posterior  surface  of 
tlie  cornea  in  punctate  keratitis:  '».  endothelial 
cells ;  '•,  cornea  ;  <t .  Descemet's  membrane;  p,  de- 
posit of  round-cells  (after  Fuchs  . 


cornea  or  a  limited  part  of  it  i-  manifest  on  illumination  of  the  fundus  with 
the  ophthalmoscope.  Usually  then'  i»  no  pain,  the  pupil  i-  commonly  some- 
what dilated, and  the  intraocular  tension  slightly  increased.  Vision  i-  usually 
much  impaired. 

Treatment. — A.tropin  must  be  avoided  unless  there  i<  an  active  plastic 
iritis.  The  progress  of  the  disease  is  usually  very  -low.  months  sometimes 
being  required  for  the  disappearance  of  the  deposits.  Mild  doses  of  bichlorid 
of  mercury,  continued  for  a  long  while,  seem  to  be  followed  by  better  results 
than  any  other  therapeutics. 

Non-inflammatory   Changes  in  the   Form   of  the   Cornea.— 

Changes  in  the  form  of  tin'  cornea  from  the  normal — which   i-   really  il 
a  triaxial  ellipsoid,  but  not  very  markedly  departing  from  that  of  fl  sphen — 
are  known  a-  astigmatism.     Those  changes  which  influi  nci   the  optical  prop- 
erties of  the  eye    thai    can    be    neutralized    are    treated  of  in  the   chapter 


::•_•> 


DISEASES  OF   THE  CORNEA   A  X  h  SCLERA. 


These  forms  usually  are  congenital,  and   ren 


nehaim-ed 


on  Refraction, 
during  life. 

There  arc  other  forms,  however,  which  appear  to  be  acquired,  though 
not  associated  with  any  inflammatory  affection.  They  are  usually  classed 
under  the  general  heading  of  Keratoconus  or  Conical  Cornea,  from  the  fact 
that  they  always  assume  a  form  approximating  that  of  a  cone.  The  cone, 
however,  is  generally  quite  irregular.  One  case  has  fallen  under  the  author's 
observation  in  which  the  curve  of  the  vertical  meridian  was  such  that  in  the 
tipper  part  of  the  pupil  there  was  myopic  astigmatism,  and  in  the  lower  half 
hyperopic  astigmatism.  The  apex  of  the  cone  is  not  always  in  the  center  of 
the  cornea. 

Except  in  a  few  cases,  perhaps,  keratoconus  is  not  congenital,  hut  begins 
to  develop  usually  about  the  seventh  or  eighth  year,  though  often  later,  reach- 
ing its  climax  not  long  after  the  establishment  of  puberty.  Women  are  more 
often  affected  than  men.  The  appearance  of  a  well-marked  case  is  shown  in 
Fig.  223. 

When  less  pronounced  the  abnormal  curve  cannot  be  detected  by  simple 
inspection,  but  is  easily  made  manifest  by  the  keratoscope  (Placido's  disk,  see 
page  145).  This  is  held  in  front  of  the  eye  or  attached  to  the  ophthalmom- 
eter of  Javal,  and  its  reflection  on  the  cornea  at  its  different  parts  observed. 
Instead  of  being  approximately  circular  at  the  center,  as  it  should  be  in  the 
normal  cornea,  it  has  some  modification  of  the  appearances  shown  in  Fig.  224. 

Illumination  of  the  fundus,  as  in  examination  by  the  "shadow  test," 
shows,     instead    of    a     uniform 

reddish    tint    of    the    pupillary  .-""" 

area,  a  dark  spot,  usually   ores-  wV'v 

centic  in  form,  in  the  red  area,  V'hl 

which  changes  with  each   move-  N$ 

ment   of  the   mirror  or  eye. 

The  gradual  change  of  form 


Pig.  223. 


Keratoconus. 
case. 


Pig    224     Keratoscopic  appearance  of  keratoconus 
Pronounced           (Placido's  disk  of  rings),    [rregularly  oval  at  apex  of  cor- 
nea  ;  draw it  into  pointed  arches  at  tin-  periphery. 

of  the  cornea  is  due  to  :i  weakening  of  the  corneal  tissue  and  an  increase  of 
the  intraocular  pressure.  The  determining  cause  is  not  known.  Vision  is 
much  reduced,  and,  since  both  eyes  are  nearly  always  affected,  though  often 
in  varying  degree,  these  patients  are  always  "  near-sighted,"  though  not  neces- 
sarily myopic,  having  to  hold  all  object-  close  in  order  to  obtain  large  retinal 
images. 

Treatment. — Tn  many  cases  vision  can  be  much  improved  by  glasses,  a 
certain  amounl  of  regular  astigmatism  being  found  by  the  ophthalmometer. 
The  light  coming  through  the  sides  of  the  cone  i-  that  generally  used,  and 
therefore,  as  m  rule,  pin-  cj  linders  arc  preferred.  Raehlmann  devised  parab- 
olic glasses  to  correspond  to  the  corneal  curve,  but  they  have  not  been  found 
of  much  practical  use. 

Surgical   treatment   in  the  way  of  flattening  the  cornea  by  the  knife  or  a 


DISEASES  OF  THE  SCLERA. 


329 


trephine,  or  burning  it  away  with  caustics,  promises  better.  The  stenopaic 
slit  is  often  of  benefit  in  obtaining  better  outlines  of  objects,  bul  the  dint 
inution  of  field  and  illumination  arc  its  drawbacks. 

Morbid  Growths  on  the  Cornea. — Of  benign  growths,  fibroma  |  Fig. 
225)  is  the  one  most  commonly  found  on  the  cornea.  It  may  come  on  inde- 
pendently or  it  may  develop  <>n  cicatricial  tissue  the  result  of  a  previous 
ulceration.  There  is  a  tendency  to  return  alter  removal.  Papilloma  may 
also  find  its  habitat  here. 

Malignant  growths  are  usually,  perhaps  always,  of  the  epithelial  variety, 
at  least  at  the  beginning,  and  are  commonly  secondary  to  similar  growths  on 
the  conjunctiva  or  sclera.  A  t'vw  cases  of  sarcoma  appearing  primarily  on 
the  cornea  itself  have  been  reported.      Leprosy  may  attack   the  cornea. 

Congenital  Defects  of  the  Cornea. — The  most  common  of  these 
are   dermoid  tumor*  of  various   kinds   (Fig.  226).     Usually  they  are  seated 


•^ 


\^jM 


Fig.  225.— Fibroma  of  the  cornea  (after 
Falchi). 


Fig.  226.— Dermoid  of  the  limbus— colored  woman  aged 
twenty-one  years  (from  the  author's  clinic). 


on  the  corneo-scleral  margin,  and  are  sometimes  associated  with  some  other 
malformation  of  the  eye,  generally  coloboma  of  the  lid. 

Congenital  opacities  are  not  common,  but  a  number  of  cases  have  been 
recorded.  They  may  be  due  to  intra-uterine  inflammation  or  to  arrest  of 
development  :  in  the  latter  ease  the  two  eyes  are  apt  to  be  affected  in  approx- 
imately the  same  manner.  Congenital  staphyloma  has  been  described.  It 
may  be  associated   with  a  dermoid  growth. 

Microphthalmos  is  that  condition  in  which  the  entire  eye  remains  in  a 
rudimentary  state,  and  in  which  the  cornea   is   reduced   in  all  it-  diameters. 

Megalophthalmos  (see  Buphthalmos,  p.  385). 

Sclerophthalmia  is  that  condition  in  which,  owing  to  an  imperfect  differ- 
entiation of  the  sclera  and  cornea,  the  former  encroaches  on  the  latter,  so  that 
only  the  central  part  of  the  cornea  remains  clear.  Sometimes  only  the  upper 
half  of  the  cornea   is  affected. 


DISEASES   OF  THE   SCLERA. 

Episcleritis. — The  most  common  form  of  scleral  inflammation  i-  that 
known  as  episcleritis,  in  which  the  subconjunctival  tissue  and  superficial 
layers  of  the  sclera  are  conjointly  affected. 

Symptoms. —  Episcleritis  manifests  itself  as  an  ill-defined  spol  of  infiltra- 
tion with  an  elevation  of  1  to  1.5  mm.  [ts  seal  of  election  is  from  2  to  »i  mm. 
distance  from  the  corneal  edge  and  to  the  outer  side,  [ts  color  is  nol  of  a  pure 
deep  red,  but  rather  of  a  bluish  or  violet  hue  ;  it  i-  not  movable  on  the  ball  and 
i-  more  or  less  sensitive  to  touch.  The  conjunctival  vessels  leading  up 
are  congested,  bu1  the  remaining  part  of  the  scleral  surface  is  usually  < 
Then   are  in  mosl  cases  considerable  photophobia  and  lachryraation.      I  lie 


330  DISEASES  OF  THE  CORNEA   AND  SCLERA. 

disease  is  tedious  in  its  course,  sometimes  running  for  several  weeks,  and  is 
subject   to  recurrences,  and  it  may  be  at  different  localities  on  the  ball. 

A  rheumatic  or  gouty  diathesis  usually  lies  at  the  bottom  of  it,  bul  it 
also  occurs  from  exposure  and  with  scrofula   and   menstrual  disorders. 

Treatment. — General  treatment  must  be  along  these  etiological  lines. 
Large  doses  of  salicylate  of  sodium  often  have  a  good  effect  on  the  pain 
and  shorten  the  course  of  the  disease;  in  some  cases  pilocarpin  sweats  are 
beneficial.  Subconjunctival  injections  of  bichlorid  of  mercury  or  physiolog- 
ical salt  solution  have  been  u<vi\  with  good  effect.  Scarification  of  the  tissue 
has  also  been  recommended.  Heat  is  the  best  local  remedy,  and  may  be 
used  in  the  form  of  hot  bathing  or  the  Japanese  hot  box.  As  iritis  has  been 
known  to  develop  during  its  course,  atropin  should  he  \[>cd  at  the  height  of 
the  disease  ;  hut  if  there  is  no  iritis,  pilocarpin  or eserin  locally  (gr.  rV- jrr.  '  i, 
combined  with  cocain,  is  most  useful.     Galvanism  has  been  recommended. 

Transitory  Episcleral  Congestion. — This  is  the  name  given  to  a 
rather  sudden  and  sometimes  intense  hyperemia  of  the  sclera  and  overlying 
conjunctiva,   lasting  from  a   few   hours  to  a  day  or  two. 

Fuchs  (1895)  calls  it  episcleritis  partialis  fugax.  The  author  has  called  it 
a  vasomotor  dilatation  of  tht  vessels  (1892).  The  "hot-eye"  of  Hutchinson  is 
probably  of  the  same  nature.  The  affection  is  liable  to  recur  for  years,  and  is 
not  attended  with  danger  to  vision.  It  is  usually  painful  and  accompanied 
by  photophobia  and  lachrymation.      Exceptionally  it  occurs  in  children. 

Heat  for  the  relief  of  pain  i-  called  for,  and  the  careful  employment  of 
cocain  may  be  of  use.     Any  dyscrasic  condition,  especially  rheumatism  and 

gOUt,  must  he  attended  to. 

Deep  Scleritis. —  Inflammation  of  the  sclera  as  a  whole  is  very  uncom- 
mon independently  of  a  panophthalmitis.  lint  the  deeper  layer-  of  the  sclera 
can  become  inflamed,  though  this  i>  seldom  the  case,  except  in  connection  with 
inflammation  of  the  underlying  uveal  tract.  A  very  common  instance  of  deep 
scleritis  is  what  is  known  a-  sclerotico-choroiditis  posterior,  nearly  always 
found  in  high  grades  of  myopia  (  posterior  staphyloma)  (see  page  221 ).  The 
inflammation  affects  the  anterior  part  less  commonly,  when  it  is  known  as 
anil  rior  scleritis. 

The  disease  nearly  always  begins  in  the  uveal  tract,  and  the  sclera,  be- 
coming  soft,  yield-  to  the  intraocular  pressure  and  bulges,  causing  a  ciliary 
staphyloma  which  may  he  equatorial.  There  may  he  more  than  one  staphy- 
loma, and  they  may  invade  the  edge  of  the  cornea.  They  are  l>lui>h  in  color 
from  the  pigmenl  showing  through  the  thin  scleral  tissue.  There  are  con- 
siderable congestion,  lachrymation.  and  photophobia,  the  intensity  of  the 
symptoms  depending  upon  the  amount  of  ciliary  or  iritic  involvement. 

In  a  less  intense  form  the  disease  may  he  chronic  and  last  for  years,  with 
recurrences.  Rheumatism,  gout,  and  syphilis  (gummatous  scleritis)  arc  to  be 
counted  a-  it-  causes,  and  its  general  treatment  must  he  directed  to  the  cor- 
rection of  the  demonstrated  or  suspected  dyscrasia.  Locally,  heat,  atropin, 
and.  when    the    staphyl a    i<   thin.  :i    pressure    bandage,  arc    indicated. 

Tumors  of  the  sclera  generall)  are  extensions  from  the  neighboring 
conjunctiva  or  cornea.  The  benign  one-  are  fibromas  enchondromas,  and 
the  malignant   one-  are  epitheliomas  or  sarcomas. 

Melanosis  of  the  sclera  i-  usually  congenital,  and  these  dark  spots 
are  common  in  the  negro  race.     Melanosis  may  occur  in  Addison's  disease. 

Abscess  of  the  sclera  has  been  observed.  It  is  usually  the  result  of 
injury,  and  seldom  idiopathic.  One  or  two  cases  of  osseous  degeneration  of 
the  sclera  have  been   reported. 


DISEASES  OF  THE  IRIS,  CILIARY  BODY,  AND  CHO- 
ROID; SYMPATHETIC  INFLAMMATION  AND  IRRI- 
TATION. 

By  ROBERT   L.   RANDOLPH,   M.  D., 

OF    BALTIMORE.   MI>. 


DISEASES   OF   THE  IRIS. 


Congenital  Anomalies  of  the  Iris. — Heterophthalmos  is  the  con- 
dition where  the  irides  differ  in  color.  One  iris  may  be  brown  and  the  other 
bine.  These  differences  in  color  may  exist  in  the  same  iris,  so  that  one  part 
will  have  a  distinctly  different  nuance  from  its  immediate  surroundings.  The 
pupillary  margin  of  the  iris  may  he  quite  different  in  shade  from  its  peripheral 
portions.  Minute  areas  differing  in  color  are  not  infrequently  seen,  and 
sometimes  these  areas  assume  the  form  of  elevations  upon  the  surface  of  the 
iris,     i  Sec  also  page  147.) 

Persistent  pupillary  membrane  is  the  remains  of  the  membrane  which 
occupied  the  pupillary  Held  during  fetal  life,  and,  according  to  Manz,  is  part 
of  a  layer  of  tissue  of  the  head-mesoderm  containing  vessels  and  surrounding 
the  secondary  ocular  vesicle  ;  this  layer  becomes  differentiated  into  a  posterior 
portion,  the  choroid,  and  an  anterior  portion,  the  membrana  pupillaris  ( see  also 
page  2-">).  What  is  seen  of  this  membrane  consists  only  of  a  number  of  line 
(usually  pigmented)  threads,  anastomosing  with  one  another  and  arising  from 
the  anterior  surface  of  the  iris  ami  near  the  free  border  of  the  latter;  in  other 
words,  from  the  circulus  iridis  minor.  The  threads  are  never  present  in  any 
considerable  number,  for  rarely  more  than  ten  or  twelve,  and  usually  less,  arc 
seen.  These  threads  after  converging  pass  across  the  posterior  chamber  and 
come  to  a  point  on  the  anterior  capsule  of  the  lens,  this  point  being  frequently 


Fig.  227.— Persisting  pupillary  membrane  :  1,  pupil  contracted  ;  2,  pupil  dilated   Wicker! 


marked  by  a  pigment  speck,  or  they  may  reach  the  anterior  capsule  at  different 
points,  h  is  seldom  thai  the  threads  spring  from  all  sides  of  the  pupil,  but 
usually  from  one  or  two  points.     They  do  not  invariably  pass  across  to  the 


DISEASES  OF  THE  litis. 

lens  capsule,  bui  after  running  <>ut   for  quite  a  distance  into  the  pupillary 
field  they  return  to  the  iris  to  be   inserted   near  their  poinl  of  origin. 

A  persistenl  pupillary  membrane  is  nol  infrequently  confounded  with  the 
synechia  which  remain  after  an  iritis,  but  the  oblique  illumination  will  reveal 
the  true  nature  of  the  affection.  Moreover,  the  pupil  dilates  symmetrically  to 
its  full  extent  in  the  former  condition,  while  in  the  latter  case  irregularities 
may  be  seen  in  the  contour  of  the  pupil  I  Fig.  227). 

According  to  Fuchs,  persistenl  pupillary  membrane  is  of  comparatively 
frequenl  occurrence  in  the  new-born.  Jacob  and  others1  have  succeeded  in 
injecting  these  threads  soon  after  birth,  thus  showing  that  the  threads  are 
vessels.  As  is  well  known,  these  threads  undergo  atrophy  and  are  obliterated 
in  the  ordinary  course  of  events.     This  affection  is  not  often  seen  in  both  eyes. 

The  disturbance  in  vision  is  slight,  depending  upon  the  number  of  threads 
and  the  extent  to  which  the  anterior  capsule  is  involved.  The  condition 
practically  never  demands  operation,  though  von  Graefe  resorted  to  opera- 
tion   where  the   vision    was    x^u. 

Coloboma  of  the  Iris. — This  is  one  of  the  most  frequenl  malformations 
met  with  in  the  eye.  It  consists  of  an  oval-shaped  fissure  or  gap  in  the  iris, 
which  has  the  effect  of  prolonging-  the  pupil  in  a  direction  usually  down- 
ward and  a  little  inward.  A  complete  coloboma  is  where  the  fissure  separates 
the  iris  in  its  entire  breadth,  and  an  in<-<mi]>/<f<  coloboma  is  one  where  the 
cleft  stops  short  of  the  ciliary  border  of  the  iris.  The  coloboma  is  usually 
smaller  at  its  ciliary  end,  though  the  reverse  of  this  has  been  observed  quite 
often,  in  such  cases  the  borders  being  almost  parallel  instead  of  convergent. 
There  is  often  seen  just  within  the  pupillary  end  of  the  fissure  a  slight  con- 
striction which  gives  to  the  pupil  and  coloboma  together  the  appearance  of  a 
keyhole.  Sometimes  the  pupillary  ends  of  the  fissure  are  bridged  over  by  a 
.slender  membrane  or  a  thread,  forming  what  lias  been  described  as  the  bridge- 
coloboma.  In  those  cases  where  a  thread  has  been  formed  the  latter  is  sup- 
posed to  be  the  remains  of  a  pupillary  membrane. 

Coloboma  is  generally  bilateral,  though  .Man/,  is  of  the  opinion  that  the 
affection  i-  more  frequently  monolateral.  In  the  latter  variety  the  other  eye 
often  exhibits  peculiarities,  either  in  the  color  of  the  iris  or  in  the  shape  of 
the   pupil. 

The  congenital  coloboma  is  distinguished  from  the  artificial  coloboma  by 
the  presence  in  the  former  of  the  sphincter,  while  in  the  latter,  i. e.  in  an 
artificial  coloboma  fas  after  an  iridectomy),  the  sphincter  has  been  excised 
along  the  margin  of  the  coloboma. 

(  oloboma  of  the  iris  is  due  to  incomplete  closure  of  the  ocular  fissure  I  page 
22),  and  along  with  this  condition  coloboma  of  the  choroid  often  exists,  and 
Bometimes  the  fissure  is  seen  in  the  ciliary  body  and  lens,  and  even  in  the  optic 
nerve  ami  macular  region.  It  is  not  infrequently  associated  with  microph- 
thalmos and  catarad  (either  congenital  or  acquired),  and  other  fissures  which 
usually  close  in  fetal  life  may  be  seen  to  have  persisted,  forming  harelip  and 
coloboma   of  the    lid-. 

The  direction  of  the  iris-coloboma  i-  usually  downward  and  inward,  but 
exceptions  to  this  rule  have  been  observed  ;  lor  example,  the  coloboma  may 
be  up  and  in,  up  ami  out,  inward,  outward,  or  downward.  The  accompany- 
ing illustration  i-  from  a  photograph  (Fig.  228)  of  one  of  the  very  few  cases 
reported  where  the  coloboma  was  directed  upward.  The  ease  was  firsi  put  on 
record  aeveral  years  ago  by  Theobald." 

1    \fed.-Chirurg.  Trans.,  I  ondon,  vol.  \ii.  p.  515. 
-  Tran      I    ■     Ophthal.  Soc,  vol.  v.  p.  99. 


IRIDEBEMIA,    OR   ANIRIDIA, 


333 


The  possible  explanation  of  the  unusual  locations  for  the  coloboma  is 
that   the  ocular  vesicle  made  a  quarter  or  half  a  revolution  about   its  long 

axis. 

N<>  satisfactory  explanation  has  been  offered  for  the  failure  of  the  ocular 
fissure  to  close.  Some  regard  it  as  simply  an  instance  of  retarded  develop- 
ment,  while   others   think    that    inflammation    musl    have    played    a    part    in 


Fig.  226.—- Coloboma  of  the  iris  with  the  coloboma  directed  upward. 


producing  the  defect.     The  role  played  by  heredity  in  this  affection  is  cer- 
tainly worthy  of  consideration. 

Irideremia,  or  Aniridia. — This  is  a  condition  in  which  the  iris  is  either 
completely  absent  or  in  which  only  one  or  more  segments  remain.  \\  hen  the 
irideremia  is  complete,  it  is  possible  to  see  the  entire  lens,  which  is  often  so 
exposed  that  even  when  cataract  is  present  there  is  good  sight,  there  being 
space  enough  between  the  edge  of  the  lens  and  the  ciliary  processes  for 
the  li<rht  to  pass  through.  When  the  irideremia  is  incomplete  there  is  an 
absence  of  the  iris  at  certain  points,  so  that  only  a  segment  remains  here  and 
there.  The  narrow  rim  of  iris  which  is  sometimes  seen  just  behind  the 
corneo-scleral    junction   all    the   way  around    is   not    incomplete    irideremia. 

.Myopia,  hyperopia,  astigmatism,  and  amblyopia  are  often  present  in 
irideremia;  also  a  cloudy  cornea.  Cataracl  is  not  infrequently  found  asso- 
ciated with  it,  generally  in  the  form  of  the  anterior  or  posterior  polar 
cataract,  which  in  these  cases  is  usually  congenital.  It  should  be  said,  how- 
ever, that  eyes  affected  with  irideremia  are  peculiarly  prone  to  cataract,  so 
that  this  last-named  condition   may  make  its  appearance  any  time  after  birth. 

Irideremia  is  almost  always  a  binocular  affection.  A.s  regards  its  etiology, 
heredity  undoubtedly  plays  an  important  role.  The  affection  is  clearly  one 
oi   retarded  development. 

Under  this  head  should  be  mentioned  those  cases  where  there  i-  a  narrow 
rim  of  iris  springing  out   all   the  way  around   in  front  of  the   perinher 
the  lens.     This  condition  is  one  -tep  removed   from   irideremia,  and  is  really 
an  instance  of  rudimentary  development  qj  th  iris. 


334  DISEASES  OF  Till-:  litis. 

The  wearing  of  dark  glasses  in  irideremia  sometimes  gives  great  relict', 
or  spectacles  with  a  stenopaic  -lit. 

Ectopia  Pupillae  (Eccentric  Position  of  the  1'n/ii/ ;  Corectopia). — The 
normal  situation  of  the  pupil  is  not  exactly  in  the  center  of  the  iris,  hut 
a  little  below  and  to  the  inner  side  of  the  center.  Sometimes  the  pupil 
i-  found  eccentrically  located.  It  may  he  near  the  normal  site,  and  amain 
it  may  he  remote  from  this  situation,  as.  for  instance,  near  the  ciliary  border. 
Such  a  pupil  is  long-oval  in  shape,  rarely,  if  ever,  round.  The  most  usual 
location   is  downward  and   inward,  though  it  has  been  observed  upward. 

We  are  completely  in  the  dark-  as  to  the  origin  of  ectopia.  Sonic  authors 
believe  that  the  condition  is  closely  allied  in  its  origin  to  coloboma  of  the  iris, 
and  give  as  a  reason  that  the  misplacement  is  nearly  always  at  the  most  fre- 
quent location  for  coloboma.  Others  hold  the  opinion  that  ectopia  pupil  laa  is 
due  to  a  lack  of  development  of  the  muscular  elements  of  the  iris  at  a  certain 
point,  with  possibly  an  excessive  development  of  the  same  elements  at  a 
point   opposite,  the  effect   being  to  pull   over  the  pupil  to  the  stronger  side. 

A    not    infrequent   complication   of  ectopia  pupilhe   is  a  dislocated   lens. 

Dyscoria  [Faulty  Pupil). — This  is  a  condition  in  which  the  pupil  is 
faulty  or  irregular  in  shape,  and  is  usually  brought  about  by  the  presence 
of  little  excrescences  on  the  margin  of  the  pupil.  These  excrescences  may 
attain  such  a  size  as  even  to  meet  at  different  points  in  the  pupillary  field, 
leaving  only  here  and  there  small  openings — a  condition  called  corestenoma 
congenitum  (Von  Amnion),  also  polycoria.  The  condition  is  not  infrequently 
seen  in  horses.      The  nature  of  these  excrescences  is  not  known. 

Motor  Disturbances  of  the  Iris. — The  movements  of  the  iris  con- 
sist in  dilatation  and  contraction  of  the  pupil,  and  a  motor  disturbance  of 
the  iris  means  an  affection  which  is  characterized  by  some  alteration  in  the 
>ize   of  the    pupil. 

Mydriasis  and.  Myosis. — An  alteration  in  the  size  of  the  pupil  may 
show  itself  in  either  persistent  dilatation  (mydriasis)  or  contraction  (myosis) 

of  the  pupil,  or  in  a  c lition  in  which  the  pupil  is  incessantly  dilating  and 

contracting  (see  also  page  1  !!•). 

Hippus. — This  condition  is  one  which  is  characterized  by  constant  dilata- 
tion and  contraction  of  the  pupil.  It  is  really  a  clonic  spasm  of  the  sphincter 
pupillae  (sec  also  page  lol  ). 

Iridodonesis  (iris  tremulans)  is  a  tremulous  movement  of  the  iris  when- 
ever the  eyeball  is  moved,  and  is  due  to  loss  of,  or  defective  support  of, 
the  iris.  The  condition  is  often  -ecu  after  cataract  extraction,  especially 
the  simple  extraction.  It  is  observed  in  cases  of  fluid  vitreous  where 
trophic  changes  have  taken  place  in  the  lens  and  the  latter  has  become 
smaller  ;  in  congenital  cataract  where  the  lens  has  undergone  calcareous 
degeneration  and  shrinkage;  and.  finally,  in  luxation  of  the  lens.  Although 
not  :i  functional  motor  disturbance  of  the  iris,  iridodonesis  is  conveniently 
referred    to   in   this   place. 

Hyperemia  of  the  Iris. — Hyperemia  of  the  iris  is  characterized  by  a 
change  in  the  color  of  the  iris,  which  assumes  a  yellowish-red  shade,  so  that 
a  blue  or  gray  iris  appears  greenish,  and  ;i  brown  iris  will  have  in  it  a  sugges- 
tion of  red.  In  dark  eye-,  however,  this  discoloration  is  not  so  marked  as 
it  i-  in  eyes  of  the  hlond  type.  As  a  rule,  this  symptom  is  more  noticeable 
in  cases  of  hyperemia  than  in  conditions  of  marked  iritis,  where  the  iris  is 
the  seal  of  structural  changes,  and  where  the  aqueous  humor  is  filled  with 
the  product-- of  the  inflammation.  De  Wecker  remarks  upon  the  frequency 
with  which  a  similar  discoloration  of  the  iris  occurs  in  severe  subconjunctival 


miTIS.  335 

hemorrhages,  and  he  thinks  that  in  such  cases  it  is  due  to  the  lad  that  either 
the  iris  or  the  aqueous  humor  has  become  infiltrated  with  the  soluble  coloring 
matter  in  the  blood. 

In  cases  of  chronic  hyperemia  there  is  a  discoloration  of  the  iris  due  to 
changes  in  the  pigment-cells,  and  a  complete  disappearance  of  the  pigmenl  at 
the  pupillary  border,  which  becomes  ragged  and  notched.  These  changes 
are  only  seen  after  the  hyperemia  has  existed  for  a  long  time.  The  same 
appearance  of  the  iris  is  seen  in  very  old  people  without  coincident  hyperemia, 
and  is  attributable  to  senile  changes  in  the  iris. 

In  hyperemia  of  the  iris  the  pupil  no  longer  reacts  as  it  docs  nor- 
mally, but  remains  more  or  less  contracted  ;  and  this  sluggishness  of  the 
pupil  is  even  noticeable  when  atropin  is  used,  several  instillations  of  the 
mydriatic  being  required  to  secure  full  dilatation.  One  of  the  first  symptoms 
of  hyperemia  of  the  iris  is  the  pericorneal  congestion,  which  is  of  the  charac- 
ter peculiar  to  affections  of  the  uvea  and  cornea,  and  consists  of  a  number  of 
very  tine  vessels  situated  in  the  episcleral  tissue  and  running  out  in  straight 
lines  from  the  corneal  margin,  forming,  as  it  were,  a  sort  of  fringe  to  the  latter 
structure. 

Etiology. — Hyperemia  of  the  iris  often  leads  to  inflammation  of  the  iris  ; 
indeed,  it  might  be  said  that  every  iritis  is  preceded  by  a  stage  of  hyperemia. 
The  cause  of  hyperemia,  then,  may  be  sought  for  in  anything  which  will  pro- 
duce an  iritis.  Inflammation  in  structures  anatomically  connected  with  the 
iris  may  bring  about  hyperemia  in  the  latter;  for  instance,  keratitis,  partic- 
ularly the  phlyctenular  form.  A  foreign  body  on  the  cornea  or  the  effect 
upon  the  cornea  of  a  caustic  agent  will  produce  very  quickly  hyperemia  of 
the  iris.  Inflammations  of  the  choroid  and  ciliary  body  are  fruitful  sources 
of  this  phenomenon,  and  the  same  may  be  said  of  affections  of  the  sclera  ; 
for  instance,  episcleritis. 

Treatment. — Rest,  dark  glasses,  and  the  instillation  of  atropin.  An 
investigation  into  the  cause  of  the  hyperemia  will  suggest  the  proper  general 
treatment. 

Iritis  (Inflammation  of  the  Iris). — The  two  most  frequent  causes  of  iritis 
are  probably  syphilis  and  rheumatism,  and  yet  there  is  no  constant  and  dis- 
tinctive symptom  by  which  we  can  infallibly  recognize  which  diathesis  is 
present.  Symptoms  which  one  author  regards  as  characteristic  of  syphilitic 
iritis  are  mentioned  by  another  as  belonging  also  to  rheumatic  iritis,  and  rice 
versa.  If  all  cases  of  iritis  of  syphilitic  origin  presented  the  characteristic 
formation  of  nodules,  it  would  be  reason  enough  for  making  syphilitic  iritis 
one  grand  division  of  the  subject  ;  but,  in  spite  of  the  fact  that  by  far  the 
majority  of  cases  of  iritis  are  (\ur  to  syphilis,  the  appearance  of  nodules 
(macroscopically)    is   the  exception    rather  than    the   rule. 

Iritis  of  rheumatic  origin  is  supposed  by  some  authors  to  be  peculiar  in 
its  great  tendency  to  recurrence,  but  it  is  doubtful  whether  iritis  of  this  type 
possesses  greater  liability  to  recur  than  the  syphilitic  form.  Exception  mighl 
be  made  of  those  cases  of  iritis  -ecu  with  arthritis  deformans,  especially  in 
young  persons.  In  such  cases  the  prognosis  is  bad.  owing  to  the  persistency 
of  the  constitutional  affection,  [ritisof  syphilitic  origin  is  constantly  encoun- 
tered where  recurrent  attacks  have  been  making  their  appearance  fin- year-. 
In  both  syphilis  and  rheumatism  iritis  will  be  apt  to  reappear  so  long  .- 
the  constitutional  disease  is  present,  [nasmuch,  then,  as  it  confuses  the  sub- 
ject   to  treat    it   from   a  diathetic   point  of  view,  tl Id   divisions  of  irit 

plastic,   serous,   and    parenchymatous — although    by     no    mean-    free    from 
objections,  will  be  followed. 


336  DISEASES  OF  THE  IBIS. 

Objective  Symptoms. —  The  disease  in  general  is  characterized  by  all 
the  symptoms  which  have  been  described  in  connection  with  hyperemia  of  the 
iris,  excepl  thai  these  symptoms  now  arc  more  intense  and  are  associated  with 
an  exudate.  This  exudate  may  be  thrown  out  from  the  posterior  surface  of 
the  iris  and  into  the  posterior  chamber,  causing  adhesions  between  the  anterior 
surface  of  the  lens  capsule  and  the  posterior  surface  of  the  iris  {posterior 
synechia).  Sometimes,  though  no!  often,  there  is  complete  adhesion  of  the 
posterior  surface  of  the  iris  to  the  anterior  surface  of  the  lens — a  condition 
known  as  total  posterior  synechia. 

The  exudate  on  the  posterior  surface  of  the  iris  is  found  in  the  pigmentary 
layer,  and  the  region  where  the  synechia'  are  most  apt  to  occur  is  about  the 
pupil,  for  here  the  iris  is  in  contact  with  the  lens-capsule.  The  exudate  may 
be  found  also  on  the  anterior  surface  of  the  iris,  and  it  may  be  thrown  out 
into  the  aqueous  humor,  and.  dropping  to  the  bottom  of  the  anterior  chamber, 
form  a  hypopyon  '  .•  or  it  may  be  found  in  the  cornea  in  the  shape  of  small 
points  situated  in  the  membrane  of  Descemet  (so-called  keratitis  punctata,  see 
page  327).  Sometime-  the  exudate  is  poured  out  into  the  pupillary  Held,  in 
which  case  it  usually  proceeds  from  the  anterior  surface  of  the  iris.  In  such 
cases  the  iris  reflex  is  lost.  Finally,  the  exudate  occurs  in  the  substance 
proper  of  the  iris,  and  shows  itself  by  swelling  of  the  iris,  which  is  often 
thrown  into  folds. 

It  may  be  stated  broadly  that  when  the  exudate  is  mostly  confined  to  the 
region  about  the  pupil  we  are  dealing  with  plastic  iritis;  that  when  the 
exudate  is  found  in  the  anterior  chamber  and  upon  the  posterior  surface  of 
the  cornea  we  are  dealing  with  serous  iritis;  and,  finally,  that  when  the  iris  is 
Bwollen  and  thrown  into  folds  we  have  before  us  the  parenchymatous  variety 
of  the  disease. 

According  to  1  '<■  Wecker,  neither  the  plastic  nor  the  serous  form  of  iritis 
is  apt  !<>  leave  lasting  changes  in  the  iris,  while  in  parenchymatous  iritisthere 
is  more  or  less  obliteration  of  vessels  and  disappearance  of  pigment. 

Iritis  Simplex  or  Plastic  Iritis. —  Pericorneal  congestion  is  always  pres- 
ent in  this  form  of  iritis,  and  its  varying  intensity  offers  good  evidence 
of  the  grade  of  the  disease.  In  very  lighl  cases  of  plastic  iritis  the  peri- 
corneal congestion  may  be  so  insignificant  as  easily  to  be  overlooked,  while  at 
other  times  it  may  -how  itself  in  chemosis,  though  this  is  rare  even  in  the 
most  intense  inflammations  of  the  iris.  The  cornea  does  not  participate, 
thougl superficial  glance  this  does  not  seem  to  be  the  case.  Oblique  illu- 
mination, however,  will  -how  that  what  at  first  sight  seems  to  be  a  dulness  of 
the  cornea  is  nothing  more  than  a  loss  of  the  iris  reflex,  due  to  the  exudate 
upon  the  anterior  Burfaceof  the  iris  and  to  the  slightly  cloudy  aqueous  humor. 
A  cloudy  aqueous  humor  is  nol  a  noticeable  feature  in  this  variety  of  iritis, 
while  it   i-  a  condition  <|iiite  characteristic  of  serous  iritis. 

The  pupil  i-  contracted  and  sluggish,  and  shows  no  response  to  the  usual 

tests.     This  ■• lition  of  the  pupil  often   persists  in  spite  of  the  use  of  a 

mydriatic,  and  frequent  instillations  will  be  necessary  to  gel  the  same  dilata- 
tion which  ordinarily  can  be  obtained  by  one  instillation.  The  explanation 
of  this  must  be  SOIlghl  for  nol  only  in  the  ciliary  irritation,  and  in  the  dimin- 
ished activity  of  the  dilator  fibers  caused  by  their  infiltration  with  inflamma- 
tory products,  l»ut  al-o  in  the  necessary  loss  of  activity  in  a  tissue  which  is 
inflamed  and  swollen  ;  and,  finally,  in  the  presence  of  the  exudates  which  hind 
the  border  of  the  pupil  to  the  anterior  capsule  of  the  lens.     These  exudates 

1  Sometimes  :i  gelatin  like  mass  is  deposited  in  the  anterior  chamber,  which,  when  ii  con 
solidatec   n  -■  ml. I.-  a  dislocated  lens.     I  hi-  i-  the  so-called  spongy  ii  • 


TBITIS.  337 

may  be  seen  by  oblique  illumination.     Several   instillation-  of  atropin   will 
bring  out  strikingly  the  deformities  in  the  pupil ;  those  parts  of  the  pupil 

which  are  not  adherent  will  respond  to  the  mydriatic,  while  the  point-  which 
are  bound  down  to  the  lens  will  remain  fixed. 

Sometimes  the  entire  pupillary  margin  is  adherent  to  the  capsule  of  the 
lens — a  condition  known  as  seclusion  of  (he  pupil.  This  kind  of  synechia  is 
not  usually  the  resull  of  one  attack  of  iritis,  bul  is  found  as  a  sequel  of  sev- 
eral recurrent  attacks.  At  other  times  the  pupillary  field  is  completely  filled 
with  a  mass  of  exudate,  producing  the  condition  known  as  <,<-<-hisi<>,t  of  tin 
pupil.  It'  the  adhesions  are  slight,  they  can  he  broken  loose  by  the  action 
of  atropin.  and  when  this  is  done  small  pigment-specks  may  lie  seen  on  the 
surface  of  the  lens,   marking  the  points  where  the  iris   was  adherent. 

Serous  Iritis. —  Instead  of  a  plastic  exudate,  there  may  he  an  exudate, 
serous  in  character,  containing  solid  elements,  which  are  always  to  some 
extent  deposited  upon  the  posterior  surface  of  the  cornea.  There  seem-  to  We 
an  increased  secretion  of  the  aqueous  humor,  and  the  latter  is  quite  cloudy. 
The  deposits  upon  the  membrane  of  Descemet  are  sometimes  very  tine,  and 
are  to  be  seen  as  small  whitish  or  yellowish-white  dots  which  can  be  brought 
out  by  oblique  illumination  or  by  examination  with  a  strong  convex  lens  (see 
Fig.  221).  These  deposits  are  sometimes  found  on  the  anterior  capsule  of  the 
lens.  Synechia  are  not  as  prominent  symptoms  in  the  earlier  stages  of  this 
variety  of  iritis  as  they  are  in  the  plastic  form,  although  they  appear  ulti- 
mately and  contribute  very  materially  to  the  grave  prognosis. 

Atropin,  therefore,  will  not  disclose  irregularities  in  the  contour  of  the 
pupil  to  the  same  extent  as  in  plastic  iritis,  and  frequently  the  pupil  is  sym- 
metrically dilated,  though  never  ad  maximum.  The  pericorneal  congestion  is 
usually  slight.  The  tension,  as  a  rule,  is  elevated,  due,  no  doubt,  to  the 
hypersecretion  going  on  within  the  eye.  The  pupil  by  its  dilatation  shows 
the  effect  of  this  increased  tension. 

It  is  more  than  probable  that  in  serous  iritis  the  entrance  to  Schlemm's 
canal  is  blocked  with  exudate — a  condition  which  of  itself  would  be  apt  to 
bring  about  glaucomatous  symptoms.  As  a  rule,  hypopyon  is  absent  in  serous 
iritis.  Opacities  in  the  vitreous  body  are  very  common,  and  degeneration  of 
this  part  of  the  eye  usually  follows  sooner  or  later.  Ultimately,  the  inflam- 
mation affects  the  whole  eye. 

Parenchymatous  Iritis. —  In  this  form  of  iritis  the  inflammation  attacks 
the  iris  tissue  itself.  Instead  of  an  exudate  on  the  anterior  or  posterior 
surface  of  the  iris,  the  exudate  is  found  within  the  iris.  The  swelling, 
which  is  always  present,  is  often  circumscribed,  and  produces  an  impression 
as  though  there  were  nodules  within  the  iris.  The  masses  of  exudate  are 
pigmented,  and  are  found  around  the  pupillary  margin,  often  binding  the  iris  to 
the  anterior  capsule  of  the  lens.  Sometimes  these  exudate-  find  their  way  into 
the  anterior  chamber,  and,  settling  ;it  the  bottom  of  the  latter,  form  hypo- 
pyon ;  at  other  time-  they  are  thrown  out  into  the  posterior  chamber.  Even 
the  pupil  is  sometime-  tilled  with  these  yellowish  masses.  The  appearance 
of  the  iris  is  dull,  and  pericorneal  congestion  i-  usually  intense.  There  "Inn 
may  be  seen  the  formation  of  little  yellowish-red  nodules  traversed  by 
blood-vessels,  practically  what  is  observed  in  the  so-called  syphilitic  iritis, 
and  designated  iritis  papulosa  (Fuchs)  when  occurring  in  the  secondary  st 
of  syphilis \  iritis  gummosa,  in  the  tertiary  stage. 

A  typical  parenchymatous  iritis  may  be  produced  in  rabbit-  by  injecting 
a  drop  of  a  suspension  of  the  staphylococcus  aureus  into  the  anterior  chan 
the  inflammation  being  attended  with  the  formation  of  -mall  elevation-  on 

■ 

22 


DISEASES  OF  THE  THIS. 

the  iris  and  nodular  masses  al  the  pupillary  border,  not  unlike  the  appear- 
ances visible  in  the  same  disease  in   man. 

In  parenchymatous  iritis  there  is  often  present  a  pupillary  membrane 
which  stretches  over  the  entire  pupillary  area.  Sometimes  a  purulent  infil- 
tration of  the  iris  (purulent  iritis)  occurs,  with  a  deposit  of  leukocytes  in 
the  .interior  chamber.  Parenchymatous  iritis,  so  long  as  it  confines  itself  to 
the  iris,  may  leave  the  eye  unimpaired  in  its  functions. 

De    Wecker  calls  attention  to  the   peculiar   nature  of  the  hypopyon   in 

these  cases.     It   differs  fr the  hypopyon   seen    in   keratitis,   because  it  is 

much  thinner  and  changes  it-  position  with  every  movement  of  the  head, 
ami  is  remarkable  for  the  rapidity  with  which  it  undergoes  absorption,  fre- 
quently disappearing  in  the  course  of  ;i   few  hours. 

Subjective  Symptoms  of  Iritis. — While  iritis  may  exist  without  pain 
(as  is  often  the  case  in  the  serous  form),  as  a  rule  this  is  a  prominent 
symptom.  The  pain  is  not  referred  so  much  to  the  eyeball  as  to  the  temples 
ami  forehead  and  the  neighboring  regions  supplied  by  branches  of  the  fifth 
jciir.  and  is  of  a  boring  character  and  apt  to  be  more  intense  at  night.  The 
pain  is  not  only  the  result  of  pressure  upon  the  ciliary  nerves  by  the  products 
(«t*  the  inflammation,  hut  also  the  result  of  an  actual  involvement  of  these 
nervesin  the  inflammatory  process.  Pain,  however,  is  no  absolutely  reliable 
index  of  the  grade  of  an  iritis.  Plastic  iritis,  as  a  rule,  is  characterized  by 
more  pain  than  the  parenchymatous  i'<  mi.  yet  one  would  he  disposed  to 
expeel  the  opposite.  Fournier,1  among  others,  has  called  attention  to  the 
fact  thai  parenchymatous  iritis,  in  spite  of  the  extensive  anatomical  changes 
present,   is  often  associated   with  little  or  no  pain. 

Lachrymation  and  photophobia  vary  with  the  ciliary  neuralgia.  Visual 
disturbance  is  always  present,  and  varies  in  degree  with  the  clouding  of  the 
aqueous  humor  and  with  the  extent  to  which  the  pupillary  area  is  occupied 
with  exudates.  In  serous  iritis  the  disturbance  in  vision  may  he  explained 
by  changes  in  the  vitreous  body  and  choroid,  and  even  in  the  optic  nerve. 
Finally,  such  constitutional  symptoms  as  fever  and  nausea  have  been  occa- 
sionally observed,  and  a  coated  tongue  i>  a   frequenl   accompaniment. 

Etiology. — The  causes  which  give  rise  to  iritis  are  local  and  constitutional. 
Anion-  the  firsl  <d:i —  are  foreign  bodies  in  the  cornea,  which  have  remained 
there  tor  ;i  considerable  length  of  time;  the  careless  and  continued  use  of 
caustic  agents;  penetrating  wounds  of  the  eyeball;  and  swollen  masses  of 
lens-matter.  [ritis  may  arise  from  an  inflammation  of  the  cornea,  sclera, 
ciliary  body,  or  choroid,  in  which  cases  iritis  extends  hv  continuity  of  tissue. 
Finally,  iritis  may  arise  from  trouble  in  the  other  ey< — sympathetic  oph- 
thalmitis. 

Among  the  diatheses  which  give  rise  to  iritis,  syphilis  stands  easily  first. 
Indeed,  nearly  75  per  cent,  of  all  cases  of  iritis  can  probably  be  traced  to 
this  source.  The  iriti-  i-  generally  of  the  plastic  variety,  although  the 
parenchymatous  form  maj  occur.  It  -how-  it-elf  generally  in  the  secondary 
stage  of  syphilis,  and  when  the  parenchymatous  form  of  the  disease  prevails 
there  are  often  seen  small  nodules  either  at  the  margin  of  the  pupil  or  at  the 
ciliary  border  of  the  iris,  and  :it  these  points  there  are  usually  synechia?. 
W  hen  the  nodules  disappear  there  may  remain  in  the  iris  atrophic  areas.    While 

the  presence  of  these  lules  probably  justifies  the  surgeon  in  diagnosticating 

the  case  as  one  of  syphilitic  iriti-.  it  should  !><■  rein,  inhered  that  in  the  majority 
<>f  cases  of  iriti-.  where  a  syphilitic  origin  1-  clearly  demonstrable,  apparent!) 
no  nodule-  .hv  present.    The  nodules  ma)  attain  quite  :i  large  size,  and  several 

Dee  Affections  oculaires  d'origini   typhilitique,"  Journal  d'Ophtal.  de  Paris,  pp.  195  543 


i  inns.  339 

of  them  may  fill  the  anterior  chamber,  and,  Increasing  in  size,  may  burst 
through  the  envelopes  of  the  eye.  This  termination  is  rare.  Hereditary 
syphilis  seldom  gives  rise  to  iritis,  and  when  it  does  the  subjects  are  usually 
young  people,  just  as  is  the  case  with   interstitial   keratitis. 

Rheumatism  (articular)  is  another  not  infrequent  cause  of  iritis.  Two 
such  cases  the  writer  has  in  mind — one,  a  boy  fourteen  years  old,  who  has 
not  walked  for  four  years,  and  who  is  completely  disabled  from  articular 
rheumatism  ;  the  other,  a  young  woman  nineteen  years  of  age,  who  has  been 
confined  to  her  bed  tor  eight  years.  The  girl  has  only  light  perception,  her 
pupils  being-  entirely  bound  down  by  adhesions,  while  in  the  case  of  the  boy 
there  is  seclusion  of  the  pupil  in  one  eye,  and  the  other  eye  possesses  only 
sufficient  sight  to  allow  him  to  see  large  objects.  Both  these  patient-  have 
had  skilful  treatment,  which  has  availed  but  little,  owing  to  the  intensity  of 
the  constitutional  affection. 

It  is  doubtful  whether  the  rheumatic  diathesis  gives  rise  to  distinctive 
ocular  symptoms,  though  some  authors  speak  of  the  peculiarity  of  the  epis- 
cleral and  pericorneal  congestion.  As  might  be  inferred,  rheumatism  of  the 
character  seen  in  the  two  cases  just  mentioned,  when  associated  with  iritis, 
would  probably  be  the  occasion  of  recur  re  tit  attacks  of  the  eye-affection. 
In  this  connection  it  should  be   said  that  gout  often  gives  rise  to  iritis. 

Gonorrhea  sometimes  causes  iritis.  In  such  a  case  no  doubt  there  is  a 
general  infection,  although  it  is  not  at  all  probable  that  the  gonococcus  gets 
into  the  intraocular  circulation,  but  its  toxins  reach  the  eye  and  there  give 
rise  to  iritis.  Inflammation  of  the  knee-joint  commonly  precedes  the  eye- 
affection.  When  iritis  is  found  as  a  result  of  gonorrhea,  it  shows  a  tendency 
to  recur,  and  is  frequently  associated  with  a  renewal  of  the  pains  and  swell- 
ing in   the  joint. 

Scrofula  (scrofulous  iritis)  sometimes,  but  rarely,  gives  rise  to  iritis,  and, 
as  is  the  case  with  hereditary  syphilis,  the  subjects  are  young  persons. 
According  to  Fuchs,  iritis  in  these  eases  is  marked  by  the  appearance  of 
lardaceous-looking  deposits  or  exudates,  which  seem  to  grow  out  from  the 
sinus  of  the  chamber.  Anemia  may  be  associated  with  an  iritis  of  this 
character. 

Relapsing  fever  (iritis  in  acute  infectious  diseases),  typhus  and  typhoid, 
small-pox,  (■ir<il>i,o-sj)iit<t/  meningitis,  pyemia,  and  even  <j>i<lnnic  influenza 
(grippe),  have  been  known  to  cause  iritis.  Inflammation  of  the  iris  in 
relapsing  fever  is  very  tedious  in  its  course.  Iritis  is  occasionally  caused 
by  malaria  ( periodic  iritis)  and  by  irregularities  of  menstruation  (iritis 
catamenalis). 

hintx hs  (diabetic  iritis)  is  another  very  rare  cause  of  iritis.      In   spite  oi 
the  fact  that  hypopyon  is  often   observed   in   this  variety  of  iritis,  the  course 
of  the  disease   is   usually    favorable. 

Tuberculosis  in  other  organs  may  give  rise  to  iritis  (tuberculous  iritis), 
although  such  an  origin  is  not  often  seen.  Tuberculosis  shows  itself  in  the 
iris  either  in  the  form  of  grayish-red  nodules  or  as  a  solitary  tubercle 
resembling  a  ueoplasm.  Children  are  usually  the  subjects.  While  it  is  a 
very  rare  affection,  its  nature  is  well  understood,  for  Cohnheim  has  produced 
the  disease  experimentally  in  rabbits  by  introducing  small  pieces  of  tuber- 
culous material  into  the  anterior  chamber.  The  immediate  effect  "I  this 
operation  i-  apparently  negative,  but  within  a  month  iritis  sets  in  and  the 
characteristic  gray  nodules  appear.  These  increase  in  number  till  they  fill 
up  the  anterior  chamber,  when  (unless  the  animal  die-)  they  may  break 
through  the  coat-  of  the  eye.     This  i-  the  disseminated  form  of  the  affection. 


340  DISEASES  OF  THE  IBIS. 

The  little  nodules  arc  usually  located  at  the  pupillary  margin.  In  man  the 
disease  is  generally  followed  by  a  plastic  irido-cyclitis  and  loss  of  the  rye. 

Tuberculosis  of  the  iris  also  occur-  as  a  solitary  tubercle.  This  tubercle 
more  often  appears  alone,  though  it  may  exist  along  with  the  nodules. 
When  alone  the  symptoms  of  iritis  can  be  absent — that  is,  for  a  certain 
period  of  its  history — although  iritis  ultimately  appears.  It  was  regarded 
by  von  Graefe  at  first  a-  a  tumor,  and  described  as  such  under  the  name 
of  granuloma.     Baab  firs!   dei istrated   its  true  nature. 

The  disseminated  form  may  occur  in  both  eyes,  hut  the  solitary  form  has 
only  been  observed   in  one  eye.      In   both  varieties  the  eye  is  usually  lost. 

Mention  may  lie  made  here  of  what  has  been  called  recurrent  iritis,  where 
tin-  patient  for  month-  may  he  free  of  the  disease  and  suddenly  an  outbreak 
will  occur.  Both  eyes  are  usually  affected,  hut  rarely  at  the  same  time. 
Synechia  are  frequently  left  after  an  attack,  and  it  has  been  thought  that 
their  presence  determined  subsequent  attacks,  hut  it  i>  more  than  probable 
that  some  persistent  constitutional  affection  (generally  syphilis)  is  responsible 
for  the  recurrences.  It  ha-  been  observed  that  men  more  often  than  women 
are  the  subjects  of  this  variety  of  iritis. 

Traumatism  is  responsible  tor  a  number  of  eases  of  iritis.  The  injury 
may  be  accidental,  or  may  he  inflicted  during  the  course  of  an  operation,  or 
occur  as  the  re-ult  of  an  operation — e.g.  after  discission  of  the  lens. 

No  time  of  life  seems  exempt  from  iritis,  although  it  is  exceptionally  seen 
in  children  under  ten  year-  of  age,  and  it  is  not  often  met  with  after  the 
seventieth  year.  According  to  von  Amnion  and  von  Arlt,  iritis  is  more 
frequent  in  men  than   in   women. 

Pathological  Anatomy. — The  iris  is  thickened  and  infiltrated  with 
round-cells.  This  round-cell  infiltration  will  be  found  marked  along-  the 
blood-vessels.  The  exudate  is  composed  of  fibrin  tilled  up  with  leukocytes 
and  round-cell-,  and  is  generally  more  extensive  upon  the  posterior  surface 
of  the  iris.  When  found  in  the  pupillary  field  the  exudate  is  rich  in  pigment- 
granules,  although  this  i-  tin  case  to  a  certain  extent  everywhere.  The  coats 
of  the  blood-vessels  are  thickened  and  capillary  hemorrhages  are  abundant. 
Masses  of  granular  d6bris,  the  exact  natureof  which  it  is  difficult  to  deter- 
mine, are  always  present.  In  cases  where  seclusion  of  the  pupil  has  occurred 
it  will  be  found  that  the  iris  has  undergone  atrophy  in  those  parts  bordering 
upon  tin'  pupil.  Where  the  entire  posterior  surface  of  the  iris  is  bound  down 
\<<  the  lens,  sooner  or  later  atrophy  of  the  whole  iris  occurs,  and  it  will  be 
found  that  all  that  i-  left  i-  ;\  thin  membrane,  and  here  and  there  within  its 
fold-  a  clump  of  disintegrated  cells.  Sometimes  there  are  scarcely  any  traces 
of  the  structure  of  the  iris  ;  even  the  sphincter  has  disappeared. 

Diagnosis. — The  character  of  the  conjunctiva]  congestion,  the  slightly 
turbid  aqueous,  ami  the  sluggish  pupil  in  iritis  distinguish  it  from  conjuncti- 
\  iti-.  I  f  tin'  two  irides  are  compared,  the  change  of  color  of  the  affected  iris, 
ilue  to  hyperemia,  will  be  observed.  In  conjunctivitis  the  pain  is  burning 
in  character,  i-  referred  especially  to  the  lid-,  and  i-  quite  constant,  while  in 
iritis  it  i-  usually^aroxysmal,  i-  referred  to  the  temples  and  brows,  and  often 
is  more  intense  at  night.  Vision  i-  never  materially  affected  in  simple  con- 
junctivitis, while  visual  disturbance  in  iritis  is  the  rule.  Iritis  may  be  dis- 
tinguished  from  glaucoma  (with  which  it  i-  often  confounded  by  the  inex- 
perienced)  by  the  -i/e  of  the  pupil,  which  in  the  former  disease  is  contracted, 

while    in    the    latter    it    i-  dilated.        The    ten-ion.  while    it    may  be  elevated   in 

iritis  (particularly  in  the  serous  form),  ie  not   so  a-  a  rule.     The  tension  in 
glaucoma  i-  always  elevated. 


/  R  rns.  34] 

Prognosis. — This  depends  upon  the  cause  and  also  upon  the  changes 
which  have  already  taken  place  in  the  iris.  It'  the  pupil  is  completely 
dilatable  with  atropin,  the  prognosis  may  be  regarded  as  favorable.  The 
presence  of  numerous  synechia,  especially  when  one  or  more  tail  to  yield  to 
the  action  of  the  mydriatic,  mean-  often  a  recurrence  of  the  iritis,  although 
cases  are  not  infrequently  -ecu  where  two  or  three  synechia  have  been  pres- 
ent tor  several  years,  without  recurrence  of  the  iritis;  and  with  good  vision. 
Where  there  is  either  seclusion  or  occlusion  of  the  pupil,  an  accumulation  of 
aqueous  often  occurs  in  the  posterior  chamber,  and  lead-  to  a  bulging  forward 
of  the  iris  and  ultimately  to  increased  ten-ion  (secondary  glaucoma).  Where 
there  i-  a  total  posterior  synechia,  the  iris  instead  of  bulging  forward  may  be 
retracted  at  its  periphery,  and  here  we  will  have  usually  diminished  ten-ion. 
Sometime-  the  iritis  runs  a  chronic  course,  being  characterized  by  sluggish- 
ness of  the  pupil,  cloudy  aqueous,  an  occasional  synechia,  and  by  usually  no 
marked  painful  symptoms.  The  conditions  just  mentioned  mean  that  the  eye 
has  been  the  seat  of  disease  for  a  considerable  time,  that  in  consequence  the 
integrity  of  the  lens  (so-called  injUmvmatory  cataract),  of  the  ciliary  region — 
in  fact,  of  the  whole  posterior  segment  of  the  eye — has  been  in  a  measure 
permanently  impaired.  The  prognosis  then  is  bad  for  anything  like  restora- 
tion of  good  vision. 

The  condition  of  the  adjacent  structures  has  an  important  bearing  upon 
the  prognosis. 

Treatment. — In  connection  with  the  treatment  of  iritis  the  following 
rather  striking  sentences  seem  appropriate  :  "  There  is  one  ground,  however, 
on  which  I  strongly  object  to  this  ticketing  of  iritis  with  the  names  of  various 
diseases — namely,  that  habit  is  likely  to  mislead  the  inexperienced  practitioner 
into  an  endeavor  to  treat  the  name  on  the  ticket,  while  the  iritis  may  be 
neglected  until  it  has  done  irreparable  harm.  I  do  not  know  of  any  disease 
which  prevents  the  occurrence  of  iritis,  and  hence  I  do  not  know  of  any 

with  which  it  may  not  sometimes  be  associated We  do  not  understand 

a  given  case  one  whit  better  for  calling  it  '  rheumatic/  and  the  term  tends  to 
relegate  to  the  second  place,  as  a  mere  accident  of  another  affection,  a  malady 
in  which  all  our  skill  will  be  necessary  if  we  are  adequately  to  discharge  our 
responsibilities  to  the  patient"  (Robert  Brudenell  Carter).1 

Rest  for  the  iris  is  reached  by  the  instillation  of  atropin.  This  drug 
paralyzes  the  sphincter,  stops  the  incessant  movements  of  the  pupil,  reduces 
the  hyperemia,  and  by  dilating  the  pupil  breaks  loose  the  adhesions,  which 
are  not  likely  to  recur  during  mydriasis.  Atropin  is  to  the  eye  in  iritis 
very  much  what  opium  is  to  inflammations  elsewhere  in  the  body  :  it  i-.  so  to 
-peak,  the  great  anodyne  in  iritis.  Generally,  a  solution  of  four  grains  to  the 
ounce  i-  strong  enough  to  dilate  the  pupil  if  instilled  every  three  or  four 
hours  ;  but  if  a  solution  of  this  strength  doe-  not  produce  the  desired  effect,  a 
stronger  one  should  be  employed.  Not  infrequently  success  i- attained  only 
after  using  a  solution  of  sixteen  grains  to  the  ounce.  The  surgeon  should 
watch  for  the  constitutional  effects  of  the  drug,  but  an  iritis  which  call-  for 
such  a  strong  solution  of  atropin  is  apt  to  tolerate  it  without  unfavorable 
result-.  No  more  than  one  drop  i-  in-tilled  at  a  time,  and  not  oftener  than 
every  four  hours.  If  constitutional  effects  appear,  the  strong  solution  should 
be  abandoned  at  once;  but  ordinarily  two  or  three  instillations  will  give 
satisfactory  evidence  whether  any  good  will  follow  its  continued  u-'\  The 
employment  of  cocain  along  with  atropin  heightens  the  effeel  of  the  latter 
drug. 

1  Ophthalmic  Surgery,  by  II.  B.  Carter  and  W.   Ldams  If       ■  •      30,  181. 


342  DISEASES  OE  THE  IRIS. 

The  appearance  of  constitutional  symptoms,  however,  no  matter  what  be 
the  strength  of  the  atropin  solution,  necessitates  a  withdrawal  of  the  drug, 
as  well  as  of  other  mydriatics,  such  as  scopolamin,  duboisin,  and  hyoscy- 
amin.  When  a  full  dilatation  of  the  pupil  is  obtained,  it  may  be  no  longer 
necessary  to  use  the  atropin  so  often  ;  in  other  words,  its  use  should  he  regu- 
lated by  the  condition  of  the  pupil. 

Hot  applications,  either  moist  or  dry,  are  indicated.  A  small  pad  of 
surgical  gauze  steeped  in  the  following  lotion  and  applied  to  the  eye  as  hot  as 
can  lie  home  rarely  fails  to  give  comfort  :  Plumbi  acetat.,  .")  ;  opii  pulv.,  §ssj 
aq.  hull..  Oj.  A  roll  of  dry  cotton  and  then  a  layer  of  oil  silk  should  be 
placed  over  the  pad.  As  soon  as  this  application  gets  cool  it  should  be 
renewed.  Its  good  effects  are  especially  evident  when  the  inflammation  is  of 
a  violent  type.  Poultices  are  valuable  and  are  often  employed.  Cold  appli- 
cation- are  to  he  avoided,  although  some  surgeons  advise  their  use  in  traumatic 
iritis.  Four  or  five  leeches  applied  to  the  temples  or  the  artificial  leech 
(Heurteloup)  are  helpful  in  bringing  about  an  abatement  of  the  inflammatory 
symptoms,  although  this  method  of  treating  iritis  has  become  less  popular 
of  late  years.  The  Japanese  stove  or  hot  box  is  a  most  convenient  method 
of  applying  dry  heat.  The  box  should  he  wrapped  in  a  handkerchief  or  in 
any  soft  material  and  applied  to  the  eye.  A  little  bag  filled  with  hops  or 
bran  and  heated  in  an  oven  can  he  used  in  the  same  way.  These  various 
methods  of  applying  heat  are  valuable,  especially  the  first  one. 

According  to  Fuchs,  Schweigger,  and  other  writers,  a  hypodermic  injection 
of  muriate  of  pilocarpin  ( ',  grain)  every  other  day  is  very  beneficial.  Bro- 
mids  and  opiates  are  to  he  used  when  needed.  So  far  as  possible,  the  patient 
should  be  screened  from  direct  rays  of  light.  The  administration  of  calo- 
mel in  the  earlier  stages  of  the  affection  usually  proves  advantageous. 
Two  grains  are  given  in  j-urain  doses.  The  good  effects  of  this  agent  in 
all  forms  of  iritis  are  most  conspicuous.  Not  infrequently  in  cases  in 
which  atropin  apparently  ha-  produced  no  mydriasis,  after  a  thorough 
calomel  action  marked  improvement  in  the  condition  of  the  pupil  may  he 
observed. 

After  the  action  of  the  calomel  has  been  obtained  treatment  should  be 
directed  to  the  cause  of  the  iritis.  As  a  rule,  the  administration  of  salicylate 
of  -odium  in  20-grain  doses,  every  three  or  four  hours,  will  he  found  an  ad- 
mirable remedy  in  the  painful  stage  of  iritis.  It  matters  not  what  he  the 
origin  of  the  disease,  this  remedy  rarely  fails  to  prove  serviceable.  After 
the  painful  stage  ha-  passed  away  this  drug  may  he  administered  in  smaller 
doses  if  there  he  a  rheumatic  or  gouty  diathesis  present  ;  if  the  iritis  rests 
upon  a  syphilitic  basis  the  surgeon  should  resort  at  once  to  biniodid  of  mer- 
cury and  iodid  of  potassium,  or  inunction  of  blue  ointment  may  prove  tin1 
best  method  of  getting  the  mercury  into  the  system.  A  mercurial  vapor-bath 
i-  also  an  excellent  way  of  administering  this  remedy.  Usually  the  mixed 
treatment  is  adopted  in  such  cases,  and,  as  has  been  -aid,  this  consists  in  the 
administration  of  the  biniodid  of  mercury  and  iodid  of  potassium,  which  is 
continued  not  only  till  all  the  eye-symptoms  have  disappeared,  hut  until  one 
can  be  reasonably    certain  that    the    constitutional   poison   has  been    eliminated. 

Subconjunctival  injections  ot  bichlorid  of  mercury  have  been  recommended 
by  Darier  ami  other  surgeons;  similar  injections  of  physiological  -alt  act 
equally  well. 

[ritis    i-    uncommon    in    children,   and    i-    best     treated    hv    inunction-    of 

mercury.  In  serous  iritis  the  surgeon  should  he  careful  in  the  employment 
of  atroDin,  as  a  glaucomatous  condition  often  exists  which  t  he  mydriatic  would 


ANOMALIES  OF  THE  ANTERIOR  CHAMBER.  343 

tend  to  intensity.  Paracentesis  may  be  practised  in  these  cases  with  advan- 
tage, and  when  increased  intraocular  tension  persists  iridectomy  is  indicated. 

The  majority  of  cases  of  iritis,  properly  treated,  gel  well  without  adhe- 
sions  ;  still,  synechia1  may  remain  and  may  cause  recurrent  attacks.  The  ope- 
ration of  corelysis,  which  is  not  much  practised  now-a-days,  was  designed  for 
the  purpose  of  breaking  loose  these  adhesions  (see  page  579).  Whenever  it 
i-  necessary  to  operate  upon  synechia'  no  procedure  is  superior  to  iridectomy 
(see  page  575).  The  presence  of  several  broad  synechia'  near  one  another 
might  readily  explain  the  occurrence  of  frequent  attacks  of  iritis.  Such 
synechia?  should  he  operated  upon  by  an  iridectomy  at  the  point  of  attach- 
ment. One  or  two  synechia?  are  rarely  responsible  for  a  recurrence  of  iritis. 
Operative  measures  in  connection  with  iritis  are  rarely  demanded  during  the 
active  inflammation,  hut  rather  in  the  sequela?  of  the  disease. 

In  those  cases  where  the  iritis  has  resulted  from  an  injury,  if  there  are 
any  large  pieces  of  iris  protruding  they  should  he  abscised.  A  minute  hernia, 
however,  will  probably  do  no  harm  and  had  best  he  let  alone.  The  inflam- 
mation itself  should  be  treated  just  as  we  would  treat  any  plastic  iritis. 
When  the  lens  capsule  has  ruptured  and  the  swollen  masses  of  lens  are 
pressing  upon  the  iris  the  lens  should  be  removed.  In  cases  of  seclusion  or 
occlusion  of  tin'  juijii/  iridectomy  is  indicated.  Hither  of  these  condition-,  if 
neglected,  may  end  in  total  blindness.  In  seclusion,  iridectomy  is  demanded 
because  it  relieves  increased  tension  and  re-establishes  the  communication 
between  the  anterior  and  posterior  chambers,  and  by  doing'  this  the  nutrition 
of  the  eye  is  at  once  improved  and  some  vision  may  be  obtained.  For  the 
same  reasons  iridectomy  is  demanded  in  occlusion  of  the  pupil.  But  even  in 
those  cases  where  the  intraocular  tension  is  lowered  and  atrophy  has  set  in, 
as  is  sometimes  the  case  after  total  posterior  synechia1,  the  tendency  of  iridec- 
tomy is  to  do  good  by  improving  the  condition  of  the  eyeball.  Such  eves 
may  fill  out  again  and  regain  some  sight.  Where  the  entire  posterior  sur- 
face of  the  iris  is  bound  down  to  the  lens  capsule  it  is  difficult  to  pull  away 
the  iris  without  more  or  less  injuring  the  delicate  ciliary  region  ;  hence  irid- 
ectomy in  such  cases  may  be  followed  by  irido-cyclitis,  but  inasmuch  as  such 
an  eye  will  in  all  probability  cause  trouble  in  one  way  or  another,  iridectomy 
should  he  tried. 

ANOMALIES  OF  THE  ANTERIOR  CHAMBER. 

The  depth  of  the  anterior  chamber  varies  within  physiological  limit-. 
In  infancy  the  anterior  chamber  is  very  shallow,  becoming  deeper  a-  adult 
life  is  approached,  while  in  old  age  it  again  becomes  shallow.  In  myopia 
the  anterior  chamber  i-  deeper  than   in   hyperopia. 

Pathologically,  the  anterior  chamber  shows  variation-  in  depth.  It  may 
he  -hallow  from  the  pulling  forward  of  the  iris  by  anterior  synechia?  or  by 
the  collection  of  masses  of  exudate  behind  the  iris  in  total  posterior  synechia?. 
Sometime-  the  periphery  of  the  anterior  chamber  i-  deeper  than  the  middle 
after  a  severe  attack  of  cyclitis,  and  in  these  cases  the  outer  /one  of  the  iris 
i-  drawn  backward  by  exudates.  A  shallow  anterior  chamber  occurs  in 
glaucoma,  and  al-o  after  the  needling  operation  for  cataract,  when  the  lens 
swells  up  and  presses  againsl  the  iris,  pushing  it  forward.  A  shallow 
anterior  chamber  is  seen  in  the  later  stages  of  intraocular  tumors. 

rncreased  depth  of  the  anterior  chamber  is  seen  in  staphyloma  < 
cornea,  in   luxation  of  the  lens  into  the  vitreous  body,   in  aphakia, 
hydrophthalmos. 


344  DISEASES  OF  THE  CILIARY  BODY. 

The  contents  of  the  anterior  chamber  may  be  altered  by  the  presence  of 
1»I«>(«(1  (hyphema),  pus,  masses  of  lens-substance,  foreign  bodies,  cysticerci, 
neoplasms,  and  cilia. 

Blood   in  the  anterior  chamber  as  a  general  thing  will  disappear  under 

a  c press  bandage,  but   it'  it   persists  and   is  evidently  acting  as  a  foreign 

body,  paracentesis  of  the  anterior  chamber  at  its  lower  border  should  be 
performed.  ETyphema  most  often  follows  injuries  and  contusions  of,  and 
operations  upon,  the  eyeball.  It  is  also  seen  after  irido-cyclitis,  with  seclu- 
sion of  the  pupil  and  beginning  phthisis  bulbi,  in  which  case  the  hemor- 
rhage into  the  anterior  chamber  often  repeats  itself.  Paracentesis  under 
these  circumstances  doe-  no  good,  the  compress  bandage  being  found  more 
serviceable.  Hyphema  has  been  observed  as  a  result  of  dysmenorrhea 
and  purpura  hemorrhagica.  Mooren  and  Weber  describe  patients  who 
could  bring  on  hemorrhage  into  the  anterior  chamber  at  will.  Pus  in  the 
anterior  chamber  (hypopyon)  is  always  a  symptom,  and  must  be  treated  ac- 
cording as  it  proceeds  from  the  cornea  or  from  the  iris.  It  usually  has  its 
origin    in  affections  of  the  cornea. 

Foreign  bodies,  as  particles  of  steel  and  ulass.  may  pass  through  the 
cornea  and  resl  in  the  anterior  chamber  and  on  the  iris.  An  eyelash  may 
find  it-  way  into  the  anterior  chamber,  and  alter  a  time  grive  rise  to  an 
implantation  cyst  (seepage  189). 

Cysticerci  are  rarely  seen  in  the  anterior  chamber.  The  parasite  gener- 
ally gives  rise  to  symptoms  of  iritis,  and  can  be  seen  sooner  or  later  swim- 
ming around  in  the  aqueous  humor  or  it  may  be  attached  to  some  point  of 
the  iris.  The  JUaria  sanguinis  hominis  has  also  been  observed  in  this  locality. 
The  parasites  should  be  removed. 

DISEASES  OF  THE  CILIARY  BODY. 

Cyclitis. — Inflammation  of  the  ciliary  body  does  not  exist  as  an  isolated 
disease,  but  i-  usually  an  extension  of  an  iritis  or  choroiditis.  As  a  rule, 
iritis  is  present. 

Etiology. —  Inasmuch  as  the  disease  is  secondary  to  either  iritis  or 
choroiditis,  more  often  to  the  former,  it  has  the  same  etiology.  When 
it  i-  not  secondary  to  one  of  these  affections  it  is  the  result  of  a  wound 
or  foreign  body  in  the  ciliary  region,  or  it  may  occur  in  one  eye  as 
the  result  of  a  traumatic  cyclitis  in  the  other  (sympathetic  ophthal- 
mitis . 

Symptoms. — The  disease  i-  characterized  by  marked  circumcorneal  con- 
gestion and  more  Or  less  hyperemia  of  the  iris,  which  shows  itself  in  dilatation 
of  the  blood-vessels  and  slighl  discoloration.    The  anterior  chamber  is  deeper 

thai nnal  at  it-  periphery,  owing  to  the  traction   of  exudates  from  behind. 

These  exudate-  are  pla-tie  in  character — hence  the  name  plastic  cyclitis — and 
usually  arc  not  -ecu  in  the  pupillary  field.  The  pupil  is  often  dilated.  The 
hyperemia  of  the  iris  sooner  or  later  passes  over  into  iritis,  and  finally  the 
choroid  becomes  involved.  S< 'times  these  symptoms  are  much  less  pro- 
nounced ;  indeed,  there  may  lie  entire  absence  of  plastic  exudate-,  and,  while 
in  the  beginning  the  anterior  chamber  is  deep,  later  on  it  becomes  shallow. 
A   condition  may  arise  very  similar  to  what   i-  seen   in  serous  iritis.     Fine 

opacities  make  their  appearance  in  the  anterior  part  of  the  vitreous  body — 
opacities  which    materially   interfere    with    vision.      The   tension    is   decidedly 

elevated  and  the  pupil  dilated.  Some  author-  -peak  of  this  somewhat  milder 
aspect  of  the  disease  a-  serous  cyclitis.     Again,  we  may  have  the  pericorneal 


CYCLITIS.  345 

congestion  and  hyperemia  of  the  iris  intensified,  and  this  hyperemia  may 
extend  to  the  retinal  vessels,  showing  itself  in  tortuosity  of  the  retinal  veins. 
A  characteristic  symptom  is  hypopyon,  which  disappears  and  reappears  again 
in  a  tew  days.  This  is  the  purulent  type  of  the  affection,  and  it  i-  generally 
spoken  of  as  purulent  i-j/c/iti*.  Just  as  in  the  plastic  and  serous  types,  the 
iris  is  always  implicated. 

Cyclitis  is  characterized  by  the  general  symptoms  of  inflammatory  irri- 
tation— namely,  ciliary  neuralgia,  photophobia,  and  lachrymation.  The  eye- 
ball is  exceedingly  sensitive  to  the  touch  over  the  ciliary  region.  Vision  is 
invariably  impaired. 

Pathological  Anatomy. — Small-cell  infiltration  of  the  ciliary  body  is 
present,  and  this  condition  is  especially  marked  in  the  purulent  variety 
of  cyclitis.  Hemorrhages  are  frequent  in  all  tonus  of  cyclitis.  Both 
the  circular  and  radiating  fibers  of  the  ciliary  muscle  contain  exudate, 
and  this  exudate  (fibrinous)  is  considerable  enough  at  times  to  push  aside 
the  individual  fibers.  The  neighborhood  of  Schlemm's  canal  is  always 
densely  infiltrated,  and  no  doubt  the  inflammatory  products  in  this  locality 
by  blocking  up  the  entrance  into  the  canal  have  not  a  little  to  do  with  the 
development  of  glaucomatous  tension.  The  formation  of  membranes  is 
usually  seen.  The  eyclitic  membrane*  may  cover  the  entire  posterior  and 
anterior  surface  of  the  iris,  and  also  the  ciliary  body,  and  even  extend  into 
the  vitreous  body.  This  membrane  not  infrequently  envelops  the  lens,  and, 
contracting  about  it,  cuts  it  off  from  its  sources  of  nutrition.  As  a  result 
of  this  the  lens  is  often  found  as  a  small  calcareous  mass  entangled  in  the 
meshes  of  the  membrane  and  bearing  no  resemblance  to  its  former  shape. 
In  the  contraction  which  the  eyclitic  membrane  undergoes  the  ciliary  body 
is  drawn  away  from  its  normal  site,  and  is  to  be  seen  as  a  narrow  strip  of 
tissue,  having  lost  its  natural  shape.  This  eyclitic  membrane  is  composed 
of  connective  tissue  with  interlacing  bands.  All  shapes  of  cells  will  be 
found  present.  In  very  light  cases  this  membrane  may  disappear  by  resorp- 
tion. Masses  of  black  pigment  are  to  be  seen  here  and  there  throughout 
the  diseased  parts.  According  to  Pollock,  hemorrhages  arc  common  in  the 
eyclitic  membrane,  although  the  author  has  not  observed  any  in  the  speci- 
mens which  have  come  under  his  observation.  In  the  early  stage  the  ciliary 
processes  are  thickened;  finally,  however,  they  undergo  atrophy  and  become 
very  much  thinned.  When  the  process  has  reached  this  stage  atrophy  of  the 
eyeball  is  usually  only  a  cjucstion  of  time. 

Diagnosis. — The  question  is  between  iritis  and  irido-cyclitis.  The  symp- 
toms which  determine  the  existence  of  a  cyclitis  have  been  enumerated  by 
Fuchs  as  follows :  Inflammatory  symptoms  of  considerable  degree,  especially 
if  edema  of  the  upper  lid  is  present  (this  edema  of  the  lid  doe-  not  occur  in 
pure  iritis):  sensitiveness  to  touch  in  the  ciliary  region;  retraction  of  the 
periphery  of  the  iris,  indicating  total  posterior  synechia'  ;  disturbance  in  vision 
more  considerable  than  would  be  expected  from  the  opacities  within  the 
confine-  of  the  anterior  chamber;  and,  finally,  tension  either  elevated  or 
lowered. 

Prognosis. — The  prognosis  in  cyclitis  i-  always  grave,  especially  so  in 
the  plastic  form.  The  cvelitic  membrane  usually  covers  the  entire  ciliary 
region,  and  in  the  contraction  and  organization  which  follow  the  retina  ami 
ciliary  body  are  torn  out  of  position,  the  lens  undergoes  degeneration,  and 
atrophy    end-    the   scene. 

The  gerous foitn  in  it-  early  stages  i-  often  characterized  by  ;i  glaucomatous 
condition  which  is  followed  by  softening  and  atrophy  of  the  eyeball. 


346  1> TS /:. I S ES  OF  THE  CILIARY  BODY. 

The  purulent  form  of  cyclitis,  seen  as  a  result  of  infection  after  cataract 
extraction,  as  a  rule  ends  in  sloughing  of  the  whole  eyeball. 

Treatment. — The  treatment  i-  practically  the  same  as  that  employed  in 
iritis.  Heal  and  atropin,  then,  should  be  used  locally.  The  latter  remedy 
is  withdrawn  when  a  glaucomatous  condition  is  present.  The  constitutional 
treatment  which  has  been  suggested  in  connection  with  iritis  is  equally 
applicable  here. 

Injuries  of  the  Ciliary  Body. — Injuries  of  the  ciliary  body  arise  from 
penetrating  and  non-penetrating  wounds  of  the  ciliary  body,  and  arc  fully 
described  on  pages  •'!•!  1  and  .')<>7. 

Irido-choroiditis  (('/ironic  Serous  Trido-choroiditis). — This  disease 
usually  originates  in  the  iris;  that  i>  to  say,  the  presence  of  posterior 
synechias  may  result  in  chronic  iritis  which  passes  backward  and  invades 
the  choroid.  Sometimes  the  inflammation  originates  in  the  choroid  and  passes 
forward  and  involves  the  iris. 

Etiology. — Old  synechia'  are  generally  responsible  for  this  affection. 
Where  the  disease  -tarts  in  the  choroid  it  not  infrequently  is  to  be  attributed 
to  a  dislocated  lens  which  has  been  either  resting  upon  the  retina  and  choroid 
or  floating  about  in  the  vitreous  body.  Edward  Meyer  mentions  instances 
where  the  affection  was  traceable  to  menstrual  disturbances  and  to  the  cli- 
macteric. 

The  pathological  anatomy  is  practically  the  same  as  that  which  has 
been  described  in  connection   with   Iritis. 

Symptoms. — Even  when  the  process  lias  originated  in  the  iris  the  irrita- 
tive symptoms  are  never  conspicuous,  certainly  not  to  the  extent  in  which 
tiny  arc  found  in  iritis.  The  iris  is  often  bulged  forward,  and  may  be  press- 
ing against  the  cornea.  This  condition,  however,  is  only  seen  in  those  cases 
where  the  pupil  i>  completely  occluded  and  communication  between  the  two 
chambers  is  interrupted.  It  is  caused  by  the  collection  of  effusions  behind 
tin'  iris.  The  vitreous  body  i-  generally  filled  with  opacities.  Pain,  as  might 
be  expected,  j-  ;iu  insignificant  symptom.  Visual  disturbance  is  always 
present,  and  i-  in  proportion  to  the  condition  of  the  pupil  and  involvement 
of  the  choroid. 

Where  the  inflammation  ha-  started  in  the  choroid  the  visual  disturbances 
are  more  pronounced.  Nearly  always  in  this  event  there  are  detached  retina, 
dense  opacities  in  the  vitreous  body,  and  a  degenerated  lens.  By  the  time 
the  inflammation  reaches  the  iris  sight  has  been  nearly  extinguished.  From 
now  on  the  symptoms  resemble  those  seen  when  the  inflammation  originates 
in  the  iris.  Meyer  has  suggested  the  following  points  as  important  in  deciding 
:i-  to  tin  probable  origin  of  the  affection,  whether  in  the  iris  or  choroid  :  In 
case  the  inflammation  had  started  in  the  iris  the  patient  would  be  apt  to  recall 
some  attack  of  iritis,  ami  it  would  be  noticed  that  the  structure  of  the  iris 
had  undergone  changes  to  some  extent,  being  discolored  and  atrophied.  As 
a  rule,  the  lens  -how-  no  participation  in  the  affection  till  the  process  has 
found  its  way  backward.  When  visual  disturbances  are  absent  one  can  be 
reasonably  certain  thai  neither  the  leu-  nor  the  vitreous  body  i-  to  any  extent 
involved. 

If  the  process  has  started  in  the  choroid,  visual  disturbances  will 
always  be  prominent  features,  owing  to  the  opacities  in  the  vitreous  body. 
Retinal  detachment  will  be  noticed,  the  intraocular  ten-ion  will  be  lowered, 
;md  the  lens  will  often  be  found  to  ha\'e  undergone  calcification.  Neither  of 
these  forms  exhibits  acute  symptoms,  both  being  very  insidious  in  character. 

Prognosis. — Where  the  process  baa    started    in    the    in-  and    ha-  been 


SYMPATHETIC  OPHTHALMITIS.  347 

properly  treated  in  the  early  stages  there  is,  comparatively  speaking,  hope  for 
restoration  of  useful  sight.  But  where  the  disease  begins  in  the  choroid  the 
outlook  is  exceedingly  bad.  Even  it'  the  retina  is  ool  detached  or  the  lens 
opaque,  the  integrity  of  the  entire  uveal  tract  has  been  to  some  extent 
permanently  impaired. 

Treatment. — Atropin  must  be  employed,  bul  it  should  be  remembered 
that  intraocular  tension  is  sometimes  elevated  in  the  course  of  the  disease. 
When  the  communication  between  the  anterior  and  posterior  chamber  is 
interrupted,  iridectomy  should  be  performed,  for  a  continuance  of  this  condi- 
tion means  blindness.  The  surgeon  should  not  hesitate  to  repeat  this  opera- 
tion as  often  as  the  new  pupil  is  closed  with  exudates,  and  should  nol  be 
deterred  even  by  a  condition  of  diminished  tension.  The  lens  being  diseased 
and  more  or  less  opaque,  its  removal  is  frequently  indicated  Constitutional 
treatment  should  not  be  neglected.  Mercury  should  be  tried  in  the  form  of 
the  bichlorid  and  in  small  doses.      lodid  of  potassium  is  also  indicated. 

SYMPATHETIC   AFFECTIONS  OF  THE  EYE. 

Sympathetic  Ophthalmitis. — This  disease  is  one  of  the  most  inter- 
esting and  at  the  same  time  the  most  obscure  in  the  whole  range  of  eye 
affections. 

Definition. — Sympathetic  ophthalmitis  is  an  inflammation,  usually  plastic, 
but  sometimes  serous,  which  affects  the  iris,  ciliary  region,  and  choroid  of  one 
eye  ("the  sympathizer"),  and  which  originates  in  a  traumatic  inflammation 
of  the  same  parts  in  the  other  eye  ("the  exciter").  The  three  fundamental 
elements  of  true  sympathetic  ophthalmitis  are — first,  a  traumatic  irido-cyclitis 
of  one  eye;  second,  a  plastic  uveitis  of  the  other  eye;  and  third,  a  certain 
period  of  time  which  always  elapses  before  the  outbreak  of  the  sympathetic 
disease — i.  e.  the  period  of  incubation.  The  existence  of  these  three  factors 
certainly  warrants  the  diagnosis  of  sympathetic  ophthalmitis. 

Etiology. — Penetrating  wounds  are  chiefly  concerned  in  the  production 
of  sympathetic  ophthalmitis — wounds  either  from  sharp  instruments,  such  as 
scissors  and  knives  ;  or  wounds  caused  by  the  entrance  into  the  eyeball  and 
the  lodgement  there  of  small  fragments  of  steel,  percussion  cap-,  particle-  of 
stone  or  glass.  Schirmer,  Mackenzie,  Knapp,  and  others  report  eases  which 
followed  simply  a  blow  upon  the  eyeball  without  a  rupture.  This  mechanism 
is  entirely  contrary  to  the  rule,  and  most  of  these  instances  are  open  t<>  grave 
criticism. 

Penetrating  wounds  of  the  ciliary  rer/ion  are  especially  apt  to  give  rise  to 
the  disease,  and  it  makes  no  difference  whether  the  wound  i-  large  or  -mall. 
Mooren  has  described  sympathetic  ophthalmitis  after  the  entrance  into  the 
eyeball  of  -mall  particles  of  iron,  and  has  seen  it  follow  the  bursting  of  the 
eye  by  a  blow  with  a  stick.  According  to  Mackenzie,  protrusion  of  the  iris 
and  its  incarceration  in  the  wound  are  conditions  which  are  peculiarly  liable 
to  give  rise  to  the  disease. 

Wounds  which  pass  through  the  cornea  ami  the  pupillary  border  of  the 
iris,  even  though  the  lens  is  injured  and  cataract  results,  are  not  a-  dangerous 
as  when  the  wound  passes  through  the  ciliary  border  of  the  iris.  Traumatic 
cataract  of  itself  ha-  no  significance  in  the  etiology  of  sympathetic  ophthal- 
mitis, though  a  swollen  len-,  by  pressing  upon  the  surrounding  part-. 
certainly  aggravate  an  already  existing  cyclitis.  The  operations  of  iridodesi 
discission,  iridectomy,  reclination,  and  cataract  extraction  have  been  followed 
by  sympathetic  ophthalmitis.      Mackenzie  states   in   his  I k   that   he  never 


348  SYMPATHETIC  AFFECTIONS  OF  THE  EYE. 

saw  sympathetic  ophthalmia  follow  any  of  the  operations  for  cataract.  Among 
other  causes  mentioned  by  most  writers  arc  intraocular  tumors,  particularly 
the  melano-sarcomata,  and  cysticercus  is  reported  to  have  given  rise  to  sympa- 
thetic ophthalmitis  (two  cases).  There  arc  good  reasons,  however,  for  regard- 
ing both  sarcoma  and  cysticercus  as  very  doubtful  agents  in  the  production 
of  the  affection,  and  the  same  may  be  said  of  ossification   within  the  eve. 

Symptoms. — Accommodative  asthenopia  is  the  first  symptom,  and  shows 

itself  on  the  slightest  attempt  to  fix  an  object,  no  matter  of  what  size  or  at 

what  distance.     This  symptom  may  be  lacking,  and  instead  of  it  the  patient 

a  mist  around  everything.     Pain  is  usually  absent,  but  pressure  on  the 

ciliary  region  elicits  tenderness  which  is  often  quite  characteristic. 

Pericorneal  congestion  is  more  or  less  marked.  The  media  are  cloudy. 
The  earlier  stages  of  the  affection  are  associated  with  slight  increase  in  intra- 
ocular tension,  followed  by  vacillating  conditions  of  tension,  mounting  up  to 
a  high  grade  in  the  glaucomatous  stage,  while  at  the  last  the  tension  is  much 
diminished.  The  iris  is  hyperemic.  Pagenstecher  has  called  attention  to 
the  fact  that  in  this  kind  of  iritis  the  pupil  can  readily  be  dilated  in  spite  of 
the  synechia?.  It  is  possible  for  the  process  to  disappear  at  this  point  and 
never  return,  hut  this  is  seldom  the  ease.  The  attacks  come  at  frequent 
intervals  and  with  renewed  intensity.  After  every  recurrence  the  synechia 
are  firmer  and  the  pupil  is  harder  to  dilate.  Pain  may  now  develop.  Small 
grayish  dot-  appear  on  the  posterior  surface  of  the  cornea.  Synechia'  are 
to  be  seen  extending  all  the  way  around  the  pupil.  Recession  of  the  iris 
periphery  is  present. 

In  nearly  every  case  the  primarily  affected  eye  is  blind  before  the  outbreak 
of  tin1  sympathetic  disease;  but  cases  are  on  record  where  vision  was  still 
present  in  the  injured  eye  at  the  time  of  the  appearance  of  the  sympathetic 
inflammation.  The  following  constitutional  symptoms  may  be  seen  :  a  quick- 
ened pulse,  thirst,  pallid  complexion,  and  obstinate  constipation.  The  course 
of  the  disease  is  usually  tedious. 

Sympathetic  serous  iritis  is  a  much  milder  type  of  the  disease.  The 
symptoms  are  those  of  serous  iritis.  This  may  be  regarded  as  a  comparatively 
benign  form  of  sympathetic  ophthalmitis,  which  may  pass  over  into  the  per- 
nicious form — plastic  irido-cyclitis — which  has  been  described  above. 

Sympathetic  papillo-retiniHs  has  been  observed  a  certain  number  of  times, 
and.  in  contradistinction  to  the  genuine  sympathetic  ophthalmitis,  shows  no 
tendency  to  relapses.  Schirmer  state-  that  the  disease  has  never  been  ob- 
served after  the  enucleation  of  the  injured  eye.  It  is  a  benign  affection,  and 
restoration  of  sight  i-  the  ride.  A  sympathetic  choroido-retinitis  has  also  been 
described. 

Diagnosis. — The  disease  has  no  peculiar  train  of  symptom-  by  which  it 
can  be  invariably  recognized.  If  pronounced  objective  symptoms  of  a  plastic 
irido-cyclitis  appear  in  an  eye  which  had  remained  sound  for  three  weeks 
after  the  fellow-eye  hud  been  the  -eat  of  a  traumatic  irido-cyclitis,  the  case 
maj  lie  regarded  ;i-  one  of  sympathetic  ophthalmitis.  The  diagnosis  will  be 
fr<  er  of  doubt  if  three  weeks  i-  considered  as  die  earliest  date  for  the  outbreak 
of  the  sympathetic  affection ;  later  than  the  fourth  month  the  diagnosis  be- 
comes more  or  less  uncertain. 

Mackenzie  says  that  the  disease  may  be  complicated  with  scrofula  and 
assume  :i  good  deal  of  the  scrofulous  character,  or  it  may  be  complicated  with 
syphilis.  Cerebral  complications  have  been  mentioned  in  connection  with 
sympat  net  ic  opht  halraia. 

Sympathetic  Irritation. — This  condition  was  once  regarded  a-  simply 


SYMPATHETIC  OPHTHALMITIS.  349 

the  forerunner  of  sympathetic  inflammation  ;  l>ut  it  is  a  much  more  frequent 
affection  than  the  latter  disease,  ;m<l  differs  from  it  in  several  vital  points. 
Photophobia,  lachrymation,  pains  in  the  head  and  orbit,  and  blepharospasm 
arc  frequently  present.  The  affection  reminds  one  somewhal  of  phlyctenular 
conjunctivitis.  The  neuralgia  is  often  remittent  in  character  and  very  violent. 
There  i-  concentric  narrowing  of  the  field  of  vision.  Shadow  s  and  clouds  are 
often  seen  when  an  effort  is  made  to  look  at  an  object.  More  or  less  ob- 
scuration of  objects  occur-  from  time  to  time,  the  obscuration  lasting  several 
seconds,  and  then  the  objects  appear  as  distinct  as  ever.  The  pupil  is 
generally  small,  but  the  movements  of  the  iris  are  intact.  According  to 
Noyes,  the  range  of  accommodation  is  diminished. 

The  disease  -how-  itself  at  period-  ranging  from  two  and  three  week-  to 

fifteen  and  twenty  years  after  the  injury  of  the  first  eye,  and  i-  c< nunicated 

to  the  sound  eye  through  the  medium  of  the  ciliary  nerves. 

Pathogenesis  of  Sympathetic  Ophthalmitis. —  Up  to  1858,  Mackenzie's 
views  prevailed  pretty  generally — namely,  that  the  optic  nerve  was  the 
channel  of  communication.  Miiller,  however,  concluded  that  the  sympathetic 
disease  was  due  to  irritation  of  the  ciliary  nerves,  together  with  an  influence 
which  affects  nutrition,  secretion,  and  accommodation.  Midler's  views  gained 
many  adherents,  among  others  von  Graefe  ;  indeed,  the  so-called  dliary-nerve 
theory  became  at  once  the  popular  one,  and  remained  so  for  a  long  time. 

The  optic-nerve  f/n  <>,■//  was  revived  by  Homer  and  Knies  in  1879. 

In  1881,  Snellen,  Berlin,  and  Leber  advanced  the  opinion  that  the  disease 
was  of  parasitic  origin. 

Maats,  under  Donders'  direction,  in  1869  undertook  the  experimental 
solution  of  this  problem,  and  his  experiments  were  repeated  at  a  later  date 
by  Snellen  and  Rosow.  All  three  of  these  observers  obtained  negative 
results. 

Of  all  the  experimental  work  on  this  subject,  that  of  Prof.  R.  Deutsch- 
mann  of  Hamburg  has  attracted  the  most  widespread  attention,  and  his 
results  were  regarded  at  first  as  absolutely  conelusive.  He  claimed  to  have 
produced  sympathetic  ophthalmitis  in  the  eye  of  a  rabbit  by  injecting  a  drop 
of  a  suspension  of  the  staphylococcus  aureus  into  the  vitreous  body  of  the 
fellow-eye.  Quite  a  number  of  experiments  were  made,  and  he  felt  justified 
in  the  following  conclusions:  That  sympathetic  ophthalmia  is  a  parasitic 
disease  which  make-  its  way  from  one  eye  to  the  other  by  way  of  the  optic 
nerve-  and  chiasm.  The  organisms  work  their  way  forward  by  reason  of 
a  certain  impetus  which  comes  from  their  growth,  as  well  as  from  their 
power  of  spontaneous  movement.  In  this  way  they  reach  the  base  of  the 
brain,  where  they  are  -wept  down  by  the  lymph-stream  into  the  .-heath-  of 
the  opposite  optic  nerve,  and  thus  reach  the  second  eye.  This  movement  on 
the  part  of  the  lymph-stream  explain-  why  the  organisms  do  not  spread 
themselves  over  the  base  of  the  brain  and  produce  meningitis. 

The  experiment-  of  Deutschmann  were  subjected  to  the  closesl  scrutiny, 
and  in  spite  of  the  work  of  Alt,  Gifford,  Mazza,  Randolph.  Limbourg  and 
Levy,  Schirmer,  Greef,  Qlrich,  and  Bach,  there  ha-  never  appeared  any 
evidence  to  lend  us  to  believe  that  Deutschmann's  experiment-  are  conclu- 
sive. In  fact,  the  investigations  of  these  observers  strengthen  the  view 
which  ha-  been  held,  that  sympathetic  ophthalmitis  cannot  lie  produced  in 
the  lower  animal-,  certainly  not  with  the  pus-organism.  From  this  it  would 
seem  that  Deutschmann's  work  i-  by  no  means  conclusive,  and  that  i 
more  than  probable  that  this  observer  fell  into  errors  of  interpretation.  The 
pus-organism  probably  plays  no  part  in  the  production  of  the  disease  in  man. 


350  SYMPATHETIC  AFFECTIONS  OF  THE  EYE. 

as  is  illustrated  by  the  rarity  of  sympathetic  ophthalmitis  niter  panophthal- 
mitis, where  the  pus-organisms  arc  usually  present  in  such  great  numbers. 

Wounds  of  the  ciliary  region  have  been  thought  to  peculiarly  predispose 
to  sympathetic  ophthalmitis,  but  experiments  on  the  lower  animals  have 
shown  that  so  long  as  the  instrument  was  sterilized  the  wound,  no  matter  if 
located  in  the  ciliary  region,  healed  invariably  with  little  or  no  inflammatory 
phenomena.  Experiments  <>t'  this  character  show  that  injuries  in  the  ciliary 
region  are  not  in  themselves  sufficient  to  give  rise  to  sympathetic  ophthalmitis, 
l>iii  that  something  else  is  necessary,  a  something  modifying  the  character  of 
the  wound  itself.  A  wound,  however,  which  is  infected  would,  for  sound 
anatomical  reasons,  be  more  apt  to  set  up  sympathetic  trouble  if  located  in 
the  ciliary  region  than  if  located  anywhere  else  in  the  eye.  Reference  here 
may  be  made  to  the  works  "f  Bach  and  Schmidt-Rimpler,  both  of  whom 
Iran  toward  a  somewhat   modified  ciliary-nerve  theory. 

The  uniformly  negative  results  of  the  various  experimenters  do  not  dis- 
prove the  bacteric  origin  of  sympathetic  ophthalmitis,  but  before  regarding; 
the  theory  as  proved  the  specific  organism  must  be  identified. 

Prognosis. — The  prognosis  is  always  a  matter  of  grave  doubt.  Well- 
established  recoveries  are  rare.  Waldispuhl,  summing  up  the  statistics  of 
Prof.  Schiess's  clinic  in  Bale,  reports  four  recoveries  in  ten  years.  Cases  of 
recovery  arc  reported  by  Hirschberg,  Laqueur,  Schirmer,  Rogman,  and  Ran- 
dolph. Relapses  are  the  ride,  and  this  fact  should  lead  us  to  be  guarded  in 
holding  out  the  prospect  of  definite  recovery.  A  patient  whit  has  passed  two 
years  without  a  relapse  may  be  regarded  as  comparatively  sale. 

Treatment. — The  'prophylactic  treatment  naturally  plays  a  most  prom- 
inent part  in  dealing  with  sympathetic  ophthalmitis,  and  it  seems  clear  that 
the  only  eei-tain  prophylaxis  is  the  enucleation  of  the  injured  eye.  When 
sympathetic  irritation  exists  and  there  is  no  special  reason  for  believing  that 
sympathetic  inflammation  will  appear,  resection  of  the  optic  nerve  may  be 
Substituted  for  enucleation.  This  is  often  the  case  in  eyes  which  have  been 
lost  from  other  causes  than  from  penetrating  wounds j  for  instance,  in  abso- 
lute glaucoma  or  where  inflammation  has  destroyed  the  entire  cornea  and 
phthisis  bulbi  has  followed.  It  would  be  safer  to  enucleate  an  eye  blind  from 
a  penetrating  wound.  When  the  eye  has  some  vision,  it  is  an  exceedingly 
difficult  question  to  decide.  The  best  guide  in  such  a  case  is  probably  the 
ten-ion  and  sensitiveness  to  touch.  If  the  eyeball  is  sensitive  to  the  touch 
and  the  tension  diminished,  and  at  the  same  time  only  light-perception  is 
present,  the  chance-  of  improvement  for  this  eye  are  bad,  and  especially  so 
if  these  condition-  persisl  for  several  day-  after  the  injury.  In  this  case 
enucleation   i-  indicated. 

W  hen  the  injured  eye  i-  blind  and  sympathetic  irritation  i-  present  in  the 
ol her  eye,  it  i-  best  to  enucleate. 

N\  hen  the  injured  eye  possesses  a  little  vision  and  symptoms  of  irritation 
appear  in  the  other  eye.  every  effort  must  be  made  to  improve  the  condition 
of  the  injured  eye;  and  this  mean-  to  apply  the  rules  governing  the  treat- 
ment  of  an  irido-cyclit  is. 

VI  hen  sympathetic  inflai ation  has  broken  out  the  injured  eye,  if  blind, 

should  be  removed  :  if  not  blind,  the  same  course  should  be  pursued  as  sug- 
gested when  thee lition  i-  that  of  sympathetic  irritation  in  the  second  eve 

— in    other    word-,    do    not    enucleate. 

A-  regards  medicinal  ag<  nts,  we  possess  nothing  which  exercises  a  specific 
influence  for  good  in  this  disease.  A.tropin  should  be  used,  but  always 
guardedly.     Absolute   resl   and   darkness  are  essential.      Hot    fomentations, 


CONGENITAL  ANOMALIES  OF  THE  OHORQID.  :;"»1 

such  as  have  been  described  in  the  treatment  of  iritis,  do  good  service; 
so  also  the  various  ways  of  applying  dry  heat.  Calomel  in  small  doses  is 
certainly  helpful.  Injections  of  pilocarpin  have  been  known  to  <lo  good. 
The  injection  of  one  drop  of  a  sublimate  solution  ( 1  :  1000)  has  been  strongly 
advocated  by  Abadie. 

The  influence  of  an  operation  is  hurtful  so  long  as  there  is  present  any 
evidence  of  an  acute  inflammation.  The  chief  obstacle  to  vision  is  the 
opaque  lens,  and  after  all  acute  symptoms  have  disappeared  ( Jritchett  suggests 
the  following  procedure:  A  fine  needle  is  directed  to  the  center  of  the  opaque 
capsule,  and  the  latter  is  pierced.  Another  needle  is  passed  in  from  the 
opposite  side,  and  by  bringing  the  penetrating  force  of  one  needle  to  hear 
upon  the  other  a  small  opening  is  made  in  the  capsule.  The  points  of  the 
needles  are  then  separated.  In  this  way  quite  a  rent  is  made.  There  is 
generally  an  escape  of  lens  matter.  Little  or  no  reaction  follows.  An 
interval  of  several  weeks  is  allowed  to  pass  to  permit  the  absorption  of  some 
lens  substance,  and  then  the  operation  is  repeated,  and  so  on,  the  operation 
being;  performed  every  time  with  two  needles.  Critchett  and  Story  report 
eases  where  useful  vision  was  obtained  by  this  operation. 

DISEASES  OF  THE  CHOROID. 

Congenital  Anomalies  of  the  Choroid. — Coloboma  of  the  cho- 
roid is  a  circumscribed,  frequently  half-spherical-shaped  defect  in  the  choroid 
and  retina,  as  seen  in  Fig.  I.,  Plate  3.  It  presents  a  brilliant  white  color 
(due  to  the  exposed  sclera)  with  the  ophthalmoscope,  and  it  will  be  observed 
that  the  surface  of  the  coloboma  is  distinctly  below  the  plane  of  the  retina  ; 
in  other  words,  the  surface  is  concave,  and  ridges  and  depressions  can  be 
seen  upon  it.  Generally,  two  or  three  fine  retinal  vessels  can  be  seen  to 
dip  at  the  edge  of  the  coloboma,  and  then  pass  on  over  the  surface  of  the 
latter.  The  coloboma  usually  begins  a  short  distance  from  the  optic  nerve, 
or  it  may  take  in  the  papilla,  and,  assuming  the  shape  described,  pass  down- 
ward and  come  to  a  stop  at  a  certain  distance  from  the  ciliary  body.  It 
may  reach  a  point  so  far  forward  that  its  anterior  border  can  no  longer 
be  seen.  The  border  of  the  coloboma  is  pigmented,  and  pigment-spots  are 
often  to  be  found  upon  its  surface.  Coloboma  of  the  choroid  is  generally 
associated  with  the  same  defect  in  the  iris.  Such  eves  are  sometimes  microph- 
thalmia. The  retina,  as  well  as  the  choroid,  may  be  absent  at  the  site  of 
the  coloboma,  and  only  the  sclera  remain  beneath.  At  other  times  the  retina 
maybe  present,  and  covers  the  coloboma  in  its  entire  extent.  Of  course 
there  is  always  a  defect  in  the  visual  field  corresponding  to  the  location  of 
the  coloboma.  According  to  Meyer,  myopia,  amblyopia,  and  accommodative 
asthenopia  are  often  present. 

White  depressions  of  various  sizes  situated  in  the  macular  region  are 
regarded  by  some  author-  as  similar  defects,  and  are  spoken  of  as  macular 
eolobomata,  while  Lindsay  Johnson  describes  them  as  the  atrophied  remains 
of  nevoid  growths  in   the  choroid. 

Coloboma  of  the  choroid  is  due  to  incomplete  closure  of  the  ocular 
fissure,  and  it  is  an  affection  which   in  a   marked  degree  is  transmissible  by 

inheritance  ( see  also  page    L92  ). 

Albinism. — This  is  a  condition  where  there  is  either  a  partial  or  complete 
absence  of  pigmenl  in  the  choroid.  The  affection  is  congenital.  The  pupil 
has  a  reddish  luster,  and  is  somewhat  -mailer  than  normal.  The  iris  ap- 
pear- reddish  by  transmitted   light.     This  latter  phenomenon   is  due  to  the 


352  />/s/:.is/:s  of  THE  choroid. 

fact  that  much  of  the  light  is  not  absorbed,  owing  to  the  lack  of  pigment. 
The  vessels  of  the  retina  and  choroid  may  be  plainly  seen  with  the  ophthal- 
moscope. Photophobia  is  the  rule  in  this  condition,  and  a  shady  place  is 
always  grateful  to  such   patients.     Nystagmus,  amblyopia,  and   high  degrees 

of  myopia  and  astigmatism  arc  usually  coincident  conditions.  The  cells 
which  usually  contain  the  pigment  arc  present,  but  the  pigment  itself  is 
absent.  The  affection  is  hereditary.  The  treatment  consists  in  measures 
to  ameliorate  the   photophobia  and   the  correction  of  the  refractive  error. 

There  is  a  condition  in  which  the  stroma  of  the  choroid  is  richly  pig- 
mented, while  the  epithelium  is  lacking  in  pigment,  and  consequently  is 
transparent.  Under  these  circumstances  the  so-called  choroidal,  intervascular 
spaces  exist,  which  look  very  dark,  owing  to  the  character  of  the  stroma- 
pigment.     This  condition   is  sometimes  seen  in  negroes. 

Hyperemia  of  the  Choroid. —  This  condition  undoubtedly  exists,  bul 
i-  questionable  whether  il  can  be  diagnosticated.  According  to  de  Schweinitz, 
we  may  assume  hyperemia  of  the  choroid  when  the  nerve-head  presents  dis- 
tinct redness,  which  is  imperfectly  differentiated  from  the  unduly  flannel-red 
appearance  of  the  surrounding  choroid,  or  when  the  choroid,  instead  of 
exhibiting  its  usual  red  color,  has  changed  into  what  has  been  denominated 
a  •'  woolly  choroid,"  with  faint  dark  areas  in  the  periphery,  indicating  the 
inter-pace-  between  the  choroidal  vessels  and  more  or  less  retinal  striatums 
surrounding  the  disk.  The  condition  is  ordinarily  supposed  to  he  i\uc  to 
"  eye— train,"  and  should  be  treated  accordingly.  Dark  glasses  and  complete 
resl  should  be  ordered  until  the  changes  described  have  entirely  disappeared, 
and  then  the  error  of  refraction  should  he  corrected. 

Choroiditis. — Inflammation  of  the  choroid  may  be  either  non-suppura- 
tir,  (commonly  called  exudative)  or  suppurative. 

1.  Exudative  Choroiditis. —  Etiology. — The  most  common  cause  is  syph- 
ilis, both  hereditary  and  acquired.  Any  profound  disturbance  in  the  nutri- 
tion, such  a-  scrofula  or  anemia,  may  give  rise  to  the  same  disease,  Meyer 
mention-  the  fact  that  this  form  of  the  disease  is  sometimes  found  in  women 
who  suffer  with  menstrual  disturbances  or  at  the  climacteric.  Myopia  can- 
not be  -aid  to  cause  choroiditis  in  the  same  sense  as  syphilis,  for  the  changes 
in    the    former  arc  more   of  the    nature   of  degenerative  changes  than  of  true 

inflammatory  one-,  ami  are  due  to  the  stretching  to  which  the  posterior 
segment   of  the  eyeball   i-  exposed   in   myopia  of  very  high  grade. 

Pathological  Anatomy.— The  histological  changes  are  usually  sharply 
defined,  and  correspond  to  the  opthalmoscopic  picture;  that  is  to  say,  there 
i-  no  general  involvemenl  of  the  choroid  except  in  cases  of  many  years' 
standing.  The  vessels  are  frequently  engorged,  and  round-cell  infiltration 
i-  found  near  them.  Small  open  spaces  containing  fibrin  and  hyalin  drops 
arc  often  Men.  Hemorrhages  are  occasionally  observed.  The  pigment- 
cells  are  sometimes  devoid  of  processes,  and  often  have  a  proliferation  of 
pigment.  Later  on  the  choroid  becomes  atrophied  and  fibrous,  and  the 
pigment-clumps  become  scarcer  and  may  disappear  entirely.  In  those  cases 
where  the  exudate  ha-  forced  its  way  into  the  layer  of  rods  and  cones,  this 
layer  may  l»e  completely  broken  up. 

The  following  interesting  changes  are  mentioned  by  Schweigger  as 
occurring  in  disseminated  choroiditis:  Little  nodules  are  seen  scattered 
through    the    3troma    of    the    choroid,    which  consist    of  nucleated    libers   and 

non-pigmented  cells.  The  surface  of  these  oodules  is  at  first  covered  with 
very  black  pigment  epithelium,  which  gradually  disappears  from  the  center 
outward,  so  that  we  have  the  well-known   picture  of  ,-i  white  area  surrounded 


Plate  3. 


Vic.  I.  -Coloboma  of  the  choroid  ;  the  case  also  bad  a  coloboma  of  the  lens. 
Fig.  II.  Disseminated  choroiditis ;  uearlj  oorcnal,  central  acuity  of  vision. 
Fig.  III.     Rupture  of  the  choroid  from  :l  blow  with  a  ball. 


CIIOHOIHITIS. 


353 


with  a  black  ring.  At  points  we  have  a  proliferation  of  the  pigment- 
epithelium.  The  new-formed  cells  contain  n<>  pigment.  When  the  process 
extends  into  the  retina,  we  have  an  elongation  of  the  radiating  fibers,  and 
they  sometimes  bend  abruptly  and  are  found  bound   fast   to  the  choroid. 

Symptoms. — With  the  ophthalmoscope  will  he  seen  yellowish-white  spots 
scattered  over  the  red  fundus  and  lying  under  the  blood-vessels  of  the  retina 
(recent  choroiditis).  As  time  goes  on  this  yellowish  color  disappears,  and 
U'ives  way  to  white,  which  is  an  indication  that  the  choroid  has  lost  its  pig- 
ment (atrophy)  and  that  the  sclera  is  exposed.  Specks  of  pigment  are  often 
to  be  -ecu  on  these  atrophic  areas.  Sometimes  the  exudates  are  very  -mall, 
and  are  found  either  isolated  or  in  groups,  and  located  in  various  parts  of  the 
fundus  (disseminated  choroiditis).  Dust-like  opacities  and  floating  membranes 
in  the  vitreous  body  are  common  in  exudative  choroiditis  (Fig.  IT.,  Plate  3). 

Disturbances  in  vision  are  always  present,  showing  themselves  in  narrow- 
ing of  the  field  and  loss  of  visual  acuity,  though  it  is  astonishing  how  good 
vision  may  he  in  cases  where  the  ophthalmoscope  shows  an  involvement  of 
apparently  the  entire  fundus.  The  patient  complains  of  seeing  specks  floating 
before  the  eyes.  Photophobia,  metamorphopsia, and  night-blindness  arepreseni 
in  a  certain  number  of  cases.  The  disturbances  in  vision  arise  partly  from 
the  opacities  in  the  vitreous  body,  and  partly  from  a  functional  disturbance 
of  the  retina,  which  is  always  to  some  extent   involved. 

In  the  earlier  stages  of  disseminated  choroiditis  there  is  often  a  coin- 
cident dilatation  of  the  retinal  blood-vessels,  owing  to  the  involvement  of  the 
retina.  This  variety  of  choroiditis  is  sometimes  called  syphilitic  choroiditis 
(see  page  419). 

Again,  in  the  vicinity  of  the  optic  nerve  rather  prominent  foci  of  inflam- 
mation, composed  of  transparent,  non-pigmented  tissue,  may  be  found  ;  and 
at  these  points  the  retina  is  atrophic.  These  areas  appear  at  first  as  deeply 
pigmented  spots,  having  a  bright  yellowish  center  and  surrounded  by  a   red 


Pig.  229.— Central  choroiditis  (DeWecker  and  .Tnopron.    The  circular  character  of  the  patch  and  the  ex- 
posure and  partial  atrophj  oithe  deep  vessels  are  well  shown. 

hyperemic  ring.      Later  on  these  areas  become  flatter,  are  bordered  with  pig- 
ment, and  traversed  by  choroidal  vessels.    This  is  areolar  choroiditis (Forst 
In  both  areolar  and  disseminated  choroiditis  the  regions  of  the  fundus   be- 
tween  the  diseased  area-  are  usually  sound  in  the  earlier  stages  of  the  affection. 

23 


354 


DISEASES  OF  Till:  CHOROID. 


Sometimes  the  exudates  arc  located  chiefly  in  the  macular  region  [central 
choroiditis,  Fig.  229).  The  disturbance  in  visual  acuity  in  this  variety  of  the 
affection  is  very  pronounced.  While  any  of  the  causes  mentioned  above  may 
give  rise  to  central  choroiditis,  it-  most  frequent  cause  is  myopia  of  high  grade. 
Among  other  special  causes  are  contusions  of  the  eyeball  ;  for  instance,  a  blow 
which  gives  rise  to  rupture  of  the  choroid  will  often  he  followed  by  choroidal 
changes  in  the  macular  region. 

The  macular  region  may  Ik-  the  seat  of  a  large  white  patch,  while  the  resl 
of  the  fundus  is  normal  [senih  areolar  atrophy  of  the  <-/mr<>i<l). 

Again,  in  the  same  locality  may  he  found  small  while,  glistening  -pot- 
closely  resembling  the  changes  which  are  seen  in  albuminuric  retinitis. 
Generally  these  changes  are  found  in  both  eyes.  They  constitute  the  senile 
guttate.  choroiditis  of  Tay  and  Hutchinson.  The  white  -pecks  are  due  to 
colloid  degeneration  of  the  choroid  (Fig.  2.30). 


Fig.  230.  -  Colloid  change  in  the  macular  region  (de  Schweinitz). 

Changes  in  the  macular  region,  consisting  of  white  plaques  of  various  sizes 
ami  shapes,  associated  with  atrophy  of  the  choroid  at  the  border  of  the  disk, 
are  often  -ecu  iii  high  grades  of  myopia,  and  are  spoken  of  as  myopic  choroid- 
itis. The  peculiar  crescent-shaped  area  at  the  disk  is  known  as  posterior 
staphyloma,  and  i-  to  he  attributed  to  the  protrusion  of  the  sclera  backward. 

Patches  of  choroidal  atrophy  may  he  found  at  any  point  in  the  fundus, 
and  may  result  from  various  causes,  as  from  the  action  of  brilliant  lighl  or 
the  glare  of  heat,  or  from  the  so-called  hemorrhagic  choroiditis  in  young  men 
(Hutchinson).  These  and  other  changes  in  the  choroid  which  are  typical  of 
no  special  lesion  are  regarded  as  unclassified  forms  <>f  choroiditis. 

Diagnosis. —  It  is  certain  that  in  the  majority  of  cases  there  are  changes 
in  the  retina,  so  this  condition  may  he  assumed  to  lie  present.  It  i-  very  often 
a  question,  however,  whether  the  exudates  -ecu  with  the  ophthalmoscope 
lie  in  the  retina  or  the  choroid.  Retinal  exudates  are  supposed  to  he  more 
opaque,  and  to  he  bordered  by  fine  radiating  lines  corresponding  to  the 
direction  of  the  nerve-fibers  (Meyer).  The  blood-vessels  of  the  retina  in 
retinitis  are  tortuous,  and  often  disappear  under  the  exudates,  while  the  course 
of  the  retinal  vessels  may  he  plainly  traced  when  the  exudates  lie  in  the 
choroid  ;  a  n<  I  thi-  rule  also  applies  to  I  he  -it  nation  of  pie  incut -ma— es.       Masses 

of  pigment  resembling  bone-corpuscles  are  always  situated  in  the  retina  (Net- 
tle-hip). 


CHOROIDITIS.  355 

Prognosis. — When  atrophy  of  the  choroid  has  taken  place,  the  outlook  is 
absolutely  bad.  Floating  opacities  in  the  vitreous  body,  as  a  rule,  persisl  in 
spite  of  all  treatment.  As  a  general  thing,  the  prognosis  in  choroiditis  is 
unfavorable,  and  worse  when  the  changes  are  prominenl  in  the  macular  region. 
Of  course  the  earlier  the  disease  is  recognized  the  inure  may  be  hoped  for 
from  treatment.  Those  eases  clearly  due  to  syphilis  offer  the  besi  chances 
for  improvement. 

Treatment. — Antisyphilitic  treatment  in  certain  cases  is  followed  by  im- 
provement, and  even  by  cure.  Recurrences  are  very  common.  In  cases 
where  syphilis  can  be  excluded  the  mercurials  and  iodid  of  potassium  through 
their  absorptive  power  do  good  service,  and  should  be  used.  The  applica- 
tion of  six  or  eight  leeches  or  the  artificial  leech  (Heurteloup)  to  the  skin 
behind  the  mastoid  process  has  been  strongly  recommended.  Good  results 
have  been  reported  from  the  injection  of-]-  grain  of  muriate  pilocarpin  every 
other  night.  Cod-liver  oil  and  iron  are  specially  indicated  in  children.  The 
eyes  should  not  be  used  for  work,  and  dark  glasses  are  advisable.  Subcon- 
junctival injections  of  bichlorid  and  cyanid  of  mercury  have  been  recommended 
by  Darier  and  others,  but  are  of  doubtful  value. 

2.  Suppurative  Choroiditis. — As  the  name  implies,  this  is  an  affection 
of  the  choroid  suppurative  in  character,  and  one  which  rapidly  involves 
the  iris  and   ciliary  body. 

Etiology. — -The  most  frequent  causes  are  injuries  from  penetrating  for- 
eign bodies.  Suppurative  choroiditis  sometimes  follows  unsuccessful  cataract 
operations.  Xo  matter  what  kind  of  instrument  produces  the  wound,  after 
all  infection  is  responsible  for  the  suppurative  process.  Sloughing  ulcers  of 
the  cornea  and  the  progress  inward  of  the  suppuration  may  be  responsible  for 
the  affection. 

The  disease  may  result  from  endogenous  infection — that  is  to  say,  from 
the  organism  itself.  In  these  cases  septic  substances  form  a  locus  of  inflam- 
mation, get  into  the  circulation,  and  are  carried  into  the  choroidal  vessels, 
and  here  stop  and  form  a  septic  embolus,  which  at  once  gives  rise  to  the 
choroiditis  (metastatic  choroiditis).  This  phenomenon  is  sometimes  seen  in 
the  pyemia  of  the  puerperal  state.  Suppurative  choroiditis  may  follow  cerebro- 
spinal meningitis  and  typhus.  Inflammation  of  the  umbilical  vein  and  throm- 
bosis of  the  orbital  veins  have  been  known  to  cause  the  disease. 

Pathological  Anatomy. — The  choroid  and  retina  are  enormously  thickened 
and  infiltrated  with  round-cells.  In  fact,  in  advanced  stages  the  choroid  and 
retina  lose  their  identity  almost  entirely,  and  we  simply  find  large  areas  made 
up  of  coagulated  material  and  round-cells,  with  here  and  there  a  clump  of 
pigment-granules.  The  exudate  having  found  its  way  into  the  vitreous  body, 
the  latter  i<  converted  into  a  homogeneous  mass  of  exudate.  Round-cell 
infiltration  of  the  iris  and  ciliary  body  is  seen  with  numerous  hemorrhages 
and  more  or  less  change  in  the  pigment-epithelium,  the  latter  changes  mani- 
festing themselves  either  in  a  breaking  up  or  in  an  entire  disappearance  of  the 
epithelium. 

Symptoms. — The  lids  are  red  and  swollen,  so  much  so  that  often  they  can- 
not be  opened,  and  the  orbital  tissue  is  frequently  so  infiltrated  as  to  interfere 
with  the  movements  of  the  eyeball.  The  conjunct iva  is  intensely  congested, 
often  reaching  the  grade  of  chemosis.  The  cornea  sooner  or  later  becomes 
clouded,  but  before  the  media  have  lost  their  transparency  one  can  see  the 
characteristic  yellowish  reflex  in  the  pupil,  arising  partly  from  the  mass  of  exu- 
date in  the  vitreous  body  and  partly  from  the  detached  retina.  1  [ypopyon  and 
anterior  synechia  are  usually  present.     The  intraocular  ten-ion  is  elevated  in 


356  DISEASES  OF  THE  CHOROID. 

the  earlier  stages,  the  pupil  i-  dilated,  and  the  anterior  chamber  shallow.  In- 
tense  throbbing  pain  is  fell  in  the  orbit  and  brow,  and  sight  is  Inst,  ('hills 
and  fever  are  frequently  present. 

Diagnosis. — Only  one  condition  simulates  the  peculiar  reflex  seen  in  sup- 
purative choroiditis,  and  that  is  glioma  of  the  retina.  Apart  from  the  general 
history,  there  is  this  marked  difference.  In  suppurative  choroiditis  the  ten- 
sion is  always  elevated  in  the  stage  when  it  is  apt  to  be  first  seen,  and  this 
condition  is  followed  soon  by  either  lowered  tension  or  by  bursting  of  the  eye- 
ball. In  glioma  the  tension  in  its  early  stages  is  normal,  and  increased  ten- 
sion does  not  make  it-  appearance  till  the  latter  stages  of  the  affection.  The 
previous  history  of  the  case  is  probably  the  most  reliable  basis  for  a  differ- 
ential diagnosis  (see  also  pages  400  and  494). 

Prognosis. — The  outlook  is  absolutely  had.  Loss  of  sight  and  shrinkage 
of  the  eyeball  [phthisis  bulbi)  are  the  ride. 

Treatment. — It  is  not  possible  to  put  a  stop  to  the  process,  so  all  that  can 
be  done  is  to  relieve  the  suffering  of  the  patient — locally  by  hot  applications, 
and  internally  by  the  administration  of  narcotics.  Violent  and  persistent 
pain  can  be  remedied  by  a  free  incision  in  the  sclera.  This  may  be  found 
necessary  in  those  cases  of  panophthalmitis  where  spontaneous  rupture  is  slow 
in  taking  place. 

As  to  the  advisability  of  enucleation  or  evisceration  in  the  acute  stages 
of  panophthalmitis,  there  is  a  difference  of  opinion.  While  a  few  cases  of 
death  have  been  reported  after  the  enucleation,  the  risk  is  very  slight,  and  it 
is  by  no  means  certain  that  the  operation  was  responsible  for  the  unhappy 
issue  in  those  few  cases.  Meningitis  has  been  reported  after  evisceration, 
and,   indeed,   where  no  operation   was   performed. 

Tuberculosis  of  the  Choroid. — This  condition  was  first  described  by 
•  I  iger,  and  later  by  -Manx,  Busch,  and  Bouchut.  The  tubercles  appear  as 
-mall,  round,  slightly  elevated,  reddish  or  gray  nodules,  varying  in  size  from 
0.3  to  2.5  nun.  The  spots  are  sometimes  quite  numerous,  even  as  many  as 
fifty  being  noticed,  and  they  are  distinguished  from  somewhat  similar  cho- 
roidal changes  in  that  they  are  not  surrounded  with  a  border  of  pigment. 
These  nodule-  are  usually  found   in   the   vicinity  of  the  optic  nerve. 

The  little  nodule-  on  anatomical  examination  arc  seen  to  possess  the 
typical  structure  of  tubercle-.  A  part  of  them  sometimes  undergoes  caseous 
degeneration  (Man/.).  Giant-cells  have  been  observed  in  them  (Ah),  and 
the  tubercli  bacillus  has  been  demonstrated.  According  to  Cohnheim,  the 
affection  form-  one  of  the  symptoms  of  acute  general  miliary  tuberculosis, 
and  it   may  aid  in  diagnosticating  the  constitutional  disease. 

Sometimes  a  solitary  tubt wele  is  observed,  which  grows  like  any  other 
intraocular  neoplasm,  and  finally  break-  through  the  sclera.  This  condition 
i-  a  rare  one,  and  i-  usually  associated  with  cerebral  tuberculosis,  and  is  an 
affection  peculiar  to  children. 

Treatment.— Miliary  tubercle-  demand  no  special  treatment,  but  enuclea- 
tion i-  the  proper  course  to  pursue  in  solitary  tubercle  in  order  to  prevent  a 
general   infection. 

Atrophy  of  the  Byeball. — Atrophy  of  the  eyeball  consists  in  a 
gradual  diminution  in  the  size  of  the  eyeball,  accompanied  with  diminished 
intraocular  tension  and  altered  3hape.  The  change  in  the  size  and  shape  is  to 
be  attributed  to  the  contraction  of  the  exudate-  within  the  eyeball — exudates 
which  have  resulted  from  the  plastic  irido-cyclitis.  Fucns  says  that  this 
condition  differs  from  phthisis  bulbi  in  thai  the  latter  affection  is  a  much  more 
rapid  one,  and  results  from  the  rupture  of  the  eveball  and  the  evacuation  of 


OSSIFICATION  OF  THE  CHOROID. 

its  contents.     After  panophthalmitis  the  eyeball  often  becomes  as  small  as  a 
hazelnut  or  even  smaller,  while  in  atrophy  no  such  stage  is  commonly  reached. 

Essential  Phthisis  Bulbi  (Ophthalmomalacia). — This  is  a  ven  rare 
affection  in  which  there  are  lowered  intraocular  ten-inn  and  diminution  in 
the  size  of  the  eyeball  without  any  assignable  cause.  Photophobia,  neuralgic 
pains,  myosis,  and  partial  ptosis  arc  sometimes  present.  The  condition  may 
last  for  several  days,  and  then  disappear  without  leaving  any  traces.  It  is 
supposed  to  he  due  to  a  lesion  of  the  sympathetic.     It  may  follow  injury. 

Rupture  of  the  Choroid.— Rupture  of  the  choroid  is  caused  by  a 
powerful  blow  upon  the  eyeball.  The  blow  ha-  the  effect  of  stretching 
the  sclera.  At  first  it  is  impossible  to  make  out  the  exact  nature  of  the 
trouble,  owing  to  the  extravasations  in  the  vitreous  body.  As  soon  as  the 
vitreous  body  becomes  transparent  one  can  see  a  long,  bright,  sickle-shaped 
streak  on  the  temporal  side  of  the  papilla,  and  with  the  concavity  of  the 
sickle  directed  toward  the  papilla.  When  first  seen  the  streak  is  yellowish 
in  color,  but  it  soon  becomes  white  and  ha-  a  pigmented  border.  Small 
spots  of  choroidal  atrophy  are  frequently  -ecu  in  the  neighborhood  of  the 
rent,  and  these  changes  may  invade  the  macular  region.  It  is  certain  that 
the  retina  and  sclera  are  both  injured.  The  retinal  vessels  will  generally  lie 
-ecu  passing  over  the  injured  point,  except  in  those  cases  where  the  retina 
itself  participates  in  the  rupture.  Xo  good  reason  has  been  advanced  a-  to 
why  the  posterior  part  of  the  choroid  i-  disposed  to  rupture.  We  may  have 
the  rupture  occurring  in  one  spot  or  in  several  spots  (Plate  3,  Fig.  III.). 

The  vision  at  first  is  almost  extinguished,  but  after  the  blood  in  the  vitre- 
ous clears  away  good  vision  is  often  restored.  Cases  are  reported  by  Knapp 
and  Saemisch  where  central  visual  acuity  returned  to  almost  the  normal  stand- 
ard. As  a  consequence  of  rupture  of  the  choroid,  retinal  detachment,  glau- 
coma, and  optic-nerve  atrophy  have  been  observed.  Traumatic  cataract  and 
dislocation  of  the  lens  are  also  complications  (see  page  364).  The  treatment 
consists  in  a  compress  bandage  and  atropin.  It  is  doubtful  whether  the  sub- 
sequent use  of  strychnin  or  iodid  of  potassium  does  good. 

Detachment  of  the  Choroid.— This  is  an  exceedingly  rare  condition. 
One  observes  a  round-looking  mass  projecting  into  the  vitreous  body.  The 
surface  of  this  ma—  i-  perfectly  smooth,  and  the  retinal  vessels  can  be  seen 
upon  it.  The  color  of  the  protuberance  i-  sometimes  yellowish,  with  pig- 
mented area-  here  and  there  about  it.  Meyer  says  it  may  be  distinguished 
from  detachment  of  the  retina  because  it  doe-  not  move  with  every  movement 
of  the  eyeball.  Detachment  of  the  retina  i-  usually  present.  The  ten-ion  in 
detachment  of  the  choroid  i-  always  diminished.  Mar-hall  thinks  that  the 
following  factor-  arc  necessary  to  cause  this  condition  :  hyalitis  with  shrink- 
ing ;  choroido-retinitis  leading  to  adhesions  an. I  serous  exudation  between  the 
choroid  and  sclerotic.1  Risley  report-  detachment  of  the  choroid  caused  by 
the  concussion  at   the  discharge  of  a  gun.2 

Ossification  of  the  Choroid.— This  is  not  infrequently  found  in 
shrunken  eyes  where  sight  has  been  lost  many  year-  previously.  A  thin 
shell  of  bone  is  found  in  the  posterior  part  of  the  eyeball,  with  a  small  hole 
in  its  middle  for  the  passage  of  the  optic  nerve;  or  sometimes  -imply  a 
spicule  i-  found.  The  mass  possesses  all  the  histological  characteristics  of 
bone  anywhere  else  in  the  body.  The  eyeball  is  often  painful  to  the  touch. 
and  it  may  give  rise  to  sympathetic  irritation  ;  so  enucleation  is  always  advis- 
able.    Calcareous  degeneration  is  also  common  in  eye-  of  this  character. 

1  '•  Detachment  of  the  Choroid,"  by  C.  D.  Marshall,  V  ■•  ■■.  Ophthul.  Soc.  U.  A.,  xvi.  p.  98. 
•  Amer.  Journ.  Ophthal.,  March,  1897. 


INJURIES   OF  THE   EYE  AND   ITS   APPENDAGES. 

Bi    AIAIN   A.   HUBBELL,  M.  D.,    Ph.D., 

OF    BUFFALO,    X.  Y. 


Tin:  eve  may  be  injured  in  a  great  variety  of  degrees  and  ways  by  con- 
tact with  overheated  substances,  as  hoi  vapors,  liquids,  or  solids;  or  with 
can-tie-  or  escharotics,  as  acids,  caustic  alkalies,  and  lime,  whereby  the  parts 
Income  burned  or  corroded  ;  or  by  mechanical  forces  or  bodies  impinging 
upon  it,  whereby  its  tissues  are  contused,  lacerated,  abraded,  cut,  or  pene- 
trated. 

Injuries  of  the  Cornea  and  Conjunctiva  from  Heat  and  Chem- 
icals.—  Heat  and  chemical  substances  affect  the  tissues  of  the  eye  similarly. 
The  anterior  portion  of  the  eyeball  i-  most  exposed  to  these  agencies,  and 
i-  therefore  more  frequently  injured  by  them,  the  palpebral  conjunctiva  suf- 
fering only  when  the  injurious  substance  gets  beneath  the  lids.  Burning 
gases  and  hot  water  or  oil  cool  quickly,  and  seldom  reach  the  surface  under 
the  lids.  Their  effects,  therefore,  are  more  superficial  and  less  extended  than 
those  of  hot  or  molten  metal-  or  of  chemical-  and  lime. 

When  the  injury  i-  superficial  a  whitish  film  is  formed  which  i-  soon 
thrown  off,  and  the  parts  rapidly  regain  their  epithelium  and  their  normal 
transparency  (Plate  4,  Fig.  [.).  When  the  injury  affects  the  deeper  tissues 
the  eschar  is  thicker,  and  it-  elimination  leaves  a  granulating  surface,  which 
on  healing  may  contract  or  lead  to  adhesions  if  it  i-  on  the  conjunctiva,  or 
produce  an  opacity  if  it  is  on  the  cornea.  Should  the  whole  thickness  of  the 
cornea  be  involved,a  perforation  will  take  place  with  all  of  its  consequences. 

Symptoms. — Besides  the  appearances  above  noted,  there  are,  imme- 
diately nfter  the  injury,  severe  burning  pain,  redness  of  the  eyeball,  and 
lachrymation.  Later,  active  inflammation  may  take  place,  with  increased 
redness,  mid  even  chemosis,  of  the  conjunctiva  and  swelling  of  the  lids. 
When  a  considerable  surface  of  the  conjunctiva  is  affected,  the  secretion 
becomes  muco-purulent,  and  sometimes  purulent.  Implication  of  the 
cornea   causes    much    pain    ami    impairment    of  vision. 

Treatment.  —  When  the  case  is  -ecu  immediately  and  the  injury  is  from 
an  add,  it  -hoiild  be  neutralized  by  the  application  to  the  affected  area  of  a 
weak  alkaline  solution.  For  thi-  purpose  bicarbonate  of  soda  or  bicarbonate 
of  potash  (saleratns)  may  be  used.  Tin-  latter  has  the  advantage  of  access- 
ibility, :i-  it  may  be  found  in  almost  every  house.  When  the  offending  agent 
is  lime,  eau-tie  -oda.  caustic  potash,  or  other  alkali,  it  may  be  neutralized  by 
an  acid  largely  diluted,  and  lure  vinegar,  diluted,  answers  the  purpose,  and 
generally  is  also  within  easy  reach. 

\ftcr  neutralizing  the  chemical  and  removing  such  foreign  substances  as 
may  lie  present,  the   parts  should  be  cleansed  with  some  mild  antiseptic,  and 


Plate  4. 


Pig.  I 


Fig.  II 


Fig'  I.     Burn  of  the  bulbar  conjunctiva  from  bichlorid  of  mercury. 

Fig.  II.     Rupture   of    the   sclerotic,    with    hemorrhage   into   the   anterior  chamber 

Siclidj. 


MECHANICAL   INJURIES  OF  THE  CORNEA. 


359 


Fig.  231.— Symblepharon  (Sichel). 


iced  cloths  kepi  constantly  applied  over  the  eye  till  the  burning  pain  lias 
ceased.      Frequent   instillations  of  a  cocain  solution   will   contribute   much 

toward  the  relief  of  the  pain.      The  subsequent  treatment  i-  tin    same  a-  that 
of'  conjunctivitis  or  of  ulceration  of  the  cornea  from  other  causes. 

In  cases  where  opposing  surfaces  of  the  conjunctiva  are  denuded,  hut  the 
retrotarsal  fold  i<  unaffected,  adhesion, 
or  symhlepharon  (Fig.  231  ),  may  he  pre- 
vented by  frequently  drawing  the  lid 
away  from  the  eyeball  or  by  interposing 
some  smooth,  flat  substance  between 
the  lid  and  hall.  But  when  the  denuda- 
tion includes  the  retrotarsal  fold,  such 
efforts  will  he  absolutely  fruitless  and 
may  as  well  he  withheld.  Should  the 
lesion  of  the  ocular  conjunctiva  he 
limited  in  extent,  it  may  be  covered, 
either  immediately  after  the  injury  or 
after  the  eschar  has  sloughed  off,  by 
drawing  the  surrounding  conjunctiva 
over  it  with  sutures  introduced  from 
side  to  side.  Sometimes  adhesions  can 
thus  be  very  much  restricted  or  even 
prevented. 

Mechanical  Injuries  of  the  Cornea  without  the  lodgement  of 
Foreign  Bodies. — These  injuries  include  scratches,  confusions,  superficial 
punctures,  and  erosions,  and   may  be  inflicted   in   a  multitude  of  way-. 

Symptoms. — Injury  of  the  cornea  is  determined  by  inspection,  aided  by 
oblique  illumination,  and  is  shown  by  loss  of  epithelium  and  irregularity  of 
the  injured  surface.  The  denuded  area  may  be  deteeted  by  coloring  it  with 
fluorescin  (page  145).  Should  ulceration  or  suppuration  of  the  cornea  take 
place,  there  will  be  added  the  appearances  which  these  conditions  usually 
present. 

There  is  a  scratching,  pricking  feeling  in  the  eye  at  first,  and  afterward 
there  may  he  severe  pain.  The  eyeball  becomes  red,  there  is  t'w(-  lachryma- 
tion,  and,  with  a  lesion  centrally  situated  on  the  cornea,  vision  is  more  or 
less  impaired. 

Prognosis. — This  depends  on  the  part  injured  and  the  progress  of  the 
case.  There  i-  impairment  of  sight  in  proportion  to  the  involvemenl  of  the 
•  •enter  of  the  cornea  and  the  distortion  of  it  which  the  injury  and  cicatriza- 
tion cause.  Wounds  of  the  cornea  are  extremely  liable  to  infection,  and  are 
therefore  prone  to  ulceration  or  suppuration. 

Treatment. — The  eye  should  first    lie  cocainized,  and   the   injured   parts 
gently   hut    thoroughly   cleansed    with     1  : 4000    solution    of   bichlorid   of 
mercury,  care  being  exercised  not  to  rub  away  or  loosen  the  adjacenl  corneal 
epithelium.     Atropin    solution    should    then    he    instilled    and    a     comp 
bandage  applied. 

The  subsequent  treatment  consists  in  using  some  form  of  antisepsis,  con- 
tinuing the  instillations  of  atropin.  and  keeping  the  eye  covered.  Should 
ulceration  or  suppuration  take  place,  it  i-  to  be  treated  a-  elsewhere  described 
(see  page  •"»!  5). 

Mechanical  Injuries  of  the  Conjunctiva  without  the  lodge- 
ment of  Foreign  Bodies. — The  conjunctiva  may  lie  cut,  lacerated, 
punctured,  or   contused    in    many    way-   and    by    many    kind-   "1    objects. 


360         INJURIES  OF  THE   EYE  AND   ITS  APPENDAGES. 

Symptoms. — An  effusion  of  blood  (ecchymosis  of  the  conjunctiva),  some- 
times only  Blight,  underneath  the  conjunctiva  at  the  site  of  the  injury  is  one 
of  die  mosl  constant  symptoms.  The  ecchymosis  usually  spreads,  and  may 
even  surround  the  cornea.  A  puncture  or  small  cut  is  not  always  apparent, 
but  when  the  wound  is  larger  it  i-  recognized  by  its  roughened  surface  and 
reddened  edges,  and  later  by  the  whitish  appearance  of  the  parts  denuded 
of  conjunctiva.  There  is  seldom  any  pain  beyond  a  scratching  feeling,  as 
it'  a  foreign  body  were  beneath  the  lid,  and  the  inflammatory  reaction  is 
seldom    marked. 

Treatment. — When  the  conjunctiva  is  cut  or  torn  in  such  a  manner  as  to 
•rap  or  produce  a  flap,  the  eye  should  be  cocainized  and  the  wound  closed  by 
tine  silk  sutures,  [nstillations  of  boric-acid  solution  afterward  are  usually  all 
the  treatment  that  is  necessary.  Should  the  ecchymosis,  however,  he  large 
and  disfiguring,  its  absorption  may  he  hastened  by  bathing  the  closed  eye 
with  water  a-  hot  as  can  he  hornc  for  fifteen  or  twenty  minutes  at  a  sitting, 
repeated   two  or  three  times  a   day. 

Injuries  of  the  Eyeball  from  Contusion,  Concussion,  and 
Compression. — A  blow  on  the  eye  by  some  blunt  substance,  or  striking  the 
eve  against  some  object,  or  a  sudden  compression  of  the  eyeball  by  some 
peculiarly  directed  force,  or  a  violent  explosion  near  the  eye,  may  result  in  a 
solution  of  continuity  and  contiguity  of  its  tissues,  without  their  being  pene- 
trated by  the  offending  agent  itself.  Such  lesions  are  single  or  multiple, 
and  consist  in  general  contusions  of  the  ball  ;  rupture  of  the  intraocular 
blood-vessels;  rupture  of  the  outer  coat  of  the  eye;  laceration  of  the  iris; 
displacement  of  the  iris;  laceration  of  the  ciliary  body;  detachment  of  the 
choroid  ;  rupture  of  the  choroid  ;  detachment  of  the  retina  ;  rupture  of  the 
zonula  ;  dislocation  of  the  lens  ;  rupture  of  the  capsule  of  the  lens  ;  iridoplegia  ; 
cycloplegia;  spasm  of  the  circular  fibers  of  the  iris;  spasm  of  the  ciliary 
muscle  ;  anesthesia  of  the  retina  ;  "  commotion  "  of  the  retina  ;  and  pigmenta- 
tion of  the  retina. 

Contusion  of  the  Eyeball. — A  blow  on  the  eye  may  bruise  the  tissues 
without  causing  any  apparent  laceration  or  other  lesion. 

Symptoms. — There  are  rednessand  tenderness  of  the  eyeball,  and  some- 
times pain.  Occasionally  there  is  produced  anesthesia  of  the  retina,  myd- 
riasis, loss  of  accommodation,  spasm  of  the  sphincter  of  the  iris,  or  spasm  of 
the  ciliary  muscle,  with  the  symptoms  belonging  to  each. 

Traumatic  amblyopia  or  amaurosis  (Berlin)  is  said  to  exist  when  the 
vision  becomes  slightly  and  transiently  impaired  or  entirely  and  permanently 
lost  without  visible  anatomical  change  in  the  retina. 

\  similar  condition  has  been  described  as  traumatic  anesthesia  qftheretina 
i  Leber).  This  i-  shown  by  weakness,  unsteadiness,  and  impairment  of  vision, 
with  restriction  of  the  visual  field — conditions  which  may  continue  for  several 
weeks  or  months  I  see  also  page  111). 

///  mydriasis  (iridoplegia)  the  pupil  is  usually  widely  dilated.  The  dila- 
tation may  disappear  in  a  few  days,  but  it  is  frequently  permanent.  While 
it  exists  vbion  is  dazzled  when  exposed  to  ordinary  daylight  from  the  admis- 
sion of  too  much   light   into  the  eve. 

Paralysis  <>(  tin  ciliary  muscle  {cycloplegia)  is  often  associated  with  myd- 
riasis, although  it  may  exist  alone.  The  patient  cannot  accommodate  for  near 
objects,  while  the  vision  lor  distance  may  not  be  affected. 

Spasm  <>i  tin  iris  and  ciliary  musch  is  indicated  by  a  contracted  pupil  and 
by  apparent  myopia. 

Treatment. — The  eye  should   be  given  rest,  cold  applications  should  be 


RUPTURE  OF  THE  EYEBALL.  361 

used,  pilocarpin  or  eserin  should  be  instilled  for  mydriasis  aud  loss  of  accom- 
modation, and  atropin  for  spasm.  Retinal  anesthesia  has  been  treated  by 
" suggestion,"  on  the  theory  thai   it   is  hysterical   in   it-  nature. 

Rupture  of  the  Eyeball.— Rupture  of  the  outer  coal  of  the  eye  is  of 
rare  occurrence,  and  is  produced  by  extreme  violence.  It-  location  is  scarcely 
ever  in  the  cornea,  hut  it  is  most  frequent  in  the  anterior  part  of  the 
sclera.  It  is  largely  determined  by  the  position  of  the  eye  at  the  time  of  the 
injury, which  is  usually  upward  ;  the  direction  of  the  blow,  which  i>  generally 
from  below  or  from  below  and  outward  ;  and  the  comparative  weakness  of 
the  sclera  between  the  margin  of  the  cornea  and  the  ciliary  region.  It  is 
found,  therefore,  in  most  oases  from  one  to  three  millimeters  behind  the  mar- 
gin of  the  cornea  in  the  upper  or  upper  and  inner  part  of  the  sclera.  Some- 
times it  is  in  the  upper  and  outer  part,  or  directly  inward  or  directly  outward. 
It  is  seldom  directly  outward.  The  rupture  usually  spans  one-third  to  one- 
half  of  the  periphery  of  the  cornea.  Partial  rupture  may  occur  in  which  the 
inner  filters  of  the  sclera  are  torn,  while  the  outer  one-  arc  more  or  less 
stretched.  Rupture  of  the  eyeball  occurs  almost  exclusively  in  adult-  (see 
Plate  4,  Fig.  II.). 

Symptoms. — A  rupture  of  the  eyeball  is  signalized  by  the  following 
symptoms  :  immediate  loss  of  sight,  which  may  or  may  not  be  regained  after- 
ward ;  softness  of  the  eyeball  ;  congestion  and  ecchymosis  of  the  conjunctiva  ; 
and,  when  the  conjunctiva  is  not  torn  or  the  rupture  is  not  situated  anterior 
to  its  circumcorneal  attachment,  the  presence  of  a  distinct  elevation  or  "  tumor" 
of  the  conjunctiva  from  the  extrusion  of  more  or  less  of  the  intraocular 
structures.  The  edges  of  the  rupture  are  ragged,  and  the  lens,  iris,  ciliary 
body,  choroid,  retina,  or  vitreous  humor  may  be  protruding  through  it  or 
entangled  in  it.  Sometimes  the  iris  or  lens  is  entirely  expelled  from  the  eye  or 
lodged  underneath  the  conjunctiva.  The  other  appearances  are  such  as  belong 
to  rupture  of  blood-vessels,  laceration  of  the  iris,  rupture  of  the  choroid,  and 
other  lesions. 

There  is  usually  very  little  if  any  pain  at  any  time,  unless,  as  sometimes 
happens,  severe  inflammation  supervenes. 

Prognosis. — The  prognosis  is  usually  very  unfavorable,  although  in 
exceptional  cases  useful  vision  has  been  known  to  return.  The  extensive 
lesions,  the  large  amount  of  hemorrhage,  the  excessive  loss  of  vitreous,  and 
the  inflammatory  reaction  are  generally  sufficient  to  produce  loss  of  vision 
and  shrinking  of  the  eyeball.  Should  the  wound  unite  imperfectly,  scleral 
staphyloma  may  follow.  Incarceration  of  the  iris  or  ciliary  body  in  the 
wound  or  a  laceration  extending  into  the  ciliary  body  may  cause  sympathetic 
ophthalmitis. 

Treatment. — When,  because  of  very  great  injury  of  the  intraocular  struct- 
ures, excessive  hemorrhage  into  the  vitreous  chamber,  or  extreme  collapse  of 
the  eyeball,  there  is  no  possible  hope  of  recovery,  time  ami  suffering  can  he 
Baved  by  enucleating  or  eviscerating  the  eye  at  once.  I  Jut  when  there  is 
reason  to  believe  that  there  is  a  possibility  of  the  eye  being  saved  with  par- 
tial vision,  the  practitioner  is  justified  in  making  an  attempt  to  do  so,  at  leasl 
for  two  or  three  week-,  during  which  time  there  is  scarcely  any  danger  of 
sympathetic  inflammation.  At  the  end  of  tin-  time,  it'  the  symptoms  promise 
well,  the  effort  may  he  continued.  Hut  if  not.  further  risk  should  not  he 
taken,  except   under  peculiar  and   pressing  circumstances. 

If  it  be  decided  to  try  to  save  the  <■}<■.  it  should  he  cocainized,  and  with 
strict  antiseptic  precautions  the  rupture  should  he  closed,  Vo  this  end  the 
conjunctiva,  if  not  already  ruptured,  should   he  opened  (contrary  to  the  old 


362  INJURIES  OF  THE  EYE  AND  ITS  APPENDAGES. 

practice),  and  all  extraneous  substances  carefully  removed,  both  from  the  out- 
side ami  from  between  the  lip-  of  the  wound.  Protruding  iri>,  ciliary  body, 
or  other  tissue  should  be  withdrawn  and  excised  or  cautiously  replaced,  as 
incarceration  would  interfere  with  solid  union  or  cause  irritation  in  the  future. 
Am  loose  shreds  hanging  from  the  edges  of  the  wound  should  also  be  cut  off. 
Having  thus  made  the  wound  as  clean  and  smooth  as  possible,  a  sufficient 
number  of  fine  antiseptic  sutures,  either  silk  or  catgut,  should  he  introduced 
from  within  outward  and  at  a  depth  sufficient  to  hold  firmly,  and  its  edges 
closely  drawn  together.  After  tying  and  cutting  off  the  threads,  the  wound 
should  be  covered,  if  possible,  by  conjunctival  flaps  held  in  place  by  suit- 
ably adjusted  sutures.  Catgut  sutures  may  be  allowed  to  remain,  hut  silk 
ones  should   be  removed   in   two  to  four  day-. 

Having  closed  the  wound,  a  solution  of  atropin  should  be  instilled,  the 
eye  bandaged,  and  the  patient  put  to  bed  and  kept  quiet  for  several  days. 
Cold  application-  are  useful,  especially  if  inflammatory  reaction  threatens. 
<  >ther  conditions  and  symptoms  arc  to  be  treated  as  they  arise  and  according 
to  direction-  given  elsewhere. 

When  a  case  is  not  seen  until  after  the  wound  has  united  the  practitioner 
is  generally  quite  powerless.  Prolapse  of  the  iris  may  be  reduced  by  the 
galvano-cautery.     Other  lesions  must  be  treated  according  to  indications. 

A  rupture  of  the  cornea  is  to  be  treated  similarly  to  that  of  the  sclera, 
except  that  it  is  not  usually  practicable  to  introduce  sutures  or  to  cover  the 
wound  with  conjunctival  Baps  (see  also  page  569). 

Rupture  of  Ocular  Blood-vessels. — Contusion  of  the  eyeball  may 
rupture  blood-vessels  of  the  iris  causing  effusion  of  blood  into  the  anterior 
chamber — lijijtlicmii — or  of  the  choroid  or  retina,  causing  effusion  of  blood 
into  or  beneath  these  membranes  or  into  the  vitreous  humor — hemophthalmia. 

Symptoms. — Then'  i-  seldom  any  pain  beyond  that  produced  by  the 
contusion.  The  presence  of  the  blood  usually  obstructs  the  vision,  either 
partially  or  totally.  When  the  Mood  is  in  the  anterior  chamber  it  settles  to 
the  dependent  portion,  and  its  upper  edge  or  surface  is  straight  (see  Plate  4, 
Fig.  II.).  It  i-  seen  in  its  natural  color  or  perhaps  a  little  darkened.  Blood 
in  the  vitreous  humor  appears  with  the  ophthalmoscope  as  a  dark  object,  and 
when  large  in  quantity  it  may  be  seen,  with  the  pupil  dilated,  by  oblique 
illumination  as  a  dark-red   reflection. 

Prognosis. — A  hemorrhage  into  the  anterior  chamber  of  a  previously 
healthy  eye  i-  absorbed  in  two  to  four  days,  but  one  into  the  vitreous  humor 
requires  weeks  or  month--  for  absorption,  and  when  it  is  of  considerable  size  it 
often  Leaves  permanenl  residues  and  opacities,  and  may  even  lead  to  disor- 
ganization of  the  vitreous  humor  and   shrinking  of  the  eyeball. 

Treatment. — 'flic  treatmenl  i-  limited  to  covering  the  eye.  giving  it 
rest,  and  instilling  ;i  weak  solution  of  atropin.  In  some  cases  it  may  he 
preferable  to  instil  pilocarpi n  instead  of  atropin.  Hot  water  or  hot  fomenta- 
tions continuously  applied  over  the  eye  for  fifteen  to  twenty  minute-  two  or 
three  time-  a  day  hasten  the  absorption  of  the  blood.  The  internal  admin- 
istration of  iodic!  of  -odium  or  similar  alterative  is  useful. 

Contusion-injuries  of  the  Iris;  lacerations  or  Ruptures  of  the 
Iris. — A-ide  from  hemorrhages,  the  most  common  lesions  of  the  iris  from 
blows  or  contusions  are  rents  or  lacerations.  In  extreme  cases  the  iris  may 
he  torn  entirely  from  ii-  peripheral  attachment  {traumatic  <iniri<li<i),  and 
when  the  eyeball  is  ruptured  it  may  be  expelled  from  the  eye  or  a  segment  of 
it  may  be  torn  away  instead  of  the  whole  (traumatic  coloboma).  Partial 
detachment  of  the  iris  from  its  periphery  at  s  or  more  points  (iridodialysis) 


DISPLACEMENTS  OF  THE  THIS. 


363 


is  the  form  of  rent  most  frequently  found.  Radial  lacerations  rarely  occur, 
ami  are  usually  at  the  pupillary  border  (rupture  of  sphincter). 

Symptoms. — Hemorrhage  is  usually  present  in  the  anterior  chamber  at 
first,  and  it  may  obscure  the  parts,     lint  alter  its  absorption  inspection  with 

or  without  oblique  illumination  will  reveal  a  laceration  or  rent  of  the  iris  if 
one  exists,  or  the  absence  of  the  iris  if  it  has  been  expelled.  When  it  has 
been  entirely  detached,  but  not  expelled,  it  will  be  seen  in  the  bottom  of  the 
anterior  chamber  as  a  rounded  mass,  dark  in  color  at  first,  but  soon  changing 
to  an  ash-gray.     It  rapidly  shrinks  to  an  inconspicuous  size. 

In  a  rent  of  the  pupillary  border,  involving-  a>  it  doe-  the  sphincter  of  the 
iri>,  the  pupil  is  widely  and  permanently  dilated  (Fig.  232). 


Fig.  232.— Radial  laceration  of  the  iris  (Harlan). 


Fig.  233.— Iridodialysis. 


Traumatic  coloboma  in  connection  with  rupture  of  the  sclera  should  not 
be  mistaken  for  retroflexion  of  the  iris. 

In  iridodialysis  the  rent  is  easily  discerned,  unless  very  small  and  hidden 
by  the  opaque  limbus  cornea?.  The  portion  of  the  iris  detached  retract-  toward 
the  centre  of  the  pupil,  and  the  latter  loses  its  circular  form  and  becomes 
somewhat  kidney-shaped  (Fig.  233).  With  the  ophthalmoscope  the  fundus- 
reflex  can  be  seen  through  the  new  opening  as  well  as  through  the  pupil. 

Treatment. — Very  little  can  be  done  to  remedy  mosi  of  these  Lesions. 
Dr.  Eugene  Smith  1  of  Detroit  has  suggested  that  iridodialysis  be  corrected 
by  making  a  small  incision  at  the  corneoscleral  junction  at  the  place  of  the 
detachment,  and  by  means  of  iris-forceps  catching  the  vd^v  of  the  iris  and 
drawing  it  into  the  incision.  It  is  usually  held  in  place  by  the  compression 
of  the  lip>  of  the  wound  ;  but  if  this  be  not  sufficient,  it  may  be  attached  by 
a  delicate  suture  to  the  neighboring  conjunctiva.  Before  attempting  this 
operation  all   irritation   from  the  original   injury  must   have  subsided. 

Displacements  of  the  Iris :  Retroflexion  and  Anteversion.— 
Both  retroflexion  and  anteversion  of  the  iris  arc  very  rare.  In  retroflexion 
a  part,  sometimes  the  whole,  of  the  iris  is  thrown  backward,  so  as  to  lie 
against  the  ciliary  body.  The  pupillary  portion  alone  may  be  thus  displaced, 
or  it  may  carry  with  it  the  whole  width  of  the  membrane.  It  occur-  almost 
exclusively  in  cases  where  the  lens  has  also  become  displaced.  Only  a  part 
of  the  circumference  of  the  iris  is  implicated  in  mosl  cases,  and  this  part 
becomes  invisible,  the  appearance  being  much  like  that  of  an  iridectomy. 
When   the  whole  iris  has  thus  receded   the  appearance  is  thai  of  aniridia. 

In  anteversion  a   portion  of    the  iris  is  torn  from   its    periphery  (irido- 
dialysis), and  the   loosened   segment   is  twisted  upon  itself  or  turned  ov< 
th.it  it-  posterior  surface  is  directed  forward.     The  exposure  to  view  of  the 
pigment-surface  of  the  iris  and   the  partial  or  complete  obstruction  of  the 

1  Joui  rud  of  tht  .  1  tru  i  ican  M<  du       I  Sept 


364  INJURIES  OF  THE  EYE  AND   ITS  APPENDAGES. 

pupil,  together  with  the  traumatic  opening  of   the   iridodialysis,  determine 

the  existence  of  this  double  lesion. 

These  displacements  call  for  no  treatment,  unless  the  vision  be  inter- 
fered with  in  anteversion  by  the  detached  membrane  lying  across  the  pupil, 
when  it  may  be  excised  by  an   iridectomy. 

Contusion-injuries  of  the  Ciliary  Body. — These  undoubtedly  may 
occur,  l>nt  outside  of  such  as  accompany  rupture  of  the  sclera  their  existence 
is  always  difficult  to  ascertain  and  their  diagnosis  is  doubtful. 

Contusion-injuries  of  the  Choroid. —  These  are  hemorrhage,  detach- 
ment, or  rupture. 

Hemorrhage  may  take  place  beneath  the  choroid,  into  its  substance,  or 
into  the  vitreous  humor.  In  itself  it  obstructs  the  visual  Held,  cither  as  a 
whole  or  in  section-,  according  to  its  extent  and  situation.  When  the  hem- 
orrhage is  in  or  beneath  the  choroid  it  may  be  small  or  large,  and  appears 
with  the  ophthalmoscope  as  a  bright-red  spot  of  irregular,  oval,  or  circular 
form.  The  retinal  vessels  pass  over  it  without  interruption.  In  extravasa- 
tions into  the  vitreous  humor  the  conditions  and  appearances  are  those  already 
described. 

Detachment  of  the  choroid  is  but  the  effect  of  a  subchoroidal  hemorrhage. 
It  disappears  with  the  absorption  of  the  blood,  and  unless  it  is  very  small  a 
long  time  will  he  required  to  accomplish  this  result.  Spots  of  localized  de- 
generation and  atrophy  of  the  choroid  will  he  left  with  pigmentary  deposits 
around  them   (see  also   page  357). 

Rupture  <>(  the  ch<>r<>i<l  is  usually  single  and  situated  between  the  optic 
disk  and  macula  lutea,  and  the  retina  is  seldom  involved.  It  is  generally 
curved  and  runs  vertically,  its  concavity  being  toward  the  optic  disk.  It 
varies  in  width  from  one-third  to  one-half  the  diameter  of  the  optic  disk, 
tapering  toward  its  extremities,  and  in  length  from  one  to  four  diameters. 
Exceptionally,  there  may  he  more  than  one  rupture,  or  it  may  he  branched 
and   its  direction   may  be  oblique  or  horizontal. 

The  rupture  cannot  he  seen  until  the  blood,  which  has  generally  been 
effused  into  the  vitreous  humor,  has  been  absorbed.  It  is  then  shown  by  the 
ophthalmoscope  a-  a  more  or  less  sharply  defined  rent,  at  first  yellowish  with 
red  margins,  and  later  white  with  pigmented  margins,  and  with  retinal  ves- 
sel.- passing  unbroken  across  it  (consult  Plate.'),  Fig.  III.).  Detachment  of 
tin    r<tin<i   sometimes   follows  cicatrization   of  a   ruptured  choroid. 

In  rupture  of  the  choroid  vision  is  at  first  much  reduced  or  lost.  After 
two  or  three  weeks  sighl  begins  to  return,  hut  it  is  seldom  fully  regained. 
There  is  always  left  a  scotoma  corresponding  to  the  rupture,  and  metamor- 
phopsia  is  a  common  sequence  (see  also  page  357). 

Concussion-injuries  of  the  Retina. — A  blow  on  the  eye  may  cause 
hemorrhage,  rupture,  detachment,  so-called  "commotion,"  or  pigmentation 
of  thi'   retina. 

A  retinal  hemorrhage  is  easily  recognized  by  its  elongated,  irregular  shape, 
by  the  break  of  continuity  of  a  retinal  vessel,  and,  if  near  the  macula  lutea, 
by  a  disturbance  of  vision  and  scotoma.  The  fi\^f~  of  the  rent  are  ragged 
and  thi'   choroidal  vessels  are  sometimes   exposed.        Whitish  cicatricial    lines, 

bordered  with  pigment,  are  -ecu  later  (Fig.  234). 

■•  Commotio  retina  "  is  a  term  used  to  designate  a  peculiar  effecl  charac- 
terized by  edematous  swelling  and  opacity  of  the  retina,  usually  at  the 
posterior  pari  of  the  eye  at  a  point  opposite  to  that  -truck.  It  begins  an 
hour  or  two  after  the  injury  in  disseminated  patches  as  grayish  or  "lotted 
opacities.     These  gradually  coalesce  and   become  more  dense,  until   there  is 


RUPTURE  OF  THE  ZONULA. 


365 


one  continuous,  whitish,  and  even  brilliantly  white  surface  of  ten  to  twelve 
optic-disk  diameters.  This  opacity  is  at  its  heighl  in  twenty-four  to  twenty- 
six  hours,  and  usually  disappears  in  two  or  three  days.  There  may  be 
retinal  hemorrhages,  and  the  retina  may  be  ruptured  or  fissured,  bul  its 
vessels   are   not    hidden   by  the  opacity. 

The  vision  is  much  reduced  or  abolished  at  first.  It  improves  for  a  short 
time  rapidly,  but  afterward  -lowly.  The  central  part  of  the  Held  is  that 
principally  affected,  and  there  seems  to  be  no  relation  between  the  state  of 
vision  and  the  extent  or  depth  of  the   opacity.      The   vision   is  further  dis- 


Fig.  l?A.— Ophthalmoscopic  appearance  of  traumatic  ruptnre  of  the  inferior  temporal  vein  (Oliver). 

turbed  by  astigmatism  caused  by  irregular  spasm  of  the  ciliary  muscle  and 
iris. 

Detachment  of  th<  retina  from  a  blow  is  not  different  in  character  and 
symptoms  from  that  due  to  other  causes  (page  428). 

Pigmentation  of  the  retina  is  another  result  of  contusion,  and  choroiditis, 
in  all  particulars  resembling  the  exudative  variety  of  thi-  disease,  may  have 
the  same  origin    (see  also   page  .'5o4). 

Treatment. —  In  all  these  lesions  the  eye  should  be  shaded  and  given  rest. 
Atiopin  should  be  instilled  when  there  is  evidence  of  spasm  of  the  iris  or 
ciliary  muscle.  Detachment  of  the  retina  is  to  lie  treated  like  the  non-trau- 
matic  form  of  the  disease  (see  page  4o0). 

Contusion-injuries  of  the  Crystalline  I^ens. — Contusion  of   the 
eyeball  may  cause   rupture  of  the  zonula,  dislocation  of  the   lens,  rupture  oi 
the  anterior  or  posterior  capsule  of  the   lens,  with  opacity,  or  there  may  lie 
opacity  of  the  lens  without  rupture  of  it-  capsule. 

Rupture  of  the  Zonula. — This  occurs  usually  in  connection  with  dislo- 
cati f  the  lens.     There   is  loss  of  accommodation  and  an   increase  of  the 


366 


INJURIES  OF  THE  EYE  AND   ITS  APPENDAGES. 


refraction  of  the  eye.  The  anterior  chamber  is  sometimes  deepened  and  the 
iris  tremulous. 

There  is  no  remedy  f<  >r  this   lesion. 

Dislocation  of  the  I^ens. — The  1ms  may  be  dislocated  in  differenl 
directions  and  degrees.  In  rupture  of  the  sclera  it  may  be  expelled  or  lodged 
beneath  the  conjunctiva.  It  may  be  tipped  or  turned  on  its  equatorial  plane, 
or  thrown  partly  through  the  pupil  and  there  held  by  the  sphincter  of  the 
iris,  or  it  may  l>e  completely  displaced  forward  into  the  anterior  chamber  or 
backward  into  the  vitreous  humor.  In  all  cases  the  zonula  i>  ruptured  and 
the  lens  sooner  or  later  becomes  opaque  (Figs.  235  and  236). 


Fig.  £i~i—  Dislocation  of  lens  into  the  anterior  cham- 
ber of  highly  myopic  eye  '1'-  Schweinitz). 


Fig.  236. — Subconjunctival  dislocation  of  tin-  lens 
de  Schweinitz). 


Symptoms. —  In  partial  dislocations  vision  become-  greatly  impaired  by 
the  irregular  refraction  of  the  margin  or  the  obliquity  of  the  lens,  or  by  its 
opacity.  When  the  lens  is  dislocated  into  the  anterior  chamber  and  remains 
transparent  the  retraction  is  increased  and  the  vision  is  myopic.  When  it  is 
completely  displaced  into  the  vitreous  humor  the  refraction  i-  diminished 
and   the   vision   is  that   of  an  aphakic  eye. 

A  transparent  lens  in  any  position  when  seen  with  the  ophthalmoscope 
gives  a  reddish  or  yellowish  reflex  through  it-  body,  while  its  margins,  if 
they  can  be  seen,  are  dark  or  quite  black.  When  in  the  anterior  chamber 
these  appearances  are  intensified,  and  it  i-  seen  as  a  pale,  yellowish,  or  "  pale- 
wine  yellow"  pellucid  body  with  a  brilliant  reflection  from  near  it-  edge  of  a 
golden  luster.  Winn  the  lens  i-  opaque  it  i<  shown  both  by  the  ophthalmo- 
scope and  oblique  illumination  ;i-  :i  rounded,  smooth,  dark  or  gray  body, 
sometimes  becoming  quite  white.  In  the  anterior  chamber  it  generally  causes 
much  irritation,  and  sometimes  severe  inflammation,  with  increased  ten-ion 
and  loss  of  vision.  In  the  vitreous  humor  it  causes  a  deepening  of  the  ante- 
rior chamber  and  the  iris  becomes  tremulous.  Sometimes  it  is  fixed  in  the 
bottom  of  tin  •  vitreous  humor,  and  sometimes  it  moves  about.  It  may  remain 
in  this  po-ition  without  doing  harm  for  a  long  time  ;  but  generally,  sooner  or 
later,  it  causes  glaucoma,  cyclitis,  ami  other  secondary  diseases,  and  even 
sympathetic  inflammation. 

Treatment. — A  lens  dislocated  under  the  conjunctiva  may  he  left  to  dis- 
integrate and  absorb,  or  it  may  be  removed  through  an  opening  in  the  con- 
junctiva. 

In  a  partial  dislocation  an  iridectomy  may  he  made  when  the  margin  of 
the  lens  lie-  in  the  axis  of  vision.     When  the   lens   i-   incarcerated   in  the 


PENETRATING    WOUNDS  OF  Tin;  EYEBALL.  367 

pupil  or  it  becomes  opaque, it  may  be  proper  to  dispose  of  it  !>v  discission  or 
extraction,  according  to  the  age  of  the  patient. 

When  the  dislocation  is  into  1 1 1  *  -  anterior  chamber,  an  effort  may  be  made 
to  reduce  it  by  gentle  pressure  or  rubbing  over  the  cornea,  either  with  or 
without  a  scleral   incision  behind  the  ciliary  body  to  diminish  the  ten-ion. 

Should  reduction  be  impossible  and  much  irritation  or  inflammation  be 
present,  the  lens  should  be  extracted  through  a  corneal  incision.  It  may  be 
supported  during  the  operation  by  the  "  bident"  of  Agnew. 

A  lens  dislocated  into  the  vitreous  chamber  need  not  be  disturbed  unless 
irritation  or  inflammation  take  place,  and  then  attempts  may  be  made  to 
extract  it.  This,  however,  isan  uncertain  procedure,  especially  with  a  floating 
lens,  which  it  i-  almost  impossible  to  %>  fish  "  out. 

In  any  form  of  dislocation  of  the  lens  its  extraction  is  necessarily  followed 
by  loss  of  vitreous  humor  (see  also  page  582). 

Rupture  of  the  Capsule  of  the  I^ens. — When  the  capsule  i-  torn, 
whether  anteriorly  or  posteriorly,  the  lens  gradually  becomes  opaque.  The 
rapidity  with  which  this  takes  place  depends  upon  the  size  of  the  rent.  In 
some  case-,  where  the  latter  is  very  small,  it  eloses  and  heals,  and  the  opacity 
remains  partial.  To  the  symptoms  of  cataract  are  added  those  of  the  irritant 
effeets  of  -welling  of  the  lens  or  the  exuding  of  its  substance  into  the  aqueous 
humor. 

The  pupil  should  be  kept  as  widely  dilated  as  possible  by  atropin,  and 
the  lens  should  be  extracted  when   its  swelling  causes  dangerous  reaction. 

Contusion  of  the  I^ens. — The  lens  may" be  bruised  or  contused  with- 
out rupture  of  its  capsule.  It  is  followed  by  opacity,  with  all  the  symptoms 
of  non-traumatic  cataract. 

The  treatment  is  that  of  spontaneous  cataract. 

Penetrating  Wounds  of  the  Eyeball. — Penetrating  wounds  of  the 
eyeball  are  generally  situated  in  its  anterior  part,  and  most  frequently  in  the 
cornea  or  corneo-scleral  junction.  They  assume  great  varieties  of  form,  size, 
and  shape,  some  being  so  small  as  scarcely  to  be  traced,  and  others  so  extensive 
as  to  destroy  a  large  portion  of  the  eyeball.  They  may  be  limited  to  the  ci  >rnea 
or  sclera  alone,  or  they  may  extend  deeper  into  the  iris,  lens,  and  the  structures 
beyond,  and  even  pass  through  the  eye  into  the  orbit. 

Symptoms. — The  symptoms  vary  with  the  nature  and  depth  of  the 
wound.  When  the  penetrating  object  is  small  only  a  minute  corneal  opacity 
or  abrasion  or  an  opacity  of  the  lens  will  mark  its  course.  Bui  when  a 
wound  is  of  larger  size  it  is  readily  seen  ;  the  evacuation  of  a  portion  of  the 
intraocular  fluids  causes  the  eyeball  to  become  softened,  and  there  may  be 
prolapse  of  the  subjacent  structures.  Hemorrhage  into  some  part  of  the  eve 
usually  takes  place.  Careful  examination  should  be  made  for  rent-  in  the  iris, 
opacities  of  the  leu-,  and  lesions  in  the  fundus  when  the  part-  are  not  ob- 
scured, using  the  ophthalmoscope  and  oblique  illumination  for  this  purpose. 

The  effect  of  penetrating  wounds  upon  the  state  of  vision  depend-  upon 
the  nature  of  the  lesions  present.  These  may  be  so  -light  a-  nol  t"  disturb 
vision  at  all.  or,  if  disturbed,  only  for  a  brief  time  ;  or  they  may  lie  so  ex- 
tended that  the  vi-inn  is  totally  and  permanently  lost.  Very  little,  if  any, 
pain   is  experienced,  unless  inflammation  develops. 

In  all  penetrating  wounds  there  is  great  danger  of  infection,  and  inflam- 
mation, with  or  without  suppuration,  i-  therefore  a  frequent  sequence.  An 
exuding  and  swollen  lens  is  also  a  potent   cause  of  iritis  and  cyclitis. 

Prognosis. — The  prognosis  depends  very  much  upon  the  situation  and 
nature  of  the  wound.     Opacities  of  the  cornea  and  leu-  may  obstruct  vision, 


368  INJURIES  OF  THE  EYE  AND   ITS  APPENDAGES. 

and  injury  of  the  retina  in  the  macular  region,  very  large  hemorrhages,  or 
men  loss  of  vitreous  may  at  once  destroy  it.  An  inflammation  of  the  iris 
and  ciliary  body,  caused  by  a  wounded  lens,  is  very  {liable  to  lead  to  obstruc- 
tion or  closure  of  the  pupil  and  softening  and  shrinking  of  the  eyeball. 
Punctured,  ragged,  or  gaping  wound-  of  the  ciliary  body  are  always  serious, 
and  they  especially  predispose  to  inflammation  of  the  fellow-eye  (page  347). 

Treatment. —  In  all  cases  the  strictest  antisepsis  should  be  observed. 
The  wound  should  be  freed  of  all  included  structures  by  excision  or  replace- 
ment, made  scrupulously  cl.an.  and.  whenever  possible,  closed  by  sutures 
and  conjunctival  Haps.  When  suture-  cannot  be  used  the  lips  of  the  wound 
may  often  be  approximated  or  completely  closed  by  a  compress-bandage  over 

the  eye. 

Hemorrhages  and  inflammatory  reaction  are  to  be  treated  as  elsewhere 
indicated.  In  some  cases  it  i-  besl  to  perform  an  iridectomy  and  extract  a 
wounded  and  swollen  lens.  This  will  sometimes  save  the  eye,  but  it  more 
often  fail-.  On  this  subject  that  master  of  ophthalmology,  Arlt,  has  said: 
'•  Such  removal  of  the  lens  is  to  be  considered  more  as  a  doubtful  remedy,  as 
we  seldom  succeed  in  removing  the  lens  as  a  whole,  or  even  its  greater  part, 
and  tlui-  do  not  obviate  the  dangers  of  mechanical  irritation  or  of  increased 
pressure;  perhaps,  indeed,  we  even   increase  them." 

The  causes  of  sympathetic  inflammation  not  usually  being  operative 
during  the  first  two  or  three  week-,  an  effort  may  be  made  in  some  cases  to 
save  the  wounded  eye.  Should  improvement  be  rapid  during  this  period, 
should  no  symptoms  of  cyclitis  appear,  and  especially  should  there  be 
promise  of  serviceable  vision,  such  effort  may  be  continued,  but  always  with 
a  great  deal  of  caution.  On  the  other  hand,  should  cyclitis  of  the  injured 
eye  develop  and  continue,  and  especially  should  vision  be  hopelessly  lost, 
enucleation   or  evisceration   should   lie   performed  before   the  expiration  of 

three    week-. 

There  are  Cases  in  which  the  eye  is  so  seriously  wounded  that  no  attempt 
should  be  made  to  save  it,  but  enucleation  or  evisceration  should  be  done 
without  delay. 

Foreign  Bodies  on  the  Conjunctiva  and  Cornea. — Minute  bodies 
of  various  kind-  may  become  lodged  on  the  conjunctiva  beneath  the  lids 
(usually  the  upper  one  near  the  center),  or  on  the  cornea,  becoming 
imbedded  in  it-  epithelium.  When  the  force  is  sufficient,  as  in  explosion-, 
they  may  be  driven  deeply  into  the  corneal  substance. 

A  foreign  body  on  the  conjunctiva  alone  i>  scarcely  felt,  but  when  on  the 
cornea  or  rubbing  against  it,  it  produce-  a  scratching  or  pricking  pain,  which 
i-    not    usually    severe.      There     is    considerable     lachrymation    and    the    eye 

bee ss  i<d.     If  the  body  i-  not   removed  soon,  it  may  excite  inflammation, 

particularly  if  it  is  on  the  cornea.  In  the  latter  case  also  it  may  cause  ulcera- 
tion of  the  cornea  at  the  point  where  it  is  lodged.  This  sometimes  extends 
and  causes  destruction  of  the  eye. 

The  foreign   body  i-  detected   by  careful   inspection,  aided,  if  necessary, 

by   oblique    illumination. 

Treatment. — A  body  which  i-  not  imbedded  deeper  than  the  epithelium 
of  either  the  conjunctiva  or  cornea  should  lie  picked  away  with  some  steril- 
ized, sharp-pointed  instrument.  When  one  is  driven  into  or  beneath  the  ocu- 
lar conjunctiva,  it  may  lie  excised,  taking  with  it  the  least  possible  amount 
of  tin-  membrane.  When  it  i-  imbedded  in  the  substance  of  the  cornea,  it 
should  be  jiicked  mil  with  as  little  injury  as  possible  to  the  surrounding 
tissue.     It    i-  generally  impossible  to  remove  grains  of  powder  in  this  way, 


FOREIGN  BODIES    WITHIN  THE  EYEBALL.  369 

and  they  can  be  allowed  to  remain  without  danger  of  ulceration  or  suppura- 
tion. They  simply  leave  black  stain-.  Dr.  Edward  Jackson  of  Philadelphia 
has  suggested  burning  them  out  with  a  galvano-cautery  point,  lint  such  a 
point  must  be  very  small  and  used  with  great  care,  or  the  effects  of  the  burn 
will  be  worse  than  those  of  the  powder.  It  should  aol  be  forgotten  that 
more  than  one  body  may  be  present  at   the  same  time. 

Foreign  Bodies  within  the  Eyeball. — Any  small,  hard  object,  such 
as  a  splinter  of  wood,  scale  of  iron  or  steel,  spicule  of  brass  or  copper,  frag- 
ment of  stone  or  glass,  ma)  be  projected  with  sufficient  force  to  penetrate  the 
coats  of  the  eye  and  become  lodged  at  any  point  within  them.  It  usually 
enters  through  the  anterior  part  of  the  eye.  and  most  frequently  through  or 
very  near  the  cornea. 

Symptoms. — The  symptoms  are  essentially  those  of  a  penetrating  wound, 
to  which  are  added  such  as  are  caused  by  the  presence  of  the  foreign  body. 
The  latter  arc  at  first  negative,  but  later  unusual  irritation  and  inflammation 
develop,  with  corresponding  symptoms. 

Diagnosis. — The  history  of  the  accident  is  of  great  importance.  The 
circumstances  under  which  it  happened,  the  occupation  engaged  in.  the  small 
size  of  the  object  striking  the  eye,  the  direction  of  its  course,  whether  or  not 
it  was  seen  after  striking  the  eye.  the  immediate  effect  on  vision,  and  kindred 
information,  should  be  ascertained,  if  possible.  Unfortunately,  such  infor- 
mation is  often  very   incomplete. 

If.  at  the  time  of  an  explosion  of  a  percussion-cap  or  the  discharge  of  a 
shot-gun,  or  while  hammering  iron  or  steel  or  cutting  stone,  a  small  object 
that  was  not  afterward  seen  has  struck  the  eye  and  perforated  the  cornea  or 
sclera,  the  probability  that  it  has  entered  the  eye  i>  so  strong  as  t<>  become 
almost  a  certainty.  The  reason  >f  this  is  apparent  when  it  is  remembered 
that  the  resistance  of  the  intraocular  fluids  is  not  sufficient  either  to  check 
the  course  of  the  body  or  to  cause  it  to  rebound,  and  a  force  which  was  great 
enough  to  cause  it  to  cut  through  the  tough,  outer  coat  would  carry  it  farther 
into  the  eye  after  the  opening  was  made. 

With  such  a  history  and  the  presence  of  such  a  wound  most  careful 
search  should  he  made  for  a  foreign  hotly.  Hemorrhages,  corneal  irregulari- 
ties, and  opacities  of  the  lens  or  vitreous  humor  greatly  obstruct  the  exam- 
ination ;  hut  when  the  media  are  not  obscured,  and  when  the  object  i-  not 
hidden  hy  it-  position  or  by  exudates,  the  ophthalmoscope  and  oblique 
illumination  will  often  convert  the  suspicion  of  its  presence  into  a  certainty. 
A  metallic  object  in  the  vitreous  chamber  gives  a  lustrous  reflection  when 
-ecu  with  the  ophthalmoscope. 

When,  from  any  cause,  a  foreign  body  cannot  lie  -ecu.  it  may  in  rare 
instance-,  if  of  considerable  size  and  near  the  surface,  he  felt  by  a  probe \ 
hut  this  should  he  used  with  great  caution. 

When  the  body  i-  -tee)  or  iron  the  electro-magnet  will  often  assisl  in 
diagnosis.  A  strong  one  applied  to  the  surface  of  the  eyeball  will  sometimes 
attract  the  iron  or  steel,  and  the  movement  of  the  latter  will  cause  more  or 
less  pain.  Or,  if  the  wound  i-  so  situated  a-  to  warrant  it.  an  extension- 
point  of  the  electro-magnet  of  suitable  size  may  he  carefully  introduced  into 
it.  when  it  will  sometimes  not  only  attract  the  body  t<>  the  surface,  bul  bring 
it  out. 

The  special   adaptation  of  Rontgen's  rays,  or  skiagraphy,  to  the  ey 
oftentimes  demonstrate  the  presence  of  a  foreign  body  and  also  it-  appr 
mate  position    see  Appendix,  pages  607—61  1  ). 

Should  it  he  impossible  by  mean- of  sight,  touch,  the  electro-n 

21 


370  INJURIES  OF  THE  EYE  AND  ITS  APPENDAGES. 

skiagraphy  to  ascertain  the  presence  of  a  foreign  body  beyond  doubt,  the 
presumptive  diagnosis  of  its  presence  based  upon  the  history  and  conditions 
above  outlined  should  prevail.  In  case  of  delay  such  symptoms  of  irritation 
and  inflammation  may  set  in  as  could  scarcely  be  expected  as  a  result  of  the 
wound  alone.  These  will  strongly  corroborate  the  other  evidence  of  the 
presence  of  a  foreign  body.  The  eye  may.  however,  remain  quiet  in  excep- 
tional cases,  but  this  is  not  sufficient  to  outweigh  the  primary  evidences  and 
to  nullity  the  diagnosis  of  a   foreign   body  in  the  eye. 

Prognosis. — When  a  foreign  body  is  lodged  in  the  eye  the  consequences 
of  a  penetrating  wound  follow  which  have  already  been  considered,  together 
with  those  arising  from  the  presence  of  the  foreign  body  itself. 

A-  regards  the  latter,  it  may  be  said  that,  however  small  the  body  may 
be,  whatever  may  be  it-  substance,  and  wherever  it  may  be  situated,  it  sooner 
<>r  later,  with  rare  exceptions,  causes  destructive  inflammation  of  the  injured 
eye,  and  may  also  induce  sympathetic  inflammation  of  the  other.  The  only 
structure  which  will  tolerate  a  foreign  body  without  danger  of  inflammation 
i-  the  leu-.      Even  here  vision  is  obscured  by  the  lens  becoming  opaque. 

<  lases  have  been  recorded  in  which  the  membranes  of  the  eye  or  the  iris 
have  tolerated  a  foreign  body  for  a  long  period  of  time,  or  in  which  one  has 
become  encysted  and  remained  harmless,  or  in  which  one  has  been  spon- 
taneously expelled  ;  hut  they  are  so  rare  as  not  to  have  material  weight  in 
prognosis  or  treatment.  In  every  case  it  should  be  assumed  that  the  eye  is 
sure  to  be  lost  unless  the  offending  body  is  removed.  After  its  removal  the 
eye  is  in  the  condition  of  one  with  a  penetrating  wound,  and  may  or  may  not 
be  saved  according  to  the  circumstances  of  the  case. 

Treatment. —  In  some  cases,  although  the  foreign  body  may  be  found  and 
removed,  the  injury  i-  so  extensive  that  the  eye  is  hopelessly  lost.      Immediate 

enucleati r  evisceration  is  then  the  safest  procedure.     But  when  the  nature 

of  the  injury  will  permit,  all  reasonable  effort  should  be  made  to  remove  the 
foreign  body  and  save  the  eye  with  as  much  vision  as  possible. 

W  Inn  the  presence  and  location  of  a  foreign  body  have  been  determined, 
the  course  to  pursue  will  depend  on  what  substance  it  is  and  on  its  position. 
It'  situated  in  the  anterior  chamber  or  iris,  it  may  be  extracted  with  or  with- 
out excising  a  piece  of  iris  through  an  incision  at  a  suitable  point  in  tin' 
cornea.  If  lodged  in  the  lens,  it  may  be  left  there  until  the  latter  has  become 
fully  opaque,  and  then  both  may  be  extracted  together.  Or,  should  the 
wounded  leu-  become  absorbed,  the  foreign  body  may  then  be  treated  as  if  it 
were,  from  the  first,  lodged  in  the  anterior  chamber  or  perhaps  in  the  vitreous 
humor. 

\\  hen  a  body  i-  lodged  in  the  posterior  part  of  the  eye  it  may  sometimes 
be  caught  by  forceps  (without  teeth),  hook-,  or  -coops,  and  drawn  out.  But 
Such  a  happy  re-ult  is  not  often  obtained. 

Should  tin'  foreign  body  be  steel  or  iron,  the  electro-magnet  (Fig.  '-M )  is 
of  greai   service,  and  the  chances  of  extracting  the  fragment  are  increased 

many    fold.       Wry    large    and    powerful    electro-magnets,    which    have    lately 

been  introduced  by  Haab, are  noi  often  available,  and  the  smaller  instruments 
give  eminent  satisfaction.  The  electro-magnel  should  be  armed  with  as 
short,  and  also  a-  large,  an  extension-poinl  a-  can  be  consistently  introduced, 
since  the  attractive  force  is  diminished  very  rapidly  as  the  point  becomes 
-mailer  and  longer.  The  point  should  also  be  Battened  or  squared,  instead 
of  rounded,  to  give  a-  much  surface-contacl  a-  possible.  A  rounded  point 
reduces  this  to  a  minimum. 

The  extension-point   may  be  introduced  through  the  original  wound,  or, 


INJURY  OF  THE  EYELIDS  AND   LACHRYMAL    PASSAGES.  371 

which  is  often  preferable,  through  an  incision  suitably  located  and  made  for 
the  purpose.  It  should  be  carried,  wit  Ik  mi  twisting  it  or  changing  it-  course 
toward  the  supposed  or  known  position  of  the  fragmenl  and  reintroduced  if 
necessary.  Should  it  attract  the  steel  or  iron  or  in  any  way  come  in  con- 
tact with  it,  it  will  generally  produce  a  distincl  click  which  can  be  both 
felt  and  heard.  On  withdrawing  the  point  the  steel  or  iron  is  broughl  out 
with  it,  or  perhaps  it  is  held  hack  at  the  wound,  when  the  point  should  be 
partially  reintroduced,  and  the  extraction  then  assisted  by  forceps  made  of 
some  other  material  than  iron  or  steel. 

After  removal  of  the  foreign  body  the  case  becomes  one  of  a  penetrating 
wound  of  the  eve,  and  should  be  treated  accordingly. 

Should  it  he  impossible  to  remove  a  foreign  body  whose  presence  is  ex- 
tremely probable  or  definitely  determined,  the  vision  being  without  doubt 
permanently  lost,  the  eye  should  be  enucleated  or  eviscerated.  A  delay, 
however,  may  he  made  for  a  short  time,  as  in  penetrating  wounds,  when  there 
remains  some  vision  and  the  diagnosis  i-  doubtful.  Eapid  improvement  and 
absence  of  symptoms  which  point  to  sympathetic  disease  may  justify  still 
further  delay,  hut  with  a  continuance  of  inflammatory  symptoms  and  a  pro- 
gressive deterioration  of  sight,  if  this  was  not  destroyed  at  first,  the  delay 


G.TIEMANN  &C0.N.Y. 


Fig.  237. — HubbeU's  electro-magnet,  actual  size :  .1.  .1.  t-ni  1  -  .it  cords  connecting  tin-  magnet  with  a 
galvanic  battery;  B,  slide  for  opening  and  closing  electric  circuit ;  C,  end  of  core  tapped  to  recen  e  the 
extension-points.    The  extension-points, a  few  of  which  are  shown,  may  tic  of  any  desired  length,  shape, 

curve,  or  size. 

should  not  extend  beyond  two  or  three  weeks,  as  after  this  time  sympathetic 
inflammation  becomes  imminent  at  tiny  moment. 

Injuries  of  the  Eyelids  and  lachrymal  Passages. —  Ecehymosis 
of  t/i<  eyelids  follows  contusions  and  wounds,  and  also  hemorrhages  into  the 
orbit  and  around  the  eyeball.  The  discoloration  of  the  skin  varies  in  depth 
and  extent  with  the  amount  of  blood  extravasated.  There  i-.  occasionally, 
swelling  of  the  parts  and  a  feeling  of  stiffness,  but  no  pain.  The  blood  is 
absorbed,  and  the  -kin  regains  its  normal  color  in   from  one  to  three  week-. 

Verv  little  treatment  is  necessary.  Absorption  of  the  blood  may  be 
hastened  by  bathing  the  parts  with  water  as  hot  as  can  he  borne  and  by 
gentle  frictions. 

Emphysema  of  the  eyelids  may  take  place  when  the  mucous  membrane  ^C 
the  Dose  becomes  torn   in   connection  with  a    fracture   or  injury  involving  the 
nasal  cavities,  and  a  communication  is  established  between  the  latter  and  the 
cellular  -pace-  of  the  lid-,  and  air  is  forced  into  them  by  blowing  of  th<   • 
The  part-  are  immediately  puffed  up  into  a  -oft.  crepitating,  and  pai 
swelling. 

The  patient  should  he  cautioned  against  further  blowing  of  tl  e  till 


379 


INJURIES   OF  THE   EYE  AND   ITS  APPENDAGES. 


after  the  wound  is  healed.     A  compn — bandage  should  be  applied  over  the 

lids,  and  the  air  will   lie  absorbed   in  a   few  days. 

Contusions  of  the  lids  arc  generally  followed  by  ecchymosis  with  some 
swelling  and  soreness.  Tiny  should  lie  treated  by  cold  applications,  unless 
suppuration  lake-  place,  ami  then  warm  fomentations  should  be  used,  and  the 
abscess  opened  early  by  incision. 

Punctured  wounds  are  generally  of  little  consequence,  bul  the  incased  and 
lacerated  varieties,  especially  the  latter,  require  careful  attention.  When  a 
wound  runs  parallel  with  the  edge  of  the  lid  it  will  unite  without  deformity. 
But  when  it  extends  across  the  orbicularis  muscle  or  through  the  margin  of 
the  lid.  the  wound  gaps,  and  if  not  closed  by  surgical  measures  leaves  a  de- 
pression of  the  surface  or  a  permanent  cleft  through  the  edge  of  the  lid. 
When  the  lachrymal  canals  arc  severed  they  become  permanently  closed. 

The  utmosl  eaie  should  be  taken  to  close  all  gaping  wound-  ami  to  restore 
t,>  proper  position  displaced  part-.  The  loss  of  skin  may  call  lor  a  plastic 
operation.  When  a  lachrymal  canal  has  been  severed,  it  should,  if  possible, 
he  searched   for  and  -lit  up  and   kept  open. 

Foreign  bodies  may  become  lodged  beneath  the  skin,  and  should  he  re- 
moved by  cutting  down  upon  them  and  picking  them  out. 

They  may  also  gel  into  the  lachrymal  punctum  or  canal,  and  cause  irrita- 
tion of  tile  hall  by  rubbing  against  it,  or  stillicidium  by  obstructing  the 
passage.  They  are  easily  withdrawn  when  they  arc  in  sight,  hut  when  nut  it 
will   he  necessary   to  -lit   open   the  canal  and   then   remove  them. 

Injuries  from  //<//  substances  and  escharotics  produce  the  same  symptoms 
and  require  the  same  general  treatment  a-  those  occurring  elsewhere  on  the 
surface  of  the  body  (see  Fig.  238).     The  unsightly  and  distressing  deformity 


and  loss  of  function  which  follow  cicatrization  should  he  prevented  by  skin- 
grafting,  preferably  by  Thiersch's  method.  To  thi-  end.  a-  soon  a-  the 
eschar  i-  thrown  oil'  and  the  granulating  process  is  well  established,  the 
afiected  Burface  Bhould  he  scraped,  and  the  grafts  applied  a-  described  in 
surgical  treatises.     This   part   of  the  treatment   cannot  he  ton  forcibly  urged. 


GLAUCOMA. 


By  J.  A.   LIPPINCOTT,  A.B.,  M.D., 

OF    PITTSBUBG.    PA. 


General  Considerations.— The  term  " glaucoma "  is  applied  to  a 
group  uf  phenomena,  the  most  prominent  of  which,  apart  from  a  greater  or 
less  degree  of  impairment  of  vision,  are  an  increase  in  the  hardness  of  tht 
eyeball  and  an  excavation  in  tin  hunt  of  the  optic  nerve.  Brisseau  in  the  last 
century  and  Weller  and  Mackenzie  early  in  the  present  directed  attention  to 
the  first  of  these  two  characteristics,  the  great  English  observer  especially 
dwelling  on  its  importance  and  systematically  employing  a  rational  method 
of  relieving  it — viz.  puncture  of  the  sclera  and  of  the  cornea. 

To  determine  the  pressure  and  degree  of  abnormal  tension  palpation  is 
employed  in  the  manner  described  on  page  170.  A  number  of  tonometers, 
or  mechanical  substitutes  for  the  fingers,  have  been  devised,  but,  owing  to 
defects  which  are  possibly  irremediable,  they  are  not   in  general   use. 

In   recording  the   results  of  palpation  of  the  globe  the  method   usually 
employed  is  that  suggested   by   Bowman,  according  to  which   T.  -land-  for 
normal   tension;  T.  —  ?  tension  probably  increased ;  T.  -   1    and   T.      2  -till 
higher    degrees  ;     while    T.       3     indicates 
stony   hardness.      Care  is   required   not  to 
mistake  the  rigidity  of  a  thickened  eyelid  * 

or  that  of  an  abnormal  sclera  for  an  actual 
increase  in  intraocular  tension.  In  doubt- 
ful cases  the  finger-tips  may  be  placed  on 
the  naked  eyeball.  In  investigating  ocular  ±mi^*_tf& 
tension  the  tactus  eruditus  is  an  essential 
qualification,  and  no  opportunity  of  acquir- 
ing it  should  be  neglected. 

The    excavation   of   the    optic  nerve    in 
glaucoma   involve-   the  whole  or  nearly  the  J 

whole   surface  of    the    disk,   and   attain-  a 
considerable  depth.     It-  sides  are  steep  or 

even   undercut,  SO  thai   the    Cavity  is  ampul-        Fig.  239.    Glaucomatous  excavation. 
lilbrm — i.e.  bulging  in   its  deeper  portions. 

Viewed  with  the  ophthalmoscope,  the  blood-vessels  are  crowded  toward 
the  nasal  side,  and,  as  they  dip  into  the  pit.  make  a  -harp  bend,  and  fre- 
quently disappear  behind  the  overhanging  margins.  When  they  reappear  on 
the  floor  of  the  excavation  they  are  less  distincl  and  lighter  in  color,  and 
their  continuity  i-  apparently  broken,  owing  to  parallactic  displac 
From  the  same  cause  they  appear  to  move  more  -lowly  in  response  to  later: 
movements  of  the  objeel  leu-  used  in  the  indirect  examination  than  they  do 


374 


GLA  UCOMA. 


at  the  level  of  the  retina.  Od  making  use  of  the  direct  method  a  stronger 
concave  or  weaker  convex  lens  is  required  than  the  one  u>vd  for  the  neigh- 
boring retina]  surface.  This  difference  in  refraction  constitutes  a  mean-  of 
accurately  measuring  the  depth  of  the  excavation,  an  interval  of  three 
diopters  corresponding  to  about    1   nun. 

Arterial  pulsation  is  either  spontaneous  or  is  easily  induced  by  light  pres- 
sure with  the  finger.  This  phenomenon  is  a  result  of  the  increased  intra- 
ocular pressure,  which  is  sufficient  to  retard  the  arterial  current,  except  when 
the  latter  feels  the  onward  thrust  of  the  cardiac  systole.  The  blood  thus 
enters  j»r  saltum,  instead  of  continuously  as  under  normal  conditions.  Spon- 
taneous venous  pulsation  i-  common. 

The  disk  -hows  a  bluish  or  greenish  pallor,  and  is  surrounded  by  a  more 
or  less  complete  ring,  which  sometimes  appears  yellow,  probably  by  contrast 
with  the  color  of  the  disk.  This  ring  is  due  to  atrophy  of  the  choroid  and 
i-  known  a-  the  glaucomatous  halo  (Fig.  239).  A  low-grade  neuritis  is  com- 
monly to  be  detected  in  the  nerve-head  containing  the  pathologic  excavation. 

In  common  with  most  of  the  symptoms  in  glaucoma,  the  cupping  of  the 
optic  disk   is  a  consequence  of  the   increased   intraocular  tension,  the   latter 


-:.  \  ( 


Fig.  240.— Glaucomatous  excavation,  microscopic  section. 

taking  most  effect  at  the  least  resisting  portion  of  the  ocular  envelope — viz. 
the  lamina  cribrosa.  It  is  probable  that  the  process  is  favored  in  many 
cases  by  inflammation  with  softening  and,  later,  cicatricial  contraction  of  the 
tissues  in  this  region;  and  this  factor  would  appear  to  be  sometimes  suf- 
ficient  in  itself  to  produce  an  excavation  indistinguishable  ophthalmoscopi- 
cally  from  one  known  to  result   from  abnormally  high  pressure  (Fig.  240). 

Varieties  of  Glaucoma.— Glaucomatous  manifestations  range  them- 
-eK  es  in  three  principal  groups  : 

i  Li  Primary  glaucoma,  the  pathology  of  which  is  not  positively  deter- 
mined. 

ill.)  Secondary  glaucoma,  which  obviously  depends  upon  some  pre- 
existing morbid  condition. 

fill.)  ( !ongenital  glaucoma,  usually  described  a-  buphthalmos. 

I.  Primary  Glaucoma.— This  variety,  which  may  or  may  not  exhibit 

signfl  of  inflammatii r  congestion  and   i-  subdivided  accordingly,  will  be 

iii--t  described. 

Etiology. — The  predisposing  causes  of  glaucoma  have  reference  to  age, 
sex,  race,  systemic  condition,  and  the  conformation  ami  refraction  of  the  eye. 


PlilMAIlV   (,'LA  VCOMA. 


375 


It  is  rare  in  the  young,1  and  mosl  frequent  in  the  lit'tli  and  sixth  decades 
of  life  More  women  than  men  suffer  from  inflammatory  glaucoma,  whereas 
more  men  than  women  arc  affected  with  the  non-inflammatory  form  of  the 
disease.  In  the  analysis  made  by  William  Zentmayer  and  William  Campbell 
Posey  of  167  cases  of  glaucoma  simplex,  men  were  found  slightly  more  liable 
than  women.  The  extremes  of  age  noted  were  thirteen  and  ninety-six  years. 
These  facts  arc  represented  graphically  by  these  author-  in  the  following 
diagram.     A  disproportionate  number  of  eases  are  seen   in  the  Jewish   race 


60 

AGE 

'- 

"> 

"> 

5 

i 

5 

; 

5 

> 

95 

li 

A 

J 

\ 

50 

\ 

40 

m 

< 

O30 

\ 

* 

m 

-v, 

\ 

CQ 

> 

\ 

i 

\ 

220 

/ 

.    \ 

/ 

\ 

\ 

. 

' 

kv 

10 

t' 

s 

\ 

, 

v 

'  ; 

\ 

*• 

v 

S 

n 

u 

WHOLE    NUMBER 


Fig.  241.— Chart  showing  the  relationship  of  glaucoma  simplex  to  age  and  sex  (Zentmayer  and  Posey). 

(Knapp),  and  Egyptians  are  said  to  be  peculiarly  liable.  There  appears  to 
be  a  tendency  to  hereditary  transmission.  When  this  is  the  ease  the  period 
of  life  at  which  the  outbreak  occurs  is  earlier  in  each  succeeding  generation 
(De  Wecker).  The  gouty  and  rheumatic  diatheses  favor  the  development 
of  the  malady,  and  those  who  suffer  from  arterial  sclerosis,  chronic  bronchi- 
tis, or  heart  disease  are  liable  to  the  disease.  A  causal  relationship  between 
influenza  and  non-inflammatory  glaucoma  has  been  recorded.  The  author 
has  observed  catarrhal  disease  of  the  nasal  passages  in  a  large  proportion  of 
case-  of  inflammatory  glaucoma.  Small,  hyperopic  eyes  are  more  likely 
to  be  affected  than  emmetropic  or  myopic  eyes.  This  is  explained  by  the 
limited  circumlental  space  due  to  the  hypertrophy  of  the  ciliary  muscle  in 
hyperopia,  and  also  to  the  excessive  and  practically  continuous  contrac- 
tion of  this  muscle  in  accommodation.-'  The  progressive  increase  in  the 
diameter  of  the  lens  throughout  life  noted  by  Priestley  Smith  is  claimed  by 
this  author  as  an    important   etiological  factor.     There   is  a  relation  between 

1  According  to  Priestley  Smith,  not  1  per  cent,  of  the  cases  begin  earlier  than  the  twentieth 
year.     A  few.  generally  monolateral,  cases  are  Been  in  children. 

2  Zentmayer  and  Posey's  figures  in  regard  to  the  refractive  condition  of  the  eve  in  t hoi r 
\h~  cases  are  as  follows : 

I  I y|i<Ti»jii:i  1  1(1  eve-  ; 

Myopia  28  eyes; 

Emmetropia        21  eyes. 

Twenty  eye-  were  astigmatic. 


376  GLAUCOMA. 

smallness  of  the  cornea  and  glaucoma  (normal  average  horizontal  diameter, 
LI. 6  ;  glaucoma,   1 1.1). 

Among  the  exciting  causes  may  be  mentioned  various  emotions — joy, 
grief,  anxiety,  etc. — producing  ciliary  congestion,  and  the  incautious  use  of 
mydriatics,  which,  by  thickening  the  peripheral  portion  of  the  iris,  directly 
diminish  the  filtrating  area  in  the  anterior  chamber.  An  onsel  of  the  disease 
has  been  precipitated  by  exposure  to  cold,  by  loss  of  sleep,  worry,  neuralgia, 
and  by  the  ingestion  of  a  hearty  meal.  Nettleship  relates  a  ease  which  was 
always  worse  in  warm  weather,  and  a  lady  under  the  author's  care  can  always 
bring  on  an  attack  by  abruptly  entering  a  dark  or  dimly-lighted  room. 
Over-use  of  ametropic  or  improperly  corrected  eyes  may  excite  glaucoma  in 
an  eye  predisposed  to  the  disease. 

Pathology  and  Pathological  Anatomy. — The  pathogenesis  of  glaucoma 
is  not  definitely  settled.  Because  of  the  overshadowing  importance  of  the 
increase  in  intraocular  tension  the  aim  has  mainly  been  to  account  lor  this 
phenomenon  ;  hut  half  a  century  of  active  investigation,  clinical,  experi- 
mental, and  anatomical,  has  not  resulted  in  a  completely  satisfactory  solution 
of  the  problem. 

The  hypothesis  that  glaucoma  arises  from  hypersecretion,  produced,  ac- 
cording to  v.  G-raefe,  l>v  choroidal  inflammation,  and,  according  to  Donders, 
by  nervous  irritation,  has  been  discarded,  and  various  "retention  theories," 
which  explain  the  increased  hardness  of  the  eyeball  by  an  obstruction  to  the 
escape  of  the  intraocular  fluids,  have  taken  its  place.  The  obstruction,  in 
accordance  with  the  views  enunciated  by  Knies,  and  soon  afterward  by 
Weber,  i<  generally  considered  to  he  situated  at  the  angle  of  the  anterior 
chamber,  and  to  consist  in  a  blocking  up  of  this  angle  by  apposition  or 
adhesion  of  the  peripheral  portion  of  the  iris  to  the  adjacent  sclero-cornea, 
the  iris  having  been  crowded  forward  by  the  hyperemie  and  swollen  ciliary 
processes.  Knies  believed  the  condition  to  be  one  of  adhesive  inflammation 
of  the  iris  periphery,  while  Weber  regarded  this  adhesion  as  secondary  to 
pressure.  In  his  most  recent  communication  on  the  subject  Knies  makes  a 
sharp  distinction  between  glaucoma  simplex,  which  he  conceives  to  be  an  optic 
nerve-atrophy  with  excavation,  and  true  (onus  of  glaucoma,  which  should  be 
considered  as  an  irido-cyclitis  anterior — an  inflammation  which  may  occur  in 
varying  degrees  of  intensity.  It  has  been  demonstrated  by  Leber  and  others 
that  the  ciliary  region  constitutes  the  principal  outlet  for  the  lymph-current, 
which,  starting  at  the  ciliary  processes,  proceeds  forward  through  the  zonula 
ami  pupil  into  the  anterior  chamber,  and  thence  through  the  pectinate  lig- 
ament into  the  canal  of  Schlemm,  from  which  it  finds  its  way  into  the  venous 
system.  In  the  cases  in  which  the  iris  occupies  its  normal  position  it  is 
possible  thai  filtration  may  be  hindered  by  serosity  of  the  liquids  (Priestley 
Smith)  or  by  a  choking  of  the  meshes  of  the  pectinate  Ligament  with  pig- 
ment-cells from  the  ciliary  processes  and  the  posterior  surface  of  the  iris 
I  Niesnamoff  I. 

Priestley  Smith,  as  already  intimated,  thinks  that  an  important  element 
i-  a  narrowing  of  the  circumlental  space,  due  to  a  senile  increase  in  the  size 
ol  the  lens  or  to  a  -mall  ciliarv  circle  a-  seen  in  hyperopic  eyes — hence  a 
forward  displacement  of  the  lens  ami  blocking  up  of  the  excreting  angle. 

Stilling's  view,  thai  glaucoma  max-  be  produced  bv  tissue-changes  which 
tend   to  hinder  the  exil   of  fluids  bv  way  of  the  optic-nerve  entrance,  may 

have  :i   limited   field  of  application,  a-  in  iv  also  that  of  I Mieindorf.  who  claims 

that  the  obstacle  to  the  nutritive  curreni  consists  in  a  sclerosis  of  the  len- 
ticulo-zonular  diaphragm.     Laqueur  and  other-  think  that  glaucoma  depend- 


ACUTE  GLA  (COMA. 


::77 


upon  obstruction  of  the  intraocular  lymphatics,  which   find   their   way  out 
with  the  vena  vorticosa. 

The  anatomical  conditions  which  have  been  observed  in  glaucomatous  eyes 
are,  among  others,  the  following  :  (1)  Edema,  and  a1  a  later  stage  ulcerative 
processes  in  the  cornea.  (2)  Scleral  changes,  including  rigidity,  fatty  degen- 
eration, and  equatorial  staphylomata.  (3)  ( >bliteration  (with  or  \\  ithoul  adhe- 
sive inflammation  |  of  the  angle  of  filtration,  of  the  spaces  of  Fontana,  and  of 
the  canal  of  Schlemm  (Fig.  242,  A).  (4)  Atrophy  of  the  iris,  chiefly  of  the 
external  layers,  with  destruction  of  the  vessels.  (5)  Sometimes  swelling  and 
sometimes  atrophy  of  the  ciliary  processes.  In  the  latter  case  these  bodies 
shrink  backward,  and  frequently  leave  the  iris  in  contact  with  the  cornea  (  Fig. 
242,  11).  (6)  Glaucomatous  cataract — i.e.  cataract  which  is  a  direct  result  of 
the  disease.  (7)  Fluidity  of,  and  opacities  in,  the  vitreous.  (8)  Mark-  of 
choroidal  inflammation,  such  as  atrophy  and  loss  of  elasticity  of  the  choroid. 
and  periphlebitis  with  reduced  lumen  of  the  veins,  especially  the  vasa  vorti- 
cosa. (9)  Destruction,  partial  or  complete,  of  one  or  more  of  the  retinal 
layers  and  detachment  of  the   retina.     (10)  Lastly,  the   excavation   of  the 


A 


Fig.  242.— A,  absolute  glaucoma  :  c,  cornea  :  s.  c,  Schlemm' s  canal,  partially  closed  ;  i,  iris  adherent  to 
sclera  and  closing  angle  of  nitration  ;  V.  free  portion  of  iris  ;  c.  p,  ciliary  process,  reaching  forward  and  in 
cent  act  with  iris.  /;.  absolute  glaucoma  at  a  more  advanced  stage;  i,  iris  extensively  adherent.  Schlemm's 
canal  is  entirely  obliterated.    The  ciliary  body  and  processes  are  decidedly  atrophied. 

optic  nerve,  which  may  or  may  not  show  traces  of  a  low-grade  neuritis.1 
The  precise  relation  of  the  changes  just  enumerated  to  the  glaucomatous 
process  cannot  in  the  present  state  of  our  knowledge  be  dogmatically  stated. 
Some  of  them  are  probably  etiological  factors,  while  others  arc  doubtless 
results  of  the  continued  pressure. 

Primary  glaucoma  may  be  inflammatory ',  or  simpli  i.  < .  non-inflammatory. 

Inflammatory  or  congestive  glaucoma  (glaucoma  irritatif)  is  classified  as  (a) 
acute,  (h\  subacute,  or  (c)  chronic,  according  to  the  severity  of  the  symptoms. 

(1)  Acute  Glaucoma  [Acute  Inflammatory  or  Congestive  Glaucoma).— 
(a)  Period  of  Incubation,  or  Prodromal  Stage. — The  prodromal  or  intermit- 
tent stage  is  characterized  by  mild  attack-,  in  which  the  cornea  is  slightly 
steamy  and  anesthetic,  the   pupil   moderately  dilated  and   sluggish,  and   the 

1  Marked  hyperemia  ami  edema  of  the  nerve-head,  which  afterward  becomes  cupped, 
early  symptom  in  glaucoma  I  Knies  ,  ami  actual  neuritis  in  primary  glaucoma,  usually  pret  ■ 
increased  ten-inn  (Brailey  and  Edmunds  . 


378  GLAUCOMA. 

anterior  chamber  somewhat  diminished  in  depth.  There  is  noticeable,  but 
not  pronounced,  pericorneal  injection,  and  palpation  shows  some  increase  in 
ten-ion.  The  vision  is  smoky  from  the  corneal  haziness,  and  rainbows  are 
seen  around  lights  from  the  same  cause.  The  ophthalmoscope  may  reveal 
pulsation  of  the  retinal  arteries,  but  a>  yet  there  is  no  cupping  of  the  disk. 
When  the  attack  is  ended  the  eye  returns  to  its  normal  condition,  except  that 
the  accommodative  power  is  apt  to  be  lessened,  the  patient  requiring  stronger 
reading-glasses  than  before. 

The  stage  of  prodromata  may  last  months  or  years,  the  intervals  between 
the  attack-  growing  gradually  shorter,  and  may  terminate  in  an  acute  attack. 

(6)  Period  of  Attack. — The  glaucomatous  attack,  whether  preceded  or  not 
by  an  intermittent  stage,  is  suddenly  ushered  in  by  violent  and  excruciating 
pain  in  the  eye  and  the  corresponding  side  of  the  head,  with  vomiting,  fever, 
and  even  loss  of  consciousness.  The  lids  become  edematous  and  the  ocular 
conjunctiva  reddened  and  swollen.  The  cornea  is  decidedly  hazy,  owing  to 
edema  of  it-  superficial  layers.  The  haziness  i>  generally  most  pronounced 
in  the  center,  and  is  sometimes  accentuated  in  spot>,  giving  a  dotted  appear- 
ance to  the  surface.  Corneal  sensibility  is  more  or  less  completely  abolished, 
as  shown  by  touching  it  with  a  hit  of  twisted  cotton.  The  pupil  is  dilated 
and  immobile  and  -how-  a  greenish  or  grayish-green  reflex  '  from  the  lens. 
The  dilatation  is  not  uniform,  so  that  the  pupil  is  rarely  perfectly  circular. 
The  iris  is  discolored  and  its  markings  are  blurred.  There  may  he.  accord- 
ing t"  most  authors,  some  turbidity  of  the  aqueous  and  vitreous  humors, 
although  this  turbidity  is  considered  by  other-  as  far  from  proven.  The 
sight,  owing  partly  to  the  corneal  edema  and  partly  to  the  compression  of  the 
retinal  arteries,  rapidly  fails  until  fingers  can  scarcely  he  counted.  In  the 
rare  cases  in  which  a  view  of  the  fundus  is  obtainable  hyperemia  of  the  disk 
with  pulsation  of  the  arteries  is  observed,  but  no  change  in  the  disk  level  is 
to  he  expected.  Lastly,  careful  palpation  will  disclose,  even  through  the 
edematous  lid-,  a  decided  hardness  of  the  eyeball — a  condition  which  accounts 
for  most  if  not  all  of  the  other  phenomena. 

The  intensity  of  the  symptoms  described  above  begins  to  subside  alter  a 
lew  day-  or  weeks.  The  pain,  corneal  haze,  palpebral  and  ocular  edema,  etc. 
diminish  greatly  or  disappear;  but  the  pupil  remains  dilated  and  sluggish, 
the  pericorneal  region  somewhat  injected,  the  anterior  chamber  abnormally 
shallow,  and  the  vision  is  usually  considerably  reduced.  Ten-ion  continues 
elevated.  This  condition  is  known  as  the  glaucomatous  state  (habitus  glaucom- 
atous). 

After  a  longer  or  shorter  period  of  comparative  quiet  another  outbreak 
may  occur,  and  then  another,  until  the  sight  is  wholly  destroyed — a  condition 
described  a-  absolute  glaucoma.     The  eye  assumes  a  dull,  expressionless  look. 

Tin rnea  is  surrounded  by  a  zone  of  livid  or  slaty  hue.     The  pupil  displays 

a  border  of  black  pigment  (ectropium  urea).  The  lens  and  the  narrow 
atrophic  rim  of  the  iris  are  crowded  against  the  cornea.  The  tension  of  the 
globe  i-  usually  excessive.  The  ophthalmoscope  now  generally  reveals  the 
characteristic  glaucomatous  excavation.  With  the  advent  of  blindness  the 
patienl  in  -Mine  oases  obtains  surcease  of  suffering  ;  in  others  the  attack-  con- 
tinue until  relief  i-  afforded  by  surgical  means. 

Glaucomatous  Degeneration. — After  the  glaucoma  becomes  absolute 
striking  tissue-changes  sooner  or  Inter  begin  to  manifesl  themselves.  The 
atrophied  sclera  succumbs  to  the  intraocular  pressure,  and  bluish-black  swell- 
ings appear  between  the  cornea   ami   the  equator.      The   lens  may  become 

1  Hence  tin-  name  glaucoma     from  ea  green  or  grayish  green. 


SIMPLE  GLA  UCOMA.  379 

opaque  (glaucomatous  cataract).  The  eyeball  may  go  on  t< »  atrophy,  with 
detachment  of  the  retina,  and  may  show  deep  furrows  in  the  line  of  the  recti 
muscles,  or  the  morbid  process  may  end  with  sloughing  of  the  cornea  and 
panophthalmitis. 

In  some  cases  of  acute  glaucoma  vision  is  suddenly  and  irretrievably  losl 
at  the  first  attack,  constituting  what  is  known  as  glaucoma  julminans. 

(2)  Subacute  Glaucoma. — This  variety  presents  the  phenomena  of  the 
acute  form  of  the  disease  in  a  much  less  intense  degree,  and  might  not  im- 
properly include  the  prodromal  stage  of  that  form.  But,  whether  intermittent 
or  continuous  at  the  outset,  it  passes  by  insensible  gradations  into  the  third 
and   most   common   variety — viz.  : 

(3)  Chronic  Inflammatory  or  Congestive  Glaucoma.— The  ap- 
pearance of  the  eve  in  this  affection  is  very  characteristic.  The  dull-livid  or 
dusky-red  color  of  the  sclera  with  its  swollen  and  tortuous  veins,  the  smoky 
look  of  the  cornea,  the  irregular  dilatation  and  eccentric  position  of  the  pupil, 
the  obvious  atrophy  of  the  visible  portion  of  the  iris,  the  marked  shallowness 
of  the  anterior  chamber,  and  the  greenish  reflex  from  the  lens,  combine  to 
form  a  picture  which,  once  seen,  can  always  be  recognized.  The  pain, though 
sometimes  severe,  is  not  so  intense  nor  is  the  corneal  insensibility  so  complete 
a-  in  acute  glaucoma. 

Central  vision  slowly  fade.-,  and  the  visual  field  gradually  contracts, 
especially  on  the  nasal  side.  In  the  later  stages  cupping  of  the  disk  is 
revealed  by  the  ophthalmoscope.  The  disease,  if  unchecked,  proceed-,  as 
doe-  acute  glaucoma,  to  the  establishment  of  absolute  glaucoma,  and  later  to 
one  or  more  of  the  phases  of  glaucomatous  degeneration. 

II.  Simple  Glaucoma  (Glaucoma  Simplex,  Chronic  Simple  or  Non- 
inflammatory Glaucoma). — This  i-  one  of  the  most  insidious  of  maladies.  If 
untreated  it  usually  terminates  in  blindness  :  nevertheless,  at  least  in  its  early 
stages,  it  presents  no  external  signs  of  the  grave  changes  going  on  within  the 
eve.  After  the  lapse  of  month-  or  years  there  may  be  slight  dilatation  and 
inactivity  of  the  pupil  and  moderate  distention  of  the  anterior  ciliary  vein-. 

Increased  tension,  while  seldom  pronounced,  can  in  most  cases  bedetected 
on  careful  and  repeated  examination  ;  but  it  may  be  entirely  absent.  In 
doubtful  cases  the  eye  should  be  tested  at  different  time-  of  the  day  and  under 
various  circumstances,  especially  after  a  full  meal  or  in  the  condition  of  de- 
pression following  a  restless  night.  It  should  be  remembered  also  that  there 
i-  no  fixed  and  universally  applicable  standard  of  physiological  ten-ion.  A 
careful  comparison  of  the  two  eyes,  especially  if  one  is  -till  unaffected,  will 
tend   to  eliminate  doubt. 

'flic  objective  phenomena  jusi  described  may  occur  in  attack-  resembling 
those  of  the  prodromal  stage  of  inflammatory  glaucoma.  At  such  times  the 
cornea  may  be  hazy  and  it-  sensibility  may  lie  impaired  and  rainbow  vi-i"ii 
may  be  observed.  These  attack-  in  certain  cases  appear  to  mark  a  transition 
from  the  simple  to  the  congestive  form  of  the  disease. 

Tin-  cardinal  symptom  of  simple  glaucoma  is  a  slow  but  steadily  pro- 
gressive failure  of  vision,  especially  peripheral  vision.  In  some  eases  a  good 
degree  of  central  visual  acuity  i-  preserved  for  a  long  time,  while  the  field  ol 
vision  i-  -o  encroached  upon  that  the  patient,  although  able  to  distinguish  fine 
print,  may  not  see  well  enough  to  walk  about.  In  such  cases  blindness  comes 
on  suddenly,  as  by  the  abrupt  drawing  of  ;i  curtain. 

ThefieldoJ  vision  is  almosl  always  restricted.     The  nasal  side  s 
suffers  most,  but   the  limitation  i-  very  often  concentric  (according  to  / 
mayer  and   Posey  this  is  the  mo-t    frequent  phenomenon  .  or  the  field  t 


-380 


GLA  UCOMA. 


assume  any  one  of  a  great  number  of  bizarre  forms.  Frequently  sector-like 
defects  arc  seen.  Scotomata  partial  or  total  arc  often  found.  According  to 
Bjerrum,  areas  of  special  visual  acuity,  taking  the  form  of  rings  or  segments 
of  rings  with  a  width  of  10  to  20  .and  touching  the  blind  spot  at  their 
inner  margin,  arc  sometimes  observed. 

In  the  following  visual  fields  the  boundaries  for  white  arc  represented  by 
a  continuous  line,  those  for  blue  by  an  interrupted  line,  those  for  red  by  a 
line  of  da-he-  and  dots,  and   those  for  green   by  a  dotted   line: 


Fig.  243.— Simple    glaucoma,    K.    E.   V  = 
Nasal  side  of  field  almost  obliterated 


Fig.  244.— Chronic  inflammatory  glaucoma,  R. 


x  1.  E.  V      — 


Fig  coma,  L.  1      i  tie  visual 

I'n  lii  simulates  thai  form  of  hemianopsia  in  which 
one  quadrant  is  cutout.    The  field  of  the  other 
fiows  concentric  limitation. 


Fig.  246.    Simple  glaucoma,  R,    E     Duration 
[5 
tun  years,  v      —     Fair   appreciation  of  Mur. 

\  i 
i  [i  hi  of  other  eye  still   more  contracted. 


\-  ,i  rule,  the  color-fields  -how  no  disproportionate  loss.  The  field  for 
blue  may  even  be  coextensive  with  thai  for  form.  It  is  also  true,  however, 
th.it  the  color-fields  may  be  contracted,  while  the  form-field  is  intact — a 
facl  which  tend-  to  diminish  the  value  of  the  evidence  derived  from  exam- 
inations of  the  visual  field  in  diagnosticating  between  glaucoma  and  optic- 
nerve   atrophy. 


SIMPLE  GLA  (COMA. 


381 


A>  in  the  early  stages  of  inflammatory  glaucoma,  'premature presbyopia  is 
commonly  seen. 

Excavation  of  the  optic  nerve  is  the  most  striking  objective,  a<  visual 
impairment  is  the  leading  subjective,  feature  of  the  disease.  The  cupping  is 
rarely  absent  when  the  patient  presents  himself  for  examination,  which  is 
usually  after  the  malady  has  made  decided  progress.     Furthermore,  the  de- 


Fig.  247.— Subacute  inflammatory  glaucoma,  L. 

15 
E.    Four  weeks  after  iridectomy,  V  =  — -  — .    Ab- 
solute scotoma  in  region  of  "  blind  spot." 


Fig.  248.— Chronic    inflammatory    glaucoma, 
15 
L.  E.    Duration  one  year,  V  =  —  — .   Patient  has 

arthritis  deformans. 


270 


15 


Fig.  249.— Simple  glaucoma,  R.E.V      —       Dumb-bell  field.    Thenotch  ..n  the  left  side  was  doubtless  a 
scotoma  at  an  earlier  stage  of  the  disease. 

pression  is  now  generally  found  to  be  characteristic,  as  described  at  the  begin- 
ning of  this  chapter,  although  it  is  sometimes  -hallow  |  Fig.  239). 

Diagnosis. — Rapidly  increasing  presbyopia,  occasional  mistiness  ot  sight, 
and  "rainbow  vision,"  so  frequently  the  harbingers  of  glaucomatous  trouble, 
should  arouse  suspicion. 

Inflammatory  glaucoma  has  been  mistaken  for  iritis.     The  diluted  pupil 
and  the  hardness  of  the  eyeball   in  the  former  affection  ought  generall 
make  such  a  mi-take  impossible.     The  pupil   may,  however,  be  bound  down 


382  GLAUCOMA. 

by  adhesions  due  to  a  previous  inflammation  of  the  iris,  and  the  author  lias 
seen  one  case  of  intermittent  glaucoma  in  which  the  pupil,  though  free,  was 
of  normal  size.  We  must  in  such  cases  be  guided  by  the  history  and  by  the 
other  symptoms,  especially  the  abnormal  hardness  of  the  globe.  That  increase 
of  tension,  rainbow  vision,  and  shallowness  of  the  anterior  chamber  areas 
pointed  out  by  Schweigger,  sometimes  observed  in  iritis,  should  be  home  in 
mind,  but  other  symptoms  of  iritis  will  then  not  be  lacking. 

Simple  glaucoma  when  typical  is  easily  recognized.  When  the  tension  is 
oo1  perceptibly  elevated,  and  other  external  symptoms,  such  as  sluggishness 
of  the  pupil  and  fulness  of  the  ciliary  veins,  arc  absent,  reliance  must  be 
placed  on  the  character  of  the  excavation  of  the  optic  nerve,  which  in  glau- 
coma, as  already  pointed  out,  covers  the  whole  surface  of  the  disk,  has  steep 
sides,  and  is  deeper  than  the  normal  level  of  the  lamina  cribrosa.  Physio- 
logical excavation  involves  only  a  portion  of  the  disk,  while  the  remainder  of 
the  surface  presents  a  healthy  appearance.  The  excavation  due  to  atrophy 
of  the  nerve  affects  the  entire  disk  surface,  but  it  is  -hallow  and  slopes  grad- 
ually to  its  deepest  point.  Moreover,  the  nerve-head  is  much  more  anemic, 
proportionately  to  the  depth  of  the  cup,  than  in  glaucoma  (consult  Fig.  131). 
The  greatest  difficulty  arises  when  an  atrophic  process  attacks  a  nerve  which  is 
the  seat  of  an  extensive  physiological  pit.  Flatness  of  the  disk  in  the  sound 
eye  is  evidence  of  glaucoma,  since  physiological  cupping  is  bilateral  (Schweig- 
ger).1 The  absence  of  the  knee-reflex  as  indicative  of  central  disease  would 
point    to  atrophy. 

The  shape  of  the  visual  fields,  especially  the  color-fields,  and  their  rela- 
tion t<>  the  acuity  of  vision  are  of  decided,  though  not  unqualified,  diag- 
nostic importance.  In  atrophy  of  the  optic  nerve  good  central  vision  and 
color  appreciation  are  not  so  apt  to  he  retained  with  a  contracted  field  for 
form  as  in  glaucoma.  (Compare  with  page  448.)  In  doubtful  eases  the 
totality  of  the  phenomena  must  be  considered,  and  sometimes  a  positive 
diagnosis  should  be  reserved  and  the  course  of  the  affection  carefully 
watched. 

The  unfortunate  mistake  of  regarding  the  gray  or  green  reflex  from  the 
lens  as  indicating  incipient  cataract,  and  the  consequent  advice  to  wait  for 
ripening  which  never  comes,  are  happily  much  rarer  now  than  they  were 
before  improved  methods  in  medical  teaching,  including  instruction  in  the 
use  of  the  ophthalmoscope,  were  inaugurated. 

Treatment. — Had  v.  Graefe  done  nothing  else  for  ophthalmology,  his 
discovery  in  1856  of  the  curative  power  of  iridectomy  in  glaucoma  would 
alone  have  secured  for  him  an  imperishable  fame.  Other  remedial  measures 
operative  and  medicinal  have  been  since  devised,  but  they  are  almost  uni- 
versally considered  to  be  of  secondary  importance. 

In  performing  iridectomy 2  for  glaucoma  the  coloboma  should  be  made 
upward,  so  as  to  be  covered  by  the  upper  lid.  unless  the  superior  portion  of 
the  iris  appear-  to  be  specially  atrophic,  and  therefore  more  difficult  to 
remove.  'l"he  i n<i~i< >n  should  lie  in  scleral  tissue,  should  be  of  ample  size, 
and  should  be  completed  with  deliberation  in  order  to  prevent  too  sudden  a 
reduction  in  tension,  which  might  be  attended  with  intraocular  hemorrhage, 
rupture  of  the  zonula,  or  other  disastrous  consequences.  The  bit  of  iris 
excised  should  be  extensive,  and  should  embrace  the  whole  width  of  this 
tissue  up  to  it-  ciliary  margin.  The  angles  of  the  wound  should  be  left 
entirely  free,  an   iris-repositor  being  used   if  necessary. 

•  Thi-  statement  of  Schweij  nol  without  exceptions,  as  ;i  unilateral  physiological 

enp  may  exist     Ed  '  The  operation  for  iridectomy  is  described  on  page  575. 


TREATMENT  OF  GLAUCOMA. 

The  operation,  which  should  of  course  be  made  with  precautions  against 
sepsis,  requires  in  inflammatory  cases  the  use  of  a  general  anesthetic,  as 
cocain  under  these  circumstances  is  very  imperfectly  absorbed.     Hemorrhage 

into  the  anterior  chamber  is  not  infrequent,  but  the  bl I   usually  underg 

absorption   in  a  few  days.     Retinal  hemorrhages  arc  also  occasionally  seen. 
These  arc  generally  not  extensive,  and  they  soon  disappear. 

Qystoid  cicatrix  from  imperfect  apposition  of  the  lips  of  the  operation- 
wound  is  sometimes  unavoidable.  Moreover,  though  a  blemish,  it  may 
serve  to  facilitate  filtration. 

The  most  brilliant  results  of  iridectomy  arc  obtained  in  acute  inflam- 
matory glaucoma,  especially  when  the  operation  is  done  without  delay.  The 
pain,  high  ten-ion.  and  corneal  cloudiness  promptly  disappear,  and  the  vision 
is  rapidly  and  decidedly  improved — sometimes,  indeed,  entirely  restored. 

In  the  chronic  forms  of  the  disease  the  operation,  owing  to  the  degenera- 
tion and  excavation  of  the  optic  nerve,  doe-  not  accomplish  so  much.  In 
chronic  inflammatory  glaucoma,  however,  the  morbid  process  is  usually 
checked  unless  the  iris-tissue  has  become  degenerated  (Gruening). 

In  simple  glaucoma  the  experience  of  v.  Graefe,  Bull,  Nettleship,  Fuchs, 
and  other-  shows  that  by  means  of  iridectomy  the  existing  vision  is  pre- 
served or  slightly  improved  in  about  halt'  the  cases.  In  some  of  the  remain- 
ing half  the  influence  of  the  operation  is  negative;  in  others  it  seems  n> 
expedite  the  morbid  process;  while  in  a  small  proportion — estimated  by 
some  authors  at  about  2  per  cent. — the  iridectomy  is  followed  by  pericorneal 
injection,  steamine-s  of  the  cornea,  and  great  increase  in  tension.  The 
anterior  chamber  remains  empty  and  vision  is  almost  always  destroyed. 
This  condition,  which  is  very  rarely  observed  in  the  congestive  types  of  the 
disease,  has  received  the  name  of  malignant  glaucoma.  The  predisposition 
to  it  seems  to  affect  both  eyes.  Hence  the  propriety  of  Schweigger's  rule  to 
operate  on  the  worse  eye  first,  even  if  it  be  blind.  If  this  heals  smoothly, 
the  other  may  be  expected  to  follow  a  similar  course,  but,  as  Friedenwald 
has  shown,  it  may  occur  even  where  the  operation  on  the  first  eye  has  healed 
without  complication. 

Absence  of  increased  tension  ami  a  greatly  restricted  visual  Held  diminish, 
although  they  by  no  means  annihilate,  the  chances  of  benefit  from  iridectomy 
in  simple  glaucoma. 

The  modus  medendi  of  iridectomy  is  not  understood.  The  explanations 
so  far  attempted  are  merely  of  speculative  interest. 

Of  the  numerous  operative  procedures  devised  to  substitute  iridectomy 
in  the  treatment  of  primary  glaucoma,  the  majority,  including  those  of 
Hancock.  Knies,  Nicati,  Pfluger,  Vmcentiis,  Badal,  and  Parinaud,  and  the 
combined  sclerotomy  of  De  Wecker,  serve  chiefly  to  illustrate  the  ingenuity 
of  their  inventors.  Iridectomy  has  only  one  serious  rival — viz.  sclerotomy, 
and  this  i-  by  alnio-t  universal  consent  relegated  to  a  subordinate  place 
Sclerotomy,  the  technique  of  which  i-  described  on  page  •")•>!),  ought  to  be 
performed  when  the  symptoms  persist  after  a  well-executed  iridectomy,  and 
preferably  opposite  the  latter.  It  may  also  be  resorted  to  when  the  iris  has 
undergone  degenerative  change-  which  would  be  likely  to  preclude  a  satis- 
factory excision  of  this  tissue.  If  done  in  a  case  of  simple  glaucoma  with 
a  contractile  pupil,  eserin  should  be  previously  instilled  in  order  to  prevent 
prolapsus  iridis.  Priestley  Smith  and  Harold  Gifford  strongly  recommem 
scleral  puncture  5  mm.  behind  the  cornea  a-  a  preliminary  step  to  iridectomy 
in   case-   where   the  anterior  chamber   i-   very    -hallow. 

In  cases  of  absolute   glaucoma  which  are  attended  with   great   pain  imrc- 


384  GLAUCOMA. 

lieved  by  iridectomy,  or  in  which  this  operation  is  impossible  of  performance, 
enucleation,  or,  according  to  some,  optico-ciliary  neurotomy,  becomes  neces- 
sary. 

The  non-surgical  treatment  of  glaucoma  consists  principally  in  the  instil- 
lation into  the  conjunctiva]  sac  of  solution-  of  eserin  or  pilocarpin  of  mod- 
crate  strength,  gri  \  to  .',  to  fjj,  although  much  stronger  solutions  arc  frequently 
required.  Myotics  arc  most  serviceable  in  the  prodromal  stage  of  inflam- 
matory glaucoma,  bu1  they  will  often  hold  an  acute  attack  in  check,  and  thus 
permit  of  delay  if  circumstances  prevent  an  immediate  operation.  They  arc 
useful  in  many  cases  of  simple  glaucoma,  especially  with  increased  ten-inn, 
in  which  an  operation  is  oontraindicated  or  is  rejected  by  the  patient.  Ii  is 
known  that  iridectomy  in  a  case  of  unilateral  glaucoma  is  sometimes  suddenly 
followed  by  the  appearance  of  the  disease  in  the  normal  eve.  The  use  of 
eserin  in  the  latter  at  the  time  of  the  operation  is  believed  to  be  an  efficient 
means  of  averting  the  danger.  As  regards  the  use  of  myotics,  the  general 
consensus  of  opinion  is  that  they  are  rarely  more  than  palliative  in  their 
action.  They  should  not  he  employed  too  long,  because,  apart  from  the 
external  irritation  often  produced  by  them,  they  tend  to  increase  ciliary  con- 
gestion, and  they  do  not  always  retard  the  progress  of  the  excavation  in  the 
optic   nerve. 

The  efficacy  of  massage  of  the  eyeball,  recommended  by  Gould  and  other 
observers,  has  not  yet  been  sufficiently  tested.  It  might  he  useful  in  deepen- 
ing a  -hallow  anterior  chamber  previously  to  operating. 

Constitutional  remedies  for  glaucoma  do  not  have  much  vogue,  but  the 
reports  of  Sutphen  and  Friedenwald  indicate  that  sodium  salicylate  in  large 
doses   has  decided  therapeutic   value. 

Glaucomatous  tendencies  should  he  combated  by  the  correction  of  re- 
fractive errors,  by  the  avoidance  of  constipation  and  of  over-indulgence  in 
eating  and  drinking,  by  regular  open-air  exercise,  and.  above  all,  by  the 
cultivation  of  -elf-control,  since  a  glaucomatous  attack  so  frequently  means 
the  explosion  of  emotional  dynamite. 

1  1.  Secondary  glaucoma  is  the  name  employed  to  describe  a  condition 
in  which  the  more  striking  phenomena  of  glaucoma — increase  of  tension, 
shallowness  of  the  anterior  chamber,  etc. — arc  developed  as  consequences  of 
-nine  antecedent  disease  or  injury. 

The  pathological  condition-  which  most  frequently  give  rise  to  secondary 
glaucoma  are  perforating  wounds  of  the  cornea,  cither  accidental  or  surgical 
(e.g.  bypopyon-operations),  suddenly  closed  corneal  fistula?,  corneal  cicatrices, 
especially  with  staphyloma  or  incarceration  of  the  iris,  serous  iritis  and  irido- 
choroiditis,  occlusion  of  the  pupil,  traumatic  catarad  with  swelling  of  the 
lens,  dislocation  of  the  lens,  either  forward  againsl  the  cornea  or  backward 
into  the  vitreous,  intraocular  tumors,  and  contused  wounds  of  the  eyeball. 
The  author  ha-  observed  glaucoma  follow  a  blow  causing  rupture  of  the 
choroid. 

1.  Hemorrhagic  glaucoma  i-  consecutive  to  retinal  hemorrhage  due  to 
atheromatous  or  hyalin  disease  of  the  blood-vessels.  It  may  appear  with 
albuminuric  retinitis.  The  intensity  of  the  symptoms  varies  very  much  in 
differenl  cases,  ;i-  doe-  also  the  time  of  their  appearance  after  the  discovery 
of  the  extravasations,  h  is  difficult  in  many  cases  to  decide  whether  the 
glaucoma  i-  produced  Wythe  hemorrhage  or  the  hemorrhage  by  the  glaucoma. 
In  -even-  cases  hemorrhage  into  the  vitreous  entirely  obliterates  the  fundus 
reflex. 

'_'.  Complicated  glaucoma  comprises  those  cases  of  the  disease  which 


BUPHTJKALMOS.  385 

arise  during  the  progress  of  some  other  affection,  but  in  which  the  causative 

influence1  of  the  latter  is  doubtful.  The  most  noteworthy  of  such  complications 
are  cataract,  atrophy  of  the  optic  nerve,  pigmentary  retinitis,  and  myopia  of 
high  degree. 

Treatment. — The  treatment  of  the  different  forms  of  secondary  glaucoma 
depends  upon  etiological  considerations.  A  swollen  or  dislocated  lens  should 
lie  removed, an  incarcerated  iris  set  free,  and  an  occluded  pupil  remedied  by 
a  generous  iridectomy. 

Hemorrhagic  glaucoma  responds  badly  to  any  form  of  treatment.  Iri- 
dectomy is  dangerous,  being  Liable  to  be  followed  by  increased  retinal  hemor- 
rhage. Anterior  sclerotomy  or  eserin  may  prove  of  service.  In  some  cases 
posterior  sclerotomy  has  been  found  beneficial.  General  treatment  should  not 
he  ueglected — ergot,  cautious  use  of  cardiac  sedatives,  the  alteratives,  and  strict 
regulation  of  diet  and  mode  of  life. 

III.  Buphthalmos. — Kerato-globus,  Congenital  Hydrophthalmos  {Glau- 
coma Congenitum). — This  is  a  form  of  glaucoma  pertaining  to  childhood,  and 
characterized  not  only  by  elevated  tension  and  cupping  of' the  optic  disk,  hut 
also  by  enlargement  of  the  globe.  The  cornea,  which  may  he  either  clear  or 
opaque,  is  usually  very  thin  and  its  diameter  greatly  increased.  The  anterior 
chamber  is  deep,  the  pupil  dilated,  and  the  iris  tremulous  from  stretching  or 
rupture  of  the  zonula.  The  lens  remains  small.  The  pathology  is  obscure, 
hut  the  condition  is  supposed  to  he  due  to  an  inflammation  of  the  uveal  tract 
dating  hack  to  intra-uterine  lifeand  causing  an  obstruction  to  excretion.  The 
distention  of  the  eyeball  is  explained  by  the  fact  that  the  sclera  of  the  child 
is  more  yielding  than  that  of  the  adtdt. 

Treatment. — Iridectomy  is  contraindicated.  Stolting  report-  favorable 
results  from  repeated  sclerotomies,  and  Snellen  from  frequent  puncturing  of 
the  anterior  chamber.  Eserin  and  pilocarpin  should  be  tried.  The  prognosis 
is  very  unfavorable. 

25 


DISEASES  OF  THE  CRYSTALLINE  LENS. 

BY   WILLIAM   E.  HOPKINS,   M.D., 

OF    SAN     FRANCISCO,    CAL. 


Cataract. — The  general  term  u  cataract"  is  accepted  in  modern  medicine 
as  meaning  any  opacity  of  the  crystalline  lens.  A  capsular  opacity  is  denom- 
inated a  capsular  <-at<tr<ict,  and  an  opacity  involving  both  capsule  and  lens 
substance  a  capsvlo-lenticular  cataract. 

History. — While  cataract  was  well  known  to  the  ancient  Greek  and 
Roman  physicians,  our  knowledge  of  its  true  nature  dates  from  the  begin- 
ning of  the  last  century.  Even  before  this  one  or  two  savants,  as  Mariotte 
and  Boerhaave,  recognized  the  real  situation  of  the  opacity,  but  their  doctrines 
failed  to  obtain  general  acceptance.  In  the  year  1705,  Brissean,  a  French 
surgeon,  had  the  opportunity  of  making  an  autopsy  upon  the  body  of  a 
soldier  who  had  a  mature  cataract.  Brissean  performed  depression  of  the 
cataract  upon  the  cadaver  and  then  opened  the  eye,  when  he  found  that  the 
opacity  which  he  had  depressed  into  the  vitreous  was  the  lens.  He  laid  his 
observations,  together  with  the  conclusions  drawn  from  them,  before  the 
French  Academy,  but  they  obtained  no  credence.  The  Academy  confuted 
him  by  holding  up  the  doctrines  of  Galen  in  regard  to  cataract.  It  was  not 
till  three  years  later,  when  new  proofs  had  been  brought  forward,  that  the 
Academy  recognized  the  new  doctrine,  which  soon  found  general  acceptance. 

Varieties  of  Cataract. — Cataract  may  be  primary,  or  secondary  to  some 
ocular  disorder,  or  it  may  be  symptomatic  of  systemic  disease  or  local  injury. 

It  may  be  progressive  or  stationary,  partial  or  complete,  and  in  color  black, 
white,  or  amber. 

Various  classification-  of  cataract  have  been  adopted  by  different  author- 
ities, the  simplest  divisions  being  into  the  soft,  hard,  secondary,  and  irregular 
and  special  forms,  with  their  subdivisions: 


,  ,  ..    i  I     (  'oiniilete,     r    r  n  1 

(  ongemtal  d~«*£i         •    Lamellar,  or  zonular. 

I    Pyramidal,  or  polar. 


Soft, 


II:! 


oilmen,!... 

Partial, 
or 

Juvenile, 

( implicated 

or 

Traumatic. 

i   Cortical 

i    Nuclear 

|    A  nterior  Polar  (  ataract. 

Secondary,       Posterior  Polar  ( 'ataract. 

I    V.fter-cataract. 

[rregular  and  special  Clinical  Forms. 


Se 


lllle. 


77/.  I  (  W. I  Tit '  CA  71 1  RA  (  T.  387 

I.  Congenital  or  Juvenile  Cataract. — While  the  congenital  or  juve- 
nile cataract  is  the  commonest  form  of  the  soft  variety,  developing  idiopathi- 
cally,  its  complete  variety  is  not  frequently  encountered,  J>c  Wecker  having 
noted  but  .*'>•>  in  40,000  cases  of  ocular  disease. 

(a)  Lamellar  or  Zonular  Cataract. — This  is  the  most  frequent  variety 
of  congenita]  opacity  of  the  lens.  The  opacity  exists  only  in  certain  layers 
of  the  lens,  between  which  are  perfectly  clear  spaces.  It  is  distinctly  seen 
with  oblique  illumination,  the  opacities  appearing  of  a  light-gray  color  with 
translucent  interspaces.  When  partial,  little  beyond  a  gray  blur  can  be 
detected  by  close  examination.  Through  the  dilated  pupil  the  ophthalmoscope 
will  reveal,  however,  a  sharply-cut,  well-defined  opacity,  surrounded  l>v  a 
reddish  circle  due  to  reflection   from  the  fundus. 

GonstituUonal  conditions  are  important  factors  in  the  development  of 
this  variety  of  cataract,  rachitis,  hereditary  syphilis,  or  scrofula  often  being 
associated  with  it.  There  may  be  imperfect  cerebral  development,  and  Arlt 
found  in  29  such  cases  that  25  were  affected  with  convulsions.  Dental 
defects  are  common,  the  incisors  and  canines  being  marked  with  transverse 
lines,  furrows,  or  terraces.  Usually  lamellar  cataract  is  double,  but  it  may 
be  monolateral,  and  is  either  congenital  or  forms  in  early  infancy.  The 
former  variety  may  lie  ascribed  to  developmental  defects;  the  latter,  to  dis- 
turbances of  nutrition  dependent  upon  the  causes  just  enumerated. 

Congenital  cataract  may  be  found  with  other  abnormal  ocular  states, 
coloboma,  microphthalmos,  irido-choroiditis,  and  choroido-retinitis  being  the 
most  common.  Disturbances  of  nutrition  during  intra-uterine  life,  arrest 
of  development,  and  the  influence  of  heredity  are  factors  in  the  production 
of  congenital  cataract.  In  forms  of  cataract  developing  during  early  life  the 
influence  of  heredity  is  strong,  and  notable  examples  of  the  affection  appear- 
ing in  many  members  of  the  same  family  are  on  record. 

(b)  Complete  Cataract  of  Young-  Persons. — This  is  a  soft  cataract  of 
milky  or  bluish-white  color.  It  has  no  yellow  reflex  ;  it  belongs  to  youthful 
life  and  rarely  occurs  after  thirty-five  years,  before  which  period  the  lens  is 
"soft" — i.  e.  the  nucleus  is  small.  It  may  degenerate  and  become  fluid,  or 
cholesterin  crystals  or  chalky  deposits  may  be  found  in  it.  It  may  arise 
without   known  cause,  and   often   is   monolateral. 

II.  Traumatic  Cataract. — This  may  develop  from  direct  laceration  of 
the  capsule  and  lens-fibers,  and  the  rapidity  of  its  progress  is  dependent  upon 
the  amount  of  surface  exposed  by  the  torn  capsule.  A  normal  lens,  freshly 
removed  and  placed  in  water,  very  soon  will  absorb  abundant  fluid,  and  in 
tiie  process  of  doing  so  will  swell  and  become  opaque  and  disorganized. 
This  is  exactly  what  takes  place  when  the  capsule  is  wounded.  If  the 
anterior  capsule  is  opened,  the  aqueous  i-  absorbed  ;  if  the  posterior  capsule, 
the  vitreous. 

Within  a  few  hours  after  the  accident  the  lens  in  the  vicinity  of  the 
injury  become-  -lightly  puffed  and  cloudy.  Soon  tin-  soft,  pulpy  mass  forces 
itself  through  the  capsular  wound  and  protrudes  into  the  anterior  chamber. 
It  may  be  absorbed,  but  in  the  mean  time  mass  after  mass  of  the  swollen 
liber-  follows  and  the  entire  lens  becomes  opaque  and  gradually  disappears. 
Hence  in  favorable  cases  a  clear,  black  pupil  with  good  vision  may  be  the 
result.  In  unfavorable  cases  some  inflammatory  complication  arises — iritis 
or  cyclitis — and  if  there  i-  any  infection  through  the  corneal  wound.  ;i  puru- 
lent process  may  develop  which  will  probably  destroy  the  eye.  At  best,  adhe- 
sions re-ult  which  may  had  to  detachment  of  the  retina  or  increase  of  tension. 
A  lens  which  swell-  very  quickly  may  produce  a  pressure-inflammation. 


388 


DISEASES  OF  THE  CRYSTALLINE  LENS. 


Cataracl  may  develop  from  an  indirect  injury,  without  apparent  rupture 
of  the  capsulej  such  as  a  blow  on  the  head  or  side  of  tlje  face,  or  as  the  result 
of  an  explosion,  and  it  is  then  termed  "  concussion  cataract"  In  these  cases 
there  is  a  slight  rupture  of  either  posterior  or  anterior  capsule.  Occasionally, 
after  both  direct  or  indirect  trauma  of  the  lens,  the  opacity  is  limited  and 
remains  stationary. 

I I I.  Complicated  Cataract. — This  may  develop  as  the  result  of  path- 
ological changes  in  almost  any  of  the  tissues  of  the  eye.  It  is  commonly 
associated  with  iritic  adhesions,  cyclitis,  irido-choroiditis,  glaucoma,  opacity 
of  the  vitreous,  and  detachment  of  the  retina.  The  prognosis  of  complicated 
cataract  is  far  less  certain  than  inordinary  eases,  and  operation  more  difficult. 
Indeed,  operative  treatment  is  frequently  contraindicated,  or  some  special 
method   of  surgical   procedure   must   be  devised   to  meet   the  indications. 

IV.  Senile  Cataract. — Hard  (because  the  nucleus  is  large),  simple, 
gray,  or  senile  cataract,  as  it  is  variously  designated,  develops  after  middle 
life,  most   commonly  after  forty-live  years. 

The   rate    of    development    varies  greatly.      Sometimes    the   cataract    will 
:;  2  l 


Fig.  250. — Nuclear   cataract:  I,  section  of  lens,  central   position  of  opacity;  2,  appearance  by  trans- 
mitted  light;  :'•.  appearance  bv  oblique  illumination.    (Modified  from   Nettleship.) 

3  2  1 


>n  oi   tens,  opacities  beneath  the  capsule ;  2,  opacities  si 
transmitted  light  (ophthalmoscope  mirror);  3, opacities  seen  bj  reflected  light  (oblique  illumination). 
Modified  from  Nettleship.  i 


remain  stationary  for  years ;  again,  it  will  ripen  completely  in  a  few  months. 
It  may  progress  rapidl}  for  a  time,  then  remain  stationary  for  year-,  and 
finally  resume  it-  rapid  progress.  It  nearly  always  affects  hotli  eyes,  hut 
usually  one  considerably   in  advance  of  the  other. 

Alnio-i  from  birth   there  is  greater  density  in  the  deeper  or  more  central 
layers  of  the  lens  than  in  the  superficial.     This  i-  nol  appreciable  until  after 


SECONDARY  CATARACT, 


the  age  of  thirty-five.  Then  close  examination  will  discover  thai  the  lens 
consists  of  a  dense,  hard,  more  opaque,  central  part,  the  nucleus,  and  a  softer 
and  more  transparent  surrounding  mass,  the  cortex. 

This  physiological  condition  may  continue  indefinitely,  with  perfeel  vision, 
or  the  centra]  part  may  become  denser,  more  deeply  -mined  and  opaque,  and 
form  a  nuclear  cataract  (  Fig.  250).  But  pure  nuclear  cataract  is  rarely  found. 
The  cortex  almost  invariably  is  involved  in  the  cataractous  process  (cortical 
cataract)  I  Fig.  '_'•"">  1 ),  but  the  conditions  of  hard  interior  and  softer  surface  con- 
tinue in  greater  or  less  degree  in  all  cases. 

The  commencement  of  a  senile  cataract  i-  somewhal  variable.  It  may 
first  appear  in  dark,  linear  striations  passing  from  the  margin  to  the  center 
of  the  lens,  or  it  may  proceed  from  the  anterior  to  the  posterior  surface. 
There  may  he  stellate  opacity  or  irregular  and  unequal  dotted  space.-.  The 
cataract  may  commence  at  the  equator  or  edue  of  the  lens,  or  centrally  at  the 
nucleus.  In  some  cases  these  linear  striations  remain  stationary  for  many 
years.  While  evidently  indicating  beginning  cataract,  they  have  received  the 
name  of  "gerontoxon  lentis"  or  "amis  senilis  lentis." 

V.  Secondary  Cataract. — This  includes  three  chief  varieties: 

("  )  Anterior  polar  or  pyramidal  cataract  result-  from  a  central  perforat- 
ing ulcer  of  the  cornea  (Fig.  252).     It  may  appear  as  a  conical  mass  projecting 


Fig.  252.- 


-Anterior  polar  cataract  (after  Nettle- 
ship). 


Fig.  253.— Posterior  polar  cataract  seen  by  trans- 
mitted light  (from  a  case  of  pigmentary  degenera- 
tinn  of  the  retinal. 


forward  from  the  surface  of  the  lens,  attached  to  the  margin  of  the  ulcer,  or 
having  a  thread-like  connection  with  it,  or  as  a  small  white  dot  on  the  capsular 
surface.  This  condition  is  extremely  unsatisfactory  in  regard  to  treatment. 
and  its  effect  on  vision   is  most  serious. 

(6)  Posterior  polar  or  pyramidal  cataract  is  dependent  on  choroidal  dis- 
ease, especially  disseminated  choroiditis.  It  is  found  a- a  star-shaped  opacity 
associated  with  high  myopia,  and  often  with  extensive  opacities  in  the  vit- 
reous, and  less  frequently  with  pigmentary  degeneration  of  the  retina  (Fig. 
253).  It  is  al-<»  caused  by  the  vestigial  remains  of  the  hyaloid  artery  at  its 
lenticular  attachment.  Small  posterior  capsular  opacities  from  this  source 
are  common  and  do  not  disturb  vision.  Among  1884  patients  examined  by 
Mittendorf,  14  were  thus  affected.  In  the  course  of  posterior  polar  cataract 
the  lens  it-ell*  will  often  become  opaque,  the  opacity  manifesting  itself  a-  a 
general  cloudiness  or  as  innumerable  dots  scattered  throughout  the  lenticular 
tissue. 

(c)  After-cataract  (al-o  called  secondary  cataract  is  the  condition  usually 
left  after  the  operation  of  extraction  of  cataract.  Tin  changes  occur  in  the 
capsule  ;  the  opening  may  be  closed  by  a  delicate  veil  ;  the  capsule-cells  may 
proliferate,  resulting  in  increased  thickening;  or  there  may  he  a  plastic  de- 
posit, leading  t elusion  of  the  pupil. 


390  DISEASES  OF  THE  CRYSTALLINE  LENS. 

VI.  Capsular  Cataract. — This  name  is  applied  to  any  thickening  or 
hyperplasia  of  the  capsular  epithelium,  which  resembles  connective  tissue. 
It  may  be  congenital  or  result  from  ulcerative  processes  in  the  cornea,  either 
with  or  without  perforation  of  the  cornea.  According  to  Mules,  cretified 
remains  of  the  pupillary  membrane  explain  some  eases. 

VII.  Capsulo-lenticular  Cataract. — Not  only  is  there  lenticular 
change  in  this  variety,  but  there  is  hyperplasia  of  the  cells  on  the  posterior 
surface  of  the  anterior  capsule,  causing  thickening  of  that  membrane,  com- 
monly  in   its  center. 

VIII.  Special  Clinical  Forms  of  Cataract. — a.  Diabetic  Cataract. 
— This  is  usually  of  the  soft  variety,  is  rapid  in  its  formation,  and  almost 
invariably  affects  both  eyes.  If  it  develops  in  elderly  persons,  it  may  be 
more  consistent  and  have  a  more  or  less  firm  nucleus,  it  is  often  accom- 
panied by  lesions  of  the  deeper  tissues  <>f  th'/  eye.  as  retinitis  or  optic  neur- 
itis. If  possible,  prior  to  operation  these  facts  should  he  carefully  ascer- 
tained on  account   of  their  bearing  on  the  prognosis. 

I>.  Albuminuric  Cataract. — Although  changes  in  the  lens  are  sometimes 
found  in  association  with  Bright's  disease,  they  are  infrequent,  and  no 
direct  connection  between  the  two  can  he  traced.  It  is  well  known  that,  as 
a  rule,  cases  of  cataract  attributed  to  albuminuria  make  good  recoveries  after 
operation,  and  a  fair  degree  of  vision  is  secured.  Other  uncommon  forms 
Of  cataract   are — 

c.  Central  lental  cataract,  which  consists  of  a  white  opacity  in  the 
center  of  the  leu-,  due  probably  to  faulty  development  at  an  early  stage  of 
intra-uterine  existence. 

'/.  Punctate  cataract,  in  which  the  opacities  present  themselves  in  the 
form  of  tine  points  and  dot-,  either  occupying  the  center  of  the  lens  or  dis- 
tributed throughout  it-  substance.  Punctate  cataract  may  he  congenital  or 
develop  in  later  life.  Usually  it  remains  stationary  for  a  long  time,  hut  occa- 
sionally progresses  to  maturity. 

>.  Fusiform  cataract,  which  is  characterized  by  an  opaque  stripe  passing 
I'min    the   anterior   to   the   posterior   pole  of  the    lens. 

Pathology  and  Pathological  Anatomy  of  Cataract. — While  the  exact 
process  which  produces  cataracts  is  still  obscure,  the  development  of  opacity 
of  the  crystalline  leu-,  mosi  frequently  associated  with  old  age,  is  undoubt- 
edly dependent  upon  some  error  of  nutrition  or  upon  some  nutritive  change 
secondary  to  disease  in  the  deeper-seated  tissues  of  the  eye.  This  is  evident 
from  its  frequent  origin  in  some  inflammatory  disease  in  the  iris,  choroid, 
ciliary  body,  or  vitreous  humor.  Any  process  which  interrupts  or  diminishes 
the  vascular  supply  to  the  anterior  region  of  the  globe,  or  interferes  with  the 

o- tic  action  of  t  he  nutritive  fluids,  will  directly  a  fleet  the  normal  conditions 

of  healthful  stability. 

This  interruption  of  natural  conditions  leads  to  slow  hut  progressive 
changes  in  the  lens-fibers.  There  is  primarily  a  slight  contraction,  followed 
by  increase  in  volume,  owing  to  the  imbibition  of'  fluid-;  cholesterin  is 
increased  in  amount,  and  the  albuminoids  diminished.  The  new  cell-produc- 
tion from  the  intracapsular  cell-  can  he  plainly  >vru  with  the  microscope. 
Later,  the  lens-fibers  atrophy,  their  volume  diminishes,  and  irregular  inter- 
spaces are  formed,  within  which  large  amount-  of  fluid  accumulate  (Mor- 
gagni'e  globules).  often  the  fibers  -how  punctate  cloudiness,  transverse 
striations,  molecular  degeneration,  fat-globules,  ami  cholesterin  (Fig.  254). 

Foreter  states  that  in  the  process  of  transformation  of  the  inner  layers 
of  the  lens  into  ;i  nucleus  the  lavers  diminish   in  volume.     Normally,  thi- 


ETIOLOG  V  OF  CATARACT. 


391 


process  is  so  slow  and  gradual  that  the  cortical  layer- adapt  themselves  to  the 
contracting  nucleus.  If,  however,  the  shrinking  progresses  rapidly  or  irreg- 
ularly, there  is  extreme  pulling  or  traction,  with  consequent  separation  of  the 
layers  which  lie  between  the  nucleus  and  cortex.  In  this  condition  fine 
fissures  are  formed  and  fluid  accumulates  in  them  ;  the  adjacent  lens-fibers 
become  opaque  and  form  the  initial  impulse  which  leads  to  complete  lenticu- 
lar opacity. 

Etiology. — Cataract  may  be  considered  a  disease  of  old  age.  While 
complete  cataract  is  found  at  almost  any  period  of  life,  it  is  comparatively 
rare  before   the   fiftieth   year. 

Sex  does  not  influence  the  development  of  cataract,  except  in  the  zonular 
variety,  in  which  greater  liability  of  females  has  been  recorded.  Occupation 
has  but  little  influence  on  the  development  of  the  disease,  although  it  has 
been  observed  to  occur  more  frequently  in  those  who  are  constantly  sub- 
jected to  intense  heat,  as  laborers  in  Turkish  bath-houses,  glass-blowing 
factories,   smelting-foundries,   etc.       Heredity  has   an    undoubted    influence. 


Fig.  254.— Cataracta  capsulo-lenticularis,  •  170:  it,  anterior  capsule  of  the  lens:  e,  epithelium,  occur- 
ring at  ei,  in  several  layers  because  of  proliferation :  I,  normal  lens-fibers;  v,  lighl  colored  vacuoles  drops 
of  liquor  Morgagni]  between  /and  the  epithelium.  The  fissures  originating  through  the  separation  of 
the  lens-fibers  are  filled  with  a  granular  mass  (coagulated  fluid),  s,  which  in  places  forms  the  spheres 
of  Morgagni,  M.  The  lens-fibers  themselves  are  swollen  up  (g),  or  transformed  into  vesicular  ce 
or  entirely  disintegrated  (s)  (Fuchs). 


There  are  examples  where  many  members  of  the  same  family  are  afflicted. 
The  author  has  met  with  cataract  in  the  four  children  of  one  family,  both 
father  and  mother  having  developed  the  disease  at  an  early  age.  Haskel 
Derby  has  recorded  8  cases  of  rudimentary  double  cataract  among  10 
members  of  the  same  family,  and  John  Green  21  cases  of  cataract  among 
71    persons  belonging  to  <>  successive  generations  of  one   family. 

Both  acute  and  chronic  diseases  of  the  eye — iritis,  irido-choroiditis,  irido- 
cyclitis, glaucoma,  diseases  of  the  vitreous,  and  most  commonly  extensive 
and  long-standing  detachment  of  the  retina — frequently  cause  cataract.  It  i- 
especially  :ipt  to  develop  after  purulent  processes,  such  a-  hypopyon-kera- 
titis or  purulent  choroiditis. 

Such  diseases  ;i~  idiopathic  fever,  typhoid  fever,  diabetes,  albuminuria, 
atheroma  of  the  carotid,  gout,  syphilis,  influenza,  rachitis,  bronchocele,  men- 
ingeal inflammation,  and  convulsive  seizures  have  been  associated  with  cata- 
ract formation.     It  has  been  attributed  to  pregnancy  and  prolonged  lactation. 


392  DISEASES  OF  THE  CRYSTALLINE  LENS. 

In  epidemics  of  ergotism  cataracts  are  frequently  found  (raphanic  cataract), 
and  artificial  cataract  may  be  induced  in  animals  by  feeding  them  with 
naphthalin  (naphthalin  cataract).  For  that  form  of  cataract  found  in  diseases 
of  the  uveal  tract  and  in  anemia  and  marasmus  the  name  "starvation  cata- 
ract "  has  been  suggested. 

The  influence  of  accommodatm  strain  on  the  production  of  cataract,  as 
well  a-  other  serious  ocular  disturbances,  is  not  thoroughly  understood.  A 
large  proportion  of  cataractous  eyes  are  ametropia  It  is  probable  that  the 
constant  effort  of  the  ciliary  muscle  unfavorably  influences  the  nutritive  pro- 
cesses of  the   lens. 

The  influence  of  trim  mutism  in  the  production  of  cataract  has  been  de- 
scribed.  Some  cases  have  followed  a  lightning  stroke,  hut  have  also  been 
associated  with  optic  neuritis,  rupture  of  the  choroid,  iritis,  or  irido-cyclitis. 

Symptoms. — During  the  development  of  cataract,  especially  the  senile 
form,  the  chief  subjective  symptom  is  a  gradual  hut  steady  loss  of  vision.  In 
those  cases  where  the  periphery  of  the  lens  is  first  affected  very  extensive 
opacity  may  form  without  great  loss  of  vision  ;  hut  if  the  opacity  invades  the 
center  or  nucleus,  the  interference  with  sight  becomes  marked  at  an  early 
stage.  This  may  be  beautifully  demonstrated  by  the  instillation  of  a  mydriatic 
— improvement  in  vision  will  at  once  appear.  It  is  in  this  latter  class  of 
cases   that   an    iridectomy  may  prolong  vision   for  years. 

The  presence  of  floating  -pots  or  muscse,  diplopia,  often  monocular,  or 
polyopia,  changes  in  refraction  with  the  development  of  astigmatism,  or  the 
alteration  of  the  axis  of  a  pre-existing  astigmatism,  are  exceedingly  common, 
and  are  mainly  due  to  the  irregular  swelling  of  the  lens-substance.  This  is 
so  -ivai  at  times  as  actually  to  produce  a  true  myopia  (the  "  second  sight  "  of 
the  aged),  and  necessitates  a  greatly  diminished  convex,  or  at  times  a  concave, 
glass  i  see  also  page  'l'1'l). 

Among  the  objective  symptoms  will  be  found  a  narrowing  of  the  anterior 
chamber  in  the  early  stages,  consequent  upon  the  advancement  of  the  iris 
and  due  t«.  the  swelling  and  bulging  of  the  lens ;  photophobia,  due  to  the 
iritic  irritation  caused  by  the  same  pressure;  stria'  or  opaque  spots,  demon- 
strable by  oblique  illumination  ;  and,  finally,  the  changed  pupil,  which  is 
altered  from  a  brilliant  black  to  a  staring  yellow,  white,  or  brown.  Some- 
times the  lens  becomes  so  deeply  stained  as  to  appear  dark  brown  or  black 
{cataracta  nigra);  sometimes  it  is  of  a  milky,  bluish-white  color  ;  and  some- 
times the  cortex  degenerates,  becomes  fluid,  and  the  hardened  nucleus  sinks 
to  the  bottom  of  the  shrivelled  capsule  {Morgagnian  or  overripe  cataract). 

For  clinical    study    l-uch-   divide-   the    periods  of    the   development    of  a 

progressive  cataract   into  four  stages,  as  follow-: 

1.  Stage  of  Tncipiency  {Cataracta   Tncipiens). — In  this  stage  opacities  are 

f( d  throughout   the  leu-,  usually   in  the  shape  of  sectors  or  -pokes,  with 

spots  -lib  transparent.     The  anterior  chamber  is  of  normal  depth. 

'1.  Stage  of  Swelling  (Cataracta  Tntumescens). —  The  lens  has  now  absorbed 

more  fluid,  -welled  up.  and  ha-  pushed  the  iris  forward  ant!  reduced  the 
depth    of   the    anterior  chamber.       The   opacity    become-    total    in    this  stage. 

The  lena  is  bluish-white  and  ha-  a  silky  luster.  The  marking-  of  the  stellate 
figures  are  very  distinct. 

;;.  st,!,/,  of  Maturity  i<  'ataracta  Matwra). — Contraction  ha-  now  taken 
place,  and  mosl  of  the  fluid  absorbed  ha-  been  lost.  The  anterior  chamber 
has  resumed  it-  normal  depth,  mid  the  lens,  losing  its  brilliant,  iridescent 
look,  ha-  a  dull-gray  or  brownish  appearance. 

I.  Stagt    of  HypermatwrUy  {Cataracta    Hypermatura). — If  the  change 


RIPENING    OF  CATARACT.  393 

continues,  the  cortex  undergoes  disintegration  and  becomes  cither  a  soft, 
pultaceous  mass  without  structural  elements,  or,  if  the  fluid  is  absorbed,  a  dry, 
inspissated,  flattened,  cake-like  body.  The  anterior  chamber  is  normal,  and 
the  surface  of  the  lens  is  homogeneous,  or  reveals  irregular  dots  instead  of 
the  usual   radial  markings. 

Diagnosis. — The  old  catoptric  test  may  still  be  used  t<>  detect  the  pres- 
ence of  cataract,  as  well  as  to  determine  the  presence  of  the  lens  or  of  a  black 
cataract.  In  a  darkened  room  a  lighted  candle  is  moved  before  an  eve  with 
properly  dilated  pupil.  If  two  erect  images  and  one  inverted  image  air 
reflected  respectively  from  the  anterior  surface  of  the  cornea  and  the  anterior 
and  posterior  surfaces  of  the  lens,  the  lens  is  intact.  If,  however,  the  pos- 
terior inverted  image  is  absent,  there  is  some  opacity  behind  the  anterior 
capsule,  and  if  the  deeper  erect  image  is  wanting,  the  opacity  involves  the 
anterior  capsule. 

With  oblique  illumination  the  opacities  appearing  as  gray  spots  or  >tria- 
tions  may  be  easily  recognized.  The  use  of  the  ophthalmoscope  has  cau-<  >d 
all  other  methods  to  he  abandoned.  It  has  rendered  the  detection  of  cataract 
a  matter  of  immediate  and  certain  demonstration.  The  patient,  with  pupil 
dilated  with  cocain  or  homatropin,  is  taken  to  a  darkened  room  and  placed  in 
the  position  for  ordinary  ophthalmoscopic  examination.  Light  is  reflected 
from  the  mirror  through  the  enlarged  pupil,  and  the  interruptions  to  the 
normal  reflex  from  the  choroid  will  indicate  the  lenticular  opacities,  which 
appear  as  black  spots  or  as  lines  or  streaks  radiating  from  the  margin  to  the 
center.  The  nucleus  may  be  hazy,  or  the  center  may  appear  clear  with 
opaque  rings  surrounding  it.  The  sectors  of  the  lens  may  be  denser  than 
normal,  or  lenticular  flaws,  resembling  cracks  in  glass,  may  be  seen.  Finally, 
there  may  be  entire  absence  of  the  reflex  due  to  complete  opacity  of  the  lens 
body. 

The  Process  of  Ripening-. — The  course  and  development  of  cataract  van- 
greatly.      In  the  simple  or  senile  form  the  time  from  incipiency  to  ripeness 
may  vary  from  a  few  months  to  many  years;  the  usual  time  is  from  one  to 
four  years.     Cortical  cataract  may  remain  im- 
mature for  a  prolonged  period  (fifteen  to  twenty 
years)  ;  hence  the  wisdom  of  a  guarded  prog- 
no-is.      Finally,  when  the  entire  substance  of 
the  lens  has  become  opaque,  when  the  swelling 
has    subsided,    and    the    anterior    chamber    has 
resumed  its  normal  depth,  the  cataract  is  ripe. 
This  period  may  be  determined  bv  illuminating 

,  '     .,         i  p  li        l  •       "•/•    i         i      i  Fig.  255.— Shadow  ol  the  iris 

the  pupil  ami  caret  ill  I  v  Observing  it  the  ShaClOW  from  the  front,  appearing  on  that  side 

/■  ,i  •         (•.!*•••  a i      .    j    c  .1  of  the  iriswhichis  toward  the  light, 

ot  the   margin  of    the   ins  is  reflected    from   the  l  (Fuch 

lens.      In  case  no  shadow  is  seen  the  cataract  is 

complete  and  ripe  :  if  the  shadow  is  present,  there  is  still  a  transparent  re- 
flecting layer  of  the   lens  beneath   the  capsule  (Fig.  255). 

A  mature  cataract  has  the  property  of  separating  readily  from  it-  con- 
nection with  it<  capsule.  A.s  suggested  by  Arlt.  it  lie-  in  it-  capsule  like  a 
ripe  fruit  in  its  rind.  The  cause  of  this  will  probably  be  found  in  the  pre- 
liminary -welling  and  contracting  of  the  lens-substance,  and  the  consequent 
loosening  of  the  surface  from  the  capsule. 

Prognosis. — Tin-  should  be  guarded  in  immature  cataracts  of  all  varie- 
ties, but  especially  in  the  linear  cortical  variety,  with  which  g I  vision  may 

be  retained  for  a  period  varying  from  fifteen  to  twenty-five  years.  Hie  fol- 
lowing considerations  should  influence  the  prognosis  with   reference  to  the 


394  DISEASES  OF  THE  CRYSTALLINE  LENS* 

result  of  operative  procedure:  The  want  of  health  in  surrounding  tissues; 
disease  of  the  nasal  or  lachrymal  passages  ;  various  forms  of  inflammation  of 
the  conjunctiva  and  margins  of  the  litis  ;  the  size  and  consistence  of  the 
nucleus  ;  the  degree  of  maturity  of  the  cataract  ;  the  general  condition  of  the 
patient  and  the  presence  of  general  disease,  such  as  diabetes,  chronic  nephritis, 
or  bronchitis,  with  constant  cough  ;  the  presence  of  extreme  myopia  or  hy- 
peropia :  immobility  or  tremulousness  of  the  iris  ;  and  contraction  of  the 
light-field,  or  want  of  light-perception  due  to  serious  ocular  disease,  such  as 
glaucoma  or  retinal  detachment.  The  presence  of  diabetes  or  Bright's  disease, 
while  complicating,  docs  not  contraindicate  operation.  Extreme  age  does 
not  necessarily  complicate  the  result. 

The  light-field,  upon  which  the  final  prognosis  is  based,  providing  other 
complicating  circumstances  enumerated  are  absent,  is  thus  tested:  1  Mace  the 
patient  before  a  lighted  candle  about  four  meters  distant  ;  the  flames  should 
be  distinctly  recognized.  This  gives  evidence  that  the  macular  region  is 
probably  free  from  coarse  disease.  Now  cause  the  eye  under  examination  to 
fix  the  flame  attentively,  ami  move  a  second  lighted  candle  radially  through 
the  field  of  vision.  The  flame  should  be  recognized  as  soon  as  the  rays 
strike  the  edge  of  the  cornea,  and  the  patient  should  be  able  to  indicate  the 
direction  in  which  the  light  is  coming.  Thus  the  "light-field,"  or  the 
"projection  of  light,"  is  toted,  and,  if  the  answers  have  been  accurate, 
"  projection  of  light  is  good   in  all   parts  of  the  field." 

Even  after  complete  absorption  of  congenital  cataract  under  the  influence 
of  repeated  discissions,  useful  vision  is  not  always  restored,  because  of  asso- 
ciated optic  nerve-atrophy,  choroidal  disease,  or  changes  at  the  macula. 
The  functional  condition  of  an  eye  with  total  congenital  cataract  is  usually 
less   favorable   than   one   with   the   zonular   variety  of  the  disease. 

Treatment. — From  the  earliest  period  ophthalmologists  have  eagerly 
sought  some  method  of  absorbing  or  dissipating  the  cataractous  lens.  Vari- 
ous suggestions  have  been  made,  and  various  methods  of  procedure,  such  as 
massage  and  passing  the  electric  current,  have  been  tried,  but  with  negative 
results.  So  long  as  glasses,  changed  in  accordance  with  the  altering  refrac- 
tion of  the  eye,  improve  vision,  they  may  be  worn.  Tonics  are  useful  as 
adjuvants,  and  various  alteratives — e.  g.  iodid  of  potassium — to  relieve 
choroidal  congestions  may  be  exhibited.  During  incipiency  moderate 
mydriasis  may  assisl  vision.  At  the  proper  time,  however,  surgical  interfer- 
ence becomes  necessary. 

Various  important  questions  arise  in  determining  the  best  course  to  be 
followed  to  bring  the  treatment  of  cataract  to  a  happy  conclusion.  When 
should  extraction  lie  made".'  A^e  we  justified  in  hastening  the  process  of 
ripening,  and  should  we  interfere  when  one  eve  is  intact  and  has  normal 
vision  '.' 

1.  Extraction  of  Immature  Cataract. — Most  ophthalmic  surgeons 
delay  extraction    until   the   process  of  ripening  i-  complete.     While  this  i-, 

perhaps,  the  wisest   plan,  everything  considered,  it   is  by  no  mean-  tl nly 

"iK'.  flic  danger  of  an  early  operation — the  swelling  of  the  softened  unripe 
cortex— can  be  largely  overcome  l>v  washing  out  the  cavity  with  warm  -aline 
solutions,  after  the  method  df  Panas  and  other  operator-,  subsequent  to 
extracting  the  nucleus.1     About  the  sixtieth  Mar  of  life,  and  even  earlier,  an 

unripe  cataract   may  be  successfully  extracted. 

1  [rrigation  of  the  anterior  chamber,  in  tl pinion  of  the  editor,  is  an  unwise  procedure. 

[f  the  capsule  i-  properly  opened     ei  ,  the  danger  of  swelling  of  cortical  remnants 

i-  small     Bmaller  than  thai  which  follows  irrigation. 


APHAKIA.  395 

2.  Artificial  ripening  of  cataract  is  rarely  justifiable.     It   subjects 

tilt-  patient  to  a  second  major  operation  on  the  eye,  with  the  attendant 
dangers.  When  this  operation  i-  determined  upon  it  may  We  performed 
according  to  one  of  the  method-  described  on   page  584. 

:'>.  Extraction  of  Monocular  Cataract. — Unless  the  cataract  Is 
hypermature  or  a  cosmetic  effect  is  greatly  desired,  we  are  hardly  justified  in 
extracting-  an  opaque  lens  when  the  other  eye  has  normal  vision.  The  advan- 
tage- of  a  successful  operation  are  that  the  field  of  vision  of  the  affected  side 
becomes  more  extensive,  and  the  patient  possesses  an  eye  ready  for  use  should 
vision  in  the  other  eye  become  involved  from  any  cause.  On  the  other  hand, 
while  binocular  vision  i-  possible,  object-  are  constantly  blurred  and  sharp- 
ness of  contour  i>  wanting.  The  operated  eye  sometimes  lags  behind  the 
other,  giving  an  awkwardness  of  expression  more  grotesque  and  less  pleasing 
than  the  presence  of  the  cataract. 

4.  Operations  for  Cataract. — For  soft  cataracts  discission,  the  method 
of  suction,  a  combination  of  these  methods,  or  linear  incision  may  be 
practised.  The  use  of  the  needle,  repeated  if  necessary,  will  suffice  in  the 
usual  soft  varieties,  while  the  suction  method  will  quickly  extract  the  con- 
tents when  of  semifluid  consistency.  It  is  not  wise  to  delay  the  removal  of 
a  congenital  cataract  beyond  the  early  weeks  of  life,  as  interference  with  the 
development  of  the  retina  and  other  deeper  tissues  of  the  eye  may  result. 

Partial  congenital  cataracts  are  treated  by  optical  iridectomy  or  discission. 
The  former  method  is  applicable  to  those  cases  whose  vision  is  improved  by 
dilating  the  pupil. 

Discission  is  practised  for  the  after-cataract,  not  to  produce  absorption,  but 
to  open  a  passage  for  the  light-rays  (see  page  58">). 

For  the  removal  of  the  hard  or  senile  cataract  one  of  the  various  methods 
of  extraction  should  be  followed.  The  results  of  this  operation  are  such  that 
the  older  method  of  couching  has  been  completely  abandoned.  While  the 
exact  technique  of  the  various  operations  will  be  found  elsewhere  (see  chapter 
on  Operations,  p.  580),  several  important  points  may  be  properly  referred  to 
here.  The  corneal  incision  should  be  ample  in  size,  and  should  be  completed 
with  as  few  motions  as  possible,  the  subsequent  rapid  union  of  the  cut  sur- 
faces being  somewhat  dependent  upon  this.  The  question  of  an  iridectomy 
is  much  discussed,  each  individual  operator  having  finally  to  determine  the 
method  from  his  own  experience.  Probably  simple  extraction  (without 
iridectomy)  is  now  performed  in  60  per  cent,  of  the  cases,  the  maturity  of 
the  cataract,  the  condition  of  the  iris,  and  the  question  of  drainage  determin- 
ing the  method.  A  wise  rule  i-  to  perform  simple  extraction,  examine  the 
eye  within  twenty-four  hours,  and,  if  the  conditions  arc  not  favorable,  sepa- 
rate the  lips  of  the  wound  and  resect  the  iris.  The  extrusion  of  the  vitreous 
during  the  operation  i-  usually  due  to  insufficient  rupture  of  the  capsule  and 
excessive  pressure  in  delivering  the  lens.  Unless  it  is  so  great  as  to  cause 
total  collapse  of  the  globe  the  removal  of  the  lens  may  be  successfully 
attempted  by  other  mean-.  A  degenerated  or  fluid  vitreous  may  instantly 
torcc  the  operator  to  desist. 

Aphakia. — In  the  normal  eye  the  removal  of  the  lens  (aphakia)  causes 
a  high  degree  of  hyperopia,  about  11  I  >.  In  myopia  the  degree  of  hyper- 
opia will  be  lessened,  and,  indeed,  in  myope-  of  high  degree  emnietropia 
may  result  from  extraction  of  the  lens,  or,  if  the  myopia  has  been  ve 
a  portion  will  remain  unneutralized  by  the  artificial  hyperopia.  In  addi- 
tion to  the  hyperopic  refraction  which  results  from  cataract  extract 
regular  astigmatism  is  often  found.     Jt  is  probably  produced  by  the  ii 


396  DISEASES  OF  THE  CRYSTALLINE  LENS. 

alar  contraction  of  the  cicatrix,  and  is  usually  "contrary  to"  or  "against 
the  rule."  It  is  always  greatesl  in  the  early  months  alter  the  operation,  and 
slowly  diminishes.  These  conditions  can  be  much  relieved  by  the  application 
of  suitable  glasses.  In  the  average  case  a  simple  sphere  of  from  8  D.  to  1*2 
D.,  with  the  addition  of  a  cylindrical  glass  of  from  '1  D.  to  •"'>  I>.,  axis  con- 
trary to  the  ride,  will  usually  suffice  for  good  distant  vision.  For  reading  an 
additional  sphere  of  from    1  to  II  I),  must  be  added. 

Perfect  vision — i.  e.  J; — is  often  secured  after  extraction,  but  (l  or  even 
X  of  normal  vision  is  sufficient  to  place  the  case  within  the  list  of  successes. 
Frequently  the  vision  can  be  materially  improved  by  splitting  the  capsule. 
Glasses  should  nut  be  adjusted  until  all  signs  of  irritation   have  subsided. 

Changes  of  Position  of  the  Crystalline  I^ens. —  The  various 
changes  which  the  position  of  the  crystalline  lens  may  assume,  termed  luxa- 
tion and  subluxation,  may  be  congenital  or  acquired.  The  lens  i-  supported 
firmly  in  its  natural  position  by  the  zonula  of  /inn  or  the  suspensory  liga- 
ment, and  displacement  of  the  lens  is  only  possible  by  relaxation  or  elonga- 
tion of  the  zonula  fibers  or  by  their  destruction. 

1.  Congenital  dislocation,  or  ectopia  /cutis,  is  almost  invariably  a  sub- 
luxation, ami  i-  due  to  the  unequal  length  of  the  zonula  in  various  directions. 
The  zonula  being  shortest  above,  the  lens  will  be  found  displaced  upward  or 
upward  and  outward.  Later  in  life  the  displacement  may  become  complete. 
Both  eyes  are  usually  affected,  but  monocular  cases  are  reported.  Heredity 
appears  to  exert  a  marked  influence  on  the  production  of  congenital  disloca- 
tion. 

2.  Acquired  dislocation*  arc  the  result  of  injury,  usually  a  concussion 
which  forces  the  aqueous  backward  and  ruptures  the  delicate  membrane  of 
the  zonula.  The  displacement  may  be  complete  or  incomplete, the  lens  being 
forced  forward  into  the  anterior  chamber  or  backward  into  the  vitreous,  or 
through  a  laceration  of  the  external  coverings  of  the  eye  beneath  the  con- 
junctiva, and  even  under  Tenon's  capsule.  Occasionally  it  is  completely 
expelled  i -ee  also  page  366). 

Symptoms. — In  subluxation  the  anterior  chamber  is  found  of  unequal 
depth,  the  iris  being  pushed  forward  at  one  point  by  the  margin  of  the  lens. 
The  iris.  Losing  its  support  in  part,  is  no  longer  stationary,  but  trembles  with 
every  motion  of  the  eve.  With  the  ophthalmoscope  the  edge  of  the  lens  is 
-een  ;i-  a  dark  grayish  line.  There  may  be  loss  of  accommodation  and  mon- 
ocular diplopia,  [n  complete  luxation  forward  the  lens  will  be  easily  recog- 
uized  by  its  shape  as  it  iv>t<  in  the  anterior  chamber  or  bulges  out  beneath 
the  conjunctiva.  In  posh  ,-ior  dislocation  the  conditions  simulating  extraction 
are  present.  With  every  form  of  luxation  very  considerable  changes  in 
vision  are  noticed.  In  subluxation  myopia  maybe  present,  and  a  consid- 
erable degree  of  astigmatism.  In  complete  dislocation  backward  the  extreme 
hyperopia  of  the  aphakic  eye  is  produced.  The  lens  almost  invariably 
undergoes  cataractous  changes,  and  !>v  pressure  may  produce  very  serious 
inflammatory  changes  in  the  other  tissues  of  the  eve — iritis,  cyclitis,  and 
choroiditis — or  by  closing  the  angle  of  the  anterior  chamber,  giving  rise  to 
glaucoma  i  see  also  page  366 1. 

Treatment. —  In  partial  dislocations  the  vision  should  be  improved  as 
much  :i-  possible  b\  appropriate  glasses.  In  complete  anterior  dislocation 
the  lens  should  be  removed  through  :i  proper  incision.  Where  the  disloca- 
tion i-  backward,  unless  there  i-  some  irritation,  no  attempt  at  removal 
should  be  made.  When  there  is  danger  to  the  eye  an  effort  should  be  made 
to  press  the  lens  forward  into  the  pupil  space  by  passing  a  needle  through  the 


I •(> Ni ; EN TTAL   ANO M M.I ES.  397 

sclera  behind  the  lens,  and  then  extracting  it  through  a  conical  wound 
also  page  582). 

Congenital  Anomalies.-  Congenital  cataract  and  congenital  ectopia 
lentis  have  been  recorded.     In  addition,  there  remain  to  be  described — 

1.  Congenital  Aphakia. — Total  absence  of  the  lens  at  birth  is  a  condition 
of  which  there  is  no  recorded  example.  Total  absence  of  the  lens  has  been 
found,  however,  in  rare  instances, as  the  result  of  some  intra-uterine  disease. 

2.  Coloboma  of  the  Lens. — Coloboma  of  the  lens  almosl  invariably  accom- 
panies a  similar  condition  of  the  iris  or  choroid,  especially  the  former.  The 
evenly  rounded  margin  of  the  lens  is  replaced  by  a  straight  border  or,  it  may 
be,  by  a  notch  of  greater  or  lesser  depth.  Heyl  states  that  the  coloboma  is 
almost  invariably  found  in  the  lower  segment  of  the  lens.  It  may  consider- 
ably disturb  the  visual  acnteness. 

.*>.  Lenticonus. — This  rare  anomaly  consists  of  a  conical  projection  from  the 
surface  of  the  lens,  usually  from  the  posterior  surface,  or  it  may  simply  he  an 
exaggerated  curvature  of  the  lens.  On  examination  with  the  ophthalmoscope 
it  resembles  a  drop  of  oil  resting  on  the  surface.  It  may  or  may  not  be  ;i>-o- 
ciated  with  lenticular  opacity.     Anterior  lenticonus  also  occurs. 


DISEASES   OF   THE   VITREOUS. 

By   PLEMMING   CARROW,   M.D., 

<»F   ANN    ARBOB,   MICH. 


Hyalitis  (Inflammation  of  the  Vitreous). — Tliis  disease  appears  in  two 
forms — one  characterized  by  suppuration  {suppurative  hyalitis),  and  the  other 
by  either  fixed  or  floating  opacities. 

Etiology. — All  opacities  seen  in  the  vitreous,  however,  are  not  to  be 
regarded  as  the  result  of  pathologic  conditions  peculiar  to  that  body,  for  they 
are  usually  dependent  upon  some  structural  change  in  the  uveal  tract  or 
retina.  On  account  of  the  absence  of  blood-vessels  and  nerves  in  its  struc- 
ture the  vitreous  was  at  one  time  supposed  to  be  incapable  of  inflammation, 
but  recent  investigation  has  developed  the  fact  that  idiopathic  or  spontaneous 
inflammation  may  occur  without  change  of  a  textnral  character  in  any  other 
part  of  the  eye.  It  is  true,  however,  that  hyalitis  of  the  suppurative  variety 
is  generally  a  secondary  disease,  being  caused  by  an  injury  (penetrating 
wound)  to  some  adjacent  structure,  or  by  previously  existing  choroidal  disease 
which  had  its  origin,  primarily,  in  consequence  of  some  operative  procedure 
upon  some  other  part  of  the  eye  (as  after  cataract  extraction). 

Suppurative  hyalitis  may  also  be  due  to  microbic  invasion  of  old  operative 
scars  '>f  several  years'  standing,  to  exhaustion  following  any  lengthy  debili- 
tating disease,  especially  the  continued  fevers,  relapsing  fevers,  the  exanthem- 
ata, or  may  result  from  metastatic  choroiditis  after  inflammation  of  the  um- 
bilical  cord    in    new-born   children. 

Symptoms. — Since  suppurative  hyalitis  is  usually  secondary  to  disease 
of  other  structures,  we  will  find  evidences  of  the  presence  of  this  primary 
affection  in  adhesions  of  the  pupillary  margin  to  the  anterior  capsule  of  the 
lens,  and  a  history  of  iritis  and  cyclitis.  Pus  once  having  formed  in  the 
vitreous  (the  cornea  and  media  being  clear),  it  is  readily  seen  with  the  oph- 
thalmoscope occupying  a  circumscribed  area  (pseudo-glioma),  while  the  rest 
of  the  vitreous  may  appear  perfectly  clear  and  health  v.  This  condition  closely 
resembles  a  true  glioma  of  the  retina  ;  bul  the  history  of  the  case,  with  the 
symptoms  of  iritis  and  diminished  tension,  will  serve  to  distinguish  them 
(see  also  page  356). 

The  disease  may  remain  confined  to  some  peripheral  portion  of  the 
vitreous  body,  bul  usually  the  suppurative  process  extends  until  the  entire 
vitreous  becomes  involved,  and  through  a  resulting  panophthalmitis  the  eye 
is  lo-t.  The  history  of  some  pre-existing  eye-disease  and  the  ophthalmoscopic 
appearances  will  sufficiently  indicate  the  location  and  gravity  of  the  affection. 

Prognosis  and  Treatment. — The  result  of  suppurative  inflammation  of 
the  vitreous  is  usually  not  only  the  loss  of  the  affected  eye.  bul  the  atrophied 
globe  after  panophthalmitis  may  be  a  source  of  menace  to  the  sound  eye. 
Should  the  health  of  the  sound  eye  be  threatened  at  any  stage  of  the  disease, 
enucleation  of  the  affected  organ  musl  be  at  once  performed. 


OPACITIES  OF  THE    VITREOUS.  399 

During  the  course  of  any  lengthy  debilitating  disease,  should  suppurative 
hyalitis  supervene,  it  may  be  possible  to  save  the  eve  with  some  degree  of 
vision  by  vigorous  tonic  treatment.  Intraocular  injections  of  chlorin-water 
have  been  recommended  on  experimental  grounds  (Berry).1 

Opacities  of  the  Vitreous. — That  variety  of  inflammation  of  the 
vitreous  characterized  by  the  formation  of  fixed  or  movable  opacities  may  be 
either  acute  or  chronic. 

Etiology. — As  this  form  of  vitreous  disease,  like  the  suppurative  variety, 
is  secondary  to  affections  of  other  portions  of  the  eye,  the  refraction  of  the 
eve  and  the  condition  of  the  lens,  of  the  ciliary  body,  choroid,  and  retina,  must 
be  examined  for  its  cause.  High  degrees  of  myopia  associated  with  posterior 
staphyloma  constitute  a  frequent  cause  of  this  trouble.  Again,  in  choroiditis, 
and  especially  in  the  specific  variety,  a  fine  dust-like  mist  (hyalitis  jtuuefata) 
can  be  detected,  through  which  there  are  distributed  larger  flake-like  opacities 
of  irregular  shape,  which  give  individuality  to  the  primary  disease  which 
caused  them. 

Exhaustion  of  the  general  system  from  long-continued  fevers,  gout,  con- 
stipation, anemia,  interference  with  the  function  of  the  liver  by  congestion, 
irregular  menstruation,  syphilis,  and  the  action  of  drugs  (arsenic),  all  may, 
and  often  do,  produce  opacities  in  the  vitreous.  Injuries  to  the  eye  causing 
choroid"/  hemorrhage  will  also  result  in  the  formation  of  opacities,  and,  if 
extensive,  may  lead  to  suppuration. 

Benson  has  described  a  form  of  opacity  in  which  the  vitreous  is  filled 
with  minute,  light-colored  spheres  {asteroid hyalitis).  The  condition  is  con- 
genital, and  does  not  interfere  with  normal  visual  acuity. 

From  the  foregoing  statements  it  is  evident  that  opacities  in  the  vitreous 
are  generally  the  result  of  some  pre-existing  disease  of  some  other  part  of 
the  eye,  although  there  may  be  a  primary  inflammation  of  this  body  to  which 
they  owe  their  origin. 

Symptoms. — Patients  readily  see  opacities  of  the  vitreous,  either  as  fixed 
or  movable  black  spots,  and  are  quite  able  to  describe  their  situation,  >ize, 
and  shape.  There  may  be  no  diminution  of  vision,  although  central  vision 
may  be  entirely  lost  if  there  is  a  large  centrally  situated  fixed  opacity.  Should 
there  be  pain  or  evidences  of  external  inflammation,  it  must  be  taken  for 
granted  that  the  vitreal  disease  is  complicated  by  some  other  affection,  and 
probably  the  result  of  it. 

The  ophthalmoscope  offers  the  one  certain  method  of  making  a  positive 
diagnosis  if  the  media  are  clear.  The  patient  is  directed  to  move  his  eye 
quickly  in  all  direction-,  and  then  to  hold  it  quite  still.  The  floating  opaci- 
ties are  then  seen  to  move  in  the  vitreous,  and  gradually  to  sink  to  the  lower 
portion  of  the  chamber.  Not  only  can  the  size  of  the  opacities  be  correctly 
estimated  in  this  manner,  but  a  very  good  idea  of  the  degree  of  fluidity  of 
the  vitreous  can  be  obtained.  It  will  be  noticed,  when  the  interior  of  the 
•  ■ye  is  illuminated  by  reflected  light  and  the  patient  directed  to  move  hi-  eye, 
that  these  opacities  move  in  a  direction  opposite  to  the  movement  oi  the  eye  : 
when  the  eye  i-  turned  to  the  right,  the  opacities  move  toward  the  let!,  and 
in  this  way  they  can  be  distinguished  from  opacities  in  the  lens  or  cornea, 
which,  being  fixed,  move  with  the  movements  of  the  eve.  Fixed  opacities 
in  the  vitreous  may    be  discovered    by  using  a  strong  convex   lens  I       16) 

lTheeditor  hag  also  found  thai  in  experimentally  induced  suppurative  hyalitis  in  dogs 
intravitreou8  injections  of  chlorin-water  seemed  to  check  the  process,  bul   i~  in  entire  a 
with  the  author  thai  intraocular  injections  are  measures  ordinarily   i"  be  condemned 
page  WO  . 


400  DISEASES  OF  THE    VITREOUS. 

behind  the  ophthalmoscope,  the  observer  holding  hi>  eye  quite  close  to  that 
of  the  patient   (see  also  pp.  178,  1 7 1 » .  183). 

Treatment. — While  treatment  is  not  generally  effective  in  entirely  re- 
moving opacities  of  the  vitreous,  much  may  be  done  for  the  relief  of  the 
patient.  It'  myopia  is  found  to  be  their  cause,  its  correction  to  the  full  degree 
^r  the  error  should  be  ordered.  Irregularities  of  the  menstrual  function, 
disorders  of  the  liver,  or  exhaustion  from  protracted  illness  of  any  kind  must 
he  corrected.  For  syphilitic  varieties  the  mercurial  preparations  employed 
in  the  form  of  intramuscular  injections  promise  more  than  when  given  in  any 
other  way.  The  protiodid  of  mercury,  combined  with  iron,  also  gives  excel- 
lent results,  as  do  iodid  of  potassium  and  sodium.  Gout,  constipation,  and 
anemia  should  he  treated  for  the  share  they  may  have  had  in  the  production 
of  the  disease.  Diaphoresis  with  pilocarpin  hydrochlorate  (gr.  ,',,-,';  hypo- 
dermically  i  i-  of  service,  and,  according  to  de  Schwcinitz  and  Spaulding,  small 
doses  of  the  same  drug,  even  when  sweating  is  not  produced,  are  valuable. 
Electricity  in  the  form  of  galvanism  ha-  been  reported  to  he  of  use. 

Various  medicinal  agents,  such  as  the  soluble  mercurial  salts,  solutions 
of  potassium  iodid,  and  carbolic  acid,  have  been  injected  into  the  vitreous 
chamber  in  the  hope  that  absorption  of  vitreous  opacities  and  other  effused 
inflammatory  product-  might  follow.  The  writer  does  not  believe  that  such 
treatment  i-  warranted,  except  where  vision  ha-  been  reduced  to  a  mere 
quantitative  perception  of  light,  which  no  remedy,  however  severe,  can  make 
worse,  for  disorganization  and  dense  opacity  of  the  vitreous  body  are  almost 
certain  to  followits  use.  Furthermore,  the  hyaloid  and  retina  become  affected, 
and  panophthalmitis  usually  results. 

A  large  fixed  and  more  or  less  central  membranous  opacity  may  he 
divided  hv  passing  a  discission  needle  into  the  vitreous  in  front  of  the 
equator  of  the  eye,  entering  it  just  below  the  lower  border  of  the  external 
reel  ii-  muscle,  care  being  exercised  to  watch  the  movements  of  the  instru- 
ment  with  the  ophthalmoscope. 

Pseudo-glioma,  so  called  from  it-  resemblance  to  glioma  of  the  retina, 
i- a  circumscribed  suppurative  inflammation  of  the  vitreous,  generally  occur- 
ring in  tin'  periphery  of  the  chamber  near  the  ciliary  region. 

With  the  ophthalmoscope  a  yellowish-white  reflex  can  he  seen,  hut  as  there 
are  abundant  evidences  of  a  pre-existing  irido-choroiditis,  there  can  scarcely 
he  excuse  for  mistaking  this  for  a  true  glioma  of  the  retina.  Diminished  ten- 
-ion.  followed  by  shrinking  of  the  globe,  sometimes  with  subsequent  ossifica- 
tion  of  the  choroid,   marks  the   distinction   between   this  ami   true  glioma. 

fhe  treatment  i-  to  he  directed  to  the  primary  disease  standing  in  a 
causal   relation  to  this  affection  (see  also  page  355). 

Muscae  Volitantes. — Myodesopsia. — There  are  in  the  vitreous  certain 
ameboid  cells,  mosl  abundant  at  it-  periphery,  which  arc  of  normal  occur- 
rence, and  are  not  disturbing  to  vision,  as  they  are  transparent  and  readily 
transmit  light.  <  m  account  of  their  cou-taut  presence  the  mind  usually  dis- 
regards  them.  Inn  occasionally,  when  looking  at  some  white  surface,  as  the 
page  of  a    book,  and   while   there  are   no  other   retinal  images  with  which  to 

e pan-  them,  they  force  themselves  upon  the  notice  of  the  patient  and  cause 

more  or  less  distress.  They  may  be  -ecu  entoptically  by  closing  the  eyelids 
and  turning  the  face  toward  a  brighl  light.  Theyappear  a-  fine  threads  and 
-peck- of  various  size,  which  float  across  the  field  of  vision  when  the  eye  is 
being  moved,  hut  do  not  in  any  way  disturb  visual  acuity.  Occasionally 
they  assume  curiously   fantastic  shapes. 

Treatment. — As  mosl  patient-  annoyed  by  muscse  volitantes  have  some 


SYJVCHISIS  SCINTILLANS.  Jul 

error  of  refraction,  this  should  be  corrected  with  suitable  Lenses.  At  the 
same  time,  they  should  be  assured  thai  the  presence  of  these  floating  opacities 
has  no  clinical  or  pathological  significance.1 

Hemorrhage  into  the  Vitreous. — Tlii.-  mosl  frequently  follows  a 
rupture  of  some  of  the  vessels  of  the  choroid  at  its  anterior  portion  where 
the  retina  is  thinnest,  thus  allowing  a  freer  extravasation  than  would  be  the 
case  should  a  vessel  rupture  at  it-  posterior  part,  where  the  retina  is  thicker. 
Schweigger  doubts  if  extravasation  of  blood  into  the  vitreous  can  occur  as 
the  result  of  a  rupture  of  the  vessels  of  the  retina,  because,  owing  t » >  the 
arrangement  of  its  connective-tissue  fibrillar  and  the  strength  of  its  internal 
limiting  membrane,  hemorrhage  from  it  would  generally  extend  toward  the 
choroid  and  not  toward  the  vitreous.  However  this  may  be,  we  are  able  to 
see  with  the  ophthalmoscope,  if  the  hemorrhage  is  slight,  a  bright  red  reflex 
indicating  the  seat  of  the  extravasation,  or  a  red  veil  it'  the  blood  is  thinly 
distributed  over  a  considerable  extent  of  the  vitreous. 

Spontaneous  hemorrhage  into  the  vitreous  may  occur,  particularly  in  the 
case  of  young  male  adult-  who  are  subject-  of  irregularities  of  the  circula- 
tion (Eales)  and  of  gout  (Hutchinson).  Such  hemorrhagic  effusions  are  oot, 
as  a  rule,  entirely  absorbed,  but  leave  opacities  in  the  vitreous  very  damag- 
ing to   vision   if  centrally  situated. 

If  the  hemorrhage  i-  extensive,  the  sight  i-  immediately  lost,  and  it  is 
impossible  to  obtain  a  view  of  the  interior  of  the  eye.  After  absorption  of 
the  effused  blood,  and  when  the  vitreous  has  become  clear,  numerous  fixed 
and  floating  opacities  maybe  -ecu,  which  become  less  and  less  distinct  as 
absorption  goes  on,  only  to  be  followed  by  other  extravasation-,  and  perhaps 
finally  by  detachment  of  the  retina.  Permanent  opacities  are  usually  left 
behind,  even  in  those  case-  where  the  hemorrhages  do  not  recur,  and  vision 
i-  always  very  considerably  impaired. 

Treatment. — The  mercurial  preparations,  iodid  of  potassium,  pilocarpin, 
and  the  saline  mineral  waters  are  indicated  in  the  treatment  of  these  cases. 
Ergot  may  also  be  employed,  especially  early  in  the  disease.  Abadie  has 
directly  galvanized  the  vitreous,  passing  a  platinum  needle  in  the  chamber, 
in  a  case  of  chronic  vitreous  hemorrhage.  This  procedure  is  of  doubtful 
value. 

Synehisis  Corporis  Vitrei  (Fluidity  of  the  Vitreous). — During  the 
progress  of  certain  diseases  of  the  eye,  notably  retinitis,  choroiditis,  and  very 
high  degrees  of  myopia,  the  nutrition  of  the  vitreous  i-  so  seriously  impaired 
that  it<  proper  framework  is  destroyed,  and  it  loses  it-  normal  consistency 
and  become-  a  -t raw-colored  liquid.  In  extracting  a  cataractous  leu-  we 
frequently  have  to  guard  againsf  this  condition,  which  has  been  developed 
by  a  previously  existing  disease  of  some  other  part  of  the  eye.  There  are 
always  diminished  tension,  and  frequently  a  tremulous  condition  of  the  iris. 
Treatment    i-  of  no  avail. 

Synehisis  Seintillans  (( 'h<>l<-<t<  rin  Crystals  in  the  Vitreous). — The 
presence  of  minute  crystals  of  cholesterin  and  tyrosin  in  the  vitreous  pro- 
duce- a  very  interesting  ophthalmoscopic  picture,  bu1  doc-  qo!  interfere 
with  vision  if  that  body  is  otherwise  healthy.     The  crystals  are  seen  in  the 

1  For  : ■  1 1   interesting  and  suggestive  study  of  muscae  the  reader  is  referred  to  a  pa] 
'•        M.  Gould,  M.   !>.   {Medical  News,  Sept  15,  1895  .     Dr.  Gould  believes  that   then 
chamber,  which  he  calls  the  aqueo-vitreons  chamber,  situated  between  the  vitr« 
and  the  lens,  its  Ligament,  and  the  ciliary  body  anteriorly^  and  which  contains  the  n 
tie  particle-   in   suspension.     These   particles   he  regards  as  the  debris  "t'  vitreous  kataboh 
change.     Based  on  entoptical  studies,  Dr.  F.  P.  Pratt  believes  that  - 
In-  the  lymphatic  capillaries  of  the  vitreous. 

2C 


40-2 


/>/s/;asj:s  OF  THE   VITREOUS. 


eyes  of  the  agedj  usually  in  connection  with  vitreal  opacities.  They  are  not 
of  frequenl  occurrence.  They  appear  as  small  luminous  bodies  which  reflect 
the  lighl  from  the  ophthalmoscope  in  the  form  of  a  shower  of  sparks,  and  do 
not  yield  to  treatment. 

Blood-vessel  Formation  in  the  Vitreous. — Observation  with  the 
ophthalmoscope  lias  occasionally  revealed  the  formation  of  new  blood-vessels 
in  the  vitreous,  and  their  presence  is  presumptive  evidence  of  a  previously 
existing  Inflammation  of  that  body  or  of  former  hemorrhages.  Becker  relates 
that  he  observed  them  in  a  case  of  purulent  infiltration  of  the  vitreous, 
while  Hirschberg  has  seen  them  in  connection  with  specific  disease  of  the 
eye.      Tiny  -tart    from   the   nerve-head,  which   they  partly  obscure,  and    pass 


I'i<.   L'".f..— Ul 1  vc-mJs  in  the  vitreous  (Hirschberg). 

forward  into  the  vitreous  ;is  ;i  more  or  less  well-formed  veil  of  freely  com- 
municating capillaries,  without,  however,  having  any  connection  with  the 
vessels  of  the  retina   (Fig.  256). 

Kntozoa  in  the  Vitreous. —Two  distincl  parasites  have  been  found  in 
the  vitreous  of  the  human  eye — the  cysticercus  celluloses  and  the  filaria  san- 
guinis hominis  (  Man-on  |. 

The  former,  while  rare,  has  been  -ecu  most  frequently  in  North  Germany. 
It  is  the  scolex  of  the  taenia  solium,  the  eggs  of  which,  having  obtained 
entrance  into  the  stomach,  find  their  way  into  the  blood-channels,  whence 
they  are  carried  to  the  eye  and  deposited  under  the  retina.  In  the  course  of 
its  development  it  i-  provided  with  hooklets,  by  means  of  which  it  perforates 
this  tunic  and  is  sel  I've  in  the  vitreous.  Here  it  may  appear  encysted  in  a 
membrane  which  will  mask  its  distinctive  characteristics  and  prevent  acorreel 
diagnosis.  If,  however,  it  is  quite  \'vrt\  it  i-  of  a  pale,  greenish-blue  color, 
having  a  shorl  neck  surmounted  by  a  round  head  ornamented  with  minute 
suckers,  which  may  be  seen  to  move  in   undulating  lines. 

Von  Graefe  attempted  the  re val  of  a  cysticercus  through  an  incision, 

following  hi-  method  of  the  extraction  of  a  cataractous  lens.  After  delivery 
of  the  lens  he  passed  :i  Munrviook  into  the  vitr< b,  and  by  alternately  ad- 
vancing ii  toward  the  entozoon  and  then  withdrawing  it,  he  succeeded  in 
delivering  the  parasite,  without,  however,  restoring   vision. 


PERSISTENT  HYALOID  ARTERY. 


403 


The  fi/aria  sanguinis  hominis  in  the  human  eve  is  of  such  ran-  occurrence 
thai  it  requires  only  passing  mention. 

Detachment  of  the  Vitreous. — The  vitreous  is  subject  to  degenera- 
tive changes  which  produce  a  shrinkage  in  its  volume,  t hu>  removing  it  from 

direct  contact  with,  and  support  of,  the  limiting  membrane  of  the  retina.  \  - 
is  readily  seen,  this  condition  is  followed  by  detachment  of  the  retina  and 
loss  of  vision.  The  author  has  enucleated  a  painful  atrophied  eyeball  in 
which  this  condition  was  beautifully  illustrated.  The  vitreous  had  shrunken 
to  half  it>  size,  and  was  closely  enveloped  by  the  retina,  and  consisted  of 
hands  of  connective  tissue  stretching  from  the  nerve-head  to  the  posterior 
surface  of  the  lens.  This  condition  results  from  injury  to  the  vitreous,  fol- 
lowed by  choroiditis  and  hemorrhage,  or  from  extensive  posterior  staphyloma. 
The  treatment  is  enucleation. 

Fatty  Degeneration  of  the  Vitreons. — Under  this  heading  Dr. 
D'CEnch  and  Dr.  Yalk  have  reported  cases  the  diagnostic  features  of  which 


Fig.  257. — Cysticercus  in  the  vitreous  (Liebreich). 


seem  to  resemble  those  described  by  [wanoff  and  called  by  him  fatty  degene- 
ration of  the  stroma  and  cells  of  the  vitreous. 

The  ophthalmoscope  furnishes  a  picture  of  numerous  white,  glistening 
-pots  very  evenly  distributed  throughout  the  vitreous,  and  having  slight 
motion  when  the  eve  is  moved — not,  however,  an  independent  motion,  bu1 
one  seeming  to  depend  upon  the  quivering  or  tremulousness  of  the  normal 
vitreous  when  the  eye  is  quickly  moved  in  any  particular  direction,  [wanoff 
doe-  not  regard  this  condition  as  a  pathologic  change,  hut  a  quasi-physiologic 
state  due  to  senile  decay.  The  vision  is  slightly  reduced,  hut  not  to  an  extent 
requiring  special  treatment,  further  than  the  correction  of  any  existing  error 
of  refraction. 

Persistent  Hyaloid  Artery. — The  hyaloid  artery  (an  extension  of  the 
central  artery  of  the  retina)  during  fetal  life  pj#fce<  from  the  optic  nerve-head 
forward  across  the  vitreous  body,  sometimes  terminating  in  the  vitreous  and 
sometimes  extending  as  far  forward  a- the  posterior  surface  of  the  lens.      It 


404  DISEASES  OF  THE    VITREOUS. 

occupies  a  canal  (the  rami!  of  Cloquet),  which,  with  the  artery,  shrivels  up 
and  disappears  aboul   the  sixth  month  of  gestation.     (See  page  24.) 

In  exceptional  cases,  however,  it  remains,  and,  according  to  I)e  Beck, 
may  be  seen  floating  in  the  vitreous  in  one  of  the  following  forms  :  a  fila- 
mentous strand  attached  to  the  disk,  the  free  end  floating  in  the  vitreous  :  a 
strand  attached  to  the  lens,  and  the  end  floating  in  the  vitreous  ;  a  strand 
attached  to  the  disk,  and  a  like  strand  to  the  posterior  surface  of  the  lens, 
each  terminating  in  the  vitreous  ;  a  strand  passing  across  the  vitreous  and 
attached  to  the  disk  and  the  lens  ;  a  distinct  vessel  containing  blood,  passing 
entirely  across  the  vitreous ;  and  the  canal  of  Cloquet,  not  containing  any 
vessel. 

The  remains  of  this  artery  are  also  sometimes  seen  as  irregular  minute 
bodies  on  the  surface  of  the  disk,  and  it-  vestigial  remains  doubtless  produce 
that  variety  of  congenital  cataract  called  posterior  capsular  cataract  (page 
.".^!i >  when  situated  on  the  posterior  surface  of  the  lens.  (Consult  Figs.  137, 
L38  on  pages  L90,  L91.) 


DISEASES  OF  THE  RETINA. 

By   LUCIEN    HOWE,  M.  D., 

OF   BUFFALO,  X.  Y. 


Congenital  Peculiarities  of  the  Retina. — As  it  is  often  difficult  to 
define  the  limit  between  health  and  disease,  it  becomes  an  important  question 
to  determine  what  should  be  considered  a  normal  retina.  Therefore  atten- 
tion is  first  directed  to  those  congenital  peculiarities  which  cannot  be  classed 
as  pathological.  These  are  usually  described  last  in  chapters  on  the  retina, 
but  some  repetition  and  confusion  are  avoided  if  they  are  considered  first. 

Such  variations  from  the  normal  type  are  to  be  seen  (1)  in  the  vicinity 
of  the  optic  nerve;   (2)  in  the  retina;  and  (3)  in  the  macula. 

First. — Variations  near  the  nerve  are  due  to — 

('0  Insufficient  pigment,  which  should  not  be  confused  with  the  actual 
atrophy  of  the  retina  and  choroid  in  the  vicinity  of  the  nerve.  The  latter 
diseased  condition  shows  itself  as  a  crescent  more  or  less  marked,  or  even  as 
a  complete  white  circle  (see  Fig.  136). 

{/>)  Excess  of  pigment  may  be  seen  in  brunettes,  and  sometimes  amounts 
to  a  dark,  well-marked  ring  of  deposit  about  the  nerve. 

(c)  Absence  or  abundance  of  blood-vessels  at  the  edge  of  the  nerve  may 
simulate  disease  and  yet  be  within  normal  limits. 

(<l)  Ojjfique  nerve-fibers  may  present  an  appearance  which  at  first  glance 
may  be  mistaken  for  neuro-retinitis.  It  is  well  to  bear  this  in  mind  in  con- 
nection with  that  disease  (see  also  pages  189,  190,  1!)4). 

Second. — Variations  in  the   retina  are  due  to — 

(a)  Insufficient  Pigment. — When  of  slight  degree  this  gives  rise  to  a 
peculiar  appearance  in  which  the  vessels  of  the  choroid  simply  become 
unusually  prominent.  When,  however,  pigment  is  lacking  entirely,  as  in 
albinos,  a  network  of  vessels  distributed  over  a  pink  or  an  absolutely  white 
field  is  apparent. 

(b)  Excess  of  Pigment. —  In  this  condition  the  fundus  is  not  only  dark 
and  the  vessels  difficult  to  distinguish,  but  occasionally  the  pigment  is  un- 
equally distributed,  giving  rise  to  a  peculiar  mottled  appearance.  In  some 
of  these  cases  the  choroidal  vessels  are  particularly  prominent,  manifesting 
themselves  as   red    lines  distributed    over    rather  a   dark    Held. 

Any  of  the  above  variations  from  the  usual  type  are  easily  recognized  as 
physiological,  unless  the  diminution  or  excess  of  pigment  i<  confined  to  a 
certain  p;irt  of  the  retina,  when  it  may  give  to  the  fundus  an  appearance 
which   is  readily  mistaken    for  an  abnormal  condition. 

Third. — Variations  in  the  macula. 

In  typically  normal  eyes  nothing  can  be  seen  of  the  macula  except  the 
red  reflex  of  the  fundus,  the  area  usually  being  darker  than  the  resl  of 
background  and  uncrossed  by  retinal  vessels*     Bui  there  are  variations  from 
this  which  should  be  noticed.      In  blonds  and   in  retinas  having  an  unusually 
small   amount   of  pigment  the   macula  can   often   be  distinguished  as  a   ; 


406  DISEASES  OF  THE  RETINA. 

spol  od  a  darker  field,  its  edges  being  well  defined,  or,  again,  as  a  dark  area, 
the  (mIucs  of  which  blend  imperceptibly  with  the  red  of  the  retina  near  it. 
'The  latter  is  the  more  common  form.  In  exceptional  cases  the  macula  is 
dark,  and  its  edges  are  marked  by  a  ring  (macular  reflex"),  the  center  being 
then  light  or  almost  white  (fovea!   reflex)  (see  also  page  188). 

Small,  white,  glistening  dots  are  occasionally  found  in  the  vicinity  of  the 
macula.  These  are  known  as  "  Gunn's  dots"  Sometimes  they  are  quite 
numerous,  but  they  do  not  interfere  with  perfect  vision.  They  are  to  be 
taken  into  account  in  making  a  differential  diagnosis  in  cases  of  commencing 
albuminuria. 

A  simple  and  easy  plan  of  studying  the  diseases  of  the  retina  is  to  begin 
with  disturbances  of  the  circulation — First,  when  the  supply  of  blood  is 
diminished,  as  in  anemia,  or  entirely  shut  off,  as  in  embolism  ;  and  second, 
when  the  supply  is  simply  increased,  as  in  hyperemia,  or  increased  with 
other  signs  of  inflammation.  This  will  lead  to  the  consideration  of  the 
various  forms  of  retinitis,  after  which  will  follow  a  description  of  degenera- 
tive changes. 

Anemia  of  the  retina  means  properly  that  the  lack  of  blood  is  merely 
the  local  expression  of  a  general  condition,  while  ischemia  indicates  that  the 
causes  of  the  altered   circulation   are   in    the  eye   itself. 

Etiology. — Retinal  anemia  occurs  in  ordinary  syncope  or  from  any  cause 
— as,  for  example,  vaso-motor  spasm — which  contracts  the  arteries  of  the 
brain  or  lessens  the  amount  of  blood  sent  there.  Retinal  anemia,  with  con- 
tracted arteries,  may  occur  in  migraine,  and  may  be  associated  with  hemi- 
anopic  blindness. 

Symptoms. — While  very  marked  decrease  or  increase  in  the  blood- 
supply  of  the  retina  can  be  distinctly  recognized,  it  must  be  admitted  that 
the  slighter  variations  from  the  normal  standard  are  not  easily  diagnosed. 
However,  the  contracted  vessels,  the  lighter  color  of  the  retina,  the  unusual 
whiteness  of  the  nerve,  and  the  functional  disturbances,  if  present,  tend  to 
establish  the  diagnosis. 

Treatment  should  be  directed  to  the  removal  of  the  cause  producing  the 
general  anemia.  As  strychnin  has  long  been  used  hypodermatically  for  a 
diminished  supply  of  blood  in  the  optic  nerve,  as  in  atrophy,  so  has  it  been 
suggested  for  the  same  reason  in  retinal  anemia.  Nitrite  of  amy!  may  be 
used  to  relieve  spasm  of  the  arteries  of  the  retina.  A  method  of  treatment 
will  worthy  of  trial  is  to  arrange  the  position  of  the  patient,  for  as  long  a 
time  daily  as  can  be  borne  comfortably,  so  that  the  head  is  lower  than  the  rest 
of  the  body.  The  contracted  or  emptied  vessels  of  the  retina  are  filled  by  the 
force  of  gravity. 

Embolism  of  the  Central  Artery  of  the  Retina. — Etiology. — The 
most  frequenl  cause  of  embolism  is  valvular  disease  of  the  heart,  especially 
when  complicated  with  fresh  endocarditis.  It  also  occurs  with  various  forms 
of  arteritis,  with  aneurysm  of  the  aorta  and  carotid,  with  Bright's  disease,  and 
with  pregnancy j  occasionally  it  complicates  chorea.  It  may  occur  at  any 
period  of  life,  and  ha-  been  recorded  From  the  fifteenth  to  the  eightieth  year. 
Simultaneous  embolic  plugging  of  the  central  artery  in  each  eye  has  been 
described,  but  it  is  an  exceedingly  rare  condition.  It  is  more  frequenl  on 
tin-    left    than  on   the   right    side,  and    has  occurred    more   time-    in    men    than 

in  women. 

Pathological  Anatomy. —  In  the  earliest  case  observed  with  the  oph- 
thalmoscope (von  Graefe)  an  opportunity  was  afforded  to  secure  a  post- 
mortem   examination  one   and  a    half  years    later   (Schweigger).      Sections  of 


EMBOLISM   OF  THE  (EXTHAL   ARTERY  OF  THE  RETIXA.     407 

the  eye  showed  that  the  central  artery  was  completely  blocked  jusl  behind 
the  lamina  cribrosa.  The  embolus  may  be  granular  in  nature,  or  consist  of 
a  hyalin  plug,  or  may  he  covered  with  layers  of  endothelium.  Sometimes 
it  only  partially  blocks  the  Lumen  of  the  vessel;  at  other  times  it  completely 
occludes  its  caliber.  Atrophic  changes  may  he  found  in  the  retina,  the  optic 
nerve,  and  the  choroid,  according  to  the  date  of  the  examination  after  the 
embolus  has  occurred. 

The  clot  does  not  always  block  the  central  artery  itself,  but  may  lodge  in 
out!  of  the  branches  of  the  main  retinal  artery,  and  there  produce  over  a 
limited  area  the  same  symptoms,  the  same  appearance,  and  the  same  path- 
ological conditions  which  are  found  when  the  central  artery   is  affected. 

Re-establishment  of  the  circulation  may  occur  because  the  lumen  of  the 
blocked  vessel  again  becomes  free,  and  the  presence  of  cilio-retinal  vessels 
may  be  the  means  of  preserving  good  acuity  of  central  vision.  According  to 
Ward  Holden,  with  single  embolism  of  a  branch  of  the  central  retinal  artery 
there  may  be  a  field  of  irregular  form  which  to  a  considerable  extent  is  ex- 
plainable by  variations  of  the  arterial  distribution,  and  in  cases  where  the 
lumen  of  an  artery  remains  blocked  there  may  be  a  collateral  restoration  of 
its  circulation  by  anastomosing  vessels. 

Symptoms. — The  patient  may  be  entirely  ignorant  of  the  existing  con- 
dition if  the  embolus  occurs  in  one  eye  only,  for  there  is  no  special  pain  nor 
other  peculiarity  following,  which  calls  attention  to  the  difficulty,  except  the 
loss  of  vision,  which  occurs  with  characteristic  suddenness.  In  other  cases, 
however,  the  subjective  symptoms  in  the  form  of  a  species  of  aura  are  pecu- 
liar. There  are  scintillations  before  the  eyes  or  dark  rings  appear.  In  a 
very  typical  case  which  the  writer  observed  the  patient  remembered  peculiar 
flashes  which  called  her  attention  to  the  rapidly  departing  vision. 

The  ophthalmoscopic  picture  is  quite  characteristic,  being  that  of  an 
almost  pure  and  well-marked  ischemia  of  the  retina.  The  arteries  are  small, 
and  the  corresponding  veins  considerably  reduced  in  size,  or  they  may  reveal 
unequal  distention,  the  terminal  endings  of  both  being  to  a  great  extent  lost. 
Pressure  from  before  backward  causes  a  regular  current  to  How  through  the 
vessels,  which  consist  of  broken  cylinders  of  blood  separated  by  clear  spaces, 
moving  sluggishly  along.  In  the  veins,  directly  after  the  lodgement  of  the 
embolism,  an  intermittent  bloodstream  is  often  visible.  The  optic  disk  is 
blanched  almost  as  it  appears  in  atrophy,  and  the  retina,  especially  in  the 
neighborhood  of  the  papilla  and  the  macula,  is  of  a  whitish  appearance  (the 
so-called  fog-like  edema),  in  marked  contrast  with  that  of  the  other  eye.  A 
very  characteristic  feature  of  this  disease  is  the  color  of  the  macula.  The 
rest  of  the  retina  may  appear  of  a  normal  color  or  even  decidedly  whitened, 
but  the  macula  stands  out  in  contrast  with  its  surroundings  as  a  clear  cherry- 
red  spot  which  attracts  attention  at  the  first  glance.  The  reason  for  this 
peculiar  color  is  by  no  means  fully  explained.  The  general  conclusion,  how- 
ever, is  that  it  is  not  entirely  an  extravasation,  but  is  due  partly  to  an 
engorgement  of  the  choroidal  vessels  beneath  the  macula,  and  partly  to  tin 
effect  of  contrast  which  this  spot  then  presents  to  the  neighboring  retina 
(Luring).  There  are  also  changes  in  the  pigment  epithelium.  In  dark- 
skinned  races  the  cherry  spot  may  he  replaced  with  a  coal-black'  one.  This 
macular  appearance  is  more  apt  to  arise  in  stoppage  of  the  main  trunk  than 
when  onlv  a  branch  i-  plugged.  Occasionally,  if  the  embolus  lodges  in  ji 
branch  of  the  main  artery,  it  is  visible  to  the  ophthalmoscope  a-  a  small 
yellowish  body,  or  it  may  be  assumed  to  be  presenl  because  at  one  poin 
"the  artery  there   is  a   swelling,  while  beyond   it   the   vessel   is  obli  d  or 


408  DISEASES  OF  THE  RETINA. 

greatly  contracted.  In  the  course  of  several  weeks,  in  complete  eases,  the 
retinal  edema  subsides,  the  disk  undergoes  atrophy,  ami  the  vessels  are  eon- 
verted  into  white  lines. 

The  subjectivt  symptoms  are.  in  complete  eases,  sudden  loss  of  vision, 
unless  the  presence  of  a  cilio-retinal  vessel  permits  the  preservation  of  good 
acuity  of  sight,  as  reported  by  Wadsworth,  and  occasionally  headache  and 
giddiness.  According  to  ( '.  1".  ('lark.1  the  evidence  is  not  sufficient  to  war- 
rant the  conclusion  that  true  cilio-retinal  vessels  are  the  means  of  preserving 
the  integrity  of  the  papillo-macular  region  of  the  retina.  In  obstruction  of 
a  branch,  vision  may  be  very  good,  or,  indeed,  even  normal.  The  field  ';/' 
vision  depends  upon  the  extent  of  the  circulatory  obstruction.  It'  only  a 
branch  has  been  occluded,  that  portion  of  the  retina  which  receives  its  blood- 
supply  from  tin-  source  will  he  paralyzed  and  the  opposite  area  of  the  field 
darkened.  ( Occasionally  there  is  a  central  scotoma.  The  tension  may  be 
raised,  lowered,  or  normal. 

Diagnosis. — These  cases  may  simulate  anemia  of  the  retina,  because  the 
condition  of  the  heart  produces  some  general  anemia,  but  the  history  is 
usually  sufficient  to  separate  one  disease  from  the  other.  While  the  ophthal- 
moscopic appearances  already  detailed  indicate  interruption  of  the  retinal 
circulation,  it  is  often  difficult,  and  even  impossible,  to  distinguish  between 
thrombosis  and  embolism  of  the  artery.  Similar  appearances  may  be  pro- 
duced by  hemorrhage  into  the  sheath  of  the  optic  nerve  (sec  page  453). 

Prognosis. — This  depends  upon  the  rapidity  with  which  the  collateral 
circulation  is  established,  a  greater  or  less  tendency  to  this  being  apparent 
almost  from  the  first.  In  complete  embolism  of  the  central  artery  the  pro£- 
nosis  is  most  unfavorable. 

Treatment. — Paracentesis  has  been  tried  in  order  to  change  the  amount 
of  blood-pressure,  but  in  general  more  depends  upon  improving  the  condition 
which  has  caused  the  embolus  than  upon  any  attempts  at  local  medication. 
Nitrite  of  amy]  inhalations  are  recommended  by  Gifford,  and  massage  of  the 
eyeball,  in  the  hope  of  dislodging  the  embolus,  should  be  faithfully  tried. 
This  has  been  effected  in  some  cases. 

Thrombosis  of  the  Retinal  Artery.— Thrombosis  may  occur  under 
the  same  conditions  which  are  active  in  the  production  of  embolism,  and  the 
thrombus  may  form  either  in  the  central  artery  itself  or  in  one  of  its  branches. 

Ophthalmoscopically,  it  is  difficult  or  impossible  to  distinguish  between 
thrombosis  and  embolism.  According  to  Priestley  Smith,  previous  attacks 
of  temporary  blindness  in  the  affected  eye.  a  simultaneous  attack  of  tempo- 
rary blindness  in  the  unaffected  eye.  giddiness,  faintness,  and  headaches  are 
apt  to  he  associated   with   thrombosis,  and   not   with   embolism. 

The  treatment  i-  the  same  as  that  recommended  for  embolism. 

Hyperemia  of  the  Retina. — By  this  term  i>  understood  an  abnormal 

and    equal    increase    in   the   amount   of  hi 1    throughout    the   entire    retina. 

Hyperemia  of  the  larger  blood-vessels  is  easily  recognized*  When,  as  is 
usual,  this  is  accompanied  by  capillary  hyperemia,  the  condition  is  indicated 
by  a  change  in  the  color  not  only  of  the  retina  it-elf.  hut  especially  of  the 
surface  of  the  optic  nerve,  which  becomes  redder  than  normal.  Should  the 
hyperemia  exisl  in  a  marked  degree,  the  overflowing  arteries  have  a  tortuous 
appearance,  such  a-  would  naturally  be  expected  when  an  elastic  vessel  is 
filled  beyond  it-  normal  capacity.  Two  forms  of  hyperemia  are  to  he  distin- 
guished, the  active  ami  the  passive. 

1.  Active  lijij"  r<  mia  may  be  produced  by  a  variety  of  causes.     One  of 

1  Archives  oj  Ophthalmology,  x.wi.  1897,  pp.  395    l"l. 


HYPEREMIA    OF  THE  RETINA.  409 

these,  for  example,  is  long-continued  effort  at  accommodation,  especially 
when  made  by  artificial  Light  or  when  the  refractive  condition  of  the 
necessitates  an  unusual  amount  of  straining  of  the  ciliary  muscle.  De 
Wecker  has  noticed  thai  a  solution  of  the  tincture  of  opium  dropped  into 
the  conjunctival  sac  will  also  produce  a  certain  amount  of  active  hyperemia. 
It  is  commonly  present  in  eye-  exposed  to  glare  of  light  and  heat — e.  g.  in 
puddlers.  The  same  condition  occurs  in  several  of  the  inflammations  of  the 
eve,  especially  when  the  uvea  is  involved. 

Symptoms. — These  are  more  or  less  pronounced,  varying  from  slight 
sensations  of  discomfort  to  considerable  photophobia  and  lack  of  eye- 
endurance. 

Diagnosis. — This  is  not  so  easily  made  as  might  be  imagined.  As  the 
subjective  symptoms,  even  if  present  at  all,  are  usually  by  no  means  promi- 
nent, the  diagnosis  in  a  large  proportion  of  cases  must  he  determined  by  the 

ophthalmoscopic  appearance.     But  it  should  be  borne  in  mind  that  the  hi 1- 

supply  to  the  retina  may  seem  to  vary  from  the  normal  standard  when  in 
reality  this  is  not  the  case.  In  some  individuals  the  retinal  vessels  are  much 
more  abundant  than  in  others,  just  as  we  find  complexions  of  a  florid  type  or 
with  decided  pallor.  Particularly  does  the  condition  of  the  refraction  change 
the  apparent  size  of  the  vessels  when  examined  by  the  ophthalmoscope. 
Again,  a  decided  astigmatism  may  distort  the  vessels  in  different  meridians. 
Indeed,  the  beginner  with  the  ophthalmoscope  must  be  careful  not  to  fall  into 
the  common  error  of  diagnosing  a  "  retinal  congestion  "  when,  in  reality,  there 
is  nothing  of  the  kind  present.  (July  a  careful  study  of  the  case,  with  due 
regard  to  errors  of  refraction,  will  enable  one  in  certain  instances  to  decide  as 
to  the  presence  or  absence  of  hyperemia  of  the  retina. 

2.  Passwe  Hyperemia. — Any  cause  which  interferes  with  the  egre.--  of 
blood  from  the  eye  may  produce  this  condition  ;  for  example,  in  glaucoma, 
where,  as  a  result  of  the  pathological  condition  accompanying  that  disease, 
the  veins  are  enlarged  to  a  considerable  degree,  the  finer  branches  are  more 
numerous,  and  the  larger  trunks  more  tortuous,  especially  near  the  margin 
of  the  papilla.  Another  example  is  furnished  by  the  condition  known  as 
"  choked  disk."  Stasis  hyperemia  is  also  present  in  mitral  disease,  emphy- 
sema, convulsive  seizures,  and.  indeed,  in  any  state  which  prevents  the  veins 
of  the  head  and  neck  from  emptying  their  contents  into  the  venous  channels 
of  the  chest. 

Symptoms. — These  are  similar  to  those  which  occur  in  active  hyperemia. 
The  same  care  should  be  exercised  in  making  the  diagnosis,  although  in 
this   form,   mistakes  are  not  so  liable  to  occur  as   in   active  congestion. 

The  prognosis  and  treatment  depend  upon  tin-  causes. 

Somewhat  analogous  to  congestion  or  hyperemia  <>f  tin  retina  is  the  condi- 
tion known  as  hyperesthesia  of  the  retina,  or,  to  employ  the  term  suggested 
by  Jaeger  and  Loring,  irritation  of  the  retina. 

Ophthalmoscopically,  may  be  seen  undue  redness  of  the  nerve-head, 
veiling  of  it-  nasal  margins,  and  delicate  edema  of  it-  surface.  Often  the 
entire  fundus  is  ill  defined,  and  the  details  of  the  background  of  the  eye  are 
imperfectly  -ecu. 

Etiology. — ( !ases  of  this  character  are  caused  by  errors  of  refraction  and 
anomalies  of  muscle-balance.     They  are  often  associated  with  chronic  head- 
ache,  neuralgia,  and  their  subjects  suffer  from   photophobia,  blepharospasm, 
and  marked  asthenopia.      In   some  instances  there  appears  to  be  a  disl 
relation  between   retinal  irritation  ami  changes  in  the  naso-pharynx, 
larly  those  characterized   l»\  a   hypersensitive  mucous  membrane  and  \ 


410  DISEASES  OF  THE  RETINA. 

paretic  and  intih rated  turbinals.  Loring  believes  that  retinal  irritation  may 
be  a  forerunner  of  organic  optic-nerve  disease. 

Anesthesia  of  the  Retina  {Neurasthenic  Asthenopia). — This  condi- 
tion is  really  a  symptom  of  a  complicated  neurosis  rather  than  a  special  dis- 
order of  the  retina.  Its  phenomena  have  been  specially  studied  by  Wild- 
brand,  who  records  the  subjective  symptoms  as  follows:  Peculiar  contraction 
of  tin'  Held  of  vision,  indicating  retinal  fatigue  and  the  development  of  the 
so-called  counter-field  (see  page  186);  rapid  disappearance  from  view  of  any 
object  which  is  fixed  ;  diminution  of  central  vision  ;  sudden  attacks  of 
obscuration  of  vision  and  processions  of  scotomas ;  visual  hallucinations; 
lack  of  fixation  of  the  optical  memory-images;  and  marked  asthenopia. 
The  subjects  of  this  affection  are  chiefly  women,  and  often  those  afflicted  with 
ovarian  and  uterine  disease,  hysteria,  and  chlorosis.  Pure  types  are  also 
seen  in  men,  and  are  often  connected   with  sexual  derangements. 

Treatment. — This  must  be  directed  toward  the  general  condition, 
although  any  error  of  refraction  should  be  corrected  and  the  proper  glasses 
worn  constantly.  It  must  be  remembered  that  neither  in  this  type  of  retinal 
affection  nor  in  hyperesthesia  of  the  retina  are  spectacles  alone  sufficient.  A 
consideration  of  the  etiological  factors  only  will  supply  indications  for  the 
proper  constitutional  and   local  measures. 

Thrombosis  Of  the  retinal  veins  has  been  observed  as  the  result  of 
syphilis  and  with  heart-disease.  Thrombosis  of  the  central  vein  is  some- 
times -ecu  with  hemorrhagic  retinitis,  of  which  it  may  be  the  cause,  and  also 
in  a  few  other  conditions  in  which  the  walls  of  the  veins  have  undergone  some 
degeneration. 

Symptoms. —  As  these  lesion-  can  be  seen  ophthalinoscopically,  it  is  nat- 
ural to  expect  with  them  certain  symptoms  more  or  less  well  marked.  These 
are  a  scotoma  of  varying  size,  corresponding  in  extent  and  location  to  the 
part  affected  by  the  thrombus,  and  usually  floating  bodies  in  the  vitreous 
(hyalibis),  causing  muscse  volitantes.  Complete  thrombosis  of  the  central 
vessel  cause-  great  engorgement  of  the  veins,  interrupted  venous  circula- 
tion, strong  venous  pulse,  streaked  disk-margins,  and  numerous  retinal 
hemorrhages. 

The  diagnosis  is  comparatively  simple  when  the  vitreous  i>  sufficiently 
clear  to  enable  the  lesions  to  be  recognized  by  the    ophthalmoscope. 

\o  local  treatment  is  of  any  value,  but  potassium  iodid,  mercuric  chlorid, 
and  other  alteratives  may  be  given  to  encourage  absorption  of  the  effused 
blood. 

Telangiectasia  qftheretinal  vessels,  aneurysm  of  the  central  artery,  and  vari- 
cose veins  of  the  retina  have  also  been  observed,  but  they  are  so  rare  as  to 
deserve  only  mention  here.  They  show,  in  general,  that  while  we  have  in 
hyperemia  the  first  step  toward  a  real  inflammation,  the  vessels  of  the  retina 
also  undergo  the  same  variations  from  the  normal  standard  as  occur  in  other 
parts    of  the    body. 

Retinitis. — Under  this  general  term  are  included  the  various  types  of 
inflammation  of  t  he  retina. 

Forms  of  Retinitis. — These  are  not  always  properly  described  by  the 
names  given  to  them,  nor  is  the  term  itself  always  exactly  applied.  Thus, 
ii  sometimes  expresses  a  pathological  condition — for  instance,  serous,  paren- 
chymatous, or  suppurative  retinitis;  or  it  is  used  to  denote  the  results  or 
accompaniments  of  such  inflammations — for  example,  hemorrhagic  retinitis ; 
or,  again,  it  is  employed  to  describe  the  caus< — '■.  g,  syphilitic  or  albuminuric 
retinitis.     Again,  retinitis  pigmentosa  and  other  name-  indicating  inflammation 


SEROUS  RETINITIS.  Ill 

are  giveD  to  retinal  Lesions  which  arc  not   inflammations  at  all,  in  the  true 
sense  of  the  word.     Therefore,  it  is  desirable  to  keep  in  mind  the  three  types 

of  inflammation  to  which  the  retina  is  subject — namely,  the  serous,  the  paren- 
chymatous, ami  the  purulent. 

These  types,  more  or  less  modified,  are  met  with  in  conjunction  with  cer- 
tain systemic  conditions:  thus  the  serous  type  i-  often  found  with  syphilis, 
while  the  parenchymatous  type  occur-  principally  with  changes  in  the  kid- 
neys. The  different  retinal  inflammations  can  best  be  understood,  therefore, 
by  considering  these  types  first,  and  later  their  modifications,  after  which 
another  group — the  scleroses — of  which  the  so-called  retinitis  pigmentosa  is 
a  type,  will  be  described.  That  is,  all  forms  of  retinitis  may  be  arranged 
into  four  groups  : 

I.  Simple  or  Serous  Retinitis. — Allied  to  this  are — 

(a)  Syphilitic  retinitis  ; 
(6)   Sympathetic  retinitis  ; 

(c)    Retinitis  from  concussion. 

II.   Parenchymatous  Retinitis. — In  this  are  included — 

( '/ )  Albuminuric  retinitis  ; 

(b)  Diabetic  retinitis  ; 

(c)  Leukemic  retinitis  ; 

('/)  Syphilitic  chorio-retinitis ; 
(e)    Hemorrhagic  retinitis; 
(n  Macular  retinitis. 

a.   Retinitis  albescens  ; 

/9.   Retinitis  circinata  ; 

y.   Solar  retinitis ; 

d.  Symmetrical  changes  at  the  macula  lutea. 

III.  Embolic  or  Septic  Retinitis. 

IV.  Retinal  Sclerosis. 

(<i)  Retinitis  pigmentosa,  typical  form  ; 
\l>)    Retinitis  pigmentosa,  atypical  form  ; 
{<•)    Retinitis  proliferate. 

Serous  Retinitis  (Retinitis  Simplex;  Edema  of  the  Retina;  Peri- 
papillary Retinitis). — Retinal  inflammation  of  slight  degree,  marked  only 
by  hyperemia  and  exudation,  is  known  as  simple  retinitis.  When,  however, 
there  is  besides  an  alteration  of  the  deeper  tissues  (hyperplasia),  the  term 
parenchymatous  is  used.  It  is  evident  that  the  two  form-  may  merge  into 
each  other  by  imperceptible  gradations  under  certain  circumstances,  and  that 
a  process  which  begins  as  simple  retinitis  may  pass  into  the  parenchymatous 
form.  Practically,  however,  the  first  type  or  stage  retain-  its  own  character- 
istics so  constantly  that  it  may  be  properly  considered  a  distinct  disease. 

Varieties. — As  the  retinitis  may  vary  according  to  the  depth  to  which 
the  layers  are  invaded,  it  may  also  vary  in  the  extent  superficially  or  in  the 
secondary  change-  accompanying  it.  When  the  edema  i<  limited  to  that 
region  where  the  retina  is  the  thickest — namely,  about  the  edges  of  the 
nerve — the  appearance  presented  is  so  peculiar  as  to  warrant  the  name  pen- 
papillary  retinitis. 

hiffiis,  retinitis  i-  more  common.  The  edema,  extending  over  the  entire 
retina,  veils  to  a  greater  or  less  extent  the  feature-  of  the  fundus. 

Etiolog-y. — The  causes  to  which  simple  retinitis   ha-  \»>w  ascribed  are 


412  DISEASES  OF  THE  RETINA. 

manifolds  Among  these  have  been  enumerated  excessive  use  of  the  eyes 
under  unfavorable  conditions,  refractive  error,  dazzling  light,  exposure  to 
colli,  chill,  etc.  In  many  cases,  however,  it  i-  due  to  syphilis.  It  may  be 
the  initial  change  of  other  forms  of  retinitis  presently  to  be  described. 

Pathology. — The  term  inflammation  ordinarily  i>  applied  to  nutritive 
disturbances  accompanied  by  redness,  swelling,  heat,  and  pain  ;  but  it  is  neces- 
sary to  modify  this  definition  in  accordance  with  the  alterations  to  which  this 
pathological  process  is  subjected  by  the  different  structures  of  the  body  in 
which  it  occur-.  Especially  is  this  the  case  in  retinitis.  In  the  early  stages 
of  the  inflammation  a  hyperemia,  more  or  less  well  defined,  is  present.  This 
corresponds  to  the  redness  which  accompanies  an  inflammation  elsewhere.  As 
a  result  of  the  distention  of  the  vessels  there  i>  naturally  edema,  with  some 
infiltration  of  the  leukocyte-  into  the  inner  layers  of  the  retina,  particularly 
into  the  nerve-fiber  and  ganglionic  layers,  or  even  into  the  vitreous  humor. 
Similar  lesions  would  produce  swelling  if  flay  occurred  in  other  portions  of 
the  body.  These  two  pathological  changes  constitute  practically  all  which 
are  present  in   pure,  simple  retinitis. 

Objective  Signs. — The  ophthalmoscopic  changes  are  as  slight,  propor- 
tionately, as  are  the  pathological  alterations.     They  are — 

(1)  Edema  <>/  /Ac  retina.  The  features  of  the  retina  can  usually  be  dis- 
tinguished, hut  they  appear  as  if  seen  through  a  mist.  The  retina  often  has 
a  somewhat  grayish  aspect,  almost  invariably  the  vitreous  is  more  or  less 
clouded  by  the  infiltration,  and  the  details  of  the  retina  are  consequently 
indistinct. 

(2)  The  vessels,  especially  the  veins,  are  altered.  They  are  more  tortuous 
and  have  a  greater  number  of  branches  than  usual.  They  are  distended  at 
some  points  or  disappear  under  the  swollen  retina  at  others.  Sometimes  the 
arteries  appear  reduced  in  size  from  compression. 

(3)  Hemorrhages  are  occasionally  met  with,  but  are  not  common  with 
the  serous  variety  of  inflammation  ;  nor,  indeed,  are  any  other  of  the  more 
extensive  alterations  present  which  are  found  when  the  deeper  layers  of  the 
retina  are  affected. 

Subjective  Symptoms. — (1)  The  first  and  most  important  symptom  is  a 
diminution  in  the  acuity  of  central  vision,  often  associated  with  greater  or 
less  contraction  of  the  field.  Occasionally,  in  the  circumscribed  variety  of 
retinitis,  only  one  spot  is  involved,  perhaps  near  the  equator,  and  then  not 
only  is  it  ea-ily  recognized  because  of  the  contrast  which  this  area  presents  to 
the  surrounding  tissue,  but  an  exact  examination  of  the  Held  shows  a  well- 
defined  scotoma  corresponding  to  the  affected   part. 

(2)  Distortion  of  vision  due  to  the  altered  retina.  The  exudation  into 
the  retina  changes  the  position  of  that  membrane  more  or  less,  and.  together 
with  the  unequal  pressure  upon  the  rods  and  cone-,  produces  peculiar  distor- 
tion- of  the  retinal  image.  Thus,  objects  may  appear  larger  than  normal 
(megalopsia),  or  the  patient  may  describe  them  as  being  distinctly  smaller 
(micropsia),  or.  finally,  they  may  be  distorted  in  various  ways  (Loring). 
When  the  difficulty  exists  in  both  eyes  it  is  not  always  easy  to  decide  what 
the  peculiarities  are  in  each,  unless  one  eye  be  covered  or  diplopia  is  pro- 
duced   with  a  prism. 

(3)  A  symptom  occasionally  present  in  this  type  of  retinitis  is  the  ability 

to  see  better  by  imperfect  illumination — for  example,  in  the  evening — than 
where  the  lighi  i-  bright.  Tin-  condition  ha-  been  called  by  Aril  nyctalopic 
retinitis.      Evidently,  however,  it   i-  only  n   symptom. 

(4)  A-  there   are    no    sensitive    uerve-fibers    in    the   retina,  often   a    high 


sv rm uric  RETINITIS.  11:; 

degree  of  inflammation   passes  without    pain,  imperfect   and  distorted   vision 
being  about   the  only  symptoms  which  attract   the  attention  of  the  patient. 

Diagnosis. — This  is  easily  made,  especially  in  cases  nol  far  advanced, 
there  being  then  no  (lander  of  confusing  the  -emu-  with  the  parenchymatous 
form.  The  veiling  of  the  fundus  when  the  inflammation  is  diffuse,  or  the 
grayish  patches  when  it  is  ci?'cumscribed}  together  with  the  changes  in  the 
vessels,  or  swelling  of  the  retina,  with  the  corresponding  diminution  of 
vision,  furnish  a  characteristic  picture. 

Prognosis. — This  is  uncertain  and  depends  somewhat  upon  the  cause. 
It  can  never  be  safely  foretold  that  a  serous  inflammation  thus  begun 
will  not  assume  the  parenchymatous  form.  When  the  inflammation  i-  not 
present  in  a  marked  degree,  or  when  it  has  existed  for  a  comparatively  short 
time,  absorption  is  apt  to  take  place;  or  when  the  serous  inflammation  is 
dependent  upon  syphilis  the  prognosis  is  more  encouraging,  inasmuch  as  this 
variety  frequently  yields  readily  to  treatment. 

Treatment. — Whenever  the  cause  can  he  determined,  it  is  of  course 
necessary  to  combat  that  first.  Where  there  is  a  distinct  history  of  syphilis, 
or  when  the  serous  retinitis  is  apparently  connected  with  any  systemic  disturb- 
ances, the  plan  to  he  pursued  is  plain  enough  ;  hut,  unfortunately,  the  causes 
are  by  no  means  always  clear,  and  in  those  cases  only  local  treatment  remains, 
Usually  much  attention  i-  given  to  protecting  the  eye-  from  bright  light, 
colored  glasses  or  even  a  dark  room  or  a  bandage  being  advised  ;  hut  in  this 
disease,  as  in  others  requiring  confinement  in  a  dark  room,  the  patient  should 
be  given  a  certain  amount  of  exercise  daily  in  the  open  air.  The  artificial 
leech,  cold  applications,  and,  in  general,  an  antiphlogistic  form  of  treatment 
are  advisable  in  inflammations  of  the  sthenic  type.  Mydriatic-  an'  not 
usually  mentioned  in  this  connection,  but  it  is  undoubtedly  the  case  that 
atropin  often  assists  in  keeping  the  eye  entirely  at  rest,  and,  although  the 
dilated  pupil  allows  more  light  to  enter  the  globe,  the  improvement  following 
the  use  of  atropin  is  too  common  to  warrant  its  omission. 

Syphilitic  Retinitis  (Specific  Retinitis). —  It  is  a  question  whether  an 
inflammation  of  the  retina  occurs  primarily  as  a  result  of  syphilitic  infection. 
Desmarres,  among  the  French,  and  the  English  practitioners  generally,  are 
inclined  to  regard  syphilis  as  commencing  always  in  the  choroid,  and  affect- 
ing the  retina  only  secondarily.  However  this  may  be,  a  serous  inflamma- 
tion of  the  retina  often   results  from   syphilis. 

In  the  pathological  anatomy  of  this  disease  there  is  nothing  sufficiently 
characteristic  to  distinguish  it  from  serous  retinitis  due  toother  causes.  Still, 
one  peculiarity  may  he  remarked — viz.:  a  tendency  of  the  inflammation  to  be 
circumscribed  instead  of  general.  For  this  reason  it  is  also  known  as  retinitis 
with  exudative  spots  (Galezowski),  but  these  may  exist  at  the  same  time  with 
considerable  general  edema  of  the  retina. 

Symptoms. — The  ophthalmoscopic  picture  is  such  a-  ha-  been  described 
under  Serous  Retinitis,  varied  only  by  the  local  edemas  which  are  common 
in  addition  to  the  diffuse  exudation.  This,  as  before  stated,  obscures  the 
whole  fundus  more  or  less,  rendering  indistinct  the  outline  of  the  disk  and 
the  course  of  the  arteries  and  vein-,  which  are  veiled  by  line-  of  grayish 
opacity.  The  papilla  i-  discolored,  and  has  been  compared  to  a  yellowish-red 
oval  -ecu  through  a  covering  of  fog  (Plate  5,  Fig.  I.). 

The  subjective  symptoms  are  also  the   same  as  those  of  simple  reti 
The  "mist"  before'  the  eve-  thickens  slowly,  and   usually  steadily.     While 
there  is  no  decided  pain  in  the  eyes,  photophobia   is  sometimes  present,  and 
photopsies  and  scintillations  are  common.     Indeed,  some  author-  consider  the 


414  DISEASES  OF  THE  RETINA. 

last-named  symptoms  as  regular  accompaniments  of  the  serous  form  of  syph- 
ilitic retinitis.  Irregular  and  concentric  contraction  of  the  visual  field,  as 
well  as  various  forms  of  scotomas,  arc  commonly  to  be  observed. 

Date  of  Occurrence. — Diffuse  syphilitic  retinitis  may  occur  in  congenital 
and  acquired  syphilis.  In  the  acquired  form  of  the  disease  it  appears  from 
one  to  two  years  after  infection,  sometimes  as  early  as  the  sixth  month,  and, 
according  to  Alexander,  is  found  in  about  8  per  cent,  of  the  patients.  One 
eye  alone  may  be  affected,  but  usually   the  second   eye  is  also   involved. 

Diagnosis. — There  is  no  appearance  or  symptom  diagnostic  of  syphilitic 
retinitis.  The  tendency  to  develop  circumscribed  spots  of  edema,  in  addi- 
tion to  the  diffuse  exudation,  may  perhaps  point  to  syphilis,  but  a  history  of 
the  case  giving  conclusive  evidence  of  the  general  infection  is  the  only 
testimony  on   which  reliance  can  be  placed. 

Prognosis. — This  is  much  more  favorable  than  in  cases  of  retinitis 
arising  from   other  sources. 

Treatment  is  of  course  governed  by  the  cause  ;  for,  although  the  same 
precautions  are  to  be  taken  locally  as  in  serous  retinitis,  much  depends  upon 
the  antisyphilitic  remedies.  Hirschberg  insists  that  it  is  not  safe  to  rely  on 
potassium  iodid,  and  that  mercurials  should  always  be  given,  for  they  probably 
have  a  beneficial  effect  upon  such  forms  of  inflammation,  in  addition  to  their 
specific  action.  The  use  of  tonics  is  also  desirable,  and  every  effort  should 
be  made  to   improve  the  general  condition  of  the  patient. 

Central  relapsing  retinitis,  a  rare  form  of  syphilitic  retinitis,  appear- 
ing in  the  form  of  gray  or  yellow  areas  in  the  macula,  or  as  numerous 
yellowish-white  spots  and  pigment-dots,  or  as  a  diffuse  opacity  of  this  region, 
is  a  late  manifestation  of  syphilis.     Relapses  are  frequent. 

Sympathetic  Retinitis. — Before  leaving  this  group  of  retinal  inflam- 
mations mention  should  be  made  of  that  form  which  accompanies  sympathetic 
iridocyclitis  (Graefe).  While  the  ophthalmoscopic  appearances  and  symp- 
toms of  this  variety  are  virtually  the  same  as  in  other  forms  of  serous 
retinitis,  this  is  specially  important  as  being  sometimes  one  of  the  early 
manifestations  of  approaching  sympathetic  ophthalmitis.  Its  recognition 
furnishes  indications  as  to  the  advisability  of  removing  the  eye  first  affected, 
should  that   question  arise  (see  also  page  348). 

Concussion  of  the  Retina  {Commotio  Retina  ;  Edema  of  tht  Retina). 
— This  condition  may  follow  injuries  of  almost  any  variety,  but  especially  a 
blow  on  the  eye  from  a  cork,  rubber  ball.  <>r  other  similar  substance.  It  is 
characterized   by  slight    retinal   changes  and   more  or  less  loss  of  vision. 

The  pathology  of  this  condition  has  not  been  satisfactorily  settled,  for 
in  some  cases  blindness  results  when  the  ophthalmoscope  shows  an  almost 
normal  retina,  and  in  others  very  marked  variations  from  the  standard  of 
health  seem  compatible  with  <_r<">d  vision.  Whatever  other  effects  may  be 
produced  by  the  injury,  it  is  certain  that  alter  the  blow — which  is  not  neces- 
sarily directly  on  the  ey< — there  often  appeal-  small  points  of  edematous 
exudation  in  the  retina,  or  these  may  coalesce,  and  the  typical  cloudy 
exudation  seen  in  serous  retinitis  may  cover  a  considerable  area  of  the 
fundus. 

Corresponding  t"  this  or  extending  beyond  it  is  a  scotoma,  more  or  less 
well  marked.  Such  an  exudation  can  be  seen  hot  a  day  or  two  after  the 
injury,  but  ordinarily  it  soon  begins  to  absorb,  and.  though  it  may  disap- 
pear entirely,  the  blindness,  partial  or  total,  may  persist.  Decided  retino- 
choroiditis,  the  result  of  concussion,  may  occur.  These  cases  are  often  <>f 
interest  from  a  medico-legal  point  of  view,  and  when  malingering  is  suspected 


PARENi  '11  VJL  I  TO  ( 'S   HF/I'IM TIS.  415 

the  tests  for  detecting  that  must  be  made  with  unusual  care.  An  im- 
portant complication  in  these  cases  is  the  development  of  transitory  astig- 
matism. 

The  treatment  locally  is  similar  to  that  for  edema  of  the  retina.  Stress 
is  laid  on  the  good  effect  of  long-continued  mydriasis  (see  also  page  •"><>  1 ). 

Parenchymatous  Retinitis  (Retinitis  Perivascularis). — In  the  serous 
type  of  retinal  inflammation,  as  already  stated,  hyperemia  and  edema  are 
present,  but  little  or  no  further  structural  change.  When,  however,  there  is 
hyperplasia,  and  when  the  deeper  parts  of  the  membrane  become  affected,  the 
condition  i-  generally  called  parenchymatous  inflammation.  It  will  be  .seen 
at  once  that  in  some  respects  this  is  like  the  type  just  mentioned,  except  that 
this  process  is  more  advanced. 

Etiology. — The  causes  are  sometimes  easily  traced,  especially  when  de- 
pendent upon  albuminuria,  intracranial  disorders,  or  certain  general  diseases, 
but  at  other  times  they  are  difficult  to  determine. 

Pathology. — The  same  changes  occur  as  in  the  serous  variety — namely, 
hyperemia  with  edema,  but  the  latter  is  frequently  wanting,  and  there  develops 
instead  an  infiltration  of  cells  or  metamorphosis  of  the  connective  tissue.  This 
infiltration  takes  place,  by  preference,  in  the  inner  granular  or  in  the  inter- 
granular  layer  (Arlt).  At  the  same  time  alterations  occur  in  the  walls  of  the 
capillaries.  It  has  not  yet  been  clearly  established  which  is  cause  and  which 
is  effect ;  and  from  the  fact  that  the  walls  of  the  vessels  so  often  undergo 
degeneration,  this  form  of  retinitis  has  also  been  called  retinitis  perivascularis 
( Iwanoff). 

After  these  early  stages  there  results — (1)  an  entire  absorption  of  the 
inflammatory  process;  or  (2)  partial  absorption  with  partial  destruction 
(namely,  partial  atrophy  of  the  retina);  or  (3)  a  total  atrophy — i.  e.  the  retinal 
elements  pass  into  a  form  of  cicatricial  tissue,  and  other  alterations  go  on  in 
the  nerve-tissues. 

Ophthalmoscopic  Appearances. — The  vitreous  being  free  from  exuda- 
tions, and  edema  usually  being  absent,  the  features  of  the  fundus  are  distinct. 
The  increased  amount  of  blood  causes  the  arteries  to  appear  full,  often  tortu- 
ous, and  the  terminal  branches  extended,  while  the  optic  nerves  take  on  a 
reddish  hue.  The  veins  give  similar  evidence  of  the  hyperemia,  and  occa- 
sionally, as  an  accompaniment  of  such  a  distention  of  both  arteries  and  veins, 
extravasations  into  adjacent  tissues  occur. 

This  is  especially  true  in  certain  forms  of  retinitis  of  nephritic  origin.  In 
these  cases  the  hemorrhages  extend  into  neighboring  parts  of  the  retina  as 
small  reddish  points.  Where  the  vessel  gives  way  through  a  considerable 
portion  of  its  extent  there  results  a  linear  extravasation.  This  form  has 
been  described  as  a  separate  kind  of  retinitis,  called  hemorrhagic  retinitis. 
In  fact,  there  i-  an  endless  variety  in  the  position,  form,  and  extent  of  these 
hemorrhages,  so  common  in  some  types  of  retinitis. 

Subjective  Symptoms. —  These  are  similar  to  those  described  in  con- 
nection with  serous  retinitis.  The  same  diminution  of  vision  is  always 
present,  but  in  a  much  more  marked  degree.  When  the  parenchymatous 
inflammation  is  general  there  may  be  t"t;d  blindness,  or,  if  il  is  circumscribed, 
there   is   a   well-marked    scotoma    in    the  corresponding  portion  of  the  field. 

Distortion  of  objects  or  similar  visual  disturbance  is  unusual,  the  retinal 
changes  being  too  deep  and  extensive,  but   photopsies  and  scintillation 
not  uncommon.      With  tin-  form  of  retinitis  also  there  i-  no  pain.      Indeed, 
the  advance  of  the  disease   is  so  entirely  five  from  this  symptom  that  when 
the    inflammation    affect-   only  one    eye    the    patient    sometimes    discovers    the 


I  hi  DISEASES  OF  THE  RETINA. 

blindness  by  chance,  or  often  not  until  the  same  process  in  the  other  eye 
makes  him  aware  of  his  condition. 

Diagnosis. — A  distinction  between  this  and  the  serous  form  of  retinitis  is 
not  difficult  in  typical  cases,  but  there  are  intermediate  stages  in  which  it  is 
unwise  to  decide  with  certainty.  Indeed,  it  is  possible  to  see  the  serous  and 
parenchymatous  type  of  inflammation  present  in  the  same  retina  at  the  same 
time. 

Prognosis. — This  is  grave.  Absorption  does  occur,  and  in  certain  in- 
stances normal  vision  returns,  but  this  is  very  rare,  except  in  the  retinitis  of 
pregnancy.  In  the  large  majority  of  eases  the  cell- infiltration  is  followed 
by  connective-tissue  changes,  with  subsequent  atrophy,  the  vessels  appearing 
later  as  whitish  threads. 

Treatment. — Locally  this  is  the  same  as  that  already  advised  for  serous 
retinitis.  The  general  treatment  depends  on  the  systemic  condition  which  is 
producing  the  disease. 

Nephritic  retinitis  is  a  generic  term  including  retinitis  albuminurica 
and  certain  other  forms  of  retinal  changes  accompanying  diseases  of  the  kid- 
neys. These  have  been  grouped  under  a  single  term,  because  they  are  the 
result  of  disease  of  the  kidney,  because  the  ophthalmoscopic  appearances  are 
similar  and  the  pathological  anatomy  is  in  some  respects  identical.  Diabetic 
retinitis  is  sometimes  described  under  the  same  generic  term,  but  inappro- 
priately, as  it  is  not  the  result  of  renal  disease.  For  a  clearer  understanding 
of'  the  subject  it  is  better  to  consider  each  of  these  varieties  in  order. 

Albuminuric  Retinitis  (Retinitis  Gravidarum;  Renal  Retinitis; 
Retinitis  <>/  Brighfs  Disease). — This  form  of  retinitis  is  characterized  by 
imperfect  vision,  by  definite  ophthalmoscopic  changes — among  which  those 
in  the  region  of  the  macula  are  most  noticeable — and  by  certain  alterations 
in  the  structure  of  the  membrane. 

Etiology. —  Even  before  Helmholtz  gave  us  the  ophthalmoscope.  Bright, 
Landouzy,  and  others  had  called  attention  to  the  frequency  with  which  so- 
called  amaurosis  accompanied  albuminuria.  It  remained  for  later  observers, 
however,  to  determine  more  exactly  the  dependence  of  one  upon  the  other — a 
relationship  which  has  been  frequently  and  carefully  studied. 

If  this  disease  is  the  result  of  albuminuria,  the  question  naturally  arises, 
Why  do  so  few  albuminuric  patients  complain  of  imperfect  vision?  The 
failure  of  vision  usually  escapes  observation,  because  there  is  seldom  or  never 
any  pain  in  the  eyes,  and,  as  the  macula  itself  is  often  the  last  to  be  affected, 
the  actual  condition  of  the  retina  is  neglected,  attention  being  directed  to 
other  symptoms.  But  ophthalmoscopic  examination  of  a  large  number  of 
albuminuric  patients,  whether  complaining  of  imperfect  vision  or  not,  indi- 
cates that  the  retina  is  affected  in  as  many  as  one-fifth  (  Lecorehe)  or  one- 
third  of  them  (Galezowski).  Indeed,  it  may  happen,  exceptionally,  that  the 
retinitis  shows  itself  in  a  typical  form  before  it  is  possible  to  detect  albumin 
in  the  urine  (Dixon,  Abadie),  as  was  illustrated  also  by  a  case  reported  by 
the  writer.1 

Although  chronic  granular  kidney  is  the  usual  cause  of  albuminuric  ret- 
initis, it  also  occurs  with  large  white  kidney  and  lardaceous  disease.  But  atten- 
tion should  be  directed  specially  to  the  albuminuria  of  pregnancy  as  a  very 
frequenl  and  important  etiological  factor.  The  relation  between  the  two  is  as 
uncertain  in  this  variety  of  the  disease  as  in  the  former,  but  without  doubt  a 
considerable  proportion  of  pregnant  women  win.  have  albuminuria  suffer  also 
from  the  form  of  retinitis  under  consideration.    Moreover,  it  is  well  known  that 

1  Trans.  Mied.Soe.StaU  of  Neu    York,  !-'.»:;. 


ALBUMINURIC  RETINITIS.  417 

patients  afflicted  in  this  way  during  one  gestation  arc  apt  to  have  a  recurrence 
of  the  same  symptoms  when  pregnant  again.  The  fact  that  the  retinitis  may 
result  in  partial  or  total  loss  of  vision,  which  can  last  permanently,  even  though 
the  cause  be  temporary,  indicates  the  importance  of  this  phase  of  the  subject. 
It  will  be  referred  to  again  when  the  question  of  treatment  is  considered. 

Symptoms  and  Pathology. — The  pathology  can  be  studied  to  best  advan- 
tage by  first  noting;  the  symptoms  and  the  ophthalmoscopic  changes  upon  which 
these  depend.  It  should  be  remembered,  however,  that  the  process  is  essen- 
tially a  parenchymatous  inflammation.  The  increased  vascularity  to  be 
described  later  tends  to  result  in  hemorrhages,  and  while  edema  is  slight  and 
the  vitreous  clear,  there  is  hyperplasia  in  the  deeper  layers  or  fatty  degenera- 
tion of  cells  into  those  portions.  Even  a  sclerosis  of  the  nerve-fibers  may 
also  occur  in  spots  (Midler). 

The  only  local  symptom  of  which  the  patient  complains  is  imperfect 
vision.  Sometimes  this  begins  gradually  and  increases  slowly  ;  sometimes 
the  onset  is  sudden  and  the  advance  rapid.  The  amount  of  inconvenience 
does  not  correspond  necessarily  to  the  extent  of  the  retinitis,  but  rather  to 
the  degree  in  which  the  macula  lutea  is  involved.  Sometimes  only  the 
macula  itself  remains  intact,  and  the  patients  are  surprised  to  find  that, 
although  the  central  vision  is  practically  normal,  they  are  otherwise  blind. 
The  impairment  of  vision,  like  the  retinal  changes,  is  usually  about  the  same 
in  each  eye  ;  but  unilateral  albuminuric  retinitis  is  not  a  rarity.  The  lesions 
may,  exceptionally,  remain  monolateral  till  death.  More  commonly  a  mono- 
lateral  case  is  converted  after  a  time  into  the  ordinary  bilateral  variety. 

The  ophthalmoscopic  appe^.  ^nces  of  retinitis  albuminurica  are — 

(1)  Fatty  deposits,  more  or  less  numerous,  in  the  posterior  segment  of  the 
retina.  These  white  or  yellowish-white  plaques  are  usually  well-defined, 
although  the  edges  shade  off  gradually  into  the  natural  color  of  the  retina. 
They  may  be  limited  to  the  vicinity  of  the  macula  from  which  they  radiate, 
or  may  cover  most  of  the  posterior  pole  of  the  eye,  according  to  the  extent 
to  which  the  retina  is  involved.  Sometimes  these  spots  of  exudation  are 
exceedinglv  small,  with  edges  so  sharply  defined  as  to  look  like  minute  white 
dots.  In  nearly  every  case  of  retinitis  albuminurica  a  group  of  these  dots 
can  be  seen  more  or  less  completely  surrounding  the  macula.  In  that 
vicinity  their  arrangement  and  form  are  so  characteristic  a-  to  present  a 
picture  quite  diagnostic  of  this  disease.  In  the  macula  itself  there  is  often 
a  white  spot,  and  almost  invariably  radiating  from  that  point  are  numerous 
thin  dashes  of  nearly  glistening  white  which  stream  off  in  different  direc- 
tions, this  appearance  being  due  to  the  arrangement  of  retinal  lifers 
(Schweigger).  The  lesion  is  sufficiently  peculiar  to  be  easily  recognized 
when  once  seen  (Plate  5,  Fig.  II.).  If  the  average  physician  appreciated 
how  readily  this  picture  of  retinitis  could  be  detected,  it  is  probable  thai 
the  ophthalmoscope  would  be  used  much  more  frequently.  Such  spot< 
about  the  macula  may  persist  long  after  every  other  trace  of  the  disease 
has  subsided.  This  is  especially  the  case  in  the  albuminuric  retinitis  of 
pregnancy. 

(2)  The  retinal  hemorrhages  which  accompany  albuminuric  retinitis  are 
peculiar.  They  are  linear  and  flame-shaped,  and  they  extend  along  the 
arteries,  which  are  perhaps  obliterated  in  part-,  the  extravasations  being 
due  primarily  to  changes  in  the  walls  of  the  vessels.  Round,  dotted,  and 
sheet-like  hemorrhages  may  also  occur. 

(3)  Next  to  the  alterations  in  the  retina  itself,  those  which  involve  the 
optic  nerve  should  be  mentioned.     A-  would  naturally  be  inferred,  tl 

27 


418  DISEASES  OF  THE  RETINA. 

of  the  nerve  become  indistinct  ;  it  is  often  swollen,  pushed  into  the  vitreous, 
apparently,  or  streaked  with  diverging  vessels  ;  in  a  word,  it  presents  the 
picture  of  neuritis  or  papillitis. 

The  foregoing  is  a  description  of  a  typical  case,  though  of  course  each 
stage  of  its  development  can  seldom  be  seen.  Many  variations  occur.  The 
disease  may  be  characterized  by  -mall  white  spots,  associated  with  compara- 
tively inponspicuous  hemorrhages  in  the  fiber-layer — the  so-called  degenerative 
type;  or  it  may  manifest  itself  as  a  violenl  neuro-retinitis,  with  extensive 
hemorrhagic  extravasations — the  so-called  inflammatory  type.  Sometimes 
comparatively  small  dots  in  the  macula  and  single  small  hemorrhages  may 
be  the  signs  of  renal  retinitis. 

Diagnosis. — This  is  not  difficult  in  typical  cases.  To  recapitulate,  the 
chief  signs  are — (1)  Imperfect  vision  in  both  eyes,  either  central,  or  with 
contracted  field,  or  with  scotoma.  (2)  Fatty  deposit-  in  the  retina,  especially 
in  the  vicinity  of  the  macula.  (3)  Retinal  hemorrhages,  striated  in  form. 
(4 1   Secondary   neuritis. 

Prognosis. — This  depends  upon  the  variety  and  extent  of  the  lesion  in 
the  kidney.  It  is  comparatively  good  when  the  amount  of  albumin  is  slight 
or  variable,  as  occurs  in  the  milder  forms  of  typical  Bright's  disease  or  fre- 
quently in  the  last  stages  of  pregnancy.1  The  question  becomes  more  serious, 
however,  when  the  renal  changes  are  extensive.  Then  the  retina  becomes 
more  and  more  involved  as  the  kidneys  become  disorganized,  and  the  slowly 
but  steadily  increasing  darkness  foretells  the  fatal  end.  While  the  albumi- 
nuric retinitis  of  pregnancy  usually  ends  with  gestation  or  soon  after,  the 
prognosis  in  certain  instances  is  grave  in  the  extreme,  for  with  vision  greatly 
impaired,  or  perhaps  lost,  the  patient  may  still  live  on  lor  years. 

Treatment. — Locally,  there  is  little  or  nothing  to  be  done.  It  is  well  to 
protect  the  eyes  from  bright  light  by  means  of  colored  glasses,  and  to  abstain 
from  prolonged  efforts  at  accommodation,  but  with  these  instructions  to  the 
patient  the  therapy  of  the  ophthalmologist  ends.  After  that  he  may  watch 
with  interest  the  progress  of  the  retinitis  ;  he  may  prescribe  iron,  alone  or 
with  bichlorid  of  mercury,  advise  steam  baths,  etc.  ;  but  the  important  part 
of  the  treatment  belongs  rather  to  the  province  of  the  physician  or,  in  certain 
cases,  to  the  obstetrician. 

When  this  retinitis  occur-  in  a  pregnant  woman  another  and  very  im- 
portant question  arises:  that  is,  whether  premature  labor  or  even  abortion 
may  not  be  induced  if  by  that  means  it  is  probable  thai  the  vision,  and  per- 
haps the  life,  of  the  patient  can  be  saved.  In  the  space  here  available  it 
i-  impossible  to  give  even  the  principal  argument.-  lor  or  against  such  a  pro- 
cedure. Suffice  it  to  say  that  in  certain  rare  instances  this  procedure  is  per- 
missible whin  thecomplaint  or  relapse  appeals  in  the  earlier  months,  or  when 
the  history  of  former  pregnancies  shows  a  tendency  to  severe  attacks  of  albu- 
minuric retinitis. 

1  The  prognosis,  so  far  as  life  is  c serned,  is  always  grave  in  renal  retinitis,  cases  occur- 
ring with  pregnancy  being  excepted.  The  very  presence  of  retinal  lesions  indicates  either 
-« •  r  i .  > 1 1 -  renal  disease  or  decided  general  arterio  sclerosis,  which  is  its  constant  associate. 

The  following  statistics  hear  upon  the  duration  of  life  after  the  development  of  albuminuric 
retinitis:  In  C.  S.  Bull's  examination  of  L  03  cases,  57,  or  more  than  50  per  cent.,  died  within  the 
Bret  year;  exceptionally,  cases  lived  five  or  even  seven  years  after  the  retinal  disease  had  ap- 
peared. According  to  Possaner,  patients  in  good  social  position  and  hygienic  surroundings 
succumb  lese  rapidly  than  those  who  are  nol  bo  favorably  placed. 

E.  O.  Belt's  statistics,  gathered  from  various  sources,  are  as  follows:  Cases  in  private  prac- 
lice,  155.  Of  these  62  per  cent,  died  within  one  year,  85  percent,  in  two  years,  and  II  per  cent, 
lived  more  than  two  years.     Cases  in  hospital  practice,  75.     Of  these  85  percent,  died  within  one 

year,  93  per  cent  within  tWO  years,  and  6  per  cent,  lived  fur  more  than  tWO  years. 


SYPHILITIC  CHORIO-RETINITIS.  U9 

Diabetic  Retinitis. — Another  variety  of  retinitis  is  thai  known  as 
retinitis  diabetica    or  glycosuria    retinitis.     In    the    typical   form    it    occurs, 

as  a  rule,  only  with  diab(  tes  mellitus,  lmt  it  has  also  hern  known  to  be 
caused  by  diabetes  insipidus  (Bowman,  Bader,  Hansell).  It  occurs  late 
in  the  disease,  when  other  serious  complications  may  be  present — e.g. 
gangrene. 

Pathology. — This  is  not  well  undersl I.     As  the  vessels  are  probably 

affected  primarily  in  all  these  tonus  of  retinitis  by  a  form  of  perivascu- 
litis, this  produces,  directly  or  indirectly,  most  of  the  changes  in  the  retina 
which  characterize  the  disease.  The  'pathological  anatomy,  as  shown  by  the 
few  sections  thus  far  made,  does  not  differ  greatly  from  that  of  albuminuric 
retinitis.  There  are  similar  deposits  of  fatty  degeneration,  similarly  situated 
with  respect  to  the  layers  of  the  retina,  hut  they  are  in  general  small,  the 
edges  are  well  marked,  and  especially  is  it  to  be  noted  that  they  are  not 
grouped  about  the  macula  in  the  manner  so  distinctive  of  albuminuric  retini- 
tis.    As  for  hemorrhages,  these  are  small,  if  existing  at  all.1 

The  secondary  neuritis  is  either  lacking  or  atrophy  begins  very  early,  the 
latter  condition  being  apparently  a  feature  of  the  pathological  picture. 

Symptoms. — These  are  similar  to  those  of  albuminuric  retinitis — viz. 
imperfect  central  vision  with  contraction  of  the  field — and  the  ophthalmo- 
scopic appearances  also  resemble  those  of  the  latter  disease  very  greatly ; 
indeed,  they  are  in  many  respects  identical,  except  that  the  hemorrhages  are 
less  in  size,  and,  as  before  remarked,  there  are  few  or  none  of  the  peculiar 
white  radiating  spots  about  the  macula. 

Diagnosis  and  Prognosis. — The  appearances  above  mentioned  may  be 
sufficient  to  render  it  possible  to  separate  this  from  other  varieties  of  nephritic 
retinitis,  irrespective  of  tests  for  sugar.     The  prognosis  is  grave. 

Treatment. — As  diabetes  is  counted  among  diseases  difficult  to  treat  suc- 
cessfully, reliance  must  be  placed  on  proper  diet.  Nothing  can  be  accom- 
plished by  local  treatment.  The  general  precautions  mentioned  under  serous 
or  parenchymatous  retinitis  should  be  observed. 

leukemic  retinitis  belongs  to  this  group  of  inflammations,  and  is 
almost  exclusively  caused  by  splenic  leukocythemia.  Both  eyes  are  affected. 
Leukocytes  not  only  invade  every  portion  of  the  retinal  tissue,  but  opaque 
deposits,  sometimes  fringed  with  a  reddish  border,  are  seen  extending  from 
the  macula  to  the  equator.  These  have  been  found  by  Leber  to  consist 
almost  entirely  of  lymph  corpuscles. 

The  color  of  the  vessels  in  the  retina  is  also  peculiar.  The  arteries  arc 
small,  pink,  or  even  yellowish,  the  veins  large,  broad,  and  rose-red,  and  the 
retinal  tissue  pale  yellow.  Considerable  swelling  of  the  papilla  is  usually 
present,  and  occasionally  spots  develop  near  the  macula  similar  to  those 
found  in  albuminuric  retinitis.  The  symptoms  are  those  of  parenchymatous 
retinitis. 

Diagnosis  is  usually  easy  ;  exceptionally,  however,  there  is  difficulty 
in  distinguishing  this  disease  from  albuminuric  retinitis,  but  a  count  of  the 
blood-corpuscles  of  course  determines  the  cause.  In  place  of  the  typical 
appearances  there   may    be  a   diffuse  opacity   of  the   retina. 

There  is  no  treatment  except  to  protect  the  eyes  and  improve  the  general 
condition,  if  possible. 

Syphilitic  Chorio-retinitis. — Syphilis,  as  before  stated,  tends  to  show 
itself   first    in    the    uvea,  and    the   retina    is    probably  affected    later;    or 
inflammation    develops   simultaneously   in    the   retina  and   choroid.      Indi 
1  According  to  Hirschberg,  then-  is  an  exudative  as  well  :i~  a  hemorrhagic  form. 


420  DISEASES  OF   THE  RETINA. 

sometimes  in  the  same  person  a  serous  retinitis  may  be  found  in  one  eye  and 
a  chorio-retinitis  in  the  other,  or  the  two  diseases  may  exist  in  the  same  eve. 
It   occurs  from  six   months  to  two  years  after  primary   infection. 

The  pathological  anatomy  combines  the  features  of  perhaps  the  serous, 
or  always  of  the  parenchymatous  retinitis,  or  of  both,  with  those  of  a  cho- 
roiditis. 

Symptoms. — In  pure  chorio-retinitis  of  certain  types  the  vitreous  is  clear, 
and  the  usual  absence  of  marked  edema  renders  the  details  of  the  retina  dis- 
tinct. In  this  class  of  cases  retinal  hyperemia,  and  often  hemorrhages,  are 
found,  or  a  neuro-retinitis.  But  the  most  characteristic  appearances  are  spots 
of  exudation  of  various  size  and  irregularly  distributed.  When  these  first 
appear  they  may  be  like  spots  of  edema — whitish  or  elevated  ;  later  more  or 
less  complete  atrophy  of  the  retina  takes  place,  and  there  results  a  dark  or 
black  area  showing  the  choroid  with  corresponding  distinctness.  These  spots, 
when  small,  are  similar  to  those  seen  in  retinitis  pigmentosa.  If  the  choroid 
also  undergoes  atrophy,  white  spots  (the  sclerotic),  fringed  with  the  black 
cells  of  the  choroid,  are  visible.  Should  an  artery  or  vein  happen  to  cross 
such  a  spot,  the  vessel  can  be  easily  distinguished  in  the  early  stage,  but 
later  its  outlines  become  indistinct  ;  it  is  cut  off,  and  atrophies  there  with 
the  surrounding  tissue  (Plate  5,    Fig.    III.). 

In  other  varieties  of  syphilitic  chorio-retinitis  in  the  early  stages  there  is 
diffuse  punctate  opacity  {hyalitis  'punctata)  of  the  vitreous,  especially  in  its 
posterior  layers,  and  marked  edema  of  the  peripapillary  retinal  layer.  Occa- 
sionally the  iris  and  posterior  layers  of  the  cornea  participate  in  the  inflam- 
mation. Later  the  ophthalmoscopic  changes  are  similar  to  those  described 
in  the  preceding   paragraph   (set'  also  page  ooO). 

The  subjective  symptoms  are  analogous  to  those  of  other  types  of  ret- 
initis— lessening  of  central  vision,  contraction  of  the  visual  field,  scotomas, 
diminished  light-sense,  and  sometimes  night-blindness.  Photopsies,  microp- 
sia, and  megalopsia  are  present. 

Treatment. — This  consists  in  the  use  of  mercurials  internally  or  by 
inunction,  and  the  administration  of  potassium  iodid.  The  eyes  should  be 
protected,  and   occasionally  the  artificial   leech   is  advisable. 

Hemorrhagic  Retinitis  is  often  described  as  a  separate  disease,  but 
really  it  is  only  a  form  occasionally  assumed  by  inflammations  of  the  serous 
type,  but  mosi  frequently  by  those  of  the  parenchymatous  type.  For  the 
latter  reason  it  is  mentioned  in  this  connection.  Again,  variously  shaped 
hemorrhages  may  appear  in  the  retina  and  occasion  sufficient  irritation  in 
surrounding  fibers  to  create  a   retinitis. 

Etiology. — The  hemorrhages  may  be  dependent  upon  syphilis,  and  in 
that  case  the  walls  of  the  vessels  are  altered  (endarteritis,  formation  of 
thrombi),  so  that  the  hemorrhages,  often  small  and  fine,  stream  off,  as  it 
we  e,  in   irregular  line-  from  the  region  of  the  nerve. 

Mosi  frequently,  however,  the  hemorrhages  are  found  with  nephritic 
retinitis  and  with  oilier  types  of  retinitis  dependent  upon  constitutional 
diseases.  Then  they  are  rather  linear  in  form,  but  often  large  and  irregularly 
distributed.  Hemorrhagic  retinitis  may  also  accompany  cardiac  disease, 
general  arterial   sclerosis,  suppressed  menstruation,  and   the  climacteric. 

Hemorrhages  into  the  retina  without  signs  of  retinitis  (apoplexy  of 
the  retina)  may  be  the  resull  of  senile  changes  in  the  walls  of  the  vessels. 
Then  the  extravasations  are  apl  to  be  large,  irregular,  and  to  appear  even 
from  the  first,  of  a  darker  hue  than  thai  otherwise  seen.  The  region  of  the 
macula  is  liable  to  be  the  -eat  of  such  extravasations  as  the  arrangement  of 


Plate  s 


Fig.  I.    Syphilil  ic  rel  initis  (serous  type  I. 
'•'";-   II-     Albuminuric  retinitis  (parenchymatous  type). 

Fi«.    HI.     Syphilitic   chorioretinitis,    late   stage,    following    hemorrhagii    retinoi 
(de  Scbwcinitz  i. 

I'  !•'■   IV.  -Subhyaloid  hemorrhage  in  the  macular  region. 


M. iCULAR   R i: TIN1 TI8.  421 

the  fibers  in  this  locality  predisposes  to  them.  When  they  occur  there  they 
produce  an  irregular  blotch  or  oval,  usually  with  the  longer  diameter  vertical, 
and  a  corresponding  central  scotoma.  Hemorrhages  of  large  dimensions  and 
drop-like  form  usually  mean  an  extravasation  between  the  internal  limiting 
membrane  of  the  retina  and  the  hyaloid  membrane  of  the  vitreous.      Etecenl 

investigations  by  J.  Herbert    Fisher  indicate  that   the  1>1 1   is  poured  out 

from  a  retinal  vessel — probably  a  minute  artery — and  detaches  the  internal 
limiting  membrane  from  the  retinal  layers,  accumulating  in  the  space  thus 
formed.  These  are  the  so-called subhyaloid  hemorrhages,  which  occur  at  the 
yellow  spot  more  than  at   other  parts  of  the  fundus  (Plate  5,  Fig.  I  Y.i. 

Although  many  of  the  causes  of  retinal  hemorrhage  have  been  enumer- 
ated, a  summary   based  upon   Dimmer's  classification   may  he  added  : 

{<[)  Hemorrhages  caused  by  changes  in  the  composition  of  the  blood  and 
the  tissues  of  the  blood-vessel  walls  :  Pyemia,  septicemia,  ulcerating  endo- 
carditis;  diseases  of  the  liver,  spleen,  kidney,  and  atheroma  of  the  vessels; 
loss  of  blood  (menorrhagia,  hematemesis),  anemia  (simple  and  pernicious), 
hemophilia,  purpura,  and  scurvy;  diabetes  and  gout;  malaria  and  recurrent 
fever. 

(6)  Hemorrhages  caused  by  disturbances  in  the  circulation  :  Hypertrophy 
of  the  heart  and  stenosis  of  the  valves;  thrombosis  of  the  central  vein  of 
the  retina  and  embolism  of  the  central  artery ;  suffocation,  compression  of 
the  carotid,  hemorrhages  in  the  newly-born  ;    and  menstrual  disturbances. 

(c)  Hemorrhages  caused  by  sudden  reduction  of  the  intraocular  tension 
— e.g.  after  iridectomy  in  glaucoma  and  by  traumatism :  Among  the  latter 
may  be  classed  retinal  hemorrhages  after  large  cutaneous  burns. 

Pathology. — A  perivasculitis  or  fatty  degeneration  of  the  walls  of  the 
retinal  vessel,  produced  by  the  general  or  local  disturbance,  permits  rup- 
ture of  the  artery  or  vein  and  consequent  extravasation.  Sometimes  the 
hemorrhage  is  caused  by  diapedesis  of  blood-corpuscles.  In  some  cases  the 
hemorrhages  are  superficial,  and  leave  the  retina  healthy,  but  in  other 
instances  atrophy  results  and  a  scotoma  permanently  marks  the  spot.  Hem- 
orrhages may  take  place  in  any  layer  of  the  retina,  and  by  preference 
follow  the  larger  blood-vessels.  Sometimes  they  burst  through  the  limiting 
membrane  and  pass  into  the  vitreous.  The  macula,  as  before  stated,  is  a 
favorite  spot  for  these  lesions.  With  the  hemorrhages  may  be  the  patho- 
logical changes  incident  to  the  various  types  of  serous  and  parenchymatous 
retinitis. 

Prognosis. — At  times,  as  already  noted,  superficial  retinal  hemorrhages 
are  absorbed  without  leaving  permanent  scars  ;  but  if  the  macula  is  attacked. 
the  visual  disturbance  is  apt  to  be  severe  and  lasting.  Xot  only  in  this  sense 
is  the  prognosis  unfavorable,  but  the  retinal  hemorrhage,  in  most  instances 
a  sign  of  serious  constitutional  disturbance,  may  be  the  forerunner  of  extrav- 
asations in  vital  centers.  Secondary  changes  in  the  optic  nerve  may  resull  : 
sometimes  glaucoma  is  a  consequence  (see  page  384). 

Treatment. — This  should  be  directed  toward  removing  the  cause  when- 
ever possible  to  determine  it.  Internally,  if  not  otherwise  contraindicated, 
iodid  of  potassium  may  be  given,  ergot,  small  doses  of  pilocarpin,  and 
bichlorid   of  mercury,  according  to   various   indication-. 

Macular  retinitis  is  a  term  which,  though  often  used  for  only  one  Conn 
of  retinal  inflammation  occurring  in  the  macula  lutea,  is  really  more  genera' 
in  its  application,  and  may  include  several  types  of  inflammatory  retinal 
change  specially  located  in  this  region.      The  details  of  these  alteration-  arc  not 

yet  clearly  understood,  and  consequently  they  cannot  he  separated  from  each 


422  DISEASES  OF  THE  RETINA. 

other,  neither  by  their  ophthalmoscopic  features  nor  by  what  we  know  thus 
far  <>i"  their  pathology  :  for  it  will  be  remembered  that  the  appearances  of  the 
macula  Intra  vary  considerably  within  normal  limits. 

Mention  has  already  been  made  of  the  so-called  "  Gunn's  dots,"  and  these 
are  ordinarily  considered  as  non-pathological  variations  of  the  macula,  for  the 
reason  thai  normal  vision  is  found  when  they  exist.  Very  nearly  allied  to 
them   we  have 

Retinitis  Punctata  Albescens  {Central  Punctate  Retinitis). — This 
affection  is  classed  as  a  pathological  condition,  not  so  much  because  it  differs 
materially  in  appearance  from  the  Gunn's  dots,  but  because  central  vision  is 
more  or  less  impaired.  Fuchs  and  Liebrecht  call  attention  to  the  similarity 
which  this  disease  may  hear  to  retinitis  pigmentosa,  in  so  far  that  it  may 
occur  in  children,  affecting  several  members  of  the  same  family,  and.  more- 
over, in  children  of  blood-relations.  Occasionally  there  are  night-blindness 
and  contraction  of  the  visual  field.  Other  cases  have  been  reported  in  middle- 
aged  patients  with  unchanged  peripheral  fields. 

The  most  prominent  feature  is  a  group  of  tine,  shining  dots  in  the  vicinity 
of  the  macula,  often  extending  toward  the  optic  nerve.  Sometimes  the  dots 
are  presenl  in  greal  numbers.  A  central  scotoma,  more  or  less  marked,  can 
be  found,  though  often  exact  measurements  are  necessary  to  determine  it; 
the   peripheral    held   is  unaffected.     Sometimes  vitreous  hemorrhages  occur. 

Nieden  and  Landesberg  think  the  spots  can  be  made  to  disappear  by  the 
administration  of  potassium  iodid  and  mercury,  but  the  real  effect  of  any  treat- 
ment is  uncertain. 

Retinitis  circinata  is  a  term  recently  used  by  Fuchs  to  describe  an 
appearance  of  the  macula  somewhat  similar  to  that  found  in  albuminuric 
retinitis.  A  yellowish-gray  opacity  i^  found  in  the  macular  region,  sur- 
rounded at  some  distance  by  a  zone  of  white  spots  or  larger  white  patches.  It 
is  probable  that  this  is  not  an  inflammatory  process,  and  that  it  is  due  to 
hemorrhages  taking  place  in  this  locality.  Some  writer-  regard  these  points 
only  as  accompaniments  of  albuminuric  retinitis  (Spicer  Holmes),  but  in  a 
typical  case  recently  described   by   Hartridge  no  albumin  could   be  found. 

Solar  Retinitis.  — Since  the  sight-purple  in  the  retina  was  discovered 
by  Boll,  what  before  appeared  a  mysterious  action  of  the  light  upon  the 
retina  is  better  understood.  When  an  excessive  amount  of  lighl  enter-  the 
eye  for  a  considerable  time  the  sight-purple  is  destroyed  to  such  an  extent 
that  it  is  not  renewed  either  promptly  or  entirely.  These  changes  in  the 
retina  when  slight  are  not  visible  with  the  ophthalmoscope.  Their  effect  is 
shown  by  considerable  loss  of  central  vision,  though  this  is  not  necessarily 
complete,  and   by  more  or  less  limitation  of  the  visual   fields. 

When,  however,  the  crystalline  lens  has  focussed  the  ray-  from  a  strong 
light,  with  the  accompanying  heat,  upon  the  retina— as,  for  example,  when 
.in  eye  has  been  directed  toward  the  sun — the  changes  produced  in  the  yellow 
-pot  are  not  only  more  lasting,  but  they  can  often  he  seen  with  the  ophthal- 
moscope. Thi-  ha-  occurred  particularly  during  observations  of  an  eclipse 
of  the  -nil.  or  the  effect  of  such  -iron-  lighl  has  been  shown  by  experiments 
on  animals.  A  distincl  exudation  in  the  form  of  small  spots  of  retino- 
choroiditis  can  be  seen  in  the  vicinity  of  the  macula,  and.  although  these 
appearances  gradually  subside,  a  central  scotoma  may  persist,  which  indicates 
that  the  alterations  in  the  retina  were  extensive. 

'flic  pathological  changes  are  not  clearly  understood,  but  they  are  proba- 
bly more  nearly  allied  to  the  parenchymatous  type  of  inflammation  than  to 
any  other. 


8UPPUBA  TIVE  RETINITIS. 

No  treatment  has  been  found  of  value  in  even  lessening  the  size  of  the 
scotoma,  although  the  protection  and  rest  of  the  eye  are  indicated. 

Symmetrical  Changes  at  the  Macula  I^utea  in  Infancy. — This 
peculiar  and  rare  condition  was  first  described  by  Waren  Tay,  the  clinical 
appearance  being  in  every  way  similar  to  that  which  exists  in  cases  of 
embolism  of  the  centra]  artery.  The  cherry-red  color  of  the  macula,  in 
the  center  of  a  grayish-white  zone  about  the  size  of  the  papilla,  is  here,  as 
in  embolism,  a  very  marked  feature   of  the   ophthalmoscopic   picture. 

The  condition  of  the  patient  is  always  peculiar,  the  mental  and  physical 
condition  being  decidedly  below  the  normal.  It  i-  not  certain  what  gives 
ri-e  to  this  appearance  of  the  retina,  although  the  changes  are  probably  in 
the  deeper  layer-,  and  examination-  after  death  -how  a  degeneration  of  the 
spinal  cord  and  the  pyramidal  cell-  of  the  cortex.  The  disease  i-  always 
fatal,  death  occurring  in  from  one  to  two  years.  In  most  of  the  cases  reported 
the  children  were  of  Hebrew  parentage.' 

Suppurative  Retinitis  {Purulent  Retinitis;  Embolic  Retinitis). — This 
usually  occur-  in  connection  with  severe  inflammation  of  the  choroid,  but  in 
rare  instances  the  proeess  can  be  noticed  beginning  in  the  retina  before  the 
vitreous  has  become  cloudy. 

Etiolog-y. — It  may  be  caused  by  injury  (e.  g.  foreign  body),  but  the 
typical  form-  are  due  to  cerebrospinal  meningitis  or  to  septic  or  puerperal 
conditions.  It  i-  also  known  to  exist  with  a  gouty  or  rheumatic  diathesis. 
In  some  cases  it  is  not  easy  to  understand  how  infection  occurs  ;  but  it  i-  also 
beyond  question  that  bacteria  may  be  transported  from  other  parts  of  the 
body  into  the  circulation,  and,  finding  lodgement  in  the  retina,  give  rise  to  a 
purulent  inflammation. 

Symptoms. — It  may  happen  that  imperfect  vision  first  attracts  the  atten- 
tion of  the  patient,  but  ordinarily  the  iris  of  choroid  has  previously  become 
involved,  giving  ri-e  to  ciliary  injection,  pain.  etc..  the  decrease  in  the  field 
of  vision  or  in  the  more  important  central  vision  resulting  from  the  general 
inflammation.  The  disease  is  often  limited  to  one  eye.  An  ophthalmoscopic 
examination  -how-  changes  in  the  retina  only  in  the  early  stages.  These 
are  exudation-  and  hemorrhage-  which  usually  extend  into  the  vitreous,  the 
latter  soon  becoming  so  turbid  a-  to  obscure  the  detail-  of  the   fundus. 

The  diagnosis  is  easily  made  on  account  of  the  acute  symptoms,  or  when 
these  are  absent  the  appearance  of  the  fundus  i-  sufficiently  characteristic. 

The  prognosis  is  extremely  unfavorable.  After  suppurative  retinitis  is 
well  established  cure  is  impossible.  Occasionally  the  more  acute  symptoms 
will  subside,  but  the  retina  is  always  left  thickened,  more  or  less  detached, 
and  shrinks   finally   into  a   band  of  connective  tissue. 

Treatment. — This  is  similar  to  that  employed  for  an  iritis  or  an  irido- 
choroiditis.  It  is  antiphlogistic.  Atropin  is  of  undoubted  benefit  in  solu- 
tions strong  enough  and  used  often  enough  to  keep  the  pupil  dilated.  Pro- 
tection of  the  eve  from  light  gives  comfort,  and  the  use  of  cold  applications 
i-  uecessary.  When  it  i-  possible  to  reduce  the  temperature  of  the  globe, 
it  is  probable  that  the  development  of  the  microbes  is  either  temporarily  or 
permanently  arrested.      In    making  cold  application-  to  the  eye  they  should 

be    used  only  for  a  few  minute-   at  a  time,  and    care   -I Id  be  taken  that  the 

cloth  or  gutta-percha  bag  or  coil  is  not  kept  on  the  globe  long  enough  to 
become  warm. 

Attempts  have  been   made  recently  to  carry  oul   the  principles 

'  For  a  summary  *<\  the  Literature  of  tlii-  unusual  disease  consult  an  article  by  l\'-ll<>r  in 
the  V  •        of  ill-  Aim  riean   Ophlhalmological  Society,  1896,  vol.  vii..  Tart  iii.,  p.  I 


424  DISEASES  OF   THE  RETINA. 

sepsis  in  the  treatment  of  these  suppurative  conditions.  We  know  that 
sublimate  solutions  may  be  injected  under  the  conjunctiva  with  but  little 
inconvenience,  and  efforts  have  been  made  to  extend  the  same  plan  of  treat- 
ment to  inflammation  of  the  choroid  or  retina.  Thus  far,  the  method  has 
met  with  indifferent  success,  but  it  is  probable  that  intraocular  injections,  in 
some  form,  will  prove  of  value,  and,  theoretically,  they  give  promise  of  a 
brilliant   future  (see  also  page   100). 

RETINAL  SCLEROSES. 

Tints  far.  the  forms  of  retinitis  which  are  more  or  less  of  an  inflammatory 
nature  have  been  considered.  In  addition  to  these,  however,  there  are  path- 
ological changes  which  take  place  in  the  retina,  not  associated  with  any  of 
the  cardinal  signs  of  inflammation,  lint  which  can  he  recognized  by  the 
ophthalmoscope,  and  which  are  characterized  by  certain  symptoms.  They 
are  usually  described  as  forms  of  retinitis,  although  it  is  a  question  whether 
that  term  should  be  applied  to  them.  It  is  therefore  better  to  class  them 
together  as  forms  of  retinal  sch  rosis.  In  this  group  we  have  retinitis  pigmen- 
tosa of  the  typical  variety  and  of  the  variety  with  little  or  no  pigment,  and 
with  these  may  also  be  classed   the  so-called   retinitis  proliferans. 

Pigmented  Sclerosis  of  the  Retina  (Retinitis  Pigmentosa;  Pig- 
mentary Degeneration  of  the  Retina;  Pigmented  Retina  anil  Choroiditis. — 
The  term  retinitis  pigmentosa  is  usually  applied  to  an  affection  characterized 
by  deposits  of  pigment  in  the  retina  of  more  or  less  peculiar  form  and  loca- 
tion, the  appearance  being  accompanied  by  certain  definite  symptoms. 

A-  this  term  is  ordinarily  used,  without  qualification,  it  probably 
includes  two  and  perhaps  three  diseases.  The  study  of  a  large  number  of 
these  cases  shows  that  the  retinas  vary  much  from  each  other,  and  also  that, 
while  there  is  a  certain  type  of  symptoms  to  be  expected,  these  are  by  no 
means  always  constantly  present.  A.S  for  the  pigment,  this  not  only  varies 
in  form  and  in  the  abundance  with  which  it  is  found,  but  in  some  cases, 
where  the  subjective  symptoms  are  particularly  well  marked,  the  'pigmenta- 
tion is  absent  entirely.  En  defining  retinitis  pigmentosa,  therefore,  we  must 
consider  that  this  is  simply  the  name  of  a  group  of  pathological  processes 
nearly  allied   to  each   other,   the  exact  nature  of  which   is  still   unknown. 

Etiology. — The  etiology  of  the  disease  is  also  obscure.  It  was  formerly 
considered  that  consanguinity  was  the  most  important  element  in  its  produc- 
tion, and  the  evidence  undoubtedly  shows  that  it  is  a  factor  in  the  causation 
of  certain  varieties.  Bui  it  is  probable  that  the  importance  of  this  has  been 
overestimated,  while  that  of  hereditary  syphilis  and  some  other  conditions 
ha-  been  overlooked.  It  i-  markedly  hereditary.  The  affection  has  been 
found  anions  deaf-mutes,  idiot-,  and  epileptics.  The  disease  is  either  con- 
genital or  begins  in  childhood. 

Pathology. — In  considering  the  pathology  of  retinitis  pigmentosa  it  is 
proper  to  describe  the  morbid  process  which  goes  on  in  a  typical  case,  but  it 
i-  equally  necessary  to  remember  that  this  process  is  liable  to  many  varia- 
tion-. It  eoii~i~t>,  in  general — (1)  Of  a  proliferation  <»f  the  connective- 
tissue  cells  which  form  pari  of  the  supporting  structure  of  the  retina;  {'1) 
;i  sclerosis  in  the  wnll-  of  the  vessels,  and  consequently  a  contraction  of  their 
diameters;  (3)  atrophy  of  the  oerve-elements,  with  the  destruction  of  the 
rod- mid  com- ;  (  1)  usually  pigmentary  degeneration,  taking  on  certain  shapes 
which  will  be  referred  to  Inter. 

Symptoms. — The  Bymptoms  and  the  ophthalmoscopic  appearances  of 
retinitis  pigmentosa  arc — 


PKIMEXTKI)  SCLEROSIS  OF  THE  RETINA. 


125 


(a)  Night-blindness. — This  symptom  is  the  one  which  ordinarily  first 
attracts  attention  to  the  disease,  although  it  is  seldom  noticeable  until  the 
ophthalmoscope  shows  changes  in  the  retina  ahcadv  well  advanced. 

(6)  Diminution  of  the  Central  Vision. — This  is  almosl  invariably  present, 
although  occasionally  good  visual  acuity  remains  for  a  longtime.     Sometimes 


Fig.  258.— Visual  field  in  retinitis  pigmentosa. 


it  is  associated  with  a  true  myopia,  but  more  frequently  the  myopia  is  only 
apparent ;  for  the  patient  approaches  close  to  objects  in  order  to  obtain  as 
large  a  retinal  image  as  possible. 

(c)   Contraction  of  the  Visual  Field. — In  typical  cases  this  contraction  is 
peculiar,  because  the  concentric  restriction  occurs  with  almost  perfect  regu- 


Fig.  259.— Pigmentary  degeneration  of  the  retina  (Jaeger). 

larity  (Fig.  258).     The   contraction    may   he  extreme,  only   a   -mall    central 
area  of  the  field   remaining.      It   i>,   however,   Liable  t"  many   variations. 
(d)  Occasional  Color-blindness. —  Failure   t<»   recognize  red  and  green    is 

the   usual    variety   of  this   defect. 

Oj)hth(din(>xc<>pic  examination   reveals  the   pigment,  especially  along  the 


126  DISEASES  OF  THE  RETINA. 

lines  of  the  vessels,  and  always  more  abundant  in  the  periphery  than  near 
the  center  of  the  retina.  The  temporal  side  of  the  ftmdus  is  generally  more 
affected  than  the  nasal  side.  The  pigment-masses  assume  an  appearance 
resembling  bone-corpuscles,  and  l>\  the  frequent  union  of  their  processes 
simulate  the  Haversian  canals.  This  results  in  a  picture  so  peculiar  a>  to  be 
easily  recognized  when  once  it  has  been  seen  (Fig.  259). 

The  papilla  is  usually  yellowish-gray  in  color,  with  only  slight  mixing 
of  red.  and.  as  Leber  has  noticed,  it  sometimes  has  a  glistening,  tendon-like 
whiteness,  such  as  i-  -ecu  in  extraocular  atrophy.  The  lamina  cribrosa  is 
also  more  or  [ess  covered,  and  the  whole  papilla  is,  in  general,  -mailer  than 
is  ordinarily  the  ride.  The  vessels  are  greatly  contracted  and  their  number 
is  diminished.  Often  their  wall-  contain  white  patches  or  are  edged  with 
white  line-.  The  general  fundus  is  frequently  wainscotted  on  account  of  the 
absorption  of  the  retinal  pigmented  epithelium.  Posterior  polar  cataract 
may  he  a  complication.     Opacities   in   the   vitreous  are   rare. 

Diagnosis. — This  is  usually  easy.  The  symptom  of  myopia  might  lead 
one  to  suspect  this  defect  of  vision  at  first,  hut  in  the  typical  forms  it  is  only 
nece--ar\  to  examine  the  periphery  of  the  retina,  when  the  peculiar  star-like 
pigment-dots  which  characterize  the  disease  become  apparent.  The  diagnosis 
is  further  confirmed  by  the  presence  of  the  other  symptom-  detailed,  especially 
the  night-blindness.  The  disease  i-  distinguished  from  disseminated  choroid- 
itis by  the  difference  in  the  pigmentation.  There  is  some  resemblance  between 
this  affection  and  certain  type-  of  syphilitic  retino^choroiditis  ;  hut  in  the 
latter  the  pigment-spots  are  not  of  characteristic  form,  they  do  not  follow 
the  blood-vessels,  and  vitreous  opacities  are  usually  present.  Pigmentary 
degeneration  of  the  retina   i-  always  bilateral. 

Prognosis. — The  disease  invariably  progresses  from  bad  to  worse.  In  cer- 
tain cases  it  remains  at  an  apparent  standstill  for  many  year.-,  but  gradually 
new  spots  appear,  nearer  ami  nearer  the  center  of  the  retina  and  associated  with 
a  corresponding  contraction  in  the  field.  The  night-blindness  becomes  more 
annoying,  and  bythe  time  middle  life  is  reached  or  old  age  approaches  a  large 
proportion  of  the  sufferers  cannot  find  their  way  about  without  assistance. 

Treatment. — Thus  far.  this  has  been  equally  unsuccessful  in  all  forms. 
It  i-  true  that  the  subcutaneous  injection  of  strychnin  seems  to  retard  the 
disease  in  some  cases,  and  report-  of  the  o-ood  effecl  of  electricity,  in  the  form 
of  galvanism,  have  appeared,  but,  nevertheless,  the  treatment  may  be  summed 
up  by  saying  there  is  none  thus  far  to  be  relied  upon. 

Non-pigmented  Sclerosis  of  the  Retina  [Retinitis  Pigmentosa 
Atypica ;  Pigmented  Retinitis  without  Characteristic  Pigment). — This  form 
has  been  referred  to  when  considering  the  typical  disease,  and  the  differences 
between  the  varieties  have  been  noticed.  While  it  may  occur  in  extreme 
cases,  as  before  stated,  thai  all  the  subjective  symptom-  of  retinitis  pig- 
mentosa are  present,  with  no  pigment,  so  also  are  there  various  degrees 
between  these  two  extreme-  in  which  the  ophthalmoscopic  picture  agrees 
more  or  less  completely  with  what   might   be  expected  from  the  symptoms. 

The  pathological  process  in  these  atypical  form-  i-  not  difficult  to  under- 
stand. The  di-ea-e  apparently  passes  through  three  of  the  stages  described 
when  considering  the  usual  form,  bul  the  la-t  i-  omitted — little  or  no  pig- 
mentary degeneration  take-  place.  This  i-  the  only  essential  difference  in  the 
two  form-,  the  clinical  history,  course,  and  prognosis  being  the  same.1 

1  Gould  (Annals  "f  Ophthalmology,  \i.,  L897  thinks  these  cases,  which  may  be  designated 
non-pigmented  retinal  atrophy,  are  more  numerous  than  i-  suspected.  In  bis  paper  the  lit- 
erature  i-  n-\  iewed. 


ANGIOID  STREAKS  IX   THE  RETINA. 


127 


Other  atypical  varieties  have  been  described  :  massing  of  the  pigment  in 
the  macular  region  and  corresponding  central  scotoma  ;  irregular  distribution 
of  the  pigment,  associated  with  clear,  shining  spots  lying  beneath  the  vessels  ; 
and  pigment  degeneration  accompanied  with  broad  peripheral  zone-  of  cho- 
roidal atrophy.  In  rare  instances  the  disease  is  complicated  with  chronic 
glaucoma. 

Retinitis  Proliferans. — This  disease,  like  retinitis  pigmentosa,  is  nol  a 
true  inflammation  of  the  retina,  l»ut  has  been  considered  by  Manz  to  rep- 
resent a  proliferation  of  the  connective  tissue  of  thai  membrane.  Indeed, 
there  is  a  proliferation  of  Muller's  fibers  and  a  formation  of  new  connec- 
tive tissue  among  them.  It  presents  itself  as  feathery,  bluish-white  expan- 
sions of  tissue,  often  extending  from  the  retina  into  the  vitreous.  These 
bands  may  occur  in  any  portion  of  the  fundus,  and  may  follow  the  course  of 
the  vessels,  but  they  are  usually  situated  near  the  optic  nerve,  and  bend  about 
it  in  more  or  less  concentric  curves  (Denig).  New-formed  bl l-vessels  occa- 
sionally lie  above  the  masses.     Vision  is  usually  seriously  disturbed. 

The  cause  of  the  affection  is  not  well  known  ;  syphilis  and  trauma- 
tism are  etiological  factors.  Leber  attributes  the  formation  of  these  masses 
to  repeated  hemorrhages  in  the  vitreous  or  retina.  As  a  complicating  cir- 
cumstance there  may  be  detachment  of  the  retina.  The  ophthalmoscopic 
appearance  is  striking.  In  one  case  of  retinitis  albuminurica  which  the  writer 
has  observed  these  bands  of  connective  tissue  almost  encircled  the  entrance 
of  the  nerve,  and,  curving  thence  toward  the  macula,   presented  a    highly 


Pig.  260     Angioid  streaks  in  the  retina  (from  a  case  under  the  care  of  Dr  '!<•  Schweinitz). 

characteristic  picture.     A.s  far  as  known,  they  continue  unchanged  in  spite 
of  all   treatment.1 

Angioid  Streaks  in  the  Retina  (Retinal  Pigment  Stria). — Pigi 

1  For  an  ezcellenl  account  of  retinitis  proliferans  consult  an  article  by  Wi 
Amer.   Ophth.  Soc,  viii.,  1897,  p.  158. 


428  DISEASES  OF  THE  RETINA. 

striae,  the  result  of  the  metamorphosis  of  retinal  hemorrhages,  diffused,  ac- 
cording  to  Ward  Holden,  in  a  linear  manner  through  the  deep  layers  of  this 
membrane,  present  a  striking  ophthalmoscopic  picture,  resembling,  in  many 
respects,  a  system  of  obliterated  vessels.  Hark,  reddish-brown,  somewhat 
granular  bands  <>r  striae,  lying  beneath  the  retinal  vessels,  often  in  the  neigh- 
borhood (if  the  disk,  extend  over  a  considerable  area  of  the  fundus.  Their 
direct  connection  with  hemorrhages  has  been  demonstrated  by  Plange,  Knapp, 
Holden,  and  de  Schweinitz  (Fig.  260). 

Retinitis  Striata. — This  name  was  proposed  by  Nagel  to  describe  an 
affection  originally  pictured  by  Jaeger,  and  characterized  by  light  or  yellowish- 
white  stripes,  often  branched,  lying  beneath  the  retinal  vessels.  The  stripes 
extend  from  the  periphery  toward  the  disk.  They  may  be  bordered  by  lines 
of  pigment.  The  etiology  of  the  stripes  is  unknown,  but,  like  the  angioid 
streak-,  they  probably  have  their  origin  in  the  metamorphosis  of  retinal 
hemorrhages  (Holden).  L.  Caspar  contends  that  all  retinal  striations — or, 
a-  he  calls  the  affection,  chorio-retinitis  striata — represent  the  final  stages  of 
spontaneously  cured  detachments  of  the  retina. 

Detachment  or  Separation  of  the  Retina  {Ablatio  sir,'  Amotio 
Retina  ). —  This  consists  in  a  separation  of  the  choroid  from  the  retina,  caus- 
ing the  latter  to  float   in   the   vitreous. 

Etiology. — The  causes  of  detachment  of  the  retina  may  be — 

1.  Stretching  of  the  sclerotic  and  choroid.  To  this  can  be  attributed  the 
greatest  number  of  eases.  It  occurs  in  high  degrees  of  myopia  (malignant 
myopia).  The  retina  is  attached  only  loosely  to  the  choroid,  and  firmly  about 
the  optic  nerve  and  near  the  ciliary  proeesses.  As  the  globe  increases  in  size, 
the  sclerotic  and  choroid,  each  being  somewhat  elastic,  are  stretched  more  and 
more,  until  the  circumference  of  the  retina  becomes  less  than  the  space  which 
it  should  fill,  and  there  is,  consequently,  separation  of  the  retina  from  the 
adjacent  choroid  throughout  a  part  or  the  whole  of  its  extent. 

2.  The  retina  may  be  pushed  from  the  choroid  into  the  vitreous.  This 
may  be  due  to  (a)  a  solid  substance,  as  a  tumor  or  cysticercus ;  or  (b)  a  fluid, 
such  as  an  exudation  from  the  choroid.  It  is  possible  that  a  serous  inflam- 
mation of  the  choroid  is,  in  many  cases,  a  cause  of  the  retinal  detachment. 
Hemorrhages  in  the  choroid  would,  of  course,  produce  the  same  result,  this 
occurring,  for  example,  in  operations  for  glaucoma  or  as  the  result  of  injury. 

."I.  The  retina  may  be  drawn  away  from  the  choroid  into  the  vitreous. 
Leber  and  Nordenson  hold  that  the  changes  commence  primarily  in  the 
vicinity  of  the  ciliary  body.  A  fibrillary  degeneration  of  the  vitreous  com- 
mences, and  a-  that  humor  shrinks  the  retina  is  gradually  drawn  away  from 
the  choroid.  Rupture  of  the  retina  occur-,  and  the  fluid  from  the  vitreous 
passes  beneath  it  through  the  opening.  Detachments  of  the  retina  of  a  simi- 
lar kind  may  also  occur  when,  from  injury  or  operation,  there  has  been  any 
considerable  lose  of  the  vitreous  humor. 

Retinal    detachment    i-    more   frequent    in    men    than    in    women. 

Symptoms  and  Pathology. — The  morbid  condition-  vary  according  to  the 
causes  above  mentioned.  Where  the  membrane  has  been  pushed  away  and 
-till  rests  on  n  -olid  b:i-e,  ;i-.  for  example,  on  a  sarcoma  of  the  choroid,  it  is 
immovable,  -till  retains  more  or  less  of  it-  normal  color,  and  in  parts  may 
be  found  to  be  more  v;i-cular  than  usual.  Ordinarily,  however,  there  is 
fluid  behind  the    retina,  and  ii   floats    in    a  fluid  vitreous.       Then  it   has  lost  its 

usual  color,  and,  although  the  vessels  retain  their  place  with  regard  to  the 
retina,  both  may  floal  together,  moving  with  the  motions  of  the  globe.  As 
the  retinal  vessels   rise  over  the   separated   portion,  they  first   lose  the  light 


Fig.  261.— Detachment  of  the  retina. 


DETACHMENT  OR  SEPARATION  OF  THE  RETINA.         129 

streak,  and  finally  appear  as  -lark,  tortuous  cords,  and  are  apparently  smaller 
than  normal.  he  border  of  the  detachment  is  usually  sharply  marked  from 
the  normal  fundus,  and  may  be  accentuated  by  a  yellowish  or  even  pigmented 
line.  _  ]  he  fluid  tends  to  gravitate  toward  the  lower  portion  of  the  globe  and 
even  it  the  detachment,  which  may  be  partial  or  complete,  occurs  originally 
at  the  side  or  above,  the  fluid  finds  its  way  between  the  retina  and  choroid 
usually  to  the  lower  portion  of  the  eye.  Sometimes  the  detachments  are 
quite  small,  like  a  series  of  furrows; 
ai  other  times  an  almost  circular  sepa- 
ration occurs. 

Important  changes  also  take  place 
in  the  tissue  of  the  retina  itself 
(Kiel)-).  As  the  rods  and  cones  are 
macerated  by  the  fluid  in  which  they 
float  they  become  swollen,  entirely 
losing  their  original  structure  and  con- 
sequently their  function.  The  bearing 
of  these  facts  on  attempts  to  replace 
the  retina  is  evident. 

The  ophthalmoscopic  picture  of  ex- 
tensive retinal  detachment  is  one  which 
cannot  be  mistaken  for  anything  else. 
With  the  upright  image  the  observer 
sees  the  grayish-white  fold  waving  as 
the  eye  moves  in  various  directions, 
and  in  the  undulations  the  branches 
of  the  vessels  are  brought  into  view.  The  inverted  image  give-  a  general 
view  of  the  condition,  and  often  the  whole  or  most  of  the  detached  area 
is  brought  into  the  field  at  once,  showing  still  better  the  arrangement  of 
the  retinal  vessels.     They  spread  over  the    surface    of  the    floating    retina, 

sometimes  appearing  on  the  surface 
or  again  depressed  beneath  it.  where 
it  may  be  covered  with  a  whitish 
cloud,  probably  due  to  local  extrava- 
sation of  the  subretinal  fluid.  The 
other  portions  of  the  retina  are  often 
almost  normal,  although  the  papilla 
may  appear  more  eon-, -ted  than 
usual  (Fig.  261). 

Subjectm     Symptoms.^-(l)    Im- 
perfection   of   the    Visual    Field. — 
When    the  detachment   occurs  sud- 
denly— for    example,     immediately 
following  some   -train   or  effort   of 
the  individual — he  notices  what   he 
calls  :i   dark   cloud   or    mist,  which 
he  may  try  to  push  away.     This,  of 
course, is  the  scotoma  corresponding 
to  the  detachment.     Wherever  the 
detachment    occur-    there   i-  corre- 
sponding loss  of  vision,  and  consequently  the  field  assumes  even    possible 
variety  oi   form  (Fig.  262 ;  see  also  Figs.  287  and  21 

2.  Metamorphopsia.     This   is  not  of  the  -li-ht   degree   found   in  » 


Fir;.  262.-    Visual  field  in  detachment  of  the  retina. 
ine  shading  indicates  «  hi  re  v  ision  was  lost. 


430  /) I.SK ASKS   OF   THE  RETINA. 

retinitis,  but  is  so  great  as  to  cause  the  lines  of  a  page  to  be  zigzag  or  the 
letters  to   be  separated   widely  from  each  other. 

."..  Dyschromatopsia  is  also  present,  and  the  difficulty  in  recognizing  colors 
is  noted  even  in  parts  of  the  field  apparently  unaffected. 

Scintillations  or  phosphenes  cannot  be  produced  by  pressure  on  the  eyeball 
over  the  separated  retina. 

Other  alterations  are  not  infrequent  with  detached  retina;  opacities  may 
appear  in  the  vitreous  humor,  and  with  these  or  independently  of  them  iritis, 
irido-ehoroiditis,   or  cataract. 

Diagnosis. — Extensive  detachment,  as  before  stated,  is  easily  recognized, 
both  because  of  the  clearness  of  the  ophthalmoscopic  picture  and  from  the 
subjective  symptoms.  If  the  vitreous  is  filled  with  opacities  and  obscures 
the  details  of  the  fundus,  an  examination  of  the  visual  held  gives  diagnostic 
proof.  The  difference  between  a  retina  separated  by  fluid  or  by  a  solid 
growth — e.  g.  a  tumor — lias  been   pointed  out. 

Course  and  Prognosis. — Usually  the  detachment  extends  more  and  more, 
and  the  portions  of  the  retina  which  at  first  remained  comparatively  healthy 
either  become  detached  or  undergo  pathological  changes.  In  certain  rare 
instances,  however,  the  fluid  is  absorbed,  and  the  retina  is  reapplied  to  the 
choroid  with  a  corresponding  improvement  in  the  vision.  It  is  not  at  all 
certain   under  what  circumstances  such  an   improvement  occurs. 

Treatment. — Inasmuch  as  many  of  the  cases  of  improvement  have 
occurred  when  the  patient  was  in  a  recumbent  position  for  a  considerable 
time  because  of  illness  or  for  other  reasons,  the  plan  of  treatment  usually 
advised  first  is  rest  in  bed  for  days  or  even  weeks.  This  is  much  easier  to 
prescribe  than  to  accomplish.  Various  other  plans  have  therefore  been  sug- 
gested, which   have   for  their  object — 

(a)  Absorption  of  the  fluid  by  medication.  This  includes  the  adminis- 
tration of  laxatives,  salicylate  of  sodium,  iodid  of  potassium,  the  hypodermic 
use  of  pilocarpin,  mercurial  inunctions,  etc. 

(b)  Absorption  of  the  fluid  or  coagulation  by  electrolysis.  Attempts  have 
been  made  by  Wray  and  others  to  produce  absorption  of  the  snbretinal  fluid 
by  means  of  the  electric  current.  Clavelier  recommends  a  strength  of  five 
milliamperes  continued  one  minute,  and  many  excellent  results  have  followed 
tlii—  method.  More  testimony  is  necessary,  however,  before  definite  opinions 
can  be  formed  as  to  the  relative  value  of  this  agent. 

(c)  Removal  of  the  fluid  by  operation.  Again,  numerous  attempts  have 
been  made  to  give  exit  to  the  snbretinal  fluid,  with  the  hope  that  as  the 
retina  came  in  contact  with  the  choroid  it  would  be  reapplied  and  resume  its 
function.  But  whether  that  fluid  was  drawn  away  with  a  syringe  or  allowed 
to  escape  through  a  puncture  in  the  sclerotic,  the  results  have  been  for  the  most 
part  unsatisfactory.     Equally  unreliable  has  been  the  plan  suggested  by  de 

Wecker  of  passing  a   gold  wire  through  the   sclerotic  and  keeping   up  a  con- 

stanl  drainage.  Closely  allied  to  this  plan  of  treatment  is  that  recommended 
long  ago  by  von  Graefe.  In  this  method  two  needle-  are  passed  through  the 
sclerotic,  and,  transfixing  the  retina  as  is  done  with  the  lens  in  laceration  of 
the  capsule,  an  opening  is  thus  made  in  the  detached  membrane,  the  sub- 
retinal  fluid  being  allowed  to  escape  into  the  vitreous.  Although  this  is  one 
of  the  oldest  methods,  it  -till  gives  as  good  results  as  any  other.  Deutsch- 
in.'iiin  has  recently  recommended  division  of  the  retina  and  vitreous  humor, 
all  strands  between  the  retina  and  the  shrinking  vitreous  being  thoroughly 
separated.  !!<•  has  also  assisted  hi>  laceration-operation  by  transplanting  the 
vitreous  humor  of  a   rabbit   into  the  affected  eye.     Finally,  attempts   have 


SI '/:  RETINAL   CYSTICERCl  T8.  431 

been  made  to  sel  up  an  inflammation  which  by  exudation  should  bring 
the  separated   membranes   together.      For  this    purpose   iodic   solution    has 

been  injected  beneath  the  retina  (Sehoeler's  method),  but  the  reaction  i-  so 
great  that  the  plan  is  only  mentioned  to  be  condemned.  Charles  Stedman 
Bull's  conclusion  in  regard  to  treatment  is  that  no  better  means  lor  dealing 
with  retinal  detachment  has  been  devised  than  resl  on  the  hack  in  bed, 
atropin,  a  bandage,  and  the  administration  of  some  drug  which  may  induce 
absorption  of  the  subretinal  fluid. 

Glioma  of  the  Retina. — This  growth  is  fully  described  in  the  section 
on  Morbid  Intraocular  Growths,  on  page  4i>4. 

Subretinal  Cysticercus. — This  is  occasionally  met  with,  especially  in 
Germany,  but  is  practically  unknown  in  America.  When  the  entozoon  is 
thus  lodged  beneath  the  retina,  it  develops  there,  pushes  out  into  the  vitreous, 
and  the  different  stages  of  its  growth  can  be  easily  studied  with  the  assistance 
of  the  ophthalmoscope.  These  parasites  have  been  removed  witli  compara- 
tively little  injury  to  the  eye  or  detriment  to  vision. 


DISEASES   OF   THE   OPTIC   NERVE 

By    HAROLD   (ilFFOKD,    M.  D., 

OF   OMAHA,  NEK. 


In  this  section  it  is  not  proposed  to  discuss  the  affections  commonly 
classed  as  amblyopias  or  amauroses,  although  in  many  of  them  the  optic 
nerve  is  primarily  or  secondarily  affected  :  they  will  be  considered  in  another 
article  (page  457),  as  will  also  many  of  the  congenital  peculiarities  of  the 
optic  disk  (pages  191-195). 

Hyperemia  of  the  Optic  Nerve. — A  congestion  of  the  optic  nerve  can 
only  be  diagnosed  with  any  approach  to  accuracy  when  the  intraocular  end 
of  the  papilla  is  involved  ;  and  the  color  of  the  normal  papilla  is  subject  to 
such  wide  variation  in  different  individuals  that  a  positive  diagnosis  of  hy- 
peremia, even  where  it  is  strongly  suspected,  is  frequently  difficult,  unless 
the  papilla  has  been  previously  examined  under  normal  conditions  or  unless 
the  nerve  in  question  can  be  compared  with  that  of  the  other  side.  It  shows 
itself  in  a  deepening  of  the  normal,  slightly  rosy  tint  of  the  papilla,  the 
larger  vessels  remaining  unchanged,  or,  at  most,  the  veins  showing  enlarge- 
ment. Its  diagnosis  is  chiefly  of  value  as  a  premonition  of  approaching 
inflammation  or  of  inflammation  already  existing  farther  back  in  the  nerve. 
It  also  occurs  in  many  cases  of  choroiditis  or  with  inflammation  or  irritation 
of  the  iris,  cornea,  or  ciliary  body.  Where,  in  addition  to  a  decided  con- 
gestion, the  outlines  of  the  papilla  become  at  all  indistinct,  it  is  preferable  to 
speak  of  slighi   or  incipient   optic   neuritis. 

Optic  Neuritis. —  Where  an  inflammation  of  the  optic  nerve  is  plainly 
revealed  by  the  ophthalmoscope,  it  is  commonly  called  'papillitis,  although  in 
many  cases  the  retro-ocular  portion  of  the  nerve  is  also  involved,  sometimes 
very  extensively. 

Where  from  the  severity  of  the  disturbance  of  vision  in  comparison  with 
the  negative  or  slightly  pronounced  character  of  the  ophthalmoscopic  symp- 
toms an  inflammation  of  the  nerves  between  the  eye  and  the  chiasm  is  diag- 
nosed, the  condition  is  termed  retro-bulbar  neuritis. 

Papillitis,  or  Intraocular  Optic  Neuritis. — Soon  after  the  invention 
of  the  ophthalmoscope  permitted  intraocular  lesions  t"  be  studied  during  life, 
v.  Graefe  was  led  to  divide  inflammations  of  the  optic  disk  into  two  classes  : 
papillitis  from  -ta-i-  (Stauungspapille\  commonly  called  choked  disk,  which 
he  supposed  to  l>e  due  to  edcina  and  hyperemia  of  the  disk  from  increased 
intracranial  pressure;  and  descending  neuritis,  sometimes  known  as  simple 
optic  neuritis,  in  which  he  believed  that  the  iiillaiiiinat i< >n  spread  down  the 
nerve-trunk  from  the  intracranial  lesion.  The  experience  of  subsequent  years 
has  shown  that  the  line-  between  these  two  forms  cannot  be  drawn  sharply, 
either  from  a  pathological  or  an  etiological  standpoint,  although  for  practical 
purposes  I  he  disf  incl  ion  is  a  useful  one. 

Objective  Symptoms.—  I  n  its  pronounced  form  choked  disk  is  charac- 


Plate  6. 


Fig.   I.     Papillitis    choked  disk)  (modified  from  Haul.  . 
Fig.   II.     Post-papillitic  atrophy  of  the  optic  dish    modified  from  rlaah). 
Fig    III.--  Simple  or  gray  atrophy  of  opl  ic  dish  <  from  a  case  of  locomotor  ataxia  |. 
Fig.  I  \'.     Embolic al  rophy  of  the  optic  disk,  with  secondary  retinochoroidal  atrophied 
il«-  Schweinitz  . 


PAPILLITIS,   OR   INTRAOCULAR   OPTIC  NEURITIS.         133 

terized  by  entire  obliteration  of  the  outlines  of  the  papilla,  an  elevated  mass 
of  tissue,  marked  on  the  surface  by  radiating  stria'  which  lade  off  gradually 
into  the  surrounding  retina,  taking  its  place;  near  the  center  of  this  the 
larger  retinal  vessels  appeal',  the  veins  being  generally  large  and  tortuous, 
while  the  arteries  often  are  apparently  reduced  in  size.  On  and  close  beneath 
the  surface  of  the  elevation  may  generally  he  seen  numerous  enlarged  capil- 
lars- vessels,  while  on  its  borders  and  in  the  surrounding  retina  small  patches 
of  whitish  exudate  and  hemorrhages,  often  flame-shaped,  are  not  uncommon. 
Very  rarely  pulsation  of  the  retinal  arteries  has  been  seen  (Plate  <>,  Fig.  I.). 

When  the  hemorrhages  and  patches  of  exudate  are  large  and  numerous  in 
proportion  to  the  elevation  of  the  disk,  the  condition  is  more  often  termed 
neuro-retinitis,  and  in  such  cases  opacities  may  develop  in  the  posterior  por- 
tion of  the  vitreous,  sometimes  with  newly-formed  blood-vessels  leading  out  to 
them.  The  height  of  the  elevation,  measured  with  the  ophthalmoscope, 
varies  from  1  D.  to  6  D.  If  it  is  less  than  this,  the  term  choked  disk  hardly 
applies,  and  tin'  condition  verges  into  that  of  simple  papillitis,  where,  with 
less  complete  obliteration  of  the  borders  of  the  papilla,  with  much  less  strongly 
marked  striatum,  hemorrhages  and  exudate  may  occur  even  more  extensively 
than  in  cases  of  pronounced  choked  disk. 

In  some  cases  the  condition  of  choked  disk  may  persist  with  little  change 
for  months  or  even  for  a  year  or  more,  but  sooner  or  later,  if  the  patient 
lives,  the  elevation  recedes  ;  the  striation  of  the  tissue  becomes  less  marked ; 
the  hemorrhages  and  exudate,  if  any  existed,  are  absorbed  ;  and  the  outlines 
of  the  papilla  begin  to  show  dimly.  With  the  continuation  of  this  retro- 
gressive process  the  picture  generally  changes  to  that  of  neuritic  atrophy,  to 
be  described  later  on.  In  some  cases,  however,  where  the  inflammation  has 
not  been  very  severe  nor  prolonged,  the  nerve  may  gradually  assume  an 
almost  normal  aspect. 

Subjective  Symptoms. — While,  in  general,  it  may  be  said  that  in  cases 
of  choked  disk  the  disturbance  of  vision  increases  with  the  evidence  of  stasis 
in  the  papilla,  this  rule  is  subject  to  great  exceptions.  The  vision  of  eyes 
presenting  the  same  ophthalmoscopic  picture  is  found  to  vary  between  the 
normal  and  complete  blindness  ;  occasionally  marked  choked  disk  persists  for 
many  months  without  any  perceptible  impairment  of  sight.  This  fact  and 
the  fact  that  the  sight  may  be  subject  to  sudden  changes  without  any  cor- 
responding difference  in  the  ophthalmoscopic  picture  suggest  that  much  of 
the  disturbance  of  vision  may  be  due  to  accompanying  retro-bulbar  or  intra- 
cranial lesions,  'flic  occurrence  of  normal  vision  with  marked  choked  disk, 
where  the  development  of  the  papillitis  is  not  too  sudden,  may  be  explained, 
as  Leber  suggests,  on  the  ground  that  the  nerve-fibers  may  accustom  them- 
selves to  the  changed  position  and  increased  pressure  without  impairment  of 
function. 

Where,  as  is  common,  the  sight  is  seriously  interfered  with  in  the  course 
of  the  papillitis,  there  i-  generally  a  gradual  reduction  of  the  central  acuity, 
sometimes  with  a  central  scotoma,  more  often  with  a  contraction  <>(  the  field 
.-it  the  periphery,  and  frequently  more  marked  at  the  nasal  side  :  I  mi  the  mode 
in  which  the  field  of  vision  is  interfered  with  is  subject  to  all  -on-  of  varia- 
tions. The  color-sense  necessarily  suffers  greatly  in  the  severe  cases,  but  il 
the  amblyopia  is  not  extreme  it  may  be  very  little  affected.  Sometimes  with 
marked  peripheric  contraction  of  the  field  lor  white  the  color-limit-  in  the 
remaining  portion  of  the  field  may  be  normal.  Disturbances  of  the  normal 
relations  of  the  color-limits  may  be  observed — e.g.  \n\  in  certain  areas  may 
be  seen  farther  toward  the  peripher)  than  blue. 

28 


13  I 


/'/>/.. I. v/.'.s-  OF  THE  OPTIC  NERVE. 


Some  patients  complain  of  flashes  of  light  and  other  subjective  phenomena 
indicating  irritation  of  the  optic-nerve  fibers. 

With  the  subsidence  of  the  ophthalmoscopic  symptoms  an  improvement 
of  vision  generally  sets  in,  which  will  be  considered  more  fully  when  treating 
of  the  Prognosis. 

Pathology. — Pathologically,  the  distinction  between  choked  disk  and  de- 
scending or  simple  neuritis  is  found  to  be  entirely  arbitrary.  In  some  cases 
in  which,  during  life,  there  was  a  cKoked  disk,  post-mortem  examination 
reveals  that  the  inflammation  is  limited  almost  entirely  to  the  intraocular 
part  of  the  nerve,  with  a  distention  of  the  intervaginal  space  by  serous  fluid 
as  almost  the  only  retro-ocular  symptom.  In  others  there  is  marked,  some- 
times purulent,  inflammation  in  the  intervaginal  space  and  the  nerve-sheaths, 
with  very  little  affection  of  the  nerve;  while  in  still  others  the  nerve-trunk 
is  the  seat  of  an  intense  interstitial  inflammation,  and  the  intervaginal  space 
and  outer  -heath  are  normal.  Conversely,  the  ophthalmoscopic  picture  of 
simple  neuritis  or  neuro-retinitis  may  coexist  with  inflammation  of  the  nerve- 
trunk  or  with  a  normal  nerve-trunk  and  extensive  hydrops  or  inflammation 
in  the  intervaginal  space  and   its  walls. 

Microscopically,  a  choked  disk  in  the  early  stages  shows  severe  venous 
hyperemia,  with  some  edema,  although  on  account  of  post-mortem  changes 


Fig.  263.-   I  r a  photo-micrograph  by  Dr.  James  Wallace  of  a  section  of  a  choked  disk  prepared  by 

I  >r.  William  Thomson. 

the  latter  lesion  is  less  marked  than  would  lie  expected  from  the  ophthalmo- 
scopic appearance;  and  a  marked  swelling  of  tin-  nerve-fibers.  Later,  the 
tissues  become  infiltrated  with  leukocytes,  and  accumulations  of  these  at 
points  corresponding  to  the  areas  of  whitish  exudate  seen  during  life  are 
found  to  have  undergone  granular  or  fatty  degeneration.  Fresh  hemorrhages 
are.  of  course,  visible  as  such,  while  older  one-  are  suggested  !>v  patches  of 
pigment.  Still  later,  the  format  ion  of  new  connective  tissue  becomes  apparent, 
especially  along  the  blood-vessels,  the  wall-  of  which  are  often  much  thick- 
ened, 'fhe  nerve-fibers  atrophy  to  a  greater  or  [ess  extent,  their  place  being 
taken  l,\  granules  and  minute  fat-like  globules,  which  in  their  turn  become 
absorbed  |  Fig.  263 . 

The  changes  in  the  retro-ocular  portion  of  the   nerve-trunk   arc  mainly 
those  ol  an  interstitial  neuritis^  the  septa  of  connective  tissue  being  infiltrated 


PAPILLITIS,   OR   INTRAOCULAR   OPTIC  NEURITIS.        435 

with  leukocytes  and,  later,  thickened  from  new  formation  of  connective  tissue. 
From  the  resulting  pressure,  and  perhaps  from  the  direct  influence  of  the 
ptoma'ins,  the  nerve-fibers,  it'  the  process  c tinues  long,  undergo  degenera- 
tive changes  and  atrophy.  The  degenerative  changes  in  the  nerve-fibers, 
sometimes  described  as  medullary  neuritis,  are  probably,  as  Alt  suggests, 
merely  secondary  to  interstitial  inflammation  or  to  degeneration  elsewhere. 

Where,  with  the  main  lesion  in  the  nerve-head,  the  signs  of  inflammation 
extend  into  the  nerve-trunk  for  a  shorl  distance  toward  the  brain,  the  con- 
dition is  termed  ascending  neuritis.  In  such  cases  edema  of  the  nerve-trunk 
has  been  frequently  found.  Besides  the  hydrops  of  the  intervaginal  space, 
which  is  so  common,  optic  perineuritis  often  occurs  in  the  form  of  more  or 
less  inflammation  <>t"  the  opposing  surfaces  of  the  pial  and  dura!  sheaths  and 
of  the  arachnoidal  framework  between  them.  This  may  be  slight,  or  so 
severe  as  eventually  to  obliterate  the  intervaginal  space  with  a  mass  of  new- 
formed  connective  tissue. 

Etiology. — The  most  frequent  cause  of  typical  choked  disk  is  the  devel- 
opment of  an  intracranial  tumor,  some  observer-  stating  that  it  occurs  in  95 
per  cent,  of  all  eases  of  such  tumors.  The  nature  of  the  tumor  seems  to  be 
of  very  little  importance:  it  may  occur  with  any  of  the  neoplasms,  whether 
of  the  brain-substance,  of  the  meninges,  or  of  the  bony  wall-,  or  with  gum- 
mata,  tubercles,  cysts  I  whether  of  entozoic  or  other  origin),  abscesses,  or  aneur- 
ysms.    Tumors  of  the  cerebellum  are  especially  apt  to  produce  it. 

The  method  in  which  brain-tumor-  cause  optic  neuritis  is  a  matter  still 
in  dispute.  Von  Graefe  supposed  that,  owing  to  the  increase  of  intracranial 
pressure,  an  abnormal  amount  of  tin  id  was  forced  into  the  intervaginal  space. 
and  produced  a  stasis  in  the  papilla  which  tended  to  become  exaggerated  on 
account  of  the  unyielding  nature  of  the  walls  of  the  channels  through  the 
lamina  cribrosa.  These  acted,  it  was  supposed,  like  the  abdominal  rings  in  a 
case  of  strangulated  hernia,  the  pressure,  naturally,  having  a  greater  efled 
upon  the  outflow  through  the  yielding  veins  than  upon  the  inflow  through  the 
-ti tier- walled  arteries.  This  theory  received  considerable  support  from  the 
observation  of  Manz  ami  other-,  that  in  many  cases  of  brain-tumor  there  act- 
ually existed  a  distention  of  the  intervaginal  -pace  with  cerebro-spinal  fluid. 

The  other  most  widely  accepted  theory  i-  that  of  Leber  and  Deutschmann, 
who  hold  that  the  optic  neuritis  in  these  cases  is  not  merely  a  stasis,  Inn  i-  an 
active  inflammation  caused  by  the  passage  of  irritating  substances,  produced 
either  directly  or  indirectly  by  the  tumor,  from  the  cranial  cavity  down  to  the 
nerve-head.  In  favor  of  this  view  it  may  be  -aid  that,  as  a  rule,  a  certain 
amount  of  meningitis  can  be  demonstrated  in  the  neighborhood  of  most  brain- 
tumors,  and  that  in  many  cases  no  hydrops  of  the  intervaginal  -pace  can  be 
found,  but.  on  the  contrary,  a  normal  intervaginal  -pace  with  marked  interstitial 
inflammation  of  the  nerve-trunk'.  The  alleged  production  of  the  symptoms 
of  choked  disk  in  animal-  by  injections  into  the  cranial  cavity  or  into  the 
vaginal  space  are  not  admitted  :i-  evidence  by  the  supporters  of  the  inflam- 
mation-theory, on  the  ground  that  higher  pressures  were  used  than  probably 
ever  occur  in  the  human  being.  The  objection  that  typical  choked  disk  i- 
seldom  observed  in  cases  of  acute  meningitis  is  met  by  the  suggestion  thai 
the  slight  neuritis  which  is  often  observed  doe-  occasionally  develop  into  a 
choked  disk   if  the  patient    lives   long  enough. 

A  careful  review  of  all  the  available  fact-  leads  one  to  believe  thai  while, 
in  certain  cases,  the  element  of  intracranial  and  intervaginal  pressure  plays 
an  important  part  in  the  production  of  choked  disk,  in  the  majority  i 
the  latter  depend-  upon  an  active  inflammation. 


136  DISEASES  OF  Till.   OPTIC  NERVE. 

In  addition,  there  should  be  mentioned  the  theory  pf  Parinaud,  who  holds 
that  choked  disk  result-  from  an  extension,  through  the  trunk  of  the  optic 
nerve  to  the  papilla,  of  the  interstitial  edema  of  the  brain-tissue  which  is  so 
commonly  found  in  intracranial  troubles.  This  edema  of  the  nerve-trunk 
is  also  recognized  by  CJlrich,  but  he  holds  that  its  effects  upon  the  papilla  are 
produced  not  directly,  but  by  compressing  the  central  retinal  vein. 

The  importance  of  optic  neuritis  as  a  symptom  of  brain-tumor  can  he 
appreciated  from  the  (act  that,  aside  from  its  frequency,  it  is  sometimes  the 
firsl  symptom  to  attract  the  notice  of  the  patient  ;  in  fact,  the  progress  of  the 
tumor  may  he  so  slow  that,  as  in  a  case  reported  by  Leber,  a  slight  optic 
neuritis  may  even  pass  over  into  atrophy  without  the  knowledge  of  the 
patient,  years  before  death  occurs.  The  occurrence  of  a  double  choked  disk, 
then,  without  other  grounds  for  its  explanation,  is  always  sufficient  reason 
for  a  strong  suspicion  of  brain-tumor.  As  a  source  of  error  in  such  cases, 
may  he  mentioned  the  unique  case  of  Krohn,  in  which  a  double  optic  neuritis 
was  caused  by  a  small  metastatic  tumor  from  an  ovarian  carcinoma  develop- 
ing in  the  optic  nerve  immediately  behind  each  globe. 

In  rare  cases  the  optic  neuritis  accompanying  brain-tumor  is  one-sided, 
and  may  even  occur  on  the  side  opposite  to  the  growth.  This  is  explained 
by  the  supporters  of  the  pressure  theory  of  choked  disk  on  the  ground  of  a 
localized  meningitis  or  hemorrhage. 

(  )f  extreme  rarity  also  is  the  occurrence,  in  a  ease  of  suspected  brain- 
tumor,  of  a  second  attack  of  papillitis  some  time  after  the  first  has  subsided. 
In  the  case  of  de  Schweinitz  and  A.  Thomson  the  neuritis,  headache,  and 
epilepsy  disappeared  after  a  simple  trephining,  but  all  returned  at  the  expira- 
tion of  a  year. 

With  reference  to  the  diagnosis  of  brain-tumor,  it  should  not  be  forgotten 
that,  occasionally,  a  tumor  may  cause  a  neuro-retinitis  precisely  like  that 
generally  considered  diagnostic  of  albuminuria. 

Discarding  the  distinction  between  choked  disk  and  simple  or  descending 
neuritis,  it  may  be  said  that  all  tumors  or  inflammations  within  the  cranial 
or  orbital  cavities  may  cause  a  papillitis;  this  naturally  includes  all  the 
varieties  of  meningitis  and   infectious  thrombosis  of  the  brain-sinuses. 

Optic  neuritis  has  also  been  observed  in  the  greatest  variety  of  infectious 
and  other  general  diseases.  It  has  been  most  commonly  noticed  in  the  course 
of  measles,  typhoid  fever,  ami  "  la  grippe,"  but  it  has  also  been  mentioned  in 
connection  with  scarlatina,  variola,  malaria,  whooping-cough,  beri-beri,  pel- 
lagra, t\  phus,  typhoid  pneumonia,  rheumatism,  diphtheria,  and  myxedema.  In 
some  of  these  cases  the  neuritis  is  undoubtedly  secondary  to  a  nephritis  ;  in 
oi  her-,  to  a  meningitis;  but  there  is  no  reason  for  supposing  that  some  of  them 
may  not  indicate  an  actual  infection  of  the  trunk  or  intervaginal  -pace  of  the 
nerve,  while  -till  others  may  result  simply  from  the  general  toxemia.  Neur- 
itis also  occurs  with  various  disorders  of  menstruation,  generally  with  a  sud- 
den checking  of  the  flow,  and  with  premature  menopause  and  atrophy  of  the 
uterus.  The  fact  that  in  adult-,  a- well  as  children,  hydrocephalus  internus 
may  cause  double-sided  neuritis  is  of  importance,  because,  on  account  of  the 
unyielding  character  of  the  skull,  the  diagnosis  is  much  more  difficull  than 
in  children,  and  the  neuritis  might  be  thought  to  confirm  an  erroneous  diag- 
of  brain-tumor. 

()pti<-  neuritis  has  also  been  observed  in  various  marked  deformities  oj  the 
skull,  particularly  in  the  high  and  narrow  variety  known  by  the  Germans  as 
"  Thurmschadel "  (tower-  or  steeple-skull).  A  post-mortem  examination  in 
one  guch  case  I  Michel)  showed  9igns  of  pachymeningitis,  with  marked  hyper- 


PAPILLITIS,   OR   INTRAOCULAR  OPTIC  NEURITIS.         137 

ostosis  of  the  skull-bones,  both  optic  foramina  being  decidedly  narrowed. 
With  multiple  foci  of  cerebral  softening  the  nerve  has,  in  the  early  stages, 
been  found  to  be  inflamed,  atrophy  setting  in  later,  though  it  seems  probable 
that  the  hemorrhagic  meningitis  which  often  accompanies  such  cases  is  the 
more  direct  cause  of  the  inflammation  of  the  nerve. 

With  various  other  brain  and  spinal  diseases,  to  be  considered  more  fully 
in  connection  with  atrophy  of  the  nerve,  a  slight  optic  neuritis  has  been  ob- 
served as  a  forerunner  of  the  atrophy. 

Syphilis  may  cause  optic  neuritis,  cither  by  attacking  the  nerve  directly 
or  by  producing  a  gumma  in  the  cranial  cavity. 

Whether  the  cases  of  neuritis  which  have  been  observed  in  the  puerperal 
state  have  been  due  to  n  general  infection,  or  whether  they  arc  more  akin  to 
the  cases  which  Valude  and  I > 1 1 1 1  have  reported,  in  which  the  optic  nerve  has 
been  attacked  in  several  successive  pregnancies,  apparently  without  any  kid- 
ney complication-,  is  uncertain.      It  is  possible,  also,  thai   s e  of  the  cases 

which  have  been  described  as  neuritis  during  lactation  may  belong  here, 
although  others  are  more  probably  akin  to  the  neuritis  which  has  been  ob- 
served in  the  course  of  chlorosis.  The  anemia  produced  by  the  too  abundant 
or  too  long-continued  lactation,  as  well  as  that  occurring  in  the  chlorosis, 
produces  neuritis,  probably  through  hemorrhages  resulting  from  malnutrition- 
changes  in  the  walls  of  the  Mood-vessels.  In  other  cases  the  affection  of  the 
optic  nerve  lias  seemed  to  be  due  to  a  sudden  checking  of  the  flow  of  milk. 

The  neuritis  which  sometimes  follows  severe  hemorrhages  is  also  probably 
due  to  alterations  in  the  blood-vessel  walls,  the  malnutrition  caused  by  the 
extreme  anemia  so  weakening  the  coats  of  the  vessels  that,  when  the  blood- 
current  begins  to  resume  its  normal  force,  transudations  and  hemorrhages 
occur  which  may  either  give  rise  to  the  picture  of  optic  neuritis  directly,  or 
possibly  indirectly,  through  pressure  in  the  intervaginal  space.  A  striking 
case  of  this  character  is  that  reported  by  Gessner,  in  which  three  weeks  after 
a  severe  post-partum  hemorrhage  the  vision  suddenly  became  affected,  the 
difficulty  progressing  within  three  days  to  complete  blindness;  the  ophthal- 
moscope revealed  a  marked  choked  disk  in  each  eye.  This  was  immediately 
followed  by  the  onset  of  an  ascending  myelitis,  which  caused  the  death  of  the 
patient  at  the  end  of  two  weeks. 

A  cause  of  neuritis  which  has  been  insisted  upon  by  Panas  is  gonorrhea, 
though,  in  the  ease  which  he  reports,  the  connection  between  the  urethral 
affection  and  the  neuritis  is  le>s  obvious  than  in  the  more  recent  case  of 
Campbell-Highet.  In  Panas's  case  one  eye  remained  blind,  the  other  being 
scarcely  affected,  while  in  Campbell-Highet's  ease  the  affection  was  one- 
sided and  ended   in  complete  recovery. 

In  treating  of  the  effects  of  nephritis '  upon  the  eye  the  main  stress  is 
usually  laid  upon  the  retinitis,  though,  so  far  a-  the  functional  disturbance  is 
concerned,  the  optic  ixii  rit  is  is  probably  of  greater  importance.  flic  retinitis 
is  much  more  apt  to  clear  up  without  leaving  permanent  damage,  it'  the 
nephritis  i-  of  the  curable  variety,  than  i-  the  affection  of  the  nerve.  The 
writer  has  a  case  on  hand  at  presenl  in  which  the  retinitis  has  been  cured  for 
i ith-.  while  the  nerves  are  -till  far  from  normal.  It  should  he  remem- 
bered, too.  that  nephritis  may  reveal  itself  in  the  eye  by  the  typical  appear- 
ance of  choked  disk  withoul  any  of  the  ordinary  retinitis  albuminurica.  It  is 
probable  also  that  nephritis  may  cause  serious  damage  to  the  optic-nerve 
trunk  through   retro-bulbar  hemorrhages  or  localized  areas  of  edema. 

1  The  nearo-retinitis  which  occurs  in  lead-poisoning  is  generally  secondary  to  the  lead-neph- 
ritis, though  sometimes  the  nerve  m;iy  be  affected  directly  in  this  :i^  in  other  sorts  of  poisoning. 


138  DISEASES  OF  THE  OPTIC  XERVE. 

Since  intranasal  cauterization  occasionally  causes  meningitis,  it  can  easily 
be  understood  how  it  might  also  cause  an  optic  neuritis,  although  in  the  case 
of  Ah.  in  which  one-sided  papillitis  developed  immediately  after  cauteriza- 
tion of  one  of  the  turbinated  bones  on  the  same  side,  there  were  uo  decided 
symptoms  of  meningitis,  and  a  nearly  complete  recovery  followed  rapidly  on 
the  subsidence  of  the  intranasal  irritation. 

While  acromegaly  generally  causes  atrophy  by  pressure  of  the  enlarged 
pituitary  body  on  the  chiasma,  it  not  infrequently  produces  optic  neuritis. 

The  cases  of  double  optic  neuritis  which  develop  immediately  after  sun- 
stroh  or  some  violent  physical  exertion  are  probably  due  to  hemorrhage  or 
effusion  within  the  cranial  cavity,  with  secondary  meningitis.  In  the  only 
case  following  sunstroke  which  the  writer  has  seen  dementia  and  permanent 
blindness  resulted.  In  a  case  following  a  violent  run  to  catch  a  car  useful 
sighl  was  recovered  after  complete  blindness  had  persisted  for  months. 

Carious  teeth  or  the  reaction  following  their  extraction  may  cause  optic 
neuritis,  apparently  through  the  extension  of  a  phlebitis  directly  to  the  orbit 
or  through  the  intervention  of  an  abscess  of  the  antrum  of  Highmore  with 
secondary  orbital  cellulitis. 

After  taking  account  of  all  the  known  causes,  there  remain  quite  a  num- 
ber of  cases  of  optic  neuritis  for  which  no  probable  cause  can  he  ascertained. 
These  cases,  in  the  experience  of  the  writer,  are  frequently  monocular  and 
may  be  slight  or  severe,  but  they  offer,  on  the  whole,  a  relatively  good  prog- 
nosis. 

Diagnosis. — The  diagnosis  of  intraocular  optic  neuritis  rarely  offers  any 
difficulty  where  the  media  are  clear;  the  only  conditions  which  are  liable  to 
he  mistaken  for  neuritis  are  hyaline  bodies  in  the  papilla  (to  be  discussed 
later)  and  an  obscuration  of  the  borders  of  the  disk  by  opaque  nerve-fibers. 
Where  these  opaque  fibers  occur  in  solid  patches  they  can  hardly  be  mistaken 
for  anything  else,  but  where  they  occur  sparingly  mixed  in  with  the  ordinary 
sheathless  fibers,  the  margin  of  the  disk  may  he  more  or  less  completely 
obscured  by  a  grayish  striation,  reminding  one  strongly  of  the  appearance  in 
a  mild  case  of  choked  disk.1  A  careful  examination  of  the  direct  image, 
showing  the  absence  of  enlarged  capillaries  and  other  signs  of  stasis,  will 
almost  invariably  clear  up  the  diagnosis,  hut  where  there  is  some  functional 
disturbance  this  condition  may  occasionally  cause  some  uneasiness,  as  is 
shown  by  a  case  -ecu  by  the  writer  in  which  an  ophthalmologist  of  the 
utmost  ability  diagnosed  neuritis;  subsequent  continued  observation  showed 
that  the  cause  of  the  blurring  of  part  of  the  disk-margin  was  due  to  this 
admixture  of  opaque  fibers.  If  the  media  are  not  perfectly  clear,  it  is  not 
always  possible  to  determine  whether  the  cause  of  the  blurred  image  of  the 
disk  is  due  entirely  to  the  interference  with  the  passage  of  the  light.  If  the 
opacities  in  the  media  are  easily  detected,  the  observer  will  naturally  lie  on 
hi-  guard,  hut  where  the  want  of  transparency  is  due  to  the  extremely  fine 
opacities  which  sometimes  exist  in  the  vitreous  or  upon  the  posterior  surface 
of  the  lens,  the  beginner  might  easily  overlook  these,  and,  thinking  the 
media  clear,  diagnose  an  incipient  neuritis  with  blurred  disk-margins.  To 
avoid  this  error  one  should,  of  course,  examine  the  cornea,  lens,  and  anterior 
vitreous  with  a  strong  convex  lens. 

Prognosis. — This  musl  always  he  guarded.  There  i-;  absolutely  no 
means  <<\'  determining  whether  ;i  case  of  neuritis,  -ecu  for  the  first  time,  will 
result  in  total  blindness  or  in  the  restoration  of  normal  vision.  Where  the 
ocular  disturbance  depend-  upon  some  general  affection  the  prognosis  will 

■  -.  probably  of  this  nature,  have  been  described  as  falsi  or  spurious  optic  neuritis. 


PAPILLITIS,    OR   TNTRAOCULMl   Ol'Tic  NEURITIS.         139 

depend  upon  the  course  taken  by  the  latter :  aside  from  the  nature  of  the 
ultimate  cause,  the  rule,  a-  would  naturally  be  expected,  is  that  the  greater 
the  severity  of  the  neuritis  the  greater  the  permanent  damage  to  the  sight, 
through  the  destruction  of  uerve-fibers,  during  the  neuritis  or  in  the  course 
of  the  subsequent  atrophy.  In  general,  it  may  be  said  that  where  the  ulti- 
mate cause  of  the  disease  is  not  of  a  lmpele-  character  the  prognosis  is 
relatively  good,  since  useful  central  vision  is  often  left,  though  frequently 
with  more  or  less  contracted  fields.  The  writer  has  certainly  seen  and  com- 
mitted more  errors  on  the  unfavorable  than  on  the  favorable  side  of  the 
question.  Where  the  course  of  the  neuritis  has  been  rapid  the  vision  is  apl 
to  improve  with  the  subsidence  of  the  ophthalmoscopic  symptoms,  sometimes 
becoming  worse  again  when  the  secondary  atrophy  sets  in.  On  the  other 
hand,  where  the  neuritis  has  run  a  "long  chronic  course,  with  only  a  moderate 
amblyopia,  the  vision  sometimes  fails  rapidly  and  continues  to  fad  throughout 
the  retrogressive  stage.  In  still  a  third  class  of  cases  the  writer  has  seen 
useful  vision  restored  at  the  retrogression  of  a  marked  papillitis  which  had 
persisted  with  absolute  blindness  for  several   months. 

Treatment. — If  the  disease  depend  upon  some  general  affection,  the 
latter,  of  course,  should  first  engage  the  attention  of  the  physician,  and  the 
ocular  condition  may  need  no  special  treatment.  Occasionally,  however,  it 
does,  on  account  of  the  danger  that  while  waiting  for  remedies  to  act  upon 
the  general  condition  permanent  damage  might  be  done  to  the  sight,  which 
could  perhaps  be  prevented  by  a  more  vigorous  line  of  treatment.  Where 
the  optic-nerve  lesion  is  not  secondary  to  any  other  affection  which  requires 
attention,  it  is  very  uncertain  what  line  of  treatment  will  have  most  influence 
upon  it.  Full  doses  of  salicylate  of  sodium  or  of  iodid  of  potassium,  mer- 
curial inunctions  (even  in  non-specific  cases),  and  the  various  forms  of  sweat- 
cures  have  all  been  used  with  apparently  good  results  in  some  cases,  while  in 
others  they  have  had  no  influence.  In  very  critical  cases  the  writer  has  used 
the  iodid  of  potassium,  inunctions,  and  pilocarpin  at  the  same  time,  with 
apparently  good  results.  Those  who  use  mercury  in  non-specific  cases 
generally  recommend  it,  in  particular,  where  there  is  evidence  of  active 
inflammation,  while  others  use  large  doses  of  iodid  in  precisely  similar  cases. 
A  sweat-cure,  either  with  pilocarpin,  salicylate  of  sodium,  or  the  Turkish 
bath,  is  always  in  order.  Where  neither  pilocarpin  nor  the  salicylate,  nor  a 
combination  of  the  two,  can  he  home  in  a  sufficiently  large  dose  to  produce 
free  diaphoresis  once  a  day,  and  circumstances  do  not  permit  visits  to  a 
Turkish  bath-house,  the  writer  has  found  an  improvised  hot-air  hath, 
obtained  by  the  use  of  a  small  lamp  and  enough  rubber  sheeting  t<»  cover 
two  chair.-,  to  be  of  great  service,  particularly  in  cases  of  nephritic  origin. 
If  mercury  is  used  at  the  start  in  preference  to  the  iodid,  it  may  he  ex- 
changed for  the  latter  when  signs  of  mercurialization  appear;  ami  its  use,  in 
any  case,  should  be  continued  off  and  on  I'm-  months  unless  a  complete  cure 
should  result  sooner.  Cupping  or  leeching  the  temples  is  -till  recommended 
by  many  and  can  do  no  harm.  It  i-  more  than  doubtful  whether  the  use  of 
Betons  in  the  temple  or  at  the  nape  of  the  neck  is  even  justifiable.  In  syph- 
ilitic lesions  of  the  optic  nerve,  rapidly  produced  mercurialization  by  inunc- 
tions, repeated  at  interval-,  with  iodid  in  lull  doses  during  the  intervals, 
gives  the  best   results. 

In  the  way  of  direct  operative  interference  de  Wecker's  plan  of  incising 
the  dural  -heath  may  he  mentioned  ;i-   a    curiosity.1       From  the  standpoint  of 

1  Von  Hoffman  in  one  case  evacuated  pus  from  the  into  rvaginal  space,  'tin-  operation  did 
not  prevent  atrophy. 


440  DISEASES  OF  THE  OPTIC  NERVE. 

v.  Graefe  1 1 1< ■  proposal  was  a  rational  one,  but  the  difficulties  and  dangers 
attending  the  operation  have  prevented  its  general  adoption.  More  promis- 
ing is  the  performance  of  trephining  the  skull,  with  os  without  the  puncture 
of  a  lateral  ventricle,  where  the  neuritis  is  due  to  hydrocephalus  internus, 
whether  the  latter  be  caused  by  brain-tumor  or  by  something  else.  Several 
cases  of  this  kind  arc  on  record  in  which  the  operation  has  been  followed 
by  a  marked  improvement  of  the  neuritis  and  of  the  vision.  This  treatment 
i-  of  course  resorted  to  only  where  the  intracranial  disease  itself  is  of  a  very 
serious  nature;  and  the  relief  and  any  improvement  of  vision  obtained  are 
not  likely  to  he  permanent,  since  the  primary  disease  is  generally  incur- 
able. 

Where  the  neuritis  depends  upon  the  pressure  of  a  brain-tumor  which  can 
he  removed  completely,  it  may  be  permanently  cured.  Operative  treatment 
may  also  cure  a  neuritis  caused  by  an  orbital  tumor  or  by  an  inflammation  or 
tumor  of  one  of  the  accessory  sinuses,  or  by  any  of  the  intracranial  inflam- 
mations of  otitic  origin. 

Acute  or  Fulminant  Retro-bulbar  Neuritis. —  In  the  eases  which 
v.  Graefe  originally  classified  here,  blindness  came  on  suddenly,  the  ophthal- 
moscope showing  very  small  but  still  permeable  retinal  arteries  and  a  very 
slight  blurring  of  the  edges  of  the  disk.  He  considered  that  the  symptoms 
were  due  to  a  compression  of  the  central  vessels  by  the  products  of  ;i  retro- 
bulbar neuritis.  Some  of  his  cases  would  now  probably  be  called  simply 
thrombosis  of  the  central   artery. 

Etiology. — In  quite  a  number  of  cases  severe  exposure  or  rheumatism 
can  be  adduced  as  a  cause  of  this  affection  ;  it  has  also  followed  infectious 
diseases,  of  which  influenza  seems  particularly  liable  to  produce  it.  In  many 
cases  no  sufficienl  cause  can  he  discovered.  The  disease  seems  to  be  one  of 
the  forms  of  multiple  neuritis  which  may  be  produced  by  any  of  the  toxins 
circulating  in  the  blood.  Acuteor  siil><t<-nt<-  myelitis  is  frequently  accompanied 
by  this  same  set  of  eye-symptoms,  excepting  that  the  ophthalmoscope  shows 
a  marked  neuritis  or  a  choked  disk  ;  hence  it  is  manifestly  arbitrary  to  make 
a  separate  group  of  the  cases  in  which  the  neuritis  happens  not  to  reach  as 
far  toward   the  distal   end   of  the   nerve  as  it  does  in  others. 

Symptoms. — At  the  present  day  the  diagnosis  of  acute  retro-bulbar  neur- 
itis i-  made  when  one  meet.-  the  following  complex  of  symptoms:  Pain  hack 
of  the  eye,  spontaneous  or  upon  movement  of  or  pressure  on  the  eyeball; 
obscuration  of  vision,  progressing  in  the  course  of  from  one  to  eight  day.-  to 
complete  or  nearly  complete  blindness  ;  ophthalmoscopically,  a  normal  disk 
or  a  hyperemic  nerve-head  with  or  without  slight  haziness  of  the  surrounding 
retina  ;  ami,  rarely,  minute  retinal  hemorrhages  and  small  grayish  or  yellow- 
ish -pot-  in  the  neighborhood  of  the  macula.  With  these  symptoms  are  not 
unfrequently  associated  others  pointing  to  acute  myelitis  or,  more  rarely, 
multiple  neuritis.  Death  may  occur  within  a  few  weeks  of  the  onset  of  the 
disease. 

Before  amaurosis  becomes  absolute  the  sight  may  undergo  sudden  varia- 
tions ;  thereafter  it  gradually  improves  slowly  until,  occasionally,  normal 
vision  is  restored.  More  frequently  the  restoration  stops  short  of  this,  and  a 
certain    degree   of  amblyopia    remain-   either  with    a  contracted    field    or    with 

central  scotoma,  or  with  both.  The  color-sense  is  apt  to  he  severely  affected 
throughout  the  disease.  A-  the  process  begins  to  decline  more  or  less  com- 
plete atrophy  of  the  di-k  occurs. 

The  affection  may  be  one-sided,  or  both  nerves  may  he  affected  simulta- 
neously, or  there  may  he  a  very  -hort  interval  between  the  attacks.      In  other 


CHRONIC  RETL'O-IirLBAR  XF.riUTIs.  HI 

cases  recurring  attack-  at  intervals  of  a  month  or  more  affect  both  nerves  or 

one   nerve  after  the  other. 

Patholog-y. — What  is  known  of  the  pathology  of  this  affection  we  owe 
almost  entirely  to  Aehard  and  Guinon,  Elschnig,  Dreschfeld,  and  Katz,  who 
have  found  interstitial  neuritis  generally  throughout  the  whole  diameter  of 
the  nerve,  in  some  cases  from  the  chiasma  to  the  globe,  with  secondary  de- 
generation  of  the  nerve-fibers.  Whether  similar  symptoms  may  not  he  pro- 
duced by  a  perineuritis  or  by  a  periostitis  in  the  optic  canal  remains  to  he 
-ecu.  As  Elschnig  suggests,  the  latter  condition  might  cause  :i  compression 
of  the  ophthalmic  artery,  and  thus  produce  the  ophthalmoscopic  picture  seen 
by  v.  Graefe.  It  is  probable  that  >till  other  cases  are  caused  by  a  pachy- 
meningitis spreading  into  the  optic  canals.  Thus,  in  a  case  observed  by  the 
writer  the  patient  had  several  attack-  of  complete  double-sided  blindness  at 
intervals  of  several  months;  the  attack-  were  preceded  for  some  time  by 
severe  headache,  and  after  the  last  attack  an  almost  constant  headache  per- 
sisted for  nearly  a  year. 

Prognosis. — The  prognosis  is  favorable  so  far  as  the  regaining  of  useful 
sight  is  concerned,  complete  blindness  remaining  very  rarely,  if  ever.  Serious 
permanent  visual  disturbances,  however,  are  not  unusual,  and  are  apt  to  be 
worse  in  those  cases  in  which  the  ophthalmoscopic  symptoms  of  neuritis  have 
been  most  pronounced. 

Treatment. — The  same  treatment  as  that  recommended  for  optic  neuritis 
in  general  should  be  ordered,  especial  stress  being  laid  upon  large  doses  of 
salicylate  of  sodium  where  the  affection  seems  to  be  of  rheumatic  origin. 

Chronic  Retro-bulbar  Neuritis. — Perhaps  some  of  the  cases  men- 
tioned in  the  preceding  section,  where  a  succession  of  acute  attacks  occur, 
might  properly  be  considered  chronic.  Besides  these  there  are  others  which 
pursue  a  slower  course,  the  loss  of  vision  progressing  during  several  weeks  or 
months  in  the  form  of  a  central  scotoma,  at  first  relative  (i.  e.  some  or  all 
color-  being  mistaken  within  its  borders).  Some  cases  are  complicated  by  a 
peripheral  contraction  of  the  field,  which  in  rare,  severe  instances  may  meet 
the  central  scotoma  so  as  to  produce  absolute  blindness.  The  ophthalmoscope 
in  the  early  stages  may  show  nothing  abnormal,  or  there  may  be  congestion 
of  the  disk  and  slight  haziness  of  the  surrounding  retina.  Later,  if  the  dis- 
ease continues  long,  atrophy  of  the  outer  quadrant  or  half  of  the  optic  disk 
becomes  evident,  and  occasionally  the  whole  disk  appears  atrophic,  even 
where  the  defect  of  vision   is  limited  to  a  central  scotoma. 

Etiolog-y. — Some  of  these  cases  can  be  attributed  to  rheumatism  or  ex- 
posure :  in  others  chronic  meningitis  or  periostitis  in  the  optic  canal  may  he 
assumed  ;  and  sometimes  no  probable  cause  can  be  assigned,  lint  the  great 
majority  are  caused  b\  systemic  poisoning  with  alcohol,  tobacco,  lead,  or 
some  other  drug  or  substance  taken  into  or  developed  within  the  body,  and 
they  have  been  so  long  classified  as  toxic  amblyopias  that  they  and  their 
pathology  will   lie  considered  fully  in  another  article  (see  page   159). 

A  special  form  of  retro-bulbar  neuritis,  commonly  known  a-  hereditary 
nerve-atrophy,  is  one  which  appears  in  members  of  the  same  family,  generally 
between  the  ages  of  eighteen  and  twenty-two.  though  it  may  occur  a-  early  as 
five  years  or  ;i-  lute  a-  forty-three.  In  the  great  majority  of  cases  male- 
alone  are  attacked,  and,  where  the  disease  can  he  traced  through  several 
generation-,  it  is  generally  transmitted  by  the  unaffected  female-  to  their 
male  offspring. 

The  course  anfl  ophthalmoscopic  symptoms  of  the  affection  are  those  oi  a 
subacute  retro-bulbar  neuritis,  a  permanent  simple  scotoma  with  more  or  less 


Hi'  diseased  of  Tin-:  optic  nerve. 

amblyopia  almost  always  remaining,  total  blindness  persisting  very  rarely. 
The  cause  of  the  affection  has  only  been  surmised.1 

Prognosis. —  In  the  cases  caused  by  systemic  poisoning  the  prognosis  for 
the  restoration  of  normal  vision  is  good  if  the  poisoning  can  be  stopped  before 
actual  destruction  of  nerve-tissue  has  taken  place,  and  even  where  the  ophthal- 
moscopic appearance  and  the  duration  of  the  affection  would  render  complete 
recovery  improbable,  normal  vision  is  restored  in  some  cases. 

In  the  non-toxic  cases  the  prognosis  is  not  so  good,  owing  to  the  doubt 
which  generally  exists  as  to  the  causej  and  as  to  the  possibility  of  any  line 
of  treatment  really  having  much  influence  upon  the  course  of  the  disease. 
Permanent  blindness  rarely  results,  however,  and  the  more  rapid  the  course 
of  the  affection  and  tin-  less  pronounced  the  ophthalmoscopic  symptoms,  the 
hitter  the  result   to  he  expected. 

Treatment. — In  the  toxic  cases  the  poisoning  should  he  stopped,  while 
in  the  other-  the  same  treatment  recommended  for  the  acute  cases  is  in  order. 

Atrophy  of  the  Optic  Nerve.— By  atrophy  of  the  optic  nerve  is 
meant,  strictly  speaking,  the  disappearance  of  a  larger  or  -mailer  proportion 
of  the  nerve-fibers,  hut  practically  the  term  is  also  used  for  any  condition  in 
which  the  ophthalmoscope  shows  the  papilla  or  a  considerable  part  of  it  to 
have  permanently  lost  its  normal  tinge  of  pink,  through  the  disappearance  of  a 
large  proportion  of  the  normal  number  of  capillary  blood-vessels  or  through 
the  formation  of  new  connective  tissue  within  it. 

If  the  reduction  of  blood-supply  he  only  temporary,  we  may  speak  of 
anemia  of  the  disk,  or,  if  it  occur-  suddenly  and  is  very  extreme,  of  ischemia 

of  tin    dish. 

Varieties  and  Objective  Symptoms  of  Optic-nerve  Atrophy. —  H  the 
atrophy  develop  without  previous  inflammation  of  the  nerve,  it  is  called  simple 
or  primary  or  non-inflammatory  atrophy.2 

The  distinction-  made  by  many  writers  between  white  and  gray  atrophy 
and  between  cerebral  and  spinal  atrophy  are  not  well  grounded,  for  the  first 
refers  merely  to  an  appearance  of  the  nerve  which  may  he  transient,  a  white 
atrophy  sometimes  passing  over  into  a  gray,  and  either  being  sometimes  pro- 
duced by  the  same  cause;  while  the  second  depends  upon  the  assumption 
that  the  optic-nerve  atrophy  in  a  large  class  of  patient-  i-  the  consequence 
of  spinal  disease,  whereas  it  is  now  known  that  the  optic  atrophy,  while 
dependent  upon  the  same  cause  a-  the  spinal  disease,  originates  quite  inde- 
pendently of  it    and   often   antedate-   it. 

[n  simple  atrophy  the  nerve  is  white,  bluish  white,  or  grayish  white, 
with  clear-cut  edges,  and  frequently  with  a  shallow  excavation  which  may 

1  <  if  interest  i-  the  apparenf  connection  with  the  brunette  type.  Thomson  reported  a 
family  in  which  the  blue-eyed  children  retained  normal  siijlit,  while  the  dark-eyed  ones  were 
affected  with  atrophy  of  the  optic  nerve.  This  recall-  the  oDservation  from  the  pre-ophthalmo- 
Bcopic times  of  Travers, who  Bays  Synopsis  of  Diseases  ••(tin  Eye,  London,  lsi'l,  p.  W2):  "  1  know 
a  family  of  several  well-formed  children,  three  of  whom  have  dark  hair  and  eves,  the  others 
light  hair  and  blue  eyes.  Toward  puberty  all  the  dark  haired  children  bave  become  epileptics 
and  gradually  lost  their  sight,  the  eve-,  except  in  the  expansion  and  immobility  of  the  pupils, 
retaining  every  appearance  of  health." 

Much  confusion  exists  in  the  terminology  of  optic-nerve  atrophy.  By  the  term  simple 
some  authors  designate  i \i<>->'  cases  for  which  no  probable  cause  can  be  assigned.  <  others  sepa 
rate  from  simple  atrophy,  as  U8ed  in  this  work,  the  case-  in  which  the  atrophy  depends  upon 
definite  retro-bulbar  lesion,  classifying  these  as  descending  atrophy.  In  general,  by  de- 
scending atrophy  is  meant  simplv  that  the  lesion  is  back  of  the  eye.  bo  thai  it  must  descend 
before  becoming  evident  in  the  disk,  while  in  ascending  atrophy  the  primary  lesion  is  more  pe- 
ripheral and  lead-  to  a  degeneration  passing  up  to  the  higher  center-.  The  term  rcrrbral  i-  some- 
times applied  to  the  cases  depending  on  an  intracranial  lesion.  /Vw/zv.-W/r  atrophy  simply 
I  hat  the  pro<  •  38  pn  adily. 


ATROPHY  OF  THE  OPTIC  NERVE.  143 

extend  to  the  temporal  margin,  hut  which  is  generally  u<>t  sharply  defined. 
The  vessels  often  show  some  reduction  iu  size,  bul  this  is  seldom  extreme, 
as  it  is  in  some  other  tonus  of  atrophy.  In  some  cases  the  lamina  cribrosa 
-hows  plainly,  in  other-  it   docs  not   (Plate  6,  Fig.  III.). 

The  atrophy  occurring  after  inflammation  of  the  intraocular  end  of  the 
nerve  (neuritie  or  post-neuritic  atrophy)  differs  from  the  preceding  form  by 
more  or  less  marked  narrowing  of  the  arteries,  by  the  presence  of  white 
streaks  of  connective  ti>-ue  along  the  large  Mood-vessels,  by  more  or  less 
irregularity  or  obscuration  of  the  margin  of  the  disk,  and  by  a  chalky, 
opaque  whiteness  in  contradistinction  to  the  clear  somewhat  translucenl 
appearance  which  .is  seen  inmost  cases  of  simple  atrophy  (Plate  <>.  Fig.  II.), 
With  the  lapse  of  time,  however,  these  differences  are  apt  to  become  much 
less  pronounced,  and  sometime-  they  disappear  altogether.  In  some  cases  of 
neuritie  atrophy  a  network  of  newly-formed  blood-vessels  is  left  upon  the 
disk;  and  this  symptom,  when  it  occurs,  is,  in  the  writer's  experience,  the 
most  permanent  of  all  the  signs  of  a  previous  neuritis.  A  moment's  consid- 
eration will  show  that  some  cases  of  atrophy  s< ndary  to  a  neuritis  will  be 

classed,  from  the  ophthalmoscopic  appearances,  with  simple  atrophy — namely, 
those  due  to  a  pure  retro-bulbar  neuritis,  so  that  in  speaking  of  a  primary  or 
secondary  atrophy  this  exception  should  he  borne  in  mind. 

A  third  type  of  optic-nerve  atrophy  is  that  described  by  Leber  as  retinal 
atrophy.  This  results  from  any  extensive  disturbance  with  the  nutrition  of 
the  retina,  and  depends  generally  upon  retinitis  pigmentosa  or  extensive 
retino-choroiditis.  In  this  class  of  cases  we  find  the  most  extreme  changes 
in  the  blood-vessels.  In  advanced  cases  of  retinitis  pigmentosa  the  vessels 
are  very  small,  and  sometimes  are  so  reduced  as  to  be  indiscernible  with  the 
ophthalmoscope.     The  disk  lias  a  dirty-bluish  or  yellowish-gray  hue. 

In  the  various  forms  of  retino-choroiditis  the  changes  in  the  vessels  and 
the  appearance  of  the  disk  are  not  apt  to  be  so  extreme  ;  but  where  there  is 
a  large  area  of  destruction,  particularly  at  the  macula,  a  corresponding  sector 
of  the  nerve  is  generally  atrophic. 

The  atrophy  which  follows  embolus  or  thrombosis  (embolic  atrophy)  of 
the  central  artery  is  also  largely  retinal  in  its  origin — i.  e.  it  depends  not  so 
much  upon  the  interference  with  its  own  blood-supply  (for  this  is  in  good 
part  derived  not  from  the  central  vessels,  but  from  those  of  the  sclero- 
choroidal  ring)  as  upon  a  degeneration  following  the  death  of  the  nerve- 
elements  in  the  retina.  It  gives  the  nerve  a  dense,  opaque  whiteness  or 
a  yellowish-white  tint  (Plate  6,  Fig.  IV.). 

Subjective  Symptoms. — Except  in  the  cases  following  retro-bulbar 
neuritis  of  the  macular  bundle  of  fibers  the  disturbance  of  vision  mosl  com- 
monly takes  the  form  of  a  reduction  of  central  acuity  with  contraction  of 
the  held  at  the  periphery,  but  central  and  ring-shaped  scotoma,  sector-shaped 
defects,  or  spurious  hemianopsia,  all  may  occur  (tor  visual  fields  see  page  477). 
The  color-sense  is  apt  to  suffer  early  in  the  course  of  the  disease,  the  outer 
limits  of  the  color-fields  sometimes  being  irregular  or  contracted  before  the 
field  for  white  shows  any  abnormality.  A  diminution  of  the  light-sensi  is 
also  common,  the  periphery  of  the  field  often  showing  a  contraction,  it  it  be 
tested  with  gray  paper  or  by  reduced  light,  when  the  ordinary  test  with  a 
white  object  show-  no  abnormality  (see  page  168).  On  the  other  hand,  some 
patients,  especially  in  the  atrophy  accompanying  retro-bulbar  neuritis, 
better  in  proportion  by  a  moderately  dim  light.  In  the  occasional  i 
where  the  functions  are  normal  and  the  disk  decidedly  atrophic-looking,  we 
have  to  assume  either  some  congenital  peculiarity  or  that  the  connective  tissue 


444  DISEASES  OF  THE  OPTIC  NERVE. 

has  been  changed  chiefly  in  appearance,  without  sufficienl  increase  in  volume 
to  cause  atrophy  of  the  nerve-fibers. 

Etiolog-y. —  It  is  evident  that  any  of  the  causes  which  have  been  enum- 
erated as  producing  optic  neuritis  may  produce  atrophy,  and,  as  the  signs  of 
neuritis  may  have  disappeared  by  the  time  the  patient  i-  firsl  examined,  the 
results  of  the  cause  may  be  set  down  as  atrophy  without  any  knowledge  of 
the  neuritis.  Besides  neuritis,  any  other  cause  that  cuts  oil'  communication 
between  the  retina  and  the  higher  nerve-centers  will  produce  atrophy. 

Brain-tumors  may  cause  atrophy,  by  the  production  of  neuritis,  by  direct 
pressure  on  the  nerve,  chiasma,  or  tracts,  by  the  pressure  upon  the  chiasma 
and  tract-  of  the  accumulation  of  fluid  in  the  ventricles  which  often  accom- 
panies them,  or  by  raising  up  the  chiasma  and  nerve,  and  thus  causing  them 
to  be  constricted  by  the  arteries  at  the  base  of  the  brain. 

Injuries  to  tin  nerve-trunk  are  followed  by  atrophy,  both  ascending  and 
descending,  while  all  the  various  processes  which  destroy  the  function  of  the 
retina,  whether  it  he  removal  of  the  globe,  the  various  conditions  which  pro- 
duce phthisis  hulhi,  inflammations  of  the  choroid  or  retina,  detachment  of 
the  latter,  or  cutting  oil'  its  blood-supply  through  thrombosis  or  embolism, 
and,  finally,  abnormal  pressure  both  upon  the  retina  and  the  disk,  as  in 
glaucoma,  produce  ascending  atrophy  of  the  nerve-trunk,  chiasma,  and  the 
tract-   leading  to  the  higher  cerebral   center-. 

The  atrophy  which  sometimes  follows  erysipelas  of  the  face  is  undoubtedly 
caused  by  the  accompanying  inflammation  in  the  orbit,  since  any  severe  orbital 
cellulitis  may  cause  atrophy,  probably  either  by  direct  pressure  on  the  nerve- 
trunk,  by  thrombosis  of  the  retinal  vein,  as  pointed  out  in  particular  by 
Knapp,  or  by  producing  a  neuritis.  Some  authors  doubt  whether  atrophy 
may  result  simply  from  hemorrhage  into  the  orbit,  but  the  writer  has  seen  at 
least  two  cases  in  which  this  undoubtedly  occurred  :  in  one  a  hemorrhage  fol- 
lowed an  extirpation  of  the  lachrymal  gland  and  led  to  atrophy,  with  the 
typical  picture  of  thrombosis  of  the  retinal  vein  and  paralysis  of  all  the  ocular 
muscles  ;  this  indicating  that  even  if  the  vein  had  not  become  obstructed, 
atrophy   might    have  resulted  directly  from   the  pressure. 

In  a  number  of  cases  optic-nerve  atrophy  follows  falls  or  blows  upon  the 
/noil,  without  any  signs  of  meningitis  or  optic  neuritis.  The  first  rational 
explanation  of  these  cases  was  given  by  Holder  and  Berlin,  who  found  that 
in  many  cases,  without  any  external  signs  of  fracture,  fissures  of  the  walls  of 
tin'  orbit  were  produced  which  extended  into  the  optic  canal,  the  nerve  in 
some  cases  apparently  being  injured  immediately  by  pressure  from  fragments 
of  the  bone  or  by  hemorrhages  into  the  optic  canal,  or  later  by  pressure  from 
the  development  of  callus.  In  the  first  two  instances  blindness  develops  at 
once  ;  in  the  la.-t  it  comes  on  gradually  after  several  days  or  weeks.  These 
cases  are  generally  one-sided,  and  apparently  may  be  produced  through 
contre-coup  by  violence  to  distant  part-  of  the  body.  Whether  the  cases 
described  by  Schweigger  a-  concussion  <>/  lite  optic  nerve  were  due  to  fractures 

of  the  bone  i-  uncertain.  In  them  violence  to  the  head  was  followed  by 
immediate  and  complete  one-sided  amaurosis.  A  certain  amount  of  useful 
vision  (in  one  case  nearly  approaching  the  normal,  the  nerve  showing  partial 
atrophy)  returned  after  some  days  or  weeks.  It  i-  possible,  also,  that  some 
of  the  atrophies  which  follow  spinal  injuries  are  produced  in  this  way  :  about 
the  real  significance  of  these  cases  there  has  been  some  dispute,  some  authors 
leaning  to  the  view  that  they  were  the  result  of  a  trophic  disturbance,  while 
others  assume  that  they  resull  from  an  ascending  meningitis  ;  but  since  it  has 
been    shown  that  a  fall  upon  the   trochanter,  for  instance,  can    produce  a  frac- 


ATROPHY  OF  THE  OPTIC  NERVE.  445 

ture  through  the  optic  canal  by  contre-coup,  it  seems  probable  that  at  least 
some  of  the  cases  have  this  origin. 

The  numerous  cases  of  optic-nerve  atrophy  in  various  forms  of  spinal 
disease  also  led  to  the   belief,  at  one  time  prevalent,  of  a  trophic  connection 

between  the  spinal  column  and  the  optic  nerve;  and  because  the  disk  in 
many  of  these  cases  (though  by  no  means  in  all)  was  of  a  grayish  hue,  it  was 
common  to  -peak  of  gray  or  spinal  atrophy.  The  spinal  affection  in  which 
atrophy  is  most  commonly  observed  is  tabes.  Out  of  109  cases  of  tabes 
which  Berger  examined  he  found  optic-nerve  atrophy  in  44,  and  amblyopia 
with  normal  disks  in  7.  It  may  be  one  of  the  earliest  symptoms  of  the  dis- 
ease, occurring  entirely  independently  of  the  spinal  lesion,  and  beginning, 
apparently,  near  the  peripheral  end  of  the  nerve.  In  the  early  stages  the 
ophthalmoscope  sometimes  shows  a  decided  congestion  of  the  disk,  though 
the  ophthalmologist  seldom  sees  the  patient  early  enough  to  observe  anything 
but  atrophy,  which  may  be  either  of  the  gray  or  white  variety.  The  dis- 
turbance of  vision  generally  takes  the  form  of  a  peripheric  contraction  of  the 
field  with  reduced  central  acuity,  but  central  scotomata  sometimes  occur. 
The  affection  almost  always  ends  in  complete  blindness  if  the  patient  live 
lon^  enough. 

In  disseminated  sclerosis  the  frequently  occurring  atrophy,  which  is  often 
confined  to  the  other  half  of  the  disk  and  produces  a  relative  central  scotoma 
oftener  than  a  contraction  of  the  field,  is  sometime-  preceded  by  moderate 
papillitis,  and  is  much  less  likely  to  lead  to  blindness  than  the  atrophy  of 
tabes.  The  disturbance  of  vision  is  more  subject  to  variations,  and  is  not 
infrequently  accompanied  by  nystagmus,  which  becomes  more  marked  or 
shows  itself  only  on  voluntary  movements  of  the  eye. 

In  progressive  paralysis,  also,  optic  atrophy  is  quite  common,  and  that  it 
may  be  a  very  early  or  perhaps  an  initial  symptom  is  indicated  by  the  fact 
that  a  large  proportion  of  patients  in  whom  apparently  idiopathic  optic 
atrophy  occurs  sooner  or  later  become  demented.  Here,  too,  Allbutt  has  ob- 
served a  stage  of  congestion  preceding  the  atrophy. 

According  to  Michel,  the  atrophy  occurring  in  multiple  foci  of  cerebral 
softening  as  a  rule  affects  only  the  temporal  side  of  the  disk.  Atrophy  has 
also  been  observed  in  chronic  bulbar  paralysis,  in  chorea,  in  epilepsy,  where 
it  is  probably  only  a  coincidence,  and  in  nearly  all  of  the  general  affections 
which   have  been  mentioned  in  connection  with  neuritis. 

Atrophy  is  quite  common  in  diabetes  meUitus;  it  also  has  been  noted  with 
diabetes  insipidus.  One  important  cause  of  atrophy  i-  pressun  upon  the 
nerve  <>r  chiasma  at  the  base  of  the  brain  or  within  the  optic  canal  by  enlarged 
arteries.  The  enlargement  may  be  aneurysmal,  but  commonly  it  i<  merely 
the  result  of  arterial  sclerosis,  and  the  resulting  pressure  on  the  nerve  may 
spread  the  latter  out  in  the  form  of  a  semi-cylinder  or  even  divide  it  into 
two   bundle-. 

The  atrophy  which  follows  severe  hemorrhages  i-  sometimes  preceded  by 
neuritis.  The  blindness  is  often  complete  ami  generally  double-sided.  It 
comes  on  sometimes  at  once,  Inn.  as  a  rule,  several  days  after  the  hemorrhage, 
and,  according  to  Fries,  out  of  '.mi  cases  the  highest  degree  of  amaui 
attained  in  the  course  of  the  case  underwent  no  improvement  in  13 :  in  28 
partial  recovery  took  place,  while  full  vision  was  restored  in  19  cases.  The 
source-  of  the  hemorrhages  are  most  frequently  the  alimentary  canal  (stomach 
and  intestines),  the  uterus,  veins  (venesection),  the  uose,  accidental  wot 
the  1  r 1 1 1 lt ~ .  and  the  urethra,  in  the  order  named.  Women  are  attacked  with 
only  -lightly  greater  frequency  than  men.     The  immediate  cause  of  blini 


446  DISEASES  OF  THE  OPTTC  NERVE. 

is  probably,  in  the  cases  occurring  at  once,  ischemia  of  the  nerve  and  retina  ; 
in  the  others  hemorrhages  into  the  nerve-,  nerve-centers,  or  intervaginal 
space  from  malnutrition  of  the  vessel-walls.  In  one  case  a  microscopic  ex- 
amination showed  fatty  degeneration  of  the  nerve-fibers  and  retina. 

Incurable  atrophy  has  occurred  in  some  cases  of  UghJtning-stroke}  while  in 
one  reported  case  the  pallor  of  the  optic  disks,  the  small  retinal  vessels,  and 
the  greal  reduction  of  sight  improved  to  normal  or  nearly  so  on  the  use  of 
nitro-glycerin. 

The  atrophy  from  affections  of  the  accessory  sinuses  will  be  discussed 
later  on. 

Under  the  head  of  congenital  atrophy  are  grouped  a  number  of  cases, 
probably  of  various  origins,  which  have  been  observed  in  infants.  Some  of 
these  are  doubtless  the  result  of  neuritis  or  of  hydrocephalus  in  utero  or  soon 
after  birth  ;  in  others,  judging  from  the  entire  absence  of  retinal  vessels,  there 
is  a  fault  of  development;  while  still  others,  which  have  been  observed 
especially  after  forceps  delivery,  are  probably  the  result  of  injury  to  the  bones 
of  the  head. 

Hydrocephalus  internus,  although,  as  has  been  mentioned,  it  sometimes 
produces  neuritis,  is  generally  found  to  have  produced  atrophy,  probably  by 
direct  pressure  upon  the  chiasma  and  tracts. 

In  quite  a  large  proportion  of  cases — Leber  estimates  it  as  high  as  50  per 
(••in. — the  most  careful  examination  fails  to  reveal  any  cause  fur  the  atrophy. 
In  these  cases  and  in  those  occurring  in  the  course  of  spinal  diseases  men 
far  outnumber  the  women,  ami  old  persons  the  young.  In  all  forms  of 
atrophy,  except  where  caused  by  affections  of  the  orbit,  globe,  or  accessory 
sinuses,  double-sidedness  is  the  rule. 

Pathology.-  In  the  atrophy  following  neuritis,  largely  as  the  result  of 
pressure  both  from  the  edema  and  the  new  connective  ti>sue,  the  nerve-filters 
degenerate,  their  sheaths  (in  the  mediillated  portions)  being  first  transformed 
into  fatty-looking  globules  and  granules,  leaving  only  the  nerve-fibrils,  which 
themselves  become  varicose,  and  then  shrink  into  very  fine  homogeneous 
fibrillar  or  disappear  altogether.  The  new  connective  tissue  may  fill  up  the 
papilla  entirely,  and  the  larger  vessels  running  through  it  generally  have 
much   thickened   wall-. 

In  the  simple  or  gray  atrophy  ("gray  atrophy,"  in  a  pathological  sense, 
refers  strictly  to  the  macroscopic  appearance  of  the  cut  surface  of  the  nerve) 
a  similar  process  of  degeneration  takes  place  without  any  ascertainable  pre- 
ceding inflammation.  It  may  occur  in  isolated  foci  or  may  affect  the  greater 
part  of  the  nerve  at  once.  In  old,  extreme  cases,  either  of  simple,  neuritic, 
or  direct-pressure  (from  tumors,  etc.)  atrophy,  all  signs  of  nerve-substance 
may   disappear  entirely,   and   only   a   cord   of  connective   tissue   remain. 

In  a  certain  sense  "  normal  "  optic  atrophy  has  been  reported  by  Fuchs  in 
tli.'  form  of  degeneration  of  a  number  of  the  most  peripheric  bundles  of 
fibers  in  a  large  proportion  of  healthy  adults.  This  observation  is  disputed 
by   Michel. 

Diagnosis.- — The  variations  in  the  normal  color  of  the  disk  are  such  that 
it  i-  sometimes  impossible  to  say  whether  an  observed  pallor  is  abnormal  or 
n.it.     Here  the  subjective  tests  are  of  greal  importance,  the  examination  of 

the   field  for  white   ami  for  color-    being   made  with  the    Utmosf    care   both    by 

full  and  l>v  reduced  light.     To  illustrate  the  importance  of  this  a  case  may 

he    mentioned    in  which,  with  decided    atrophy  of  oiie-ipiarter  of  the   disk  of 

one  eye,  with  an  absence  of  one  quadranl  of  the  field  for  white  and  of  the 

nasal  half  of  the  field   for  color-,  no  trouble  \\a-  -ii-peeted  with  the  other  eye, 


ATROPHY  OF  THE  OPTIC  NERVE.  447 

it  being  apparently  normal  both  subjectively  and  objectively.  But,  while 
the  vision  was  practically  normal  and  its  field  showed  no  defect  for  white,  an 
examination  of  the  color-limits  showed  that  in  the  nasal  hall'  of  the  field 
both  quadrants  had  lost  the  perception  of  green,  and  one  quadrant  that  of 
red,  thus  indicating  with  the  greatest  probability  the  implication  of  both 
nerves  or  of  the  chiasma. 

In  other  cases,  as  mentioned  above,  an  eye  showing  no  defect  in  the  field 
by  good  light  will,  when  tested  in  a  moderately  dim  light  or  by  using  a  gray 
paper  as  a  test  object,  show  marked  abnormalities.  In  many  cases,  where 
there  is  no  question  about  the  existence  of  atrophy,  a  careful  consideration 
of  the  symptoms  is  of  importance  in  the  attempt  to  determine  the  location 
of  the  primary  lesion  or  to  decide  on  the  nature  of  the  general  disease  of 
which  it  is  hut  one  of  the  manifestations.  Where  the  trouble  is  entirely  one- 
sided the  lesion  must,  in  the  great  majority  of  cases,  be  peripheral  to  the 
chiasma,  but  not  necessarily,  for  an  intracranial  lesion  might  affect  one  side 
of  one  optic  tract  so  as  to  produce  a  one-sided  disturbance  of  sight,  either 
crossed  or  on  the  same  side.  In  nearly  all  cases,  however,  any  affection  of 
the  chiasma  or  tracts  will  produce  a  double-sided  disturbance  in  the  fields, 
generally  more  or  less  symmetrical,  pressure  on  the  chiasma  in  front  or  behind 
tending  to  produce  defects  in  the  temporal  halves  of  the  fields  ;  while  sym- 
metrical defects  in  the  nasal  halves  indicate  pressure  on  or  lesion  of  the 
outer  side  of  the  chiasma,  tracts,  or  intracranial  portions  of  the  nerves  (see 
pages  480  and  481 ). 

An  enlargement  of  the  blind  spot  may  indicate  the  existence  of  the  so- 
called  normal  atrophy  of  Fuchs  (granting  that  this  actually  occurs),  or  a 
mild  peripheral  perineuritis,  or  some  other  affection  attacking  only  the  fibers 
close  to  the  periphery  toward  the  distal  extremity  of  the  nerve.  A  central 
seotoma,  either  relative  or  absolute,  indicates,  of  course,  an  affection  of  the 
papillo-macular  bundle  of  fibers,  but,  unless  there  have  been  symptoms  of 
congestion  of  the  disk  to  indicate  an  implication  of  the  distal  extremity  of 
the  nerve,  we  have  no  way  of  judging  whether  the  lesion  is  nearer  the  globe 
or  the  brain  unless  there  occur  with  it  an  enlargement  of  the  blind  spot  ;  in 
which  case,  as  Berger  has  recently  pointed  out,  we  may  with  some  certainty 
diagnose  distal  perineuritis,  either  present  or  past.  In  deciding  between 
atrophy  from  tabes  and  from  disseminate  sclerosis  it  should  be  remembered 
that  disorders  of  the  pnpil-reaetion  are  much  more  common  in  tabes,  while 
nystagmus  of  recent  origin  and  paresis  of  other  than  ocular  muscles  strongly 
indicate  disseminate  sclerosis.  The  partial  atrophy  occurring  in  cerebral 
softening  has  already  been  referred  to.  In  all  cases  of  atrophy,  as  of  neur- 
itis, the  importance  of  as  thorough  an  examination  as  is  practicable  of  the 
genera]   system,   reflexes,  urine,  etc.  should   not   be   forgotten. 

Prognosis. — The  prognosis  of  post-neuritic  atrophy  is,  like  that  of  the 
neuritis  itself,  relatively  favorable,  since  the  sight  that  is  left  after  the  neur- 
itis has  run  its  < rse  is  apt  to  be  retained.     In  some  cases  normal  vision  is 

kept,  but,  as  a  ride,  there  is  ;i  reduction  of  central  acuity  with  contraction 
of  the  field,  except  in  cases  in  which  the  lesion  has  mainly  affected  the 
papillo-macular  bundle,  where  a  central  scotoma  with  normal  peripheric 
field-limits  is  the  rule. 

In  the  cases  of  simph  atrophy  the  prognosis  will  depend  upon  the  cause 
if  this  can  be  ascertained.  In  tabes  it  is  almost  unqualifiedly  bad:  once 
having  set  in,  the  loss  of  sight  generally  progresses  until  the  patient  is  blind. 
In  disseminate  sclerosis  blindness  is  rare,  and  in  some  cases  the  vision,  after 
being  much  reduced,  undergoes   considerable    improvement.     In    the   other 


448  DISEASES  OF  THE  OPTIC  NERVE. 

cases  of  simple  atrophy  the  prognosis  musi  always  be  dubious  if  there  is 
evidence  «>!'  recent  progress.  The  majority  of  them  sooner  or  later,  in  spite 
of  all  treatment,  end  in  blindness.  Yet  the  surgeon  must  be  careful  not  to 
be  too  positive  in  his  expressions  of  pessimism,  for  every  now  and  then  one 
sees  a  patient  apparently  doomed  to  blindness,  one  eye  being-  already  practi- 
cally blind,  with  marked  symptoms  of  progressive  atrophy  in  the  other,  where 
to  his  surprise  the  process  stops  and  useful  sight  is  retained  for  years. 

In  toxic  amblyopia,  the  papilla  occasionally  presents  the  appearance  of  a 
general  atrophy,  and  where  this  occurs,  with  some  slight  contraction  of  the 
field,  with  myotic  pupils,  and  with  peripheral  paralysis  due  to  alcoholic;  neur- 
itis, the  diagnosis  of  some  grave  incurable  disease  may  be  erroneously  made 
in  spite  of  the  central  scotoma,  since  such  seotomata  are  not  infrequent  in 
some  such  diseases,  and  sometimes,  though  rarely,  occur  in  tabes.  On  the 
other  hand,  a  too  favorable  prognosis  may  easily  be  made  with  patients  who 
have  atrophy  of  the  outer  quadrant  or  half  of  the  papilla,  with  a  central 
scotoma,  relative  or  absolute.  In  such  a  case,  if  the  patient  happen  to  use 
tobacco  or  alcohol  freely,  it  would  be  natural  to  think  of  toxic  amblyopia  and 
give  a  relatively  good  prognosis,  although  the  use  of  these  stimulants  may  be 
a  mere  coincidence,  and  the  trouble  may  continue  to  progress  in  spite  of  total 
abstinence,  the  atrophy  being  due  to  some  entirely  different  cause.  In  two 
cases  of  this  kind,  which  the  writer  lias  seen,  the  central  scotoma  was  decidedly 
less  marked,  in  proportion  to  the  amount  of  atrophy  and  reduction  of  vision, 
than  is  usual  in  toxic  amblyopia.  The  only  safe  plan,  if  there  are  no  indica- 
tions of  disseminate  sclerosis,  cerebral  softening,  or  other  serious  nervous 
disease,  is  to  await  the  result  of  abstinence  before  making  a  diagnosis  or 
prognosis. 

In  the  rare  cases  of  spurious  hemianopsia,  when,  with  progressive  atrophy, 
the  fields  happen  temporarily  to  closely  resemble  those  in  homonymous 
hemianopsia,  the  beginner  might  consider  it  to  be  a  case  of  cortical  hemi- 
anopsia and  give  much  too  good  a  prognosis  as  to  the  chance  of  progression. 
In  such  cases  the  history,  the  more  pronounced  atrophy  of  the  disk,  the 
undue  reduction  of  the  central  vision,  and  the  disturbance  of  the  light-  or 
color~en<e  in  the  remaining  halves  of  the  fields,  will  almost  certainly  allow 
the   proper  distinction    to   lie   made. 

Where  from  the  previous  existence  of  a  large  physiological  excavation,  or 
from  an  unusually  high  normal  intraocular  pressure,  or  from  the  nature  of 
the  initial  lesion,  a  case  of  simple  atrophy  exhibits  a  deep,  sharp-bordered 
excavation,  the  problem  of  distinguishing  it  from  simple  glaucoma  with  no 
appreciable  hardness  of  the  globes  may  arise,  and  its  solution  may  be  very 
difficult  or.  in  some  cases,  at  first  impossible.  There  are  no  points  of  differ- 
ence upon  which  absolute  reliance  can  be  placed.  The  mosl  valuable  are  the 
occurrence  in  glaucoma  of  an  unusually  good  color-sense  in  proportion  to  the 
contraction  of  the  field,  and  the  ease  with  which  pulsation  of  the  retinal  arteries 
may  be  produced  by  light  pressure  on  the  globe.  All  the  conditions  have  i>> 
be  carefully  weighed  in  such  a  case,  and  occasionally  no  positive  diagnosis 
can  lie  made  al  once,  [f,  after  continued  observation,  the  doubt  should  per- 
sist, it  is  better  to  use  a  myotic,  or  even  to  operate,  than  to  allow  the  patient 
to  go  blind  by  default.     (Compare  with  page  382.) 

Treatment. — The  results  of  the  treatment  of  optic-nerve  atrophy  are 
extremely  unsatisfactory.  It  LS  entirely  probable  that,  except  where  it  de- 
pend- upon  some  still  active  inflammatory  process,  upon  some  toxemia,  or 
upon  some  neoplasm  which  can  be  removed,  no  form  of  treatment  has  any 
influence   upon   it.     This  does  not    mean,   however,  that  nothing  should  be 


TUMORS  OF  THE  OPTIC  NERVE.  449 

done  for  the  patients.  In  the  hope  that  there  may  -till  be  some  active 
process  capable  of  being  influenced,  large  doses  of  iodid  of  potassium  may  be 
tried,  or  mercury  may  be  used  if  there  is  any  suspicion  of  syphilis,  though,  as 
a  nerve-poison,  it  should  be  used  with  greal  care  if  there  is  any  spinal  trouble. 
It  is  common  to  use  strychnin  in  many  of  these  cases,  and  it  is  probably 
well  to  try  it  in  full  doses  (increasing  from  -.,-'„  grain  three  times  a  day,  if 
given  by  the  month,  to  the  limit  of  toleration,  or  injecting  from  ^  to  J0  grain 
under  the  skin  of  the  temple.  It  often  causes  a  slight  temporary  improve- 
ment of  central  acuity  or  of  the  extent  of  the  held,  and  a  number  of  cases 
have  been  reported  in  which  its  effects  have  seemed  almost  miraculous.  In 
conjunction   with   strychnin,  nitroglycerin  should  be  exhibited. 

Electricity  in  the  form  of  a  mild  constant  current  may  be  \\<c(\  for  a  few 
minutes  ever}'  day  or  two.  though  little  more  can  he  said  for  it  than  that  it 
gives  the  patient  the  benefit  of  the  doubt.  Nitrate  of  silver  is  another  remedy 
in  common  use  which  is  supposed  by  some  observers  to  have  a  particular 
value  in  checking  post-neuritie  atrophy,  and  cyanid  and  arsenite  of  gold, 
phosphate  of  zinc,  and  numerous  other  remedies  have  received  enthusiastic 
recommendations.  Where  there  are  evidences  of  active  inflammation  at  the 
base  of  the  brain  a  vigorous  course  of  salicylate  of  sodium,  iodid  of  potassium, 
inunctions  of  mercury,  or  some  form  of  sweat-cure,  or  any  two  or  three  of 
these  together,  should  never  be  omitted.  The  writer's  plan  is  generally,  as 
in  the  case  of  neuritis,  to  give  the  salicylate  a  trial  of  about  a  week  (15  grains 
eight  to  twelve  times  a  day  in  brandy);  then,  if  no  decided  effect  has  been 
produced,  to  change  to  large  doses  of  iodid  in  connection  with  the  sweat-cure 
(pilocarpin  ^  to  1  grain  in  a  glassful  of  hot  whiskey  and  water,  with  the  addi- 
tion of  15  grains  of  salicylate  of  sodium  if  the  pilocarpin  alone  does  not 
produce  free  diaphoresis). 

It  is  in  these  cases  of  meningitic  atrophy  that  Valude  has  recommended 
antipyrin. 

Tumors  of  the  Optic  Nerve. — The  primary  tumors  of  the  optic-nerve 
trunk  are  most  frequently  of  the  sarcomatous  type,  with  a  tendency  to  myx- 
omatous degeneration.  Sarcoma,  myxo-sarcoma,  myxoma,  and  myxo-fibroma 
are  the  commonest  types,  in  the  order  named,  though  glioma,  psammoma, 
endothelioma,  and  neuroma  have  also  been  described,  the  last  named  very 
rarely. 

The  point  of  departure  seems  to  be  the  pial  sheath  and  the  septa  of  con- 
nective tissue  running  off  from  it  into  the  interior  of  the  nerve,  the  tumor 
sometimes  developing  uniformly  throughout  its  diameter,  but  more  frequently 
with  a  tendency  at  first  to  spread  along  the  pial  sheath  in  the  form  of  a 
cylinder,  through  the  center  of  which  the  more  or  less  degenerated  trunk  of 
nerve-fibers  runs,  though  at  the  oldest  portions  its  identity  is  often  entirely 
lost.  These  tumors  are  generally  somewhat  spindle-shaped,  tapering  at  least 
at  one  end.  They  never  invade  the  globe  (unless  a  recent  case  of  Risley  is 
an  exception),  and  when  they  grow  forward  close  to  it  a  sharp  constriction 
separates  them  from  it;  when  the  tumor  is  continued  into  the  cranial  cavity 
there  i<  a  narrowing  corresponding  to  the  optic  canal. 

From  a  pathological  standpoint,  though  not   necessarily  differing  in  the 
symptoms  which  they  produce,  are  to  be  distinguished  the  growths  which 
take  their  origin    in  tin-  dura]   -heath.     They  are  apt  to   be   fibromata,  endo- 
theliomata,  or  sarcomata  ;  they  generally  affect  the  nerve-trunk  only  by  di 
pressure  or  by  interfering  with  its  blood-supply. 

A-  secondary  tumors  glioma  and  melanomatous  sarcoma,  spreading  from 
the  interior   of  the   globe,  arc    most    common.     Carcinoma    has   also    been 

29 


450  DISEASES  OF  THE  OPTIC  NERVE. 

observed,  in  one  case  as  metastasis  from  the  kidney  ;  in  another,  that  of 
Krohn,  already  referred  to  as  unique,  a  metastasis  from  a  carcinomatous  ovary 
occurred  in  each  optic  nerve  immediately  behind  the  globe.  Gummata  and 
sometimes  very  extensive  tuberculosis  <»t'  the  optic  nerve  have  also  been 
reported.  In  the  ease  of  Sattler  the  tuberculosis  of  the  nerve  and  it>  sheaths 
produced  a  tumor  L8  nun.  in  diameter  by  25  nun.  in  length.  Michel  has 
reported  an  unique  case  in  which  a  patient,  suffering  from  elephantiasis  of 
the  leg,  but  with  good  sight,  was  found  alter  death  to  have  the  chiasma  and 
the  intracranial  portion  of  one  nerve  very  much  thickened  by  the  uniform 
distribution,  between  the  bundles  of  fibers,  of  numerous  fibrils  similar  to 
those  of  elastic   tissue. 

Symptoms. — Tumors  of  the  nerve  are  apt  to  occur  in  children,  and 
there  is  a  certain  amount  of  evidence  to  indicate  that  contusions  of  the  eve 
and  its  vicinity  play  a  part  in  their  etiology,  though  sometimes  their  begin- 
nings are  probably  congenital.  Their  growth  is  slow,  and  pain  occurs,  if  at 
all,  only  after  they  have  attained  considerable  size.  If  the  patient  is  a  child, 
usually  the  first  symptom  to  attract  attention  is  protrusion  of  the  globe.  This 
i-  at  first,  and  sometimes  throughout,  straight  forward,  hut  as  the  tumor  gets 
larger  its  impingement  upon  the  upper  and  inner  walls  of  the  orbit  sometimes 
forces  the  eye  -lightly  down  and  out.  In  this  stage  the  general  motility  of 
the  globe  is  sometimes  impaired,  while  in  the  early  stages  it  is  remarkably 
well   preserved. 

If  examined  early,  the  eye  may  show  signs,  sometimes  very  pronounced,  of 
optic  neuritis;  later  on,  of  atrophy.  The  pupil  may  he  wide  through  pres- 
sure-paralysis of  the  oculo-motor  or  from  the  loss  of  sight.  In  older  patients 
the  existence  of  the  tumor  is  frequently  first  suspected  from  the  loss  of  sight, 
which  generally  progresses  rapidly,  though  to  this  there  are  occasional 
marked  exceptions,  as  in  the  ease  of  v.  Graefe,  where  the  chiasma  and 
adjoining  portions  of  the  optic  nerve  were  found  converted  into  a  gliomatous 
tumor  in  which  it  was  difficult  to  make  out  any  of  the  scattered  nerve-libers, 
although  up  to  a  short  time  before  death  the  sight  had  been  more  than  normal. 
In  a  more  recent  case  of  Wiegman,  a  well-developed  tumor  of'  the  trunk  of 
the  nerve,  spreading  the  bundles  of  fibers  widely  apart,  existed  with  a  vision 
of  -,"  (in  the  other  eye  j  '_' )  and  a  normal  field.  In  such  cases  the  develop- 
ment musi  have  taken  place  very  gradually,  so  as  to  allow  the  nerve-fibers  to 
accustom  themselves  to  the  pressure  and  change  of  position. 

Diagnosis. — The  main  points  in  the  diagnosis  between  these  and  other 
tumors  oi*  the  orbit  are  the  -low  and  relatively  painless  progress  (though  this 
may  apparently  be  hastened  by  an  injury),  the  propulsion  straight  forward 
or  marly  so,  the  long-retained  motility  of  the  eyeball,  and,  with  the  excep- 
tions noted  above,  the  early  loss  of  sight. 

Prognosis. —  Prognosis  as  to  sight  i>  of  course  unqualifiedly  bad,  that  as 
to  the  chance  of  retaining  the  globe  fail-,  while  as  to  the  prevention  of  recur- 
rence after  removal  it   is  decidedly  good  unless  there  be  involvement  of  the 

extra-orbital  part  of  the  nerve.  To  help  decide  this  point,  an  examination  of 
the  field  of  the  other  eye  is  very  important,  for  if  it  -how  a  well-marked 
defect,  without  Other  cause,  an  implication  of  the  chiasma  is  probable;  and. 
while  this  should  not  necessarily  contraindicate  an  operation,  the  prognosis 
should  lie  \ery  carefully  guarded. 

Treatment. —  Removal  is  the  only  treatment  allowable,  and  it  i>  probable 

that   this  Can,  in  the    majority  of  Cases,  be  done  with    retention  of  the  eyeball, 

although  hitherto  the  globe  has  in  mosl  cases  been  sacrificed  also.     In  8  cases, 

beginning  \\  ith  one  of  K  napp's,  the  nerve  has  been  cut  close  to  the  eyeball  and 


HYALINE  BODIES  TN   THE  OPTIC  DISK.  451 

at  the  extreme  apex  of  the  orbit,  and  the  intervening  portion  of  the  aerve 

with  the  tumor  removed,  the  eye  being  left  in  place.  In  mosl  cases,  the 
internal  or  external  rectus  muscle  was  cut  to  aid  in  exposing  the  tumor,  but 
in  one  case  (Knapp's  second  one)  the  tumor  could  We  brought  into  view 
through  an  incision  between  the  internal  and  inferior  rectus  and  removed 
without  cutting  any  muscle.  In  1  of  these  cases  the  eye  retained  its  normal 
appearance,  in  •">  it  became  more  or  less  phthisical,  and  in  1  there  was  slough- 
ing of  the  cornea  through  exposure  from  extreme  protrusion.  The  method 
to  be  recommended  is  that  of  Lagrange,1  who  enlarges  the  external  com- 
missure, caits  the  external  rectus,  leaving  attached  to  it  a  long  thread,  puts 
a  thread  through  the  tumor  by  which  it  is  drawn  forward  as  far  as  possible 
while  the  nerve  is  being  cut  at  the  external  optic  foramen.  The  nerve  is 
then  cut  close  to  the  globe,  the  tumor  removed,  and  the  external  rectus  and 
conjunctiva  reunited.  Since  one  of  the  subsequent  dangers  is  sloughing  of 
the  cornea  from  exposure  (in  Knapp's  case  this  occurred  in  spite  of  repeated 
suturing  of  the  lids),  it  is  well  to  check  the  bleeding  as  quickly  as  possible  by 
pressing  back  the  hall  firmly  before  stopping  to  suture  the  muscle;  this  is  to 
be  followed  by  a  pressure  bandage  and  prophylactic  lid  sutures. 

Hyaline  Bodies  in  the  Optic  Disk." — These  bodies  (known  also  as 
colloid  bodies,  verrueosities,  or  " Drusen  ")  were  first  discovered  in  microscop- 
ical specimens  examined  by  Miiller  and  by  Iwanoff,  and  for  years  little  was 
known  of  the  ophthalmoscopic  picture  which  they  presented. 


Fig.  264.-  Moderate  development  of  hyaline  bodies  al  border  of  optic  disk. 

Symptoms. — When  seen  during  life,  if  there  are  but  few  of  them  and 
they  are  rather  deep-seated,  they  can  be  barely  distinguished  a-  somewhat 
spherical  bodies  of  a  lighter  hue  than  the  resl  of  the  disk.  In  this  case  they 
are  best  seen,  as  Liebreich  suggested,  by  throwing  the  brightest  pari  of  the 
light  a  little  to  one  Bide  of  them.  When  nearer  the  surface  they  may  be 
scattered  through  the  disk  or  occur  more  commonly  in  group- at  it<  periphery 
(Fig.  264).  They  are  somewhat  translucent,  and  in  some  cases  give  back 
quite  a  brilliant   reflection.     When  they  project  well  above  the  surface  of 

'  Kronlein'a  plan  of  temporarily  resecting  the   outer  bony  margin  of  the  orbil  i 
employed,  bul  it  probably  i>  very  seldom  necessary  in  optic-nerve  tumors. 


452 


DISEASES  OF  THE  OPTIC  NERVE. 


the  disk  they  often  remind  one  of  half-soaked  grains  of  tapioca.  In  other 
cases  they  are  of  a  denser  or  slightly  yellowish  white.  In  the  direct  image, 
they  appear  to  be  about  2—3  mm.  in  diameter,  but  occasionally  bodies  two  tip 
three  times  as  large  are  seen.  The  entire  border  of  the  nerve  is  occasionally 
obliterated  by  them,  and  sometimes  they  encroach  upon  the  disk  so  as  to 
entirely  conceal  its  normal  tissue,  in  its  place  appearing  a  mulberry-like  mass, 
from  the  center  or  sides  of  which  the  blood-vessels  appear.  A  slight  encroach- 
ment upon  the  retina  is  common,  and  occasionally  isolated  granules  are  seen 
well  out  from  the  main  body.  More  rarely  large  masses  of  them  develop  out 
from   the   edges  of  the  disk    into   the   retina.      Fig.  265   represents   such  an 


Fig.  265.— Extreme  developmenl  of  hyaline  bodies  in  optic  disk-  and  retina. 

extreme  case,  in  which  some  of  the  arteries  appeared  as  white  cords  with  a 
very  minute  column  of  blood  in  the  center.  In  this  case,  repeated  small 
hemorrhages  took   place  from  the  retinal   vessels. 

'flic  affection  is  a  rare  one.  occurring  in  the  writer's  experience  in  1  out 
of  aboul  2000  cases.  It  is  met  most  frequently  in  cases  of  retinitis  pig- 
mentosa, but,  aside  from  this,  the  eyes  in  which  it  i-  seen  with  the  ophthal- 
moscope are,  in  other  respects,  often  entirely  normal,  though  there  is  some 
rather  unsatisfactory  evidence  tending  to  connect  it-  origin  with  injuries  to 
the  eye,  with  neuro-retinitis,  and  with  Bright's  disease. 

few    cases  have  been  observed   long  enough  to  note  any  change  in  the 

ophthal scopic  appearance,  but  where  this  has  been  done  a  gradual  increase 

in  tin  number  of  the  bodies  has  sometimes  been  noticed.  It  is  generally  stated 
to  he  ;i  double-sided  affection  of  advanced  life,  hut  the  writer  ha-  -ecu  it  quite 
a-  often  in  young  adults  as  in  older  patient-  (in  one  case  at  nine  years),  and 
iii  one  disk  alone  a-  often  a-  in  both  disks. 


HEMORRHAGES   TN   THE  OPTIC  NERVE.  453 

Pathology. — Our  knowledge  of  the  more  intimate  character  of  these 
bodies  we  owe  chiefly  to  EHrschberg  and  Cirincione,  Grurwitsch,  de  Schwei- 
nitz,  and   Sachsalber.     They  are    found    to    be    made   up  of    a    rather  hard 

hyaline  substance,  the  -mailer  bodies,  od  erM-~-~retii.ii.  showing  well-marked 
concentric  Lines,  the  larger  bodies  being  made  up  of  a  number  of  the  smaller 
nn,-  more  or  Less  Mended  together.  At  points  they  -how  a  tendency  to 
calcareous  degeneration.     Tincture  of  iodin  gives  tin-  substance  a  yellowish 

color,  and  no  amyloid  reactions  are  obtained  with  -atl'ranin  and  methyl-violet. 
The  earlier  view  was  that  these  bodies  had  the  same  origin  a-  the  colloid 
excrescences  of  the  lamina  vitrea  of  the  choroid,  while  the  tendency  at  pres- 
ent i-  to  regard  them  a-  something  entirely  different.  It  is  certain  that  they 
have  no  necessary  connection  with  the  /amino  vitrea,  for.  while  a  favorite 
place  for  the  development  of  the  largest  masses  is  just  between  the  termina- 
tion of  this  membrane  and  the  central  vessels  of  the  nerve,  they  may  also 
occur  well  out  in  the  retina  and  in  the  nerve,  posterior  to  the  lamina  cribrosa. 
Granting  this,  it  ha-  not  been  shown  that  their  composition  differs  essentially 
from  that  of  the  "Drusen  "  of  the  choroid  (consult  Fig.  318,  page  496  . 

Diagnosis. — In  the  less  pronounced  cases,  the  affection  is  easily  over- 
looked, for  it  i-  only  by  careful  examination  by  the  direct  method  that  the 
rounded  outlines  of  the  bodies  can  be  made  out.  In  a  more  pronounced 
form,  especially  where  they  are  grouped  around  the  periphery  of  the  disk, 
they  may  be  and  have  been  mistaken  for  optic  neuritis,  from  which,  however, 
a  careful  direct  examination  will  always  enable  them  to  lie  distinguished. 
The  most  pronounced  cases  look  like  nothing  else  to  be  seen  at  the  disk,  but 
they  might  easily  puzzle  the  beginner,  especially  since,  in  many  text-bonk-. 
they  are  not  mentioned. 

Prognosis. — In  the  case-  observed  during  life,  the  vision  has  usually 
been  found  to  be  normal  (except  in  the  cases  accompanying  retinitis  pig- 
mentosa), in  some,  even  where  they  were  so  abundant  as  to  nearly  conceal 
the  disk  ;  and  where  moderate  development  of  them  is  discovered  by  acci- 
dent, as  is  generally  the  case,  they  need  cause  no  alarm,  but  it  remains  to  be 
seen  whether  in  extreme  and  progressive  cases  they  may  not  cause  serious 
trouble.  The  case  represented  in  Fie-.  2<j5  was  one-sided,  and  the  eye  was 
entirely  blind,  but  it  i-  not  certain  that  the  blindness  may  not  have  been  due 
to  some  other  cause. 

Treatment. — Treatment  i-  not  necessary  in  the  great  majority  of  cases, 
and  it  is  not  easy  to  understand  how  anything  could  be  used  that  would 
affect    them. 

Hemorrhages  in  the  Optic  Nerve  or  in  the  Intervaginal  Space. 
— After  a   hemorrhage  at  the  base  of  the  brain  or  in  the  optic  canal,  or  even 

from  a  more  peripheral  source  (after  a  contusion  of  the  eye),  the  bl 1  may 

flow  into  the  intervaginal  -pace  and  distend  it  widely  at  its  di-tal  extremity. 

In  such  cases  the  sight  may  be  suddenly  Lost,  the  ophthalmoscope  -bow- 
ing a  somewhat  blurred  disk,  with  the  central  vessels  reduced  in  size,  some- 
times with  a  red  spot  at  the  macula  surrounded  by  a  grayish  area,  as  in 
embolus  of  the  central  artery,  and.  later  on,  the  dissolved  hemoglobin  may 
find  it-  way  into  the  disk,  so  a-  to  be  seen  with  the  ophthalmoscope,  leaving 
deposits  of  pigmenl  there  by  which  the  nature  of  the  original  process  may 
be  recognized  after  months  or  years.  The  nerve  atrophic-,  and  the  vision 
doe-  not  return  at  all.  or  doe-  so  but  imperfectly.  Where  there  i-  ii"  hi 
of  violence  the  affection  mighl  lie  mistaken  for  a  rapidly  developing  neuritis 

or  for  embolus  or  thr bosis  of  the  central  artery,  which  latter  may  indeed 

possibly  l>e  produced  by  it. 


454 


DISEASES  OF  THE  OPTIC  NERVE. 


Much  more  rarely  a  hemorrhage  occurs  within  the  pial  sheath,  and  may 
find  its  way  along  the  septa  of  the  nerve-trunk.  This  lias  been  observed  in 
connection  with   Bright's  disease. 

Optic-nerve  lesions  from  Affections  of  the  Accessory  Sinuses. 
— Inflammation  of  any  of  the  sinuses  or  of  the  ethmoid  cells  may  cause 
optic  neuritis  and  atrophy,  by  spreading  to  the  orbital  tissue  or  to  the  cranial 
cavity  ;  or  by  the  direct  pressure  of  their  distended  walls  upon  the  orbital 
tissue,  in  the  case  of  the  ethmoid  cells,  and  possibly  of  the  maxillary  and 
frontal   sinuses. 

Affections  of  the  sphenoidal  sinus  have  an  especial  significance  for  the 
ophthalmologist  on  account  of  the  intimate  relation  between  the  walls  of  this 
cavity   and    the   optic    nerve.      Fig.    266    shows    part    of    a   coronal    section 


Pig.  266.-  Coronal  sectioii  through  posterior  part  of  optic  canal:  o.n,  optic  nerve ;  s,  sphenoidal  sinus ; 
o.«,  anterior  sphenoidal  or  posterior  ethmoid  cell ;  n.n,  antrum  of  Highmore. 

through  the  -hull  passing  through  the  optic  canals.  A  glance  at  the  left  side 
of  it,  with  a  realization  of  the  facl  that  the  thin  bony  partition  separating 
the  optic  canal  from  the  sinus  is  sometimes  imperfectly  developed,  will  show 
how  easily  an  inflammation  <>('  the  sinus  mighi  cause  localized  neuritis,  with 
subsequent  descending  atrophy,  through  the  diffusion  of  ptoma'ins  into  the 
nerve,  or  an  actual  infection  of  the  intervaginal  -pace,  leading  to  perineuritis 
and  choked  disk  ;  or  an  atrophy  through  direct  pressure,  if  the  walls  of  the 
sinus  were  distended  by  fluid  or  by  a  tumor.  These  considerations  should 
lead  one  to  take  the  sphenoidal  sinus  into  account  in  all  cases  of  obscure 
optic-nerve  trouble,  especially  since  at  leasl  one  case  has  been  reported 
(Holmes)  in  which  a  puncture  of  the  anterior  wall  of  the  sinus  drew  off  a 
collection  of  pus  and  cured  an  optic  neuritis. 

The  righl  side  of  the  Bection  represented  in    Fig.  266  illustrates  a  point 


CONGENITAL   ANOMALIES  OF  THE  OPTIC  NERVE.       455 

which  seems  to  have  attracted  very  little  attention — namely,  that  in  some 
head-,  nn  at  least  "tie  side,  the  cavity  in  closesl  proximity  to  the  optic  canal 
i-  nut  the  main  sphenoidal  sinus,  but  an  entirely  separate  cell,  opening  into 
the  aose  by  an  independent  foramen  which  i-  sometimes  so  large  that  the 
cell  could,  with  propriety,  be  described  as  the  upper  extremity  of  the  nasal 
cavity.  .V  collection  of  pus  in  this  space  might  cause  a  disturbance  of  sight, 
with  symptoms  of  suppuration  of  the  sphenoidal  sinus,  although  an  operation 
on  the  latter  would  give  no  relief.  To  operate  on  this  anterior  sphenoidal 
cell  or  prolongation  of  the  nasal  cavity  would  he  more  difficult  and  dangerous 
than  to  puncture  the  main  sphenoidal  sinus,  but  a  knowledge  of  its  occasional 
relation  to  the  optic  canal  may  serve  to  explain  some  cases  of  optic-nerve 
trouble  in  which  an  ordinary  sphenoidal   operation  gives  negative  results. 

Congenital  Anomalies  of  the  Optic  Nerve. — Aside  from  congenital 
atrophy  of  the  optic  nerve  due  to  intra-uterine  neuritis,  hydrocephalus,  and 
other  causes,  the  nerve  in  the  various  degrees  of  microphthalmos  and  (inoj>li- 
thalmos  shows  more  or  less  marked  signs  of  imperfect  development.  It  may 
be  entirely  absent,  or  represented  only  by  a  cord  of  connective  tissue,  or  it 
may  simply  have  an  abnormally  small  proportion  of  nerve-fibers.  Even 
more  interesting  is  the  case  cited  by  Manz,  which,  though  old,  i-  apparently 
quite  authentic,  of  entire  absence  of  any  decussation  of  the  optic  nerves,  the 
latter  running  direct  to  the  respective  sides  of  the  brain,  without  any  sign  of 
a  chiasm. 

Some  of  the  anomalies  of  the  nerve  which  have  been  discovered  with  the 
ophthalmoscope  are  discussed  in  the  section  on  the  Ophthalmoscopic  Examina- 
tion of  the  Fundus  (pages  191-195).  Of  these,  the  condition  known  as  coZo- 
boma  of  the  optic  nerve  or  coloboma  of the  optw-nervi  sheath  is  the  most  important. 
In  the  most  common  type,  one  sees  in  place  of  the  disk  an  excavation  several 
times  as  large  as  the  ordinary  papilla,  generally  much  deeper  and  with  a  sharply- 
excavated  border  below,  while,  above,  its  floor  comes  gradually  up  to  the  level 
of  the  surrounding  retina  ;  the  main  vessels  curve  abruptly  over  the  lower 
edge,  while  the  bottom  of  the  excavation  may  be  entirely  free  from  them  or 
may  have  some  running  across  it  to  the  upper  part  of  the  retina,  crossing  the 
upper  border  without  any  break  in  their  continuity  at  that  point.  The  ex- 
cavation is  surrounded  by  a  generally  complete  pigment  ring,  outside  of 
which  there  is  often  a  narrow  white  zone  or  crescent.  If  there  is  any  sign 
of  normal  disk-tissue,  it  is  apt  to  be  above.  More  rarely,  the  entire  floor  of 
the  excavation  is  deep  below  the  retina,  with  vessels  curving  sharply  around 
its  border  at  various  points,  though  chiefly  below  and  above  (consult  fig.  141). 

The  few  microscopical  examinations  which  have  been  made  of  the  com- 
mon form  of  this  anomaly  show  that  it  depends  upon  the  non-closure  of  the 
fetal  optic-nerve  fissure;  the  central  vessels  enter  the  nerve  proper  only  in 
part,  or  more  commonly  not  at  all,  but  enter  the  eye  through  the  mass  of 
connective  tissue  which  take-  the  place  of  the  dural  -heath  below.  In  one 
case  (Magnus)  the  fissure  seems  to  have  been  at  the  nasal  side  instead  of 
below  the  Qerve.  The  deep  atypical  excavations  which  are  sometimes  seen 
within  the  borders  of  otherwise  normal  papilla'  are  probably  due  to  a  l<  — 
marked  failure  of  development  of  the  same  nature. 

Another  type  of  anomaly,  which  has  also  been  described  ;i-  coloboma  of  the 
,,,,■>■<,  consists  in  the  absence  of  a  zone  of  choroid  (often  wider  below)  around 
the  otherwise  moderately  normal  papilla,  the  blood-vessels  appearing  near 
the  ••enter  of  the  hun  r  and  passing  aero—  the  borders  of  the  zone  without  any 
displacemenl  or  other  sign  to  indicate  any  considerable  excavation.  ! 
cases,   in  the  opinion  of  the   writer,  would   be   more  accurately  d< 


456  /> /si;  AXES  OF  THE  OPTIC  NERVE. 

circvmpapiUary  eoloboma  of  tin  choroid,  and  to  this  class  the  rase-  exhibiting 
mere  crescents  <>t"  choroidal  absence  below  the  papilla  arc  most  probably  allied. 
Coloboma  of  the  nerve  is  generally  associated  with  imperfect  sight  and 
often  with  nystagmus  or  microphthalmos.  It  may  affect  one  or  both  eyes, 
and   its  etiological  relationship  to  eoluboma  of  the  choroid  is  shown  by   its 


Fig.  267.— Band  of  connective  tissue  in  optic  tlisk. 

occurring  sometimes  in  the  same  eye  with  the  latter,  or  in  one  eye  of  an  indi- 
vidual having;  eoloboma  of  the  choroid  and  iris  in  the  other  eye. 


i  :■,  a  -     Extreme  development  of  connective  tissue  in  optic  disk. 

The  bemds  of  connectivt  tismt  not  infrequently  seen  upon  the  disk  may  be, 

Masselon   suggests,  prolongations  of  the    Lamina   cribrosa,  though    they 

sometimes, as  in  Fig.  267,  appear  to  have  no  connection  with  it.     In  extreme 

cases,  as  shown  approximately  in  Fig.  268,  the  entire  disk  may  be  concealed 

by  a  pearly,  bluish-white  mass  of  connective  tissue. 


A.MBLYOPIA,  AMAUROSIS,  AND  DISTURBANCES   OF 
VISION  WITHOUT  OPHTHALMOSCOPIC  CHANGE 


liv  CASEY   A.    WOOD,   M.  D., 

OF    CHICAGO,    ILL. 


The  terms  amblyopia  (dpftAut;,  dull,  and  cb(j>,  the  eve — i.  e.  obscurity  of 
vision)  and  amaurosis  (dfiaupoc,  dark,  a  marked  blindness)  have,  since  the 
days  of  Hippocrates,  beeo  applied  to  different  degrees  of  loss  of  sighl  without 
sensible  change  in  the  ocular  structures.  The  invention  of  the  ophthalmo- 
scope and  the  use  of  the  microscope  have  greatly  diminished  the  number  of 
these  affections,  but  there  still  remain  "functional  "  diseases  of  the  eye  desig- 
nated either  by  the  dimness  of  vision  (amblyopia)  or  decided  loss  of  sight 
(amaurosis)  that  forms  the  most  prominent  symptom.  Eyes  blind  from  in- 
flammatory diseases,  as  well  as  from  certain  congenital  changes  in  the  fundi, 
may  also  be  described  as  amaurotic. 

Congenital  Amblyopia. — When  an  eye  has  never  taken  pari  in  the 
visual  act,  as  in  cases  of  early  squint,  congenital  cataract,  corneal  scars,  or 
other  obstruction  to  the  light-rays,  the  accompanying  dim  vision  may  be 
altogether  or  partly  the  result  of  simple  non-use  ;  hence  the  terms  amblyopia, 
exanopsia,  and  argamblyopia  (Gould).  In  such  cases,  especially  in  squint, 
where  the  defective  sight  is  largely  due  to  the  presence  of  high  degrees  of 
hyperopia  or  astigmatism,  or  both,  correction  of  this  ametropia,  with  exercise 
of  the  eye,  may  result  in  much  improvement  of  sight  or  even  in  a  return  to 
normal  vision.  In  other  instances,  however,  correcting  lenses  do  not  help, 
and  we  may  then  conclude,  even  in  the  absence  of  positive  signs,  thai  struc- 
tural changes  or  defects  exist,  probably  in  some  portion  of  the  extra-bulbar 
nervous  apparatus. 

In  still  another  class  of  cases  careful  examinations  with  the  mirror  show- 
in  the  nerve-head,  retina,  or  choroid  slight  departure-  from  the  normal  ap- 
pearances. The  papilla  especially  may  be  irregularly  shaped  or  dimmed  in 
outline,  while  the  perimeter  reveals  seotomata  and  peripheral  contractions  of 
the  Held.  Such  anomalies  as  colobomata  of  the  opticus,  choroid,  retina,  and 
iris,  as  well  as  non-development  of  the  whole  eyeball  (microphthalmos),  are 
usually  associated  with,  and  are  described  as,  examples  of  congenital  ambly- 
opia. Many  of  the  ocular  diseases  of  extra-uterine  life  also  affeel  the  fetal 
eye.  Among  these  are  glaucoma,  iritis,  chorio-retinitis,  and  diseases  of  the 
optic  nerve,  all  of  which  have  been  classed  with  the  congenital  amblyopias. 

Congenital  Amblyopia  for  Colors  (Subnormal  Color-sensi  ;  Color- 
blindness).— Total  absence  of  the  color-sense  (achromatopsia)   is   rare  as  a 

congenita]  condition   and  aparl   from  disease,  bul  it  ;urs   to   some  extenl 

and   for  some  color-   in  about    '■'>   per  cent,   of  the   whole   population.      I 
quite  rare  (0.20  per  cent.)  in  women,  is  sometimes  hereditary,  and  i-  almosl 
always  bilateral. 

By  far  the  commonesl   form   of  color-blindness   is  exhibited   when   the 


458  AMBLYOPIA    AND  AMAUROSIS. 

individual  fails  to  detecl  the  red  and  green  in  mixtures  containing  these 
colors.  A-  a  result  of  tins  defective  color-sense,  or  rfi/si-h/'oiiiafopsia,  the 
pure  greens  arc  readily  mistaken  for  grays  and  shades  of  red,  and  vice  versd. 

A  less  numerous  class  name  correctly  most  of  the  saturated  primary  colors, 
but  are  very  liable  to  miscall  all  or  most  of  the  color  mixtures.  They  see 
little  or  no  difference  between  orange  and  red,  blue  and  purple,  or  violet  and 
blue.  In  other  words,  they  perceive  in  a  compound  only  the  predominating 
color.  Artificial  light  generally  adds  to  the  difficulty  which  these  persons 
experience  in  selecting-  colors. 

The  nomenclature  of  color-blindness  is  built  upon  various  theories  of 
color-perception  ;  thus,  the  two  forms  of  dyschromatopsia  just  described  may 
be  designated  "red-green"  and  "blue-yellow"  blindness,  or  we  may,  with 
propriety,  speak  of  red,  green,  and  violet  dyschromatopsia  (see  also  pages 
98-100). 

Whether  the  structural  defects  that  give  rise  to  the  various  forms  of  sub- 
normal color-perception  exist  at  the  periphery  or  in  the  central  portions  of 
the  optic  tract,  they  are  equally  incurable  (see  also  Appendix,  page  603). 

Reflex  Amblyopia. — Both  amblyopia  and  amaurosis  have  resulted 
from  "reflex  irritations"  conveyed  from  remote  organs,  but  such  cases  are 
rare.  Loss  of  sight  has  been  attributed  to  diseases  of  the  reproductive 
organs,  spinal  cord,  and  digestive  apparatus.  Well-authenticated  examples 
of  amblyopia  from  intestinal  worms,  decayed  teeth,  diseases  of  the  naso- 
pharynx and  its  neighboring  cavities  (especially  neoplasms  and  muco-purulcnt 
collections)  have  also  been  recorded.  In  most  of  these  cases  there  were  no 
fundus  changes,  and  improvement  or  cure  followed  successful  treatment  of 
the  distant  lesion. 

The  etiology  of  reflex  amblyopia  is  very  obscure,  and  we  must,  for  the 
present,  continue  to  hold  to  the  vague  hypothesis  of  vaso-motor  disturbances, 
affecting  the  nutrition  of  the  retina  in  some  instances  and  of  the  central 
ganglia  in  others,  until  similar  mysteries  of  "functional  disorders"  elsewhere 
are  cleared  up.  Probably  some  of  these  alleged  reflex  manifestations  are 
really  unrecognized  cases  of  hysterical  amblyopia. 

Uremic  Amblyopia,  or  Amaurosis. — This  loss  of  vision  occurs  occa- 
sionally in  the  toxemia  of  Bright's  disease,  but  is  most  frequently  noted  in 
those  states  of  the  system  where  albuminuria  is  found  as  a  transient  condition 
— viz.  in  pregnancy  and  the  late  stage  of  scarlatina.  It  affects  both  eyes, 
comes  mi  suddenly,  often  lasts  but  a  short  time,  and  disappears  as  quickly  as 
it  came.  It  is  almost  always  associated  with  other  uremic  symptoms,  espe- 
cially with  convulsions,  headache,  vomiting,  and  coma.  The  blindness,  which 
may  be  complete,  is  probably  due  to  a  temporary  affection  of  the  visual  cen- 
ters produced   by  the  uremia. 

The  prognosis  is  uniformly  favorable.  Permanent  blindness  results  only 
when  organic  lesions  of  the  nerve  and  retina  (albuminuric  retinitis  and  optic 
neuritis  I  are  present. 

0phthalmO8COpicatty,  nothing  is  to  be  seen  in  the  retina,  although  several 
writers  describe  fulness  of  the  vessels  and  a  swollen  appearance  of  the  papilla. 

The  //'  nl  nn  nl  i-  I  hat  of  uremia. 

GlyCOSUrie  Amblyopia. — Apart  from    the  cataract  of  diabetic  patients 

and  those  retinal  ami  optic-nerve  lesions  that  so  closely  resemble  the  fundus 
changes  found  in  Bright's  disease,  there  is  sometimes  observed  a  dimness  of 
vision  thai  simulates  the  amblyopia  from  tobacco  and  alcohol.  There  arc,  in 
these  cases,  no  alterations  visible  with  the  mirror,  but  central  scotomata  for 
red  and  green  can  always  be  mapped  out. 


AMBLYOPIA    FROM   THE  ABUSE  OF  DRUGS.  459 

As  the  writer  bus  elsewhere1  pointed  out,  the  diagnosis  is  somewhat 
difficult  when  the  diabetic  patient   is  a  smoker,  but  in  such   instances  the 

color-defect  often  extends  to  blue  and  white.  In  time  white  becomes  involved 
at  the  periphery  of  the  field  also — a  condition  of  things  never  found  in  pure 
tobacco  or  alcohol  amblyopia. 

The  pathology  is  obscure,  but  Horner's  views  of  the  causation  of  alcohol- 
tobacco  blindness  may  find  acceptance  in  the  case  of  glycosuric  amblyopia — 
viz.  that  it  is  due  to  malnutrition  of  the  macular  libers,  in  this  instance 
brought  about  by  glucose  in    the  blood. 

The  prognosis,  unlike  that  of  tobacco  amblyopia,  which  it  resembles,  is 
grave;  in  spite  of  treatment  (of  the  diabetes)  the  case  usually  goes  on  to 
simple  optic-nerve  atrophy  and  terminates  in  total  loss  of  sight. 

Malarial  Amblyopia. — It  has  been  observed  that  during  the  course  of 
intermittent  fever  and  other  diseases  of  malarial  origin  an  amblyopia  accom- 
panied by  fundus  changes,  and  usually  affecting  one  eye,  may  se1  in.  The 
attacks  are  generally  of  short  duration,  but  in  some  instances  persist  for 
weeks.  The  dim  vision  is  commonly  attributed  to  the  action  of  the  malarial 
poison  upon  the  optic  nerve  and  retina.  It  must  not  be  forgotten,  in  this 
connection,  that  quinin,  so  universally  administered  in  malarial  diseases,  is 
known  to  produce  a  temporary  amblyopia  quite  apart  from  the  well-known, 
serious  fundus  lesions  of  quinin-amaurosis,  and  the  writer  is  convinced  that 
some  of  the  reported  cases  of  malarial  amblyopia  are  merely  examples  of  the 
ocular  symptoms  of  a  mild  quinin-intoxication. 

True  malarial  amblyopia  improves  under  quinin  and  other  antiperiodics, 
and  complete  recovery  is  the  rule. 

Amblyopia  from  I/OSS  of  Blood. — The  optic  nerve  bears  even  a 
temporary  anemia  very  badly,  and  many  secondary  alterations  in  its  tissues 
may  be  directly  traced  to  malnutrition  of  a  kind  that  would  be  successfully 
resisted  by  other  nerves  of  special  sense.  Instances  of  a  temporary  loss  of 
vision  following  excessive  hemorrhage  are  quite  common,  especially  from 
ulcer  of  the  stomach  or  intestines.  Post-part nm  floodings  may  also  produce 
this  form  of  amblyopia.  An  attack  of  dim  vision  may  be  the  forerunner  of 
optic  atrophy  (usually  preceded  by  optic  neuritis)  setting  in  a  week  or  ten  days 
after  the  loss  of  blood.  The  papilla,  at  the  time  of  the  bleeding,  is  quite  pale 
and  the  arteries  are  small. 

Treatment. — The  treatment  of  the  primary  amblyopia  is  the  transfusion 
of  blood  or  the  intravenous  injection  of  physiological  salt  solution.  Diffusible 
stimulants  and  rest  in  bed,  with  small  and  repeated  quantities  of  easily  assimi- 
lated food,  should  be  prescribed.  These  should  be  followed  by  tonic  mixtures 
of  iron  and  strychnin.  The  remedies  employed  for  the  relief  of  the  later  eye- 
troubles  following  profuse  hemorrhage  must  be  regulated  by  the  form  the 
fundus,  lesions  assume. 

Amblyopia  from  the  Abuse  of  Drugs. — The  poisonous  agents  that 
produce  ocular  symptoms  are  so  numerous  that  anything  like  a  complete 
account  of  all  of  them  would  be  inappropriate  here.  In  the  following  list 
the  most  important  ones  are  italicized  :  tobacco,  alcohol,  carbon  disulphid, 
iodoform,  lead-salts,  quinin,  salicylic  acid  and  other  salicylates,  cocain,  snake- 
venom,  mydriatic  alkaloids,  ptomams,  carbolic  acid,  male-fern,  aconite,  chloral, 
santonin,  picric  acid,  digitalis,  tea,  coffee,  chocolate,  gelsemium,  ergot,  coal- 

1  The  Toxic  Amblyopias,  v.  p.  14.     For  :i  full  accounl  of  this  matter  see  I  »r.  W.  O.  Moore'a 
paper  on  "Diabetic   Affections  of  the    Eye,"   N.    )'.    Medical  Journal,  Mar.  31,   18€ 
Archives  of  Ophthalmol < ion,  vol.  xxiv.  No.  2;  Hirwchberg :   Deutsch.  med.  Wochenschr.,   Mar.  26, 
1891. 


460  AMBLYOPIA   AM)   AMAl'liOSIS. 

tar  products,  arsenic,  naphthalin,  potassium  bromid,  ergot,  amy]  nitrite,  nitro- 
benzol,  mercurial  compounds,  silver  nitrate,  antipyrin,  curare,  and  a  large 
number  of  other  drugs. 

Etiology  and  Pathology. —  Tobacco-,  alcohol-,  and  tobacco-alcohol  intox- 
ications present  by  far  the  commonest  examples  of  toxic  amblyopia.  It  is 
now  admitted  that  alcohol  or  tobacco  alone  may  produce  partial  loss  of  vis- 
ion, l)iit  inasmuch  as  the  smoker  is  usually  a  drinker  and  as  the  alcoholic 
commonly  smokes,  we  almost  always  have  to  deal  with  mixed  examples  of 
intoxication. 

Sachs  (with  the  English  school)  believes  that  alcohol  predisposes  to 
tobacco-poisoning  by  producing  dyspepsia.  Horner  is  convinced  that  neither 
alcohol  nor  tobacco,  as  such,  produce-  the  pathological  changes  found  in  the 
opticus.  Together  these  drugs  produce  a  chronic  gastric  catarrh,  which,  in 
it-  turn,  brings  on  a  chronic  anemia  of  the  optic  nerve,  terminating  in  the 
retro-bulbar  neuritis  characteristic  of  alcohol  and  tobacco  amblyopia.1 

Samelsohn,  CJhthoff,  and  others  have  demonstrated  by  autopsies  that  the 
essential  lesion  in  this  disease  is  an  axial,  interstitial  neuritis,  beginning 
somewhere  between  the  papilla  and  brain,  and  probably  extending  thence 
both  toward  the;  center  and  the  periphery  (sec  Plate  7).  The  fibers 
affected  are  those  that  supply  the  macular  region — one-fourth  or  one-third 
of  the  whole  number.  The  axis-cylinder  and  the  true  nervous  elements 
mostly  escape.  The  trabecular  tissues  enclosing  these  increase  both  as  to 
number  and  size  and  press  upon  the  nerve-fibers,  bringing  about  their  partial 
atrophy,  just  as  the  connective  elements  in  cirrhosed  liver  and  fibroid  phthisis 
encroach  upon  the  more  highly  organized  tissues  of  the  liver  and  lungs. 

Recently,  Nuel  has  revived  the  theory  that  central  toxic  scotoma  is  not 
primarily  a  neuritis  of  the  macular  bundle,  but  a  disease  of  the  macula  lutea, 
causing  degeneration  of  its  cells,  and  that  the  optic-nerve  changes  are  sec- 
ondary to  the  destruction  of  the  nerve-cells  of  the  macula.  CJsher  and 
Dean  have  observed  macular-fiber  degeneration  follow  experimentally-pro- 
duced  retinal    lesions. 

'Idle  majority  of  these  cases  occur  in  persons  over  forty  years  of  age  ; 
examples  of  the  disease  in  the  female  sex  are  uncommon,  and  we  must 
remember  that  this  form  of  toxic  amblyopia  occurs  only  in  those  who  have 
an   idiosyncrasy   toward   tobacco  or  alcohol. 

Symptoms. — The  symptom  most  complained  of  is  "  misty  "  vision;  the 
patient  speaks  of  "seeing  through  a  fog"  or  "through  smoke."  Even 
earlier  than  this  he  finds  difficulty  in  reading  or  doing  any  other  form  of 
near  work,  for  which  he  usually  seeks  glasses  or  requests  to  have  his  reading 
lenses  changed.  His  visual  acuity  for  both  distance  and  near  may  fall  as 
low  a-  .,  |;  D  and  .1.,  1  1.  I  Ie  now  fails  to  distinguish  vnl  and  green  objects,  and 
on  examination  with  the  perimeter  negative  central  scotomata,  in  the  form 
of  horizontal  ovals  extending  from  the  blind  spots  and  including  the  fixation- 
points,  '"in  be  mapped  out  (Figs.  269  and  270).  Blue  and  white  are  rarely 
affected   in   pure  cases  of  tobacco  amblyopia. 

Owing  to  the  situation  of  the  scotomata,  most  patients  are  day-blind  and 
see  besl  with  a  dilated  pupil — i.e.  toward  evening  or  in  a  dimly-lighted 
room. 

The  minor  sometimes  reveals  alteration-  in  the  disk.     When  these  are 

ah-ent   it   may  be  assumed  that   the  atrophic    changes  have  not  yet   reached  the 

1  The  render  is  referred,  for  a  lull  description  of  all  thai  i^  known  of  the  toxic  amblj opias 
to  Dr.  Geo.  E.  de  Schweinitz's  work  en  thai  subject.  A  smaller  and  less  complete  monograph 
by  the  writer  of  this  article,  bearing  the  same  title,  appeared  i\\"  years  earlier. 


Plate  7. 


r',,/r  1  h;„i,iiy,- 

Fig  I. 


£//d'j 


v 


<&»<•§ 


I-   ^"/  ■; 


-% 


^a*»*»* 


88. 


Sections  of  the  ri'jhi  * > | •  t i< ■  nerve  in  :i  case  of  toxic  amblyopia,  showing  degeneration  of  the 
papillomacular  bundle;  Weigert's  stain  (de  Schweinitz  . 
Fig.  I.     Longitudinal  section  of  the  posterior  half  of  the  righl  bulbus  and  five  millimeters 
of  the  "|>t  ic  in  r\  e. 

I  p.-    II.  and    111.     Transvi  rse   sections  of  the  optic  nerve,  <i^lii  and  thirteen  millimeters, 
respectively,  behind  i  be  globe. 

Figs.  [V.  and  V.     Transverse  sections  of  the  optic  nerve  in  the  region  of  the  optic  foramen. 
Fig.   VI.     Transverse  section  of  the  nerve  in  1 1 1 < -  intracranial  region. 


AMBLYOPIA    FROM   THE  ABUSE  OF  DRUGS. 


461 


nerve-head 


The  mosi  constant  signs  arc  hyperemia  of  the  papilla  in  the 
early  stages  of  the  disease,  and  later  a  triangular  atrophic  area,  occupying 

the   temporal    third    of   the    nerve-head    and    corresponding   to    the    macular 
bundle  of  libers. 

Diagnosis. — The   diagnosis  of    the    retro-bulbar    neuritis   produced    by 
tobacco  and  alcohol   rests  upon  the  account  jn.-t   given.1     The  disease   may 


I.E. 


/.'.  /•;. 


Fig.  269.— Alcohol  amblyopia. 


i  fnv  blue 

Small  absolute  central  defect,  surrounded  bv  a  scotoma  t'"r  blue 
(Uhthoff  . 


be  mistaken  for  non-toxic  orbital  axial  neuritis,  disseminated  sclerosis,  loco- 
motor ataxia,  and  scotomatous  atrophy  of  the  optic  disk.  Everything  con- 
sidered, it  is  not  difficult  to  differentiate  these  forms  of  ocular  disease  (see 
also  page  447). 

Uhthoff  thus  summarize-;  the  points  of  diagnosis  between  the  retro-bulbar 
neuritis  of  tobacco  and  alcohol  and  that  dne  to  other  causes,  such  as  syphilis, 


Fig.  270.— Typical  oval  scotomata  from  a  i.e.  (-amblyopia.    The  patii  cty,  had 

•  i  four  pipes  of  tobacco  daily,  anil  an  occasional  cigar,  Bince  he  was  nineteen ;  a  modi 
drinker  (de  Schweinitz). 

rheumatism,  disorders  of  menstruation,  cold,  diabetes,  etc.,  as  follows  :   1.  In 
true  toxic  amblyopia  the  central  scotomata  are  almosl   invariably  confined  to 

red  and  green.     '2.  The  scol ata  and  visual  disturbances  are  bilateral,  and 

the  former  are  confined  to  the  center  of  the  field.     '■'>.   Vision  does  nol  fall 

1  For  t lie  differential   diagnosis  between  tli<-  various  forms  of  central  amblyopia 
Schweinitz,  toe.  cii ,  pp.   B5,  36. 


liii'  AMBLYOPIA    AXD  AMAUROSIS. 

below  .,;';,,.  4.  The  form  of  the  scotoma  is  that  of  an  oval,  including  both 
blind  spot  and  fixation-point,  with  its  long  axis  lying  above  the  horizontal 
meridian.  ■">.  The  vision  becomes  gradually  less.  <i.  The  disease  affects 
men  above  forty  years  of  age.  7.  Pain  is  noticed  mi  extreme  <><-n/<ir  m<>r<- 
ments  in  essential  retro-bulbar  neuritis,  but  i>  invariably  absent  in  the  toxic 
form. 

He  Schweinitz  says  of  the  non-toxic  variety  that  there  is  a  history  of 
chilling  of  the  body,  excessive  exertion,  suppression  of  menses,  or  of  infec- 
tious diseases,  rheumatism,  etc.  ;  there  is  no  special  relation  to  sex  or  age. 
The  visual  acuity  is  greatly  disturbed  ;  sometimes  there  i^  complete  blindness. 
(  M'ten  there  is  a  positive  scotoma  tending  to  pass  to  the  nasal  side  of  the  fixa- 
tion-point, and  not  specially  oval  or  horizontal.  Peripheral  contraction  of 
the  field  for  white  and  colors  may  be  present,  with  woolliness  of  the  whole 
disk  and  distention  of  the  veins.  It  is  often  rapid  in  onset,  and  is  frequently 
slow  in  responding  to  treatment. 

Prognosis. — This  is  favorable,  even  when  the  blindness  has  lasted  for  a 
long  time.  When  total  abstinence  from  the  toxic  agent  is  persistently  prac- 
tised and  there  is  no  other  optic-nerve  disease,  sight  should,  with  judicious 
management,  be  restored  in  from  six  weeks  to  three  months. 

Treatment. — This  consists,  first  of  all,  in  stopping  the  use  of  tobacco  and 
alcohol  in  all  their  forms.  It  must  be  remembered  that  the  amblyopia  is  but 
part  of  a  general  intoxication,  and  that  chronic  gastric  catarrh  is  usually 
present.  The  digestive  power  is  consequently  often  weak,  and  it  should  be 
fortified  by  appropriate  means.  Proper  food,  exercise,  bathing,  and  regula- 
tion of  the  bowels  are  valuable  adjuncts  to  tonic  remedies.  The  Turkish 
bath  has  a  decided  value,  especially  in  alcoholic  cases.  The  chief  aim  should 
be  to  furnish  a  supply  of  good  blood  to  the  badly-nourished  optic  nerve. 
Most  of  the  so-called  specifics,  mix  vomica  and  strychnin  particularly,  are 
very  useful,  especially  with  pallor  of  the  disk  and  when  general  toxic  symp- 
toms are  present.  Usually  lull  doses  of  the  elixir  of  pepsin,  bismuth,  and 
strychnin  may  be  given  internally.  This  treatment  is  accompanied  by  hypo- 
dermic injections  of  strychnin,  that  are  gradually  increased  in  strength  until 
toxic  symptoms  are  produced.  The  dose  is  then  to  be  diminished  one-fourth, 
and  so  continued  for  several  weeks.  When  there  is  an  edematous  or  hyper- 
emic  papilla,  potassium  iodid  may  be  substituted  for  the  strychnin.  When 
not  otherwise  contraindicated  and  the  Turkish  bath  cannot  be  readily  taken, 
the  hot  puck,  combined  with  hypodermic  injections  of  pilocarpin  (gr.  \)  twice 
a  week,  is  very  useful,  and  certainly  cuts  short  the  duration  of  the  amblyopia. 

Lead-amblyopia. —  Lead  and  its  salts  not  infrequently  produce  ambly- 
opia and  amaurosis.  These  cases  are  mosl  commonly  found  in  painters,  em- 
ployes of  paint-  and  lead-works,  plumbers,  as  well  as  in  persons  poisoned  from 
eating  canned  food  or  drinking  water  polluted  with  plumbic  compounds. 

The  poison  brings  about  so  many  changes  in  the  brain  and  kidneys,  as 

Well  as  in  the  optic  Derve,  that  it  is  often  difficult  tO  say  whether  the  eye 
alteration-  arc  due  to  the  direct  action  of  the  lead  on  the  optic  nerve,  retina, 
and  visual  center-,  or  whether  they  are  secondary  to  the  other  organic  lesions. 
In  any  event,  it  is  probable  that  the  ocular  changes  begin  in  the  terminal 
vessels  of  the  eye  as  a  fatty  metamorphosis  or  obliterating  endarteritis,  and 
that  subsequently  the  tissues  supplied  by  these  vessels  undergo  secondary 
metarrn  irphoses. 

These  alterations  affeel  the  retina  and  papilla,  and  may  be  studied  ophthal- 
moscopically.  The  commonest  sign  is  optic-nerve  atrophy  with  woolly  disks 
and  small  vessels.     Vision  is  always  greatly  affected,  both  at  the  center  and 


V  f  'IX1X-AMA  UBOSIS. 


163 


periphery.  In  another  class  of  cases  there  is  <>/>/!<■  neuritis,  with  the  usual 
appearances  in  and  about  the  nerve-head;  in  still  another  a  retro-bulbar 
degeneration  sets  in.  Finally,  there  arc  states  of  transient  amblyopia  without 
ophthalmoscopic  change;  indeed,  patients  suffering  from  atrophy  due  to 
Lead-poisoning  often  give  a  history  of  antecedent  " attacks "  of  dim  vision. 
These  Go wers  regards  as  analogous  to  the  temporary  amaurosis  of  diabetes 
and  uremia,  and  think-  they  are  due  to  the  direct  effect  of  the  lead  .-alts  upon 
the  visual  centers.  In  doubtful  cases  the  excreta  should  be  examined  for 
lead.  Oliver  relates  a  case  of  progressive  blindness  where  the  urine,  saliva, 
and  nasal  mucus  revealed  the  presence  of  lead.     In  a  case  reported  by  the 


Fig.  271.— Visual  field  in  lead-amblyopia. 


Fig.  272.— Visual  field  in  lead-amblyopia. 


writer  there  were  marked  optic-nerve  atrophy,  with  restricted  fields  (see  Figs. 
271  and  272),  and  almost  complete  oculo-motor  paresis  on  the  left  side 

Prognosis  is  favorable  in  the  early  stages  of  transient  amblyopia,  but 
very  unfavorable  when  optic  inflammation  or  atrophy  has  set   in. 

Treatment  consists  in  the  instant  removal  of  the  source  of  the  poison, 
the  administration  of  small  doses  of  magnesium  sulphate,  the  use  of  Turkish 
baths,  and  pilocarpin  injections.  Strychnin  before  a  meal  and  potassium  iodid 
after  it  are  usually  employed,  but  the  former  should  be  omitted  when  active 
inflammation  is  present. 

Quinin-amaurosis. — Quinin,  like  lead,  may  be  responsible  for  both  a 
temporary  amblyopia  and  an  amaurosis  with  characteristic  fundus  changes. 
The  blindness,  in  the  latter  instance,  comes  on  suddenly, is  often  complete, 
and  may  last  for  several  days.  The  pupils  are  widely  dilated,  and  do  not 
react   to  light,  although  they  may  to  accommodation. 

The  ophthalmoscope  -hows  an  absolute  anemia  of  the  Jundus.  The  papilla 
is  chalky-white,  and  no  trace  of  retinal  vessels  can  be  discovered.  This 
remarkable  condition  i-  accompanied  by  other  signs  and  symptoms  of  cincho- 
ni-ni,  although  permanent  blindness  is  excessively  rare.  In  severe  cases  the 
optic  nerve  rarely  recover-  entirely  from  the  poisonous  effects  of  the  drug,  and 
the  patient  henceforth  exhibits  decided  limitations  of  the  field  (Fig.  273),  often 
defective  central  vision,  am  1  usually  evidences  of  retinal  ischemia.  Usually, 
large  doses  of  the  drug  are  required  to  produce  amaurosis  ;  but  in  some  suscept- 
ible individual-  even  physiological  doses  have  produced  temporary  blindness 

We  are  mainly  indebted  t<>  Brunner  and  de  Schweinitz  for  experimental 
proof  that  the  amaurosis  is  due  to  a  species  of  "edema  of  the  optic-n 


4Gi 


AMBLYOPIA    AXD  AMAUROSIS. 


!      N 


Fig.  273.— Normal  optic  nerve  of  a  dog,  transverse  section ;    ■:  125,  Weigerl  stain  (de  Schweinitz). 


H  ■".  •:".'-"- 


Fio.  27i.    Optic  nerve  ol  a  dog  blind  fr<.m  the  effects  of  quinin,  showing  almost  complete  atrophy 

12  i,  w  i  Igert  -i.iin    de  Schweinitz). 


PTOMAIN-POISONLNG  .-    BQTULISMUS;   ALLANTIASIS.       165 

tissue  between  the  chiasm  and  eyeball  and  the  influence  of  quinin  on  the 
vaso-niotor  apparatus,  which  cause  excessive  constriction  of  the  peripheral 
circulation,  and  finally  local  changes  in  the  vessels  (endovasculitis)  and 
atrophy  of  the  optic-nerve  fibers"  (Figs.  27.")  and  274).  De  Bono  believes 
that  quinin  intoxicates  the  protoplasmic  elements  of  the  retina,  acting  as  a 
depressant  poison  on  the  rods  and  cones.  Ilolden  has  demonstrated  that  the 
primary  action  of  the  drug  is  upon  the  ganglion  cells  of  the  retina. 

The  treatment  of  quinin-amaurosis  is  much  the  same  as  that  of  tobacco- 
amblyopia.     Nitrite-of-amyl  inhalations  give  temporary  relief. 


L.E. 


R.E. 


Fig&  275,  276.— Visual  fields  from  Gruening's  case.    The  shaded  areas  represent  the  Limits  of  the  6elds, 
the  upper  map  three  and  the  lower  one  six  months  after  recovery  from  complete  blindness. 

Ptomain-poisoning  ;  Botulismus  ;  Allantiasis. — The  putrefactive 
alkaloids  found  in  "  high  "  game,  decomposed  sausage,  uncooked  meat,  and 
rotten  fish  (as  well  as  the  leukoina'i'ns  of  poisonous  fungi,  snakes,  and  .-hell- 
fish)  occasionally  produce  amblyopia  as  one  of  thesymptoms  of  intoxication. 
Brieger  found  ethylenediamin  to  be  the  active  principle  in  several  cases  oi 
poisoning  from  decomposed  food. 

Symptoms. — These  closely  resemble  those  of  belladonna-poisoning  ;  the 
dim  vision  is  transitory,  and  it  is  uniformly  *\^'  to  bilateral  paresis  of  accom- 
modation with  marked  mydriasis.  Ptosis  is  also  a  common  symptom.  All  the 
extrinsic  ocular  muscle-  may  be  paralyzed,  from  bilateral  and  nearly  com- 
plete ophthalmoplegia  externa  to  paresis  of  a  single  muscle.  1  here  are  no 
fundus  changes.  When  death  due-  not  occur  and  the  paralyses  persist,  these 
are  the  result  of  basilar  meningitis  or  nuclear  hemorrhages.  I  he  treatment 
is  the  same  as  thai  suited  to  atropin-poisoning. 

30 


466  A  MB  L  1  "0  PI  A    A  SD  .  I  M.  I  1 7?  OSIS. 

Male-fern  amblyopia  and  amaurosis  are  not  uncommon  from  acute  poi- 
soning with  this  drug,  but  the  ocular  symptoms  (except  that  of  blindness) 
and  the  fundus  changes  recorded  have  been  far  from  uniform.  Widely- 
dilated  pupils,  followed  by  optic-nerve  atrophy,  are  most  commonly  observed. 
I  >e  Schweinitz  and  others  have  experimented  on  the  lower  animals  with  nega- 
tive results;  but  Nuel  and  others  have  produced  optic-nerve  degeneration  by 
administering  extract  ot"  male-fern  to  animals. 

Toxic  Asthenopia. — Some  time  ago  the  writer  ventured  the  opinion 
thai  the  employment  of  certain  intoxicants,  some  of  them  drugs  and  beverages 
in  even-day  use,  is  not  infrequently  followed  by  minor  defects  of  vision,  the 
true  nature  of  which  is  unsuspected  by  the  patient  or  his  medical  attendant. 
These  symptoms,  which  are  commonly  included  in  the  term  "asthenopia," 
show  themselves  especially  as  a  decrease  in  the  amplitude  of  accommodation 
and  convergence.  Evidences  of  this  muscular  weakness  may  be  seen  in  the 
transient  intoxication  from  quinin,  the  salicylates,  iodids,  bromids,  alcohol, 
tobacco,  coffee,  tea,  chocolate,  and  such  forms  of  decomposed  food  as  "  high  " 
game,  "strong"  cheese,  etc.  The  asthenopic  symptoms  occasionally  observed 
in  some  forms  of  dyspepsia  probably  also  constitute  a  toxic  amblyopia  due  to 
ptomain-poisoning.  They  properly  belong  to  those  milder  types  of  allantiasis 
where  the  eye-signs  arc  not  sufficiently  marked  to  be  recognized  by  the 
unskilled  observer. 

Hysterical  Amblyopia. — This  curious  form  of  blindness  is  most  com- 
monly observed  in  girls  and  women,  but  typical  examples  are  not  unusual  in 
men  and  children.  The  most  constant  symptom  is  amaurosis  of  one  eye 
without  fundus  changes.  This  peculiar  loss  of  visual  power  sometimes  fol- 
lows injuries  [traumatic  hysteria,  traumatic  neurosis)  in  hysterical  subjects,  but 
it  more  frequently  come.-  on  without  warning.  The  pupil  usually  reacts  to 
light,  but  it  may  be  dilated  and  motionless.  The  patient  is  often  partially  or 
totally  color-blind.     Sometimes  there  is  a  central  scotoma. 

There  are  nearly  always  other  hysterical  symptoms  present,  especially 
hemianesthesia  (usually  variable  and  incomplete)  of  the  affected  side,  loss  of 
the  pharyngeal  and  corneal  reflexes,  ptosis,  monocular  diplopia,  micropsia 
and  megalopsia  and  blepharospasm.  The  field  j'<>r  red  and  green  is  often 
larger  than  that  for  white.  Sometimes  there  is  complete  reversal  of  the  nat- 
ural order  of  the  color-fields,  blue  or  white  being  smallest,  red  next  in  size, 
while  the  Held  for  green  is  largest  of  all  (for  diagrams  see  page  487). 

Diagnosis. — This  is  sometimes  difficult,  especially  in  recent  cases.  It  is 
well  known,  for  example,  that  the  hysterical  amblyope  can  be  made  to  see. 
An  instance  of  this  occurred  in  a  case  known  to  the  writer  where  an  hysterical 
subject  sued  for  damages  on  account  of  injury  to  the  head  causing  blindness 
to  the  right  eye.  Malingering  was  sel  up  as  a  defence,  because  it  was  shown 
that  the  patient  saw  with  the  supposed  blind  eve  when  examined  by  prisms 
and  a  light  ;it  twenty  feet.  In  all  cases  of  unexplained  monocular  blindness 
without  fundus  alterations  hysteria  should  be  suspected,  and  one  should  be 
on  the  lookout   for  it-  other  manifestations. 

Prognosis  is  favorable,  but  th«'  amaurosis  may  persisl  for  years.  Treat- 
ment should  be  directed  to  the  hysterical  state  generally.  Electricity,  mas- 
sage, outdoor  exercise,  and  tonics  furnish  the  besl  results. 

Pretended  Amblyopia  ;  Malingering. — It  is  comparatively  easy  to 
detecl  ;i  pretended  monocular  amblyopia  or  amaurosis,  but  difficull  to  uncover 
the  deception  of  the  person  who  claims  to  be  blind  in  both  eye-.  lie  may 
be  exposed  l>\  watching  him  when  he  docs  not  expecl  it.  by  flashing  a  bright 
lighl  on  his  face,  or  by  making  feints  to  strike  him,  for  the  purpose  of  elicit- 


SNOW-BLINDNESS.  167 

ing  the  lid  or  iris  reflex.  As  Swanzy  points  out,  one  cannot  depend,  for 
detection  of  the  malingerer,  upon  the  pupillary  reactions,  because  the  pupils 
contract  to  light,  even  when  the  patient  is  quite  blind,  it'  the  lesion  be  situated 
at  the  cortical  center  or  in  the  fibers  thai  conned  it  with  the  corpora  quadri- 
gemina.  Recently  Priestley  Smith  ami  E.  Jackson  have  suggested  a  simple 
tesl  for  feigned  binocular  blindness :  Place  a  lighted  candle  in  fronl  of  the 
subject  :  now  hold  a  six-degree  prism  with  its  base  to  the  temple  before  one 
eye;  it*  both  eyes  see  the  one  behind  the  prism  will  move  inward,  and  on 
removing  the  prism  will   move  outward,  the  other  eye   remaining  fixed. 

Many  plans  have  been  devised  tor  the  detection  of  simulated  ni<>ii'>r,i/<ir 
blindness,  hut.  on  the  whole,  Snellen's  colored-letter  test  for  distanl  binocular 
vision  is  the  most  valuable.  The  suspect  should  be  watched  that  In  (ln<s,i<it 
closi  f/i<  alleged  blind  eye  during  the  examination.  A  frame  holding  trans- 
parent letter-,  colored  alternately  red  and  green  and  adapted  to  five  or  six 
meters'  distance,   is  hung  in  a  window  or  is  highly  illuminated  from  behind. 

A  reversible  spectacle-frame,  fitted  with  a  plane  red  glass >ne  side  and  a 

green  u'la>-  on  the  other.  i-  placed  on  the  subject's  face.  The  red  letter-  can 
he  distinguished  only  by  the  eye  covered  with  the  red  glass  (which  s-lmts  out 
the  green  rays),  and  the  green  letters  can  he  read  through  the  green  glass 
only,  because  the  red  glass  cuts  off  the  green  rays.  If  the  subjecl  reads  red 
and  green  types  with  both  eyes  open,  or  during  several  trials,  reads  letter-  of 
a  color  that  dor-  not  correspond  with  that  of  the  u'las-  in  front  of  his  admit- 
tedly sound  eye,  he  must  have  seen  with  the  alleged  blind  eye. 

Dr.  Harlan  has  suggested  that  a  1  16  IX  lens  he  placed  before  the  eye 
acknowledged  by  the  subject  to  he  normal,  and  a  -0.25  D.  sphere  before  the 
alleged  blind  eye.  The  suspect  is  now  asked  to  read  the  ordinary  distant- 
test  types.  If  he  succeeds,  he  is  a  malingerer,  because  the  high-degree  con- 
vex lens  has  made  it  impossible  for  him  to  see  with  the  sound  eye,  and  of 
course  the  weak  concave  glass  does  not  interfere  with  vision.  An  additional 
control  test  may  now  he  made  by  placing  a  book  or  a  towel  over  the  •  16  D. 
lens.  The  malingerer  will  declare  his  inability  to  read  any  of  the  letter-. 
thus  further  exposing  his  attempted  fraud. 

J', -ism  or  diplopia  tests  are  advised  by  some  observers.  The  subject  is 
-eated  before  a  point  of  light  six  meter-  distant.  The  supposed  blind  eye 
is  covered  with  a  frosted  glass,  and  the  apex  of  a  <ir  prism,  directed  up  or 
down,  i-  -lowly  advanced  to  the  pupillary  center  of  the  sound  eye.  and  the 
suspected  person  is  asked  to  recognize  the  double  images  of  the  monocular 
diplopia  thus  produced.  This  maneuver  is  repeated,  with  the  prism  pointed 
in  various  directions,  until  he  becomes  accustomed  to  the  idea  of  diplopia. 
A  weak  concave  lens  i-  now  substituted  for  the  frosted  glass,  and  the  suspect 
i-  examined  by  Stevens's  phorometer  or  by  simple  pri.-ms  in  the  manner 
commonly  advised  for  testing  the  extrinsic  ocular  muscles.  It'  he  now 
perceives  double  images,  he  must  see  binocularly,  and  may  he  pronounced 
,-i  malingerer. 

Snow-blindness. — This  is  a  form  of  amblyopia  produced  by  the  blind- 
ing reflections  of  the  sun  upon  the  naked  eye  of  persons  (usually  Strang 
exposed  to  the  brilliant  snow-fields  of  northern  latitudes  or  mountain-resorts. 
The  dazzling  at  length  causes  contracted  pupils  and  retinal  congestion. 
Central  and  peripheral  limitation-  of  the  field  of  vision  have  been  observed, 
as  well  a-  a  lessening  of  the  visual  acuity,  especially  for  near  work. 

The  most   common  effect  of   tin-  exposure  i-.   however,  a    peculiar  form  of 

hyperemia  and  edema  of  the  conjunctiva.  This  is  accompanied  by  swollen 
lid-,  lachrymation,  burning  pain   in  the  eyeballs,  photophobia,  and  blepharo- 


468  AMBLYOPIA    AX/>  AMA  CJiOS/s. 

spasm — symptoms  attributed  ti»  "  sun-burn  "  rather  than  to  the  effects  of  the 
light-rays.  The  writer  has  had  occasion  to  study  various  grades  of  snow- 
blindness  in  Northern  Canada  and  anion*;'  the  members  of  a  party  who  spent 
some  time  on  the  Mer  de  ( rlace. 

The  light-rays  from  electric  furnaces  and  are  candles  are  capable  of  pro- 
ducing practically  the  same  symptoms,  constituting  the  so-called  electric 
ophthalmia.  Those  who  are  much  concerned  with  the  Rontgen  X-rays  may 
suffer  in  a  similar  manner. 

The  eves  remain  sensitive  to  light  and  show  signs  of  retinal  fatigue  for 
some  days,  and  the  conjunctivitis  may  persist,  requiring  treatment  proper  to 
that  condition.  Rest  in  a  darkened  room,  with  atropin  and  hot  applications, 
seems  to  give  most  relief  to  the  retinal  and  corneal  symptoms. 

Krythropsia,  or  red  vision,  is  most  commonly  seen  after  cataract  extrac- 
tion. It  has  also  been  observed  in  poisoning  by  santonin  (which  may  also 
produce  xanthopsia  or  yellow  vision),  and  as  a  phosphene-experience  in  per- 
sons suffering  from  optic-nerve  atrophy  and  glaucoma.  These  exhibitions  of 
color  may  he  due  both  to  central  irritation  and  to  excitation  of  the  retinal 
ill  incuts.1  Potassium  bromid  has  been  recommended  for  this  symptom.  After 
cataract  extraction  patients  often  complain  of  a  "glaring  white  haze"  which 
seems  to  cover  all  objects.  An  uncommon  phenomenon,  described  by  Becker 
and  Swan  M.  Burnett,  is  kyanopsia,  or  blue  vision.  According  to  the  latter 
author,  it  is  especially  observed  by  patients  with  more  or  less  amber-colored 
cataractous  lenses,  the  blue  appearance  depending  upon  fatigue  of  the  retina 
from  long-continued  exposure  to  yellow  light,  giving  blue  as  a  residual  sen- 
sation in  white  light.2 

Micropsia  and  Megalopsia. — In  hysteria,  in  some  diseases  affecting 
the  macular  region,  and  after  the  correction  of  marked  ametropia,  objects 
may  appear  smaller  or  larger  than  usual,  and  these  visual  abnormalities  are 
sometimes  accompanied  by  distortion  of  the  images,  [n  the  foregoing  class 
of  cases  the  rods  and  cone-  are  either  actually  separated  or  pressed  together 
as  a  consequence  of  retinal  infiltration,  or  the  contrast  effeel  of  corrected 
refractive  errors  may  convey  the  impression  of  altered  size.  As  Parinaud 
ha-  shown,  when  these  phenomena  are  experienced  by  hysterical  amblyopes 
they  are  probably  the  effect  of  a   variable  accommodative  spasm. 

Night-blindness  (  Functional  Night-blindness  ;  Hemeralopia,3  preferably 
Nyctalopia). — This  symptom  is  -ecu  as  a  functional  disturbance,  probably  due 
to  diminished  sensibility  of  the  retina  or  rather  imperfect  adaptation-powers 
of  the  retina,  unassociated  with  visible  change  in  the  background. 

It  ha-  been  observed  as  an  epidemic  affecting  scorbutic  soldiers  and 
sailors  who,  in  addition  to  insufficient  feeding,  have  been  exposed  for  a  long 
time  to  the  glare  of  the  sun.  Simeon  Snell  has  seen  it  among  the  pupils  of 
the  English  public  schools.  Among  the  poor  and  ill-nourished  Russian 
pea-ant-  night-blindness  has  been  frequently  noticed,  particularly  during  the 
fasts  of  Lent.  It  has  been  attributed  to  miasmatic  influences  by  Adamiick. 
\"i  only  do  nyctalopes  see  badly  on  dull  or  dark  days  and  well  on  bright 
days,  Inn  they  suffer  from  other  ocular  troubles,  the  chief  of  which  i-  a 
peculiar  wasting  disease  of  the  conjunctiva — xerophthalmia  (see  page  296). 

The  treatment  of  the  condition  that  gives  rise  to  the  night-blindness  is 

'The  reader  will  do  well  t"  codbuII  Fuchs's  paper  on  ilii-  Rubjecl  in  Qraefe's  Archiv  fu\ 
Ophthalmologic,  Bd.  \lii..  abth,  iv.,  or  the  review  of  it  by  W.   Dudlej   Hall  in  the  Ophthalmic 

■'.   I  .  b.,  1897.  Ophthalmic  Record,  \ii..  X.  S„  Inks,  p.  17. 

in  of  the  derivation,  authoritative  employment,  and  proper  definition  of  th<   e 
i'  mi-  in  it..-  Royal  London  Ophthalmic  Hospital  Reports,  vol.  x.  Pari  ii..  June,  1881,  |>.  284. 


DA  r-BLINDNESS.  169 

called  for — a  generous  diet,  ferruginous  tonics,  cod-liver  oil,  hygienic  sur- 
roundings, and   protection  from   brighi    light. 

Day-blindness  {Nyctalopia,  preferably  Hemeralopia). —  In  almost  all 
the  forms  of  central  amblyopia  (see  page  160)  patients  see  besl  on  dull  days 
or  in  a  dimly-lighted  room.  The  explanation  of  this  is  that  with  a  weak 
illumination  the  pupils  are  dilated,  and  most  rays  fall  upon  unaffected  por- 
tions of  the  retina  :  bright  light,  mi  the  other  hand,  contracts  the  pupils  and 
the  asensitive  fovea!  region  only  i-  presented  to  objects.  Personsfrom  whom 
light  has  long  been  excluded  exhibit  this  symptom,  and  it  is  said  to  be  con- 
genital in  others. 

Hemeralopia  also  occurs  in  retinitis  nyctalopia,  coloboma  of  the  iris,  and 
in  albinism. 


AMBLYOPIA  OF  THE  VISUAL  FIELD,  SCOTOMAS, 
AND  HEMIANOPIA. 


By  II.  V.  WURDEMANN,  M.  I)., 

OF    MII.W  \1   KKK.    WIS. 


THE  NORMAL  FIELD.1 


The  field  of  vision  is  that  space  perceived  when  the  visual  axis  is 
directed  to  a  stationary  point.  When  both  eyes  arc  used  the  fields  overlap, 
forming  the  binocular  field  or  field  of  fixation  (Figs.  277,  27.S). 


Fig.  277.— The  binocular  field  of  vision  (after  Foerster).4  The  tracts  from  the  right  brain  are  in  red, 
those  from  the  left  brain  in  blue.  The  corresponding  retinal  halves  and  their  fields  of  vision  are  corre- 
spondingly colored. 

The  object  fixed  is  within  the  range  of  direct  vision,  the  ray-  of  light  fall- 
ing directly  upon  the  macula  ;  those  coming  from  surrounding  objects  fall 
upon  other  parts  of  the  retina  which  have  indirect  vision.  The  visual  acuity 
diminishes  as  images  arc  removed  from  the  macula  to  the  periphery  of  the 
field.  The  norma]  field  of  vision  is  more  or  less  constricted  at  the  upper 
and  nasal  -ides  by  the  eyebrow  -  and  nose,  forming  the  upper,  inner,  and  lower 
limit-  of  the  field,  the  outer  proceeding  in  normal  eye-  to  a  little  beyond  90 
from  the  fixation-point.  Form  and  white  are  most  eccentric,  followed  in 
order  by  blue,  yellow,  vc<\,  and  green  (  Fig.  27!h.  Overhanging  eyebrows 
or  a  large  nose  materially  limit  the  field.  II*  the  chart  be  improperly  taken, 
as  when  the  patient  doe-  not  hold  hi-  head  erect,  does  not  fix  the  sight- 
hole  of  the  perimeter,  or  nips  the  eyebrows  or  eyelid-,  variation  may  be 
found. 

At  the  temporal  -ide  of  the  fixation-point  from  10-20  is  the  physiologic 
/;////(/  spot,  or  scotoma  of  Mariotte  (  Pig.  27! i).  By  careful  examination  with  very 
small  test-objects  other  blind  spots  may  be  found  which  correspond  to  the 
places  of  division  of  the  large  retinal  vessels.  The  physiologic  scotoma  may 
be  larger  or  smaller  according  to  the  size  of  the  nerve-head.      In  case  of  con- 

1  The  field  "I"  \  i-i« hi  lias  been  Fully  discussed  on  page  99  and  on  pages  162  169;  but  for 
the  convenience  of  the  reader  and  to  Facilitate  comparison  with  the  abnormalities  of  the  visual 
ti.-l.l  which  follow,  a  brief  resume*  of  the  subject  i-  here  introduced  I  Ki>.). 

I7ii 


THE  NORMAL   FIELD. 


171 


tinuance  of  the  medullary  fibers  "I"  the  disk   the  spot    may  be  very  large, 
including  even  the  fixation-point  (  Figs.  280  and  296).     A.s  this  is  covered  l>v 


Fi<;.  273.—  Binocular  field  of  both  eyes  (after  Knies):3  /.,  left.  R,  right  half  of  the  field  of  vision 
divided  by  the  vertical  line  a-b,  which  passes  through  the  point  of  fixation  /■'.  The  vertical  strip  is  the 
overlapping  portion  of  the  field  of  vision. 

the  visual  field  of  the  other  eye  in  binocular  vision,  the  existence  of  this  spot 
is  not  noticed. 


Fig.  279. — Diagram  of  normal  field  for  form,  white,  and  colors:  The  outer  continuous  line  ind 
limit  of  the  field  f>r  form  and  white,  the  dotted  lines  for  the  colors,  blue,  red,  and  ■-■'• 


Although  the  fovea  centralis  is  tli<'  point  of  besl  vision,  yel  astronomic 
observation  has  shown  thai  feebly-reflecting  stars  are  better  seen  when  the 
vision  ia  directed  a  little  to  one  side,  for  the  fovea   is   less  sensitive  to  both 


AMBLYOPIA    OF  Till  I    VISUAL    FIELD,   ETC. 


Fig.  2S0. — Physiologic  scotoma  (after  Baas) : '  ".  normal  blind  spot  (after  Helmholtz) ;  b,  persistent  opaque 

nerve  fibers  ;  <•.  normal  blind  spot. 

lighl   and  color  in  diminished  light  than  the  retina  immediately  surround- 
ing it.1 

ANOMALIES  OF  THE  VISUAL  FIELD. 

Anomalies  of  the  visual  field  occur  as  symptoms  of  disordered  conditions 
which  themselves  are  manifestations  of  well-recognized  affections,  such  as 
diseases  of  the  eve,  of  the  visual  centers,  or  of  their  connections,  which  iikiv  be 
due  to  trauma,  cerebral  or  spinal  affections,  and  which  may  in  their  turn  he 
pari   of  some  general    infection  or  condition. 

Besides  amblyopia  (loss  of  vision)  and  amaurosis  (blindness),  which  occur 
in  connection  with  actual  anomalies  of  the  visual  field,  there  exist  two  distinct 
groups  of  anomalies  (for  amblyopia  and  amaurosis,  see  page  457). 

I.  Contraction  of  the  visual  field,  which  may  be  regular  (concentric), 
irregular  (eccentric),  and  sectoral.  These  defects  may  be  due  to  local  as  well 
as  central  lesions.  There  is  also  a  characteristic  form  occurring  in  both  eyes, 
with  symmetrical  obliteration  of  halves  of  the  visual  field — true  hemianopia 
— due  to  lesion  within  the  cranial  cavity. 

II.  Seotomata,  a  group  characterized  by  formation  of  scotomata  or 
blind  spots  in  one  or  lioth  eyes,  in  some  instances  having  a  hemianopic 
aspect.  The  positivt  scotoma  is  seen  by  the  patient  as  a  dark  or  black  spot 
upon  objects.     In  the  former  case  it    is  relative,  in  the  latter  absolute. 

The  negativt  scotoma  i-  not  at  firsl  recognized  by  the  patient,  bul  is  de- 
veloped through  the  examination.  A  typical  example  of  this  is  the  normal 
blind  spot.  The  scotoma  may  occupy  various  positions,  be  single  or  multiple, 
central,  para-  or  pericentral,  or  may  have  a  circular  form,  the  so-called  ring 
scotoma  ( see  also  page  1  69). 

The  special  affections  of  the  organ  of  vision  in  which  anomalies  of  the 
visual   field  occur  ar< — 

I.  Optic  hindrance  in  the  refractive  media;   II.    Diseases  of  the  retina ; 


CHANGES   TN    VISUAL   FIELD  TN  DISEASES  OF  RETINA.     47:j 

III.  Diseases  of  the  choroid  ;  IV.  Glaucoma;  Y.  Diseases  of  the  optic 
nerve;  VI.  Diseases  of  the  chiasm;  VII.  Diseases  of  the  optic  tract  from 
the  chiasm  to  the  visual  centers;  V11I.  Functional  diseases  and  nerve- 
Lesions  of  differenl   kinds. 

Changes  in  the  Visual  Field  due  to  Optic  Hindrance. — Foreign 
bodies  or  opacities  in  the  cornea,  lens,  vitreous  (Fig.  281  |,  or  outer  layers  of 
the  retina  may  be  attended  by  obscuration  of  vision  through  optic  hindrance, 
and  cause  amblyopia,  contraction  of  the  visual  field,  and  scotoma. 

Trauma  of  the  eyeball  may  be  followed  by  either  destruction  of  tissue 
and  bleeding,  or  both,  causing  changes  in  the  visual  field.  Pre-retinal  hem- 
orrhage causes  diminution  of  the  visual  field  and  absolute  or  relative  scotoma 
(Fig.  282). 


Fig.  281. — Sectoral  contraction  due  to  ]>re- 
rctinal  hemorrhage  and  foreign  body  in  vitreous 
after  injury  by  gunpowder  explosion. 


Fig.  282.— Central  absolute  and  relativi 
toma  due  to  retinal   hemorrhage  in  congenital 
syphilitic  chorio-retinitis. 


Changes  in  the  Visual  Field  in  Diseases  of  the  Retina. — 
Changes  in  the  nutrition  of  the  retina  and  choroid,  such  as  occur  in  night- 
blindness,  produce  amblyopia,  which  is  especially  noticeable  in  diminished 
light,  together  with  contraction  of  the  visual  Held,  particularly  noticeable  for 
blue*  (  Figs.  283  and  284  (see  also  page  168)). 


Mm 


Fig.    283.    Concentric    contraction    in    chronic 
night-blindness. 


Fig.  284     Great  concentric  contraction  with 
overlapping  of  blue  field,  and  green  blind 
chorioretinitis  pigmentosa,  with  nyctalopia 


Embolism  of  the  central  artery  of  the  retina  and  thrombosis  oi  the  central 
vessels  give  rise  generally  to  amaurosis,  proceeding  to  complete  blindness,  bill 
where  the  blood-stream  is  not  completely  cul  oil' the  vision  is  diminished  and 


474 


AMBLYOPIA    OF  THE   VISUAL  FIELD,   FTC 


Fig. 285. — i  lentral  scotoma  in  partial  embolism 
of  the  central  retinal  artery,  occurring  <lnrin^ 
menstruation. 


Fig.  286.— Paracentral  scotoma  with  second- 
ary contraction  of  the  visual  field  and  enlarge- 
ment of  the  scotoma,  following  foreign  body  in 
the  retina  (alter  Baas).1 


the  field  contracted,  together  with  formation  of  scotoma,  which  is  generally 

central  (Fig.  285). 


V 187.    Typical    constriction    of    field    dm'    to 

peripheral  detachment  of  the  retina. 


58.  -Typical  contraction  of  visual  field  due 
to  circular  detachment  of  the  retina. 


Hemorrhages  into  the  retinal  structure  produce  scotoma  or  irregular  con- 
traction of  the  visual  field,  the  amount  depending  upon  the  extent  of  the  lesion. 


Pig  289     Absolute  and  relative  para  and  pericentral    cotomata  In  neuro-retlnitis albuminurica  occur 

ring  during  pr<    i 

Foreign  bodies  in  the  retina  cause  scotoma  (Fig.  286). 
Detachment  of  the  retina  from  traumatism  or  in   myopia  is  attended  by 
characteristic  defects  according  to  it-  extent  i  Figs.  287,  288). 


CHANGES  TN  ViSUAL   FIELD  IN  DISEASES  OF  CHOROID.      175 

Retinitis  albuminurica™  diabetica,  and  circinata  are  attended  by  scotoma 
(Fig.  289)3  usually  central,  and  are  followed  in  their  retrogressive  stages  by 
atrophy  of  the  retina  and  nerve,  with  amblyopia  or  amaurosis  and  contraction 
of  the  visual  field. 

Changes  in  the  Visual  Field  in  Diseases  of  the  Choroid. — 
Circulatory  disturbances  and  changes  in  the  nutrition  of  the  choroid  produce 
characteristic  changes  (  Figs.  290,  291 ).  Coloboma  of  the  choroid  is  attended 
by  sectoral  defects  and  usually  scotoma  (Fig.  290).  Rupture,  hemorrhage, 
and  tumor21  of  the  choroid  give  rise  to  defects  depending  upon  the  extent  of 
the  lesion  (Fig.  291). 


Fig.  290.—  Sectoral  contraction  of  the  visual 
field  and  enlarged  blind  spot  due  to  typical  colo- 
boma of  the  choroid  and  staphyloma  posticum. 


Fig.  291.— Sectoral  contraction  of  the  visual 
field  simulating  vertical  hemianopia  in  sarcoma 
of  the  choroid!*1 


Choroiditis,  especially  the  exudative  form,  usually  causes  multiple  scotom- 
ata  (Fig.  292)  which  are  absolute  or  relative.  By  their  coalescence  larger 
scotomata  are  formed  which  may  even  take  a  peculiar  ring  form  (Fig.  293). 
The  visual  fields  may  likewise  be  greatly  reduced.  If  the  choroiditis  be  at 
the  macula,  central   scotoma  will  be  developed. 


Fig.  292.    Para     and    pericentral    scotomata    in 
exudative  disseminated  choroiditis. 


Fig.  293.    Absolute  and  i  ig  scotoma  in 

bj  philil  H-  chorio  retinitis. 


Chorio-retinitis   pigmentosa   is  usually  attended   by  greai   contraction  ol 
the    visual   field  and  amblyopia   (Figs.  294,  295).     In    myopia  staphyloma 
posticum    may  develop,  and   the  blind   -p<»t    be   rendered    abnormally   large 
thereby,  so  thai  it  may  even  extend  to  the  fixation-point.     Tn  senile  atrophy 
of  the  choroid  central  scotoma  and  reduction  of  the  visual   fields,  with  am- 


476 


AMBLYOPIA    OF  THE    VISVAL   FIELD,    FTC 


Myopia,  result  (  Fig.  295),  the  shape  of  the  scotoma  bearing  a  relation  to  the 
shape  of  the  atrophic  area. 


Fig.  294. — Contraction  of  field  and  loss  of  vision  hw 
green  in  cnorio-retinitis  pigmentosa. 


Pig.  295. — Absolute  central  and  relative 
paracentral  scotoma  in  central  senile  atrophy 
of  the  choroid  and  retina. 


Changes  in  Glaucoma. — In  glaucoma  there  is  often  a  characteristic 
reduction  of  the  fields  toward  the  nasal  side  ;  but  many  other  types  of  visnal- 
tield  disturbance  are  common  (for  visual  fields,  see  pages  380  and  381  I. 

Changes  in  Affections  of  the  Optic  Nerve. — Changes  in  the  visual 
fields  generally  occur  in  affections  of  the  optic  nerve.  The  principal  con- 
genita] delect  is  coloboma  of  the  nerve  and  its  sheath,  and  is  attended  by 
enlargement  of  the  Mind  spot  (Fig.  '1{M'A. 

In  traumatism  with  rupture  or  bleeding  into  the  nerve  (Fig.  297)  and  in 


Fig  296     Central  and  paracentral  absolute  scoto 
with  large  relative  central  scotoma  and  preservation  of 
small   sector  of  superior  nasal  quadrant  in  colobomaof 
the  optic  nerve  and  retina  w  ith  persistent  opaque  nerve- 
fibers." 


Fig.  297.    Relative  sectoral  scotoma  from 
traumatism  of  the  optic  nei  ve  and  hemor- 
mi  the  optic  foramen. 


tumors  of  the  nerve  there  is  usually  found  a  sectoral  delect,  with  amblyopia 
and  contraction  of  the  visual  field  resulting  in  atrophy.  Diseases  affect- 
ing the  intraocular  end  of  the  optic  nerve,  such  a-  papillitis,  cause  decided 
changes  in  the  visual  Held,  depending  upon  the  amouni  of  optic  interference 
caused  l>\  the  swelling  and  bleeding  into  or  destruction  of  the  nerve-tissue. 
The  blind  spot  is  usually  much  enlarged"  (Fig.  298).  The  relation  be- 
tween the  ophthalmoscopic  appearances  and  the  visual  acuity  is  frequently 
not  commensurate.  These  cases  usually  terminate  in  atrophy  with  contraction 
or  sectoral  defect  and  scotomata. 


CHANGES  IN  AFFECTIONS  OF  THE  OPTIC  NERVE.        177 

Ttetro-bulbar  neuro-?'etinUis}  or  toxic  amblyopia  is  usually  attended  by 
central  scotoma  due  to  implication  of  the  axial  fibers.  (It  is  fully  discussed 
on  page  461.) 

Atrophy  of  the  Optic  Xcrrc. — Many  cases  coming  under  the  foregoing 
result  in  sclerotic  changes  in  the  optic  nerve.     However,  it    i-  known  thai  a 


Fig.  298.— Visual  fields  in  papillitis,  duo  to  gumma  at  the  base  of  the  brain,  showing  great  enlargement 

of  the  blind  spots. 

large  proportion  of  eases  with  diminished  vision,  due  to  atrophy  of  the  nerve- 
fibers,  are  associated  with  sclerotic  changes  in  the  spinal  cord.  Among  these 
is  atrophy  due  to  tabes,  which  in  many  instances  is  a  premonitory  sign  of 
this  disease.10  Various  forms  attended  by  non-characteristic  changes  in 
the  visual  field  occur  in  multiple  sclerosis,  progressive  paralysis,  syringo- 
myelia, amyotrophic  lateral  sclerosis,  exophthalmic  goiter,  cerebral  syphilis, 
degenerative  changes,  and  different  mental  diseases.1 

The  visual  field  in   optic-nerve  atrophy  is   usually  constricted,  and    the 
contraction  for  color  greater  than  that  for  form  and  white  (Fig.  299).     The 


Pig,  299     Contraction  of  the  field  especially 
marked  for  color  occurring  in  secondary  atrophy 

;iflcr  sypliilil  ic  inn  ri  I  rel  mil  is. 


I-  H..  300,    Moderate  conl  raction  in  tabetic atro 
phy  with  abolition  of  the  color  sense. 


color-sense  may  be  entirely  absent,  and  yet  the  field  be  of  moderate  extent 
(Fig.  300).  Scotomata  may  appear.  The  atrophy  and  consequent  loss  of 
sight    may   proceed    for  ;i    while  {sfoaJ&onary  optic-nerve  atrophy),  and    then 


478 


AMBLYOPIA    OF  THE    VISUAL    FIELD,   ETC. 


Fig.  301.— Fields  of  vision  in  hereditary  atrophy  showing  >»<t  >  >r;il  defect  of  the  right  and  relative 
scotomatous  defect  of  the  left.  The  latter  is  progressing  and  will  terminate  in  the  same  form  of  field  as 
that  of  the  right. 

definitely  stop,  or  may  progress  to  absolute  blindness  (progressive  optic-nerve 
atrophy).  A  peculiar  progressive  form  associated  with  scotoma  (hereditary 
atrophy)  comes  on  usually  between  twenty  and  thirty  years  of  age  (Fig.  301). 


THE  VISUAL    PATHWAY. 

The  visual  trad  or  pathway  (see  Fig.  302)  proceeds  from  the  retina  to  it- 
final  termination  in  the  brain,  the  separate  subdivisions  of  oerve-fibers  lying 
in  different  relations  at  different  portions  of  its  course. 

The  peripheral  percipient  elements  in  the  retina  are  the  rods  and  cones,  which  are 
connected  by  fibers  with  the  outer  and  inner  granular  layers,  which  in  the  region  of  the 
macula  lutea  are  very  fine  and  anastomose  freely,  and  cannot,  as  elsewhere,  be  separately 
traced.  The  anatomic  relations  of  the  optic  nerve-fibers,  as  given  by  Henschen  and 
described  by  Wilbrand,28  are  as  follows: 

The  macular  bundle  lies  ventro-laterally in  the  papilla  and  also  immediately 
behind  it.  At  the  latter  place  it  tonus  a  keystone-shaped  sector,  with  its  base  turned 
toward  the  pial   sheath   and   its  point  toward  the  central   vessels. 

Farther  hack  this  bundle  is  halfmoon-shaped.  Still  farther  back  it  takes  the  form 
of  an  upright  oval  and  approaches  nearer  the  axis  of  the  optic  nerve.  In  the  optic 
foramen  it  assumes  an  axial  position,  and  in  front  of  the  chiasm  the  form  of  a  horizontal 
oval.  The  macular  bundle  contains  crossed  and  uncrossed  nerve-fibers.  In  front  in  the 
papilla  the  crossed  fillers  lie  ventrally  and  the  uncrossed  ones  more  eccentrically,  being 
in  proximity  to  the  other  uncrossed  fibers.  The  fibers  spread  over  the  retina.  Farther 
back  the  macular  fibers  become  drawn  together  toward  the  center.  The  dorsal  half  of 
these  fibers  goes  to  the  dorsal  half  of  the  retina,  whilst  the  ventrally-placed  fibers  go  to 
the  ventral  half. 

(A  The  uncrossed  (not  the  macular)  bundle  is  divided  in  the  anterior  division  of 
the  optic  nerve  into  two  fascicles-  a  dorso-lateral  uncrossed  dorsal  part  and  a  ventro- 
lateral uncrossed  ventral  portion.  In  the  lamina  cribrosa  these  fibers  are  separated  by 
the  macular  bundle.  Behind  the  entrant  of  the  central  vessels  the  fascicles  approach 
one  another  and  form  a  united  balfmoon-shaped  bundle,  which  includes  the  lateral 
periphery  and   lies  somewhat    \  entro-laterally. 

I  fie  crossed  bundle  (nol  macular)  forms  a  closed  cord  in  the  whole  optic  nerve. 
In  the  papilla  it  i-  situated  dorso-medially,  and  retain-  this  position  until  it  passes  the 
chiasm. 

The  papillo-macular  bundle,  which  reaches  the  chiasm  in  the  shape  of  an  oval 
lying  horizontally,  retain-  ii-  central  position  until  it  reaches  the  chiasm.  Farther  back 
toward  the  center  of  the  chiasm  it  almost  reaches  the  periphery,  and  here  the  fibers 
belonging  to  the  fasciculus  cruciatus  cross  one  another.  It  -inks  once  more  and  lies 
ventro-centrally  in  the  tract.  The  crossed  fibers  of  this  bundle  lie  more  centrally,  and 
the  uncrossed  ones  more  laterally. 

When  a  crOSS-section  of  the  optic  tract  is  made  immediately  in  front  of  the  ehia-m. 


THE    VISUAL    I 'A  THWA  V. 


m 


it  will  be  found  that  the  crossed  fibers  occupy  the  dorso-medial  pari  of  the  periphery  of 
the  section,  and  the  uncrossed  fibers  arc  situated  in  the  ventro-medial  portion  of  the 
periphery  of  the  section.     The  bundles  then  become  divided  into  a  number  which  are 

flattened  horizontally,  and  these  intermix  with  one  another.  The  crossed  fiber-bundles 
come  together  again  at  the  ventrolateral  margin  of  the  chiasm,  forming  the  tract. 
Then  there  is  a  displacement.  The  crossing  does  not  take  place  all  at  one  point,  but 
the  dorsal  nerve-fiber  bundles  first  cross,  followed  by  the  more  centrally-situated  ones. 
At  the  posterior  angle  of  the  chiasm  the  commissural  nerve-fibers,  described  by  von 
Gudden,  Meynert,  and  Forel,  which  have  no  influence  on  vision,  are  found. 

The  macular  bundle  courses  centrally  in  the  tract.  The  uncrossed  bundle  lies  dorso- 
laterally,  forming  a  close  cord.  The  bundles  retain  this  position  until  they  enter  the  cor 
pus  geniculatum,  where  they  separate  into  a  mass  of  separate  libers.  The  crossed  bundle 
lies  ventro-medially,  and  forms  a  bundle  which  lies  slantingly  and  hangs  loosely  together. 

The  tractus  winds  around  the  cms  cerebri,  and  terminate-  in  two  roots  upon  the 
corpora  geniculate  externa  and  interna,  and  upon  the  posterior  part  of  the  optic  thalamus, 
called  the pulvinar.  Fibers  also  go  to  the  anterior  part  of  the  corpora  quadrigemina,  but 
these  organs  are  not  regarded  as  concerned  in  vision,  but  in  the  activity  of  the  pupil. 
The  parts  just  referred  to  are  called  the  primary  ritual  ganglia,  or  primary  optic  centers. 

In  them  are  found  innumerable  ganglion-cells  in  which  the  fibers  of  the  tractus  lose 


Musculus  TC£UU  \\ 
externum 


JfujcuZaj  redus 
externum. 


Xobo  Occ/pdalus 
i  i  .  302.— Scheme  of  the  optic  tract  (after  von  Monakow).1 

themselves,  and  thereafter  a  new  set  of  fibers  proceeds  backward  through  the  posterior 
part  of  the  internal  capsule  to  the  cortex,  under  the  name  of  the  visual  radial  in 
fibers  of  Qraiiolet  or  of  Wernicke.  Passing  through  the  internal  capsule,  they  cross  the 
sensitive  fibers  coming  down  from  the  hemisphere,  are  rather  closely  massed,  and  then, 
spreading  oul  like  a  fan,  rise  upward,  wind  outside  the  tip  ol  the  lateral  ventricle  to 
reach  their  destination  at  the  lower  part  of  the  median  surface  of  the  occipital 
(Fi,r   ::o-, 


(Fig.  302). 


ISO  AMBLYOPIA    OF  THE    VISUAL    FIELD,    ETC. 

DISEASE  WITHIN  THE    CRANIUM. 

Diseases  of  the  brain  affecting  the  optic  nerve  or  tracts  give  rise  to  cha- 
racteristic lesions.  Optic  neuritis  is  common,  although  not  a  constant  symp- 
tom of  brain-tumor.  It  is  attended  by  changes  in  the  visual  field,  already 
described. 

Hemianopia  or  Hemianopsia. — Hemianopia,  or  half-bljndness  of 
the  visual  field,  resulting  from  a  localized  cause,  is  common  to  both  eves.  If 
the  obliterated  half  be  toward  the  same  side  in  both  eves,  it  is  called  homony- 
mous (lateral  hemianopia) ;  if  the  opposite  sides  he  affected,  it  is  called  heterony- 
mous (nasal  or  temporal).  The  term  hemianopia  should  he  limited  to  half- 
blindness  affecting  both  eves.1  Sectoral  detects  simulating  hemianopia  may 
arise  in  one  or  both  eyes  (Figs.  281,  287,  290,  291,  297)  from  disease-  of  the 
optic  nerve  or  retina,  hut  are  not  to  he  considered  in  this  connection. 

The  hemianopia  may  include  half  of  the  fields  {complete),  or  affect  sectors 
{incomplete  or  partial),  or  involve  one-hall'  of  the  field  on  one  side  and  a 
sector  in  the  other,  or  the  blindness  may  occur  in  the  whole  of  one  eye  and 
pari  of  the  field  in  the  other  eye.  In  the  hemianopic  field  the  vision  may  he 
totally  obliterated  (absolute)  or  partially  retained  {relative).  Pressure  upon 
the  hemianopic  sides  of  the  eyeball  does  not  cause  phosphenes,  and  this  fact 
may  he  of  importance  in  cataractous  patients  with  hemianopia.8 

The  condition  cud  reaction  of  the  pupils  are  of  diagnostic  importance  in 
cerebral  diseases,  and  especially  in  those  accompanied  by  ocular  lesions  and 
changes  in  the  visual  Held.  Illumination  of  both  eyes  in  uncomplicated  dis- 
eases  of  the  centripetal  portion  of  the  optic-reflex  arc  never  produces  unequal 
pupillary  reaction.  Both  pupils  may  fail  to  react  to  light,  though  sight 
remains  good  (involvement  of  Meynert's  fibers),  or  both  pupils  may  react 
alike,  though  there  he  complete  amaurosis  (lesion  in  some  part  between  the 
( rratiolel  fibers  and  psycho-optical  cortical  center)."'  In  the  case  of  hemianopia, 
when  light  is  casl  into  the  eye  upon  the  seeing  side  of  the  retina,  if  the  lesion 
he  anterior  to  the  primary  optical  ganglia,  the  pupil  will  contract,  hut  if  light 
i-  directed  upon  the  blind  side  there  will  he  no  contraction.  If  the  lesion  he 
beyond  the  thalamus,  such  hemianopic  pupillary  inaction  cannot  occur.  This 
reaction  is  often  called   Wernicke's  symptom. 

DISEASE  OF  THE  CHIASM. 

Heteronymous  Hemianopia. — 1.  Nasal  hemianopia  has  never  been 
shown  to  be  due  to  disease  behind  the  chiasm.3  Since  these  fibers  do  not 
decussate  and  are  never  in  contact,  it  is  almost  impossible  to  conceive  of  a 
bilateral  cerebral  lesion  of  the  same  extent  and  size  affecting  the  function 
equally  on  both  sides  (Fig.  303).  In  the  liw  reported  cases  a  bilateral  affec- 
tion of  the  trunks  of  both  optic  nerves  in  front  of  the  chiasm,  extending  to 
these  and  chiefly  intense  symmetrically  at  each  side,  has  been  found  or  diag- 
nosed.3 The  visual  fields  are  obliterated  at  the  nasal  sides  of  the  fixation- 
point.  The  dividing-line  i-  apt  to  he  irregular  and  not  precisely  in  the 
vertical  meridian.  The  obliterated  areas  are  not  entirely  deficient  in  light- 
perception,  and  there  is  hemianopic  pupillary  inaction.  Usually  evidences 
of  inflammatory  changes  will  he  seen  on  ophthalmoscopic  examination  in 
disturbances  of  circulation,  swelling,  or  hemorrhages  on  the  disk,  followed 
later  by  atrophic  changes.  Disturbance  of  vision  as  regards  walking  about 
i-  not   \'i\  great. 

2.  Temporal  hemianopia  (Fig.  304)  is  caused  by  disease  of  the  chiasm 
where  the  decussating  fibers  of  both  tracts  interweave.     The  visual  fields  are 


DISEASES   OF  Till-:   O/'T/C   TUMI'. 


481 


obliterated  at  the  temporal  side  of  the  fixation-point.  The  dividing-line  is 
usually  irregular  and  the  blind  areas  may  retain  some  perception  of  light. 
Hemianopic  pupillary  inaction  is  present.  Ophthalmoscopic  examination  is 
usually  negative  except  in  the  later  stages,  when  atrophy  of  the  optic  nerve 


Fig.  303.— Nasal  hemianopia  (after  Veasey).14 

may  occur.     Disturbance  of  the  vision  is  great,  as  the  patient  may  onlv  see 
directly  ahead  and  has  difficulty  in  orientation.20 

Diseases  of  the  Optic  Tract  from  the  Chiasm  to  the  Visual 
Centers. — Lateral  or  homonymous  hemianopia  is  due  to  disease  affecting  the 
optic  tract  behind  the  chiasm.  Corresponding  sides  of  the  visual  fields  are 
affected  (Fig.   305).     The  dividing-line   between   the  seeing  and   the    blind 


■  tvh\e 

Blue 

Red 

Green    MC* 


Fig.  304.— Temporal  hemianopia  occurring  after  hemorrhage  al  Hi 

of  central  vision. 


iptic  chiasm,  «  iih  preservation 


areas  is  usually  well  defined,  running  perpendicularly  through  the  fixation- 
point,  the  visual  acuity  and  color-sense  being  normal  up  to  the  edge  of  the 
obliterated  area,  the  hemianopic  field  having  no  perception.  In  many  it  will 
be  found  that  the  central  vision  has  either  remained  or  is  entirely  obliterated. 
this  being  due  to  the  fact  that  the  macula  in  these  cases  receives  fibers  through 
both  optic  tracts  (also  proved  by  the  occurrence  of  double  hemianopia),10  and 
if  the  field  be  carefully  taken  it  will  be  found  that  there  is  a  bulge  in  the 
line  of  demarcation  between  the  hemianopic  and  tin  seeing  field.  If  the 
31 


482 


AMBLYOPIA    OF  THE    VISUAL    FIELD,  ETC. 


fixation-point  lies  in  the  obliterated  field,  there  will  be  central  blindness;  if 
in  the  remaining  field,  the  central  visioD  will  remain.  Right-sided  hemi- 
anopia  causes  more  disturbance  than  left-sided,  as  we  read  from  left  to  right.4 
Patients  see  and  walk  fairly  well  by  turning  the  head  to  one  side. 

At  first  no  lesion  will  he  found  on  ophthalmoscopic  examination,  although 
signs  of  atrophy  ultimately  appear.     If  the  left  tract  he  affected,  producing 


Fi&.  305. — Lateral  hemianopia  occurring  in  multiple  sclerosis. 

right  hemianopia,  the  righl  optic  nerve  will  in  time  become  wholly  atrophic, 
and  the  left  optic  nerve  look  normal  lor  the  reason  that  in  the  left  eye  the 
tract-fibers  are  diminished  and  the  crossing  fibers  are  good  ;  the  former  arc 
covered  by  the  whole  of  the  disk.  In  the  right  eye  the  crossing  fibers  (de- 
rived from  the  left  tractus)  are  injured  and  the  direct-tract  fibers  are  sound. 
The  crossing  fibers  are  in  front,  and  they  give  the  disk  a  look  of  general 
atrophy,  with  lesion  of  the  left  tract  (with  right  homonymous  hemianopia). 
The   left    nerve   looks   normal  ;  the  right  nerve  will  appear  atrophic.7 

A  few  cases  of  hemi-achromatopia,  in  which  the  sense  of  color  is  lost  for 
corresponding  halves  of  either  eye,  have  been  reported.  The  cerebral  cha- 
racter of  the  lesion  may  he  established  by  paresis  and  unconsciousness.  The 
site  i-  supposed  to  he  in  the  cortex/  A  separate  color-center,  however,  is 
denied  by  Ole   Bull,  Dahms,  and   Ward   Holden. 

Recently  several  cases  of  double  homonymous  hemianopia,  with  preserva- 
tion of  -mall  central  field  in  each  eye,  show  that  there  is  a  cortical  visual 
center  which  supplies  the  macula  luteal 

Monocular  //< mi/nio/iia  is  supposed  to  he  caused  by  Lesion  of  part  of  one 
tracl  involving  only  a  portion  of  its  fibers,  lmt  no  cases  have  been  well 
established.4  The  same  may  he  -aid  of  vertical  In iiii<ni<>/>i</  (Figs.  291  and 
■_!'.i7'.  Many  diseases  of  the  nerve  and  retina  simulate  a  hemianopic  field, 
hut  cannot  he  considered  under  the  classical  definition.  The  causes  of  the 
three  varieties  of  hemianopia  include  traumatism,  hemorrhages,  embolisms, 
periostitis,  tumors,  softening  and  sclerosis  of  that  portion  of  nerve  lying 
within   the  skull. 

The  Significance  of  Hemianopia. —  Hemianopia  i>  not  in  itself  a  local- 
izing symptom.  There  arc  usually  other  symptoms  which  assist  in  the 
diagnosis.     Seguin's  rule-  are  a-  follows: 

"  I.  Lateral  hemianopia  always  indicates  an  intracranial  lesion  en  the  opposite  side 
from  tin-  dark  fields,  2.  Lateral  hemianopia  with  pupillary  immobility,  optic  neuritis, 
or  atrophy,  especiallj  if  joined  with  symptoms  of  basal  disease,  is  due  to  lesion  of  one 


AMAUROSIS  PARTIALIS  Fl  <;AX.  483 

optic  tract  or  df  the  primary  optic  centers  of  one  side  i.  >.  the  corpora  quadrigemina 
and  parts  included  within  primary  optic  centers  (including  corpora  quadrigemina,  cor- 
pora geniculata,  and  pulvinar  of  the  thalamus  opticus)  (Fig.  306).  3.  Homonymous 
sector-like  defects  of  the  same  geometric  order,  with  hemianesthesia  and  choreiform  or 
ataxic  movements  of  one-half  of  the  body,  without  marked  hemiplegia,  are  probably  due 
to  lesion  of  the  cando- lateral  part  of  the  thalamus  or  of  the  posterior  i  caudal)  portion  of 
the  internal  capsule,  fasciculus  opticus,  and  radiating  visual  fibers  of  Gratiolet  in  the 
internal  capsule.  4.  Lateral  hemianopia  with  complete  hemiplegia  (spastic  after  a  few- 
weeks)  and  hemianesthesia  is  probably  caused  by  an  extensive  lesion  of  the  internal 
capsule  in  its  knee  and  caudal  part  (pulvinar) — i.  e.  farther  back  and  more  pro- 
found than  in  supposition  '■'>.  5.  Lateral  hemianopia  with  typical  hemiplegia  (spastic 
after  a  few  weeks) — aphasia  if  the  right  side  lie  paralyzed  and  with  little  or  no  anes- 
thesia— is  quite  certainly  due  to  occlusion  of  the  middle  and  adjacent  cerebral  arteries 
with  extensive  superficial  lesion,  softening  of  the  motor  zone  and  of  the  gyri  lying 
at  the  extremity  of  the  fissure  of  Sylvius — viz.  the  inferior  parietal  lobule,  the  supra- 
marginal  gyrus,  and  the  gyrus  angularis.  There  may  also  be  alexia,  word-blindness. 
6.  Lateral  hemianopia  with  moderate  loss  of  power  in  one  half  of  the  body,  espe- 
cially if  associated  with  impairment  of  the  muscular  sense,  would  probably  be  due  to  a 
lesion  of  the  inferior  parietal  lobule  and  gyrus  angularis  with  their  subjacent  white 
substances,  penetrating  deeply  enough  to  sever  or  compress  the  optic  fasciculus  on  its 
way  posteriorly  to  the  visual  center.  If  mental  blindness  exists,  the  lesion  would  lie  in 
the  more  anterior  central  parts  of  the  occipital  lobe.  7.  Lateral  hemianopia,  without 
motor  or  common  sensory  or  any  accompanying  symptom,  is  due  to  lesion  of  the  cuneus 
only,  or  of  it  and  the  gray  matter  immediately  surrounding  it,  on  the  mesial  surface  of 
the  occipital  lobe  in  the  hemisphere  opposite  the  dark  half-fields.  The  lesion  may  be 
partial  or  total.  Most  surgical  cases  come  at  once  or  after  convalescence  within  this 
rule  or  within  rule  No.  6.  In  all  cases  coming  under  rules  3  to  7,  inclusive,  the  pupils 
react  normally,  and  rarely  does  the  ophthalmoscope  show  any  lesion  of  the  optic  nerve, 
except,  of  course,  in  some  tumor  cases,  where  neuro-retinitis  may  be  expected."  12 

Amaurosis  Partialis  Fugax  (Transient  Hemianopia). —  Flickering 
scotoma  is  a  form  of  temporary  blindness  of  a  hemianopic  character  usually 
associated  with  unilateral  migraine,  which  is  accompanied  by  malaise,  vertigo, 
and  sometimes  disturbances  of  memory  or  speech.  It  is  supposed  to  be  due 
to  disturbance  of  the  circulation  from  spasm  in  the  vessels  of  the  brain,  and, 
when  accompanied  by  headache,  in  those  of  the  dura  mater.'  A  typical 
attack  usually  begins  with  a  dark  spot  in  both  eyes  in  the  same  part  of  the 
visual  field.  This  spreads,  but  remains  in  the  nasal  half  of  one  visual  field 
and  the  temporal  left  of  the  other.  Silvery  flickering  points  or  shadows 
move  in  a  zigzag  manner.  Part  of  the  dark  spot  extends  toward  the  end  of 
the  visual  field.  The  blindness  usually  lasts  a  quarter  to  a  half  hour  and 
disappears.  If  the  visual  field  be  examined  during  the  attack,  a  defect  will  be 
found.  In  one  case1''  the  scotoma  appeared  as  in  the  illustration  (Fig.  306), 
growing  larger  and  larger,  finally  obliterating  the  object  and  then  disappearing. 
In  another  case1  central  scotoma  with  loss  of  light-,  color-,  and  form-sense  was 
found.  In  only  one  case  in  the  writer's  experience  lias  this  condition  been 
associated  with  hysteria,  the  others  happening  in  persons  of  nervous  organi- 
zation whose  general  state  of  health  was  somewhat  lowered.  In  one  case,9  of 
a  physician  who  was  subject  to  the  flickering  scotoma,  an  attack  was  followed 
several  weeks  later  by  hemianesthesia,  hemiplegia,  and  death  with  bulbar 
symptoms.  At  the  autopsy  the  right  vertebral  artery  was  found  thrombosed 
and  obliterated.  In  this  case  the  "flimmer  scotom "  was  certainly  due  to 
disturbance  of  the  circulation. 

The  scotoma  scintillans  of  lasting  is  a  peculiar  subjective  visual  sensation 
of  the  same  character.  In  some  cases  there  is  q  kind  of  after-image  of  the 
true  scotoma  appearing  at  night  or  in  dim  light,  lasting  but  half  an  hour, 
which  consists  in  a  rapid  succession  of  luminous  figures  with  dark  intervals. 
In  one  case  ~~  these  appeared  in  the  upper  right  quadrant  of  the  binocular 
field  as  a  glittering  figure  quite  close  to  the  fixation-point,  of  an   irregular, 


484 


AMBLYOPIA    OF  THE    VISUAL   FIELD,  ETC. 


crescentic  shape,  increasing  for  a  while  and  gradually  receding  from  the 
center  of  the  Held,  growing  larger  and  dimmer  and  finally  fading  away. 
Reading  was  not   materially  interfered  with. 

I   remember,    1   remember,    the  house  where    I  was  born; 

The   little  window  where  the   sun  cane   peeping   in  at  morn. 

He  never   came  a  wink    too  soon,   nor  brought    too   long  a  day, 

But   now   1    often  wish   the   night  bJ^borne  my°"life   away. 

I   remember,    I    remember   the   fir   tv^/s  dark   and  high; 

I   used   to    think   their  very   tops  were   close   against    th,^  sky 

It  wae    inchildish    innocence,    but   now    'tis   little   joy 

To  knew   I'm  farther  off  from  Heaven   than  when   1  was  a  hoy.. 


1   remember,    1   remember  the  house  where    1   v.as  horn. 

The    little   window  where    the    sun  came    peeping   in  at  morn. 

He  never  came,  a  wink   too  soonf^"~"v~Mbrought   too   long  a  day 

But  now   i    often  wish   the  nlgc"         Jborne  my°llfe   away.-- 

1   remember,    1    remember    the   fh?_J>es,   dark  and   high; 

"I   used   to    think   their  very   top.»  were   close   against    the   sky 

It  was  a  chlndish   innocence  but  now    'tis    little   Joy, 

To   know    I*tr  farther   off   from  heaven   than  when  I   was  a  boy. 


1   remember,    I    remember   the  house  where    I  was  born 


The   1 ITtle  window  where    the 

He  never  cSme  a  wink   too     (7ifc$g&£!- 

But    now   I    often  wish    the  v^S> 

I    remember,    1   remember   the}5< 

I   used   to    think    their  very 

It  was   in  childish   innocence' 


^peeping    in  at  morn. 
ty**^        too   long  a  day, 
orne  my°life   away.-- 
~}rk   and  'h.ish; 
./close  against    the   8ky 
iow    'tis    little   Joy, 


To  know   I'm  farther  off  from  heaven   than  when   I   was  a  bdy 


I    remember,    I   remember   the  house  where    I  was  born; 

The    little  window  where    r/>J?>tf^iv\  peeping  in  at  morn. 

He    never   came  a  wink   t$o££§l32yttm r  brought,too  long  a  day, 

But   now   I   often  wish   frT§3fetfS>?C      borne  my^life  away. 

I    remember,    I   rememb| 

I    used    to   think   thei 

It  was   In  childish 

to  know   I'm  farther 


"y^thep;f   y^   ees  dark   and   high 
?>V/J\'y         ~~  were   close  against 

T 


the  sky 
now  'tis  little  joy, 
ven  than  when  I  was  a  boy. 


^oo  soon 

o 

the  nig) 


i  [Q. 806.— Appearand  "i  printed  page  in  amnun.M-  partialis  fugas  (after Stirling). Q*j 

Treatment  of  this  condition    consists    in   restriction   from    brain-work, 
regulation  of  diet  and  daily  life.     The  administration  of  antipyrin,  phenace- 


AXi:sTiiKSL\   or  rin:  itr/n.XA. 


485 


tin,  or  caffein  may  cut  short  the  duration  of  the  attack  and  relieve  the  symp- 
toms.    Bromid  of  potassium  and  quinin  have  been  advised. 

FUNCTIONAL  DISEASES. 

(Retinal  Anesthesia;  Neurasthenic  Asthenopia  ;   Hysteric  Amblyopia.) 

Anesthesia  of  the  retina  (sec  also  page  410)  is  characterized  by  reduc- 
tion of*  the  visual  acuity  and  concentric  contraction  of  the  visual  field  or  other 
changes,  together  with  functional  disturbances  in  other  parts  of  the  body. 

It  occurs  for  the  most  part  in  anemic  women  who  are  often  the  subjects 
of  uterine  and  ovarian  disease  or  chlorosis,  or  in  children  at  puberty  ;  occa- 
sionally cases  are  seen  in  young  men.  The  loss  of  sight  is  usually  partial, 
although  it  may  be  total,  and  in  some  eases  the  apparent  loss  is  heightened 
by  malingering.  It  is  purely  an  hysteric  manifestation,  and  as  such  may 
last  from  a  few  hours  to  days,  weeks,  or  months.  Indeed,  patients  have  been 
known  to  shut  themselves  up  in  dark  rooms  for  a  long  time,  especially  if 
attended  by  sympathizing  friends  or  relatives.  The  subjects  usually  com- 
plain of  considerable  eye-pain,  dazzling  and  photophobia,  headache,  and  blind- 
ing by  artificial  light,  haziness,  dimness  of  letters  and  lines  on  reading, 
lachrymation,  and  occasional  diplopia. 

The  causes  of  the  condition  are  over-exertion  at  school  or  over-work, 
traumatic  neurosis  from  injuries  which  are  often  trifling,  general  ill-health, 
and  diseases  of  the  genital  organs  (kopiopia  hysterica),  and  other  manifold 
causes  of  hysteric  conditions.  The  location  of  an  hysteric  symptom  is  fre- 
quently more  or  less  dependent  upon  an  actual  local  lesion.     Thus  it  is  that 


h.e 


Fig.  307.— Visual  fields  in  hysteric  amblyopia,  showing  concentric  contraction  with  overlapping  color- 
fields  anil  relative  central  scotomata. 

the  cause  of  hysteric  blindness  in  a  neurasthenic  person  may  depend  upon 
eyes  that  are  already  weak  front  an  error  of  refraction  or  actual  extrinsic 
muscle-weakness,  conjunctival  trouble,  etc.  There  are  eases  in  which  these 
causes  may  not  be  found,  and  a  diagnosis  of  true  nervous  asthenopia  may 
here  be  made.  There  is  usually  weakness  of  accommodation  and  the  extrinsic 
muscles,  especially  deficient  adduction  (insufficiency)  or  imbalance  of  the 
muscles  (heterophoria).  The  levator  is  sometimes  likewise  affected  (pseudo- 
ptosis). There  may  be  sensory  motor  paralysis  and  paresthesia  or  anesthesia 
in   various   parts  of  the   body. 

There    is  generally  concentric    contraction   of    the  visual    field,   usually 


486 


AMBLYOPIA    OF  THE    VISUAL    HELD,    ETC. 


more  on  one  side  than  on  the  other  (  Fig.  307).  The  extents  and  shapes  of  the 
fields  will  vary,  depending  upon  the  size  of  the  test  objects  and  the  condition 
of  the  patient.  The  contraction  may  be  more  pronounced  if  a  second  Held 
(the  counter-field)15  l>e  taken  immediately  after  the  first,  the  difference 
being  caused  by  nervous  exhaustion  (Ermiidungs-Typus) ; 15  or  the  second 
field  may  overlap  the  first  (Verschiebungs-Typus)13  (  Fig.  308),  or  the  colors 


IKS* 

"Njy 

ISO"/    / 

w 

y~ 

■\S!\ 

\>o* 

\V8 

ScS 

210 \\ 

JlO^v^ 

/w 

^Jwr 

Red 

Fig.  308.— Fields  for  white  of  right  eye  taken 

fifteen  minutes  apart  in  a  case  of  neurasthenia 

with  diminished  vision,  showing  overlapping  of 

ond  field,  the  fixation-point  remaining  the 

same  (Verschiebungs-Typus). 


Fig.  309.— Reversal  of  color-fields  in  hysteria. 


may  overlap  or  be  reversed  (reversal  of  the  color-fields)v  (Fig.  309).  Mixed 
forms  are  common  and  the  boundaries  are  frequently  not  sharply  defined. 
A  relative  central  scotoma   is  sometimes  found.     The  field  may  even  have  a 


10.    Hysteric  field  simulating  temporal  bemianopia. 

hemianopic  character.  <»r  be  greatly  contracted,  or  -how  sectoral  defects  I  Figs. 
310  and  .'ill).  A  peculiar  form  is  the  oscillating  field,16  in  which  the  patient 
firsl  recognizes  an  objeel  .-it  one  meridian,  then   loses  it  for  a  moment,  only  to 

\\  again. 

The  diagnosis  may  !»<■  made  by  the  accompanying  general  symptoms  and 
the  absence  of  actual  ophthalmoscopic  signs  of  disease.  The  pupils  are 
active  to  lighi  and  accommodation  and  the  visual  fields  are  usually  typical. 
The  amblyopia  is  usually  of  sudden  occurrence  and  disappears  quickly.11 


BIBLIOGRAPHY.  187 

Treatment  is  directed  toward  restoration  of  general  health,  and  should 
include  massage,  exercise,  good  food,  and  tonic-,  with  rest  of  the  eyes  from 
work,  and  the  use  of  tinted  glasses,  care  being  taken  that  the  subject  does  do< 


Fig.  311.— Great  concentric  contraction,  with  overlapping  of  the  color-fields  in  hysteric  amblyopia. 

depend  too  much  upon  their  use.  Although  subject  to  constant  relapses,  many 
cases  may  he  rapidly  brought  from  complete  or  partial  blindness  to  full  visual 
acuity  and  restoration  of  the  visual  field  by  suggestion,  electrical  treatment, 
or  simple  medicines. 

Nerve-lesions  and  general  diseases  are  sometimes  attended  by  disturbance 
of  vision  and  changes  in  the  visual   field. 

The  Significance  of  Amblyopia  and  Changes  in  the  Visual 
Field. — The  diagnostic  importance  of  loss  of  vision  depends  upon  its 
nature.  If  the  disease  be  found  in  the  eye.  it  will  depend  upon  the  extent 
of  the  lesion.  If  the  blindness  be  associated  with  symptoms  of  spinal  or 
brain  disease,  diagnostic  points  of  value  will  be  determined  from  study  of 
the  visual  acuity,  of  the  character  and  extent  of  scotomata,  and  of  alterations 
in  the  field.  If  the  latter  he  hemianopic  in  character  and  associated  with 
other  symptoms,  a  definite  localization  of  the  lesion  may  be  assigned,  although 
in  themselves  these  are  not  diagnostic,  as  such  may  he  simulated  by  hysteria. 
The  character  of  scotomata  is  sometimes  diagnostic,  especially  those  of  central 
nature  which  occur  in  toxic  amblyopia.  The  peculiar  vacillations  in  the 
visual  field  associated   with  functional  disease  are  characteristic. 


BIBLIOGRAPHY. 


1  P.aa^.  Karl:    Das  Gesichtsfeld,  1896. 

2  Baas,  Karl:  "Die  Semiotische  Bedeutung  der  Pupillenstorungen,"  1896,  Samml.  AbhdL 
d.  Gebiete  d.  Aiit/i-nhble,  i.  ■">.  ls'.ifj. 

I  Bales:  "A  Case  of  Binasal  Hemianopsia,"  The  Ophthalmic  I'        ,  July,    : 

4  Kirk.  A.  Eugen  :   Lehrbuch  der  Augenheilkunde,  Leipzig,  1884. 

5  Knies  Max. :   I  Hi'  llezlihinnji  u  </-  .-•  S,  In,, -i/nns  nnti  seiner  Erkrank  Krank- 
''■--•  Kb'rpers  »/<</  teiner  Organe,  Wiesbaden,  lsfi:*,. 

8  Krienes,  Elans:  Memeralopia,  1896. 
7  Mauthner :  Gehirn  und  Auge,  1881. 
■  Noyes,  II.  I).:   Diseases  of  th   Eye,  1890. 

9Beinhold:  "Beitrage  z.  Path.  a.  acuten  Erweichung  d.  Pons,  u.  d.  Medulla  Oblongata," 
DeuL  Zeitschr.  f.  NervenheUL,  5,  1894. 

10  De  Schweinitz,  G.  E.:   Diseases  of  the  Eye,  1892. 

II  I).-  Schweinitz,  G.  E.,  and  Mitchell,  J.  K.:  "A   Further  Study  of  Hysterica 
their  Fields  of  Vision,"  Jour,  oj  Nerv.  and  Ment.  Dis.,  Jan.,  1894. 


IS*  AMBLYOPIA    OF   THE    VISUAL    FIELD,    FTC. 

-  _ 1 1 in  :   "Contribution  to  Pathology  of  Hemianopsia  of  Central   Origin,"   Journ.  of 
Xerv.  and  MenL   Dis.,   1886. 

13  Stirling,  A.  W.:  "On  Certain  Subjective  Visual  Sensations,"  Journ.  Amer.  Med.  Assoc, 
Dee.  5,  1896. 

14  Veasey,  I  .  A..:  "Binasal  Hemianopsia,"  Ophthal.  Record.  Feb..  1S97. 

u  Wil brand,  H.  :    Di>    llemianopischen  Genichtfeldfirmen  und  das  Wiihrnehmunyszndrum,  1 890. 

18  Wilbrand,  II.:  Die  Erholungs  AusdeJmung  d.  Gesichtsfeldes  writer  normal  u.  path.  Bed- 
ingungi  n,  1 896. 

11  Wiirdemann,  II.  V.  :  "Colobomaof  the  <  > j > t i » •  Nerve  and  Retina,  witb  Persistent  Opaque 
Nerve-fibers,"    I      ik  of  Ophthal.  and  Otol.,  July.  1896. 

'*  Wiirdemann,  II.  V. :  "Albuminuric  Retinitis  in  Pregnancy,"  Ophthal.  Record,  Sept., 
1895. 

'•'  Wiirdemann,  II.  V. :  "Occurrence  of  Optic-nerve  Atrophy  in  General  Disease,"  Journ. 
Amer.  Med.  Assoc,  Oct.,  1896. 

20  Wiirdemann,  II.  V.  :  'Temporal  Hemianopia,  with  Recovery  followed  by  Right  Lateral 
Hemianopia  and  Ophthalmoplegia,"  Arch,  of  Ophthal.,  xxii.  2,  1895,  and  Arch.  J.  Augenhkde, 
ixix.,  1895. 

31  Wiirdemann,  II.  V. :  "  Illustrative  Cases  showing  the  Indications  for  Enucleation  of  the 
Eyeball,  etc.,"  Annals  of  Ophthal.,  October,  1897. 

B  Zehender,  N. :  "Das  Sichelformige  Flimmerscotom,  Listing's,"  Klin.  Monatsbl.  f. 
Augenhkde,  Jan.,  1S97. 

23  Wilbrand,  H.  :  "  Perimetry  and  it<  Clinical  Value,"  System  of  Diseases  of  the  Eye.  Ed- 
ited by  Norris  and  Oliver,  Philadelphia,  1897. 


INTRAOCULAR  GROWTHS. 

By  WARD  A.  HOLDEN,   A.  M.,  M.  D., 

OF    NEW   YORK    CITY. 


Tumors  of  the  Iris.— Strictly  speaking,  tumors  of  the  iris  include  cyst, 
sarcoma,  simple  granuloma,  pigmented  granuloma  or  melanoma,  and  angioma, 
although  besides  these  primary  tumors  there  are  the  nodules  of  tuberculosis 
and  lepra,  the  condylomata  and  gummata  of  syphilis,  and  the  lymphomata  of 
general  leukemia,  which  will  not  be  treated  of  in  this  article. 

I.  Cysts  of  the  Iris. — (1)  Cyst  of  the  stroma  of  the  iris  usually  follows  a 
perforating  wound  of  the  cornea,  and  appears,  some  months  or  years  after  the 
trauma,  as  a  smooth,  round  tumor,  translucent  and  non-inflammatory,  pro- 
jecting from  the  surface  of  the  iris  and  distorting  the  pupil. 

In  color  the  cyst  ranges  from  bluish-gray  to  yellow  according  to  its  size, 
the  thickness  of  its  walls,  and  the  consistency  of  its  contents. 

The  cyst  as  it  grows  preserves  its  globular  form  until  it  impinges  on  the 
cornea,  when  it  flattens  and  moulds  itself  to  the  shape  of  the  anterior  chamber. 
At  the  outset  it  is  not  accompanied  by  signs  of  inflammation,  but  as  it  increases 
in  size,  particularly  if  the  increase  is  rapid,  there  appear  evidences  of  irrita- 
tion, soon  followed  by  true  iridocyclitis.  The  latter,  which  is  associated 
often  with  glaucoma  or  even  with  sympathetic  disturbance,  destroys  the  sight 
and  at  length  necessitates  enucleation. 

Since  the  growth,  if  neglected,  is  fatal  to  the   eye,  an  early  attempt  at 
removal  should  be  made,  but,  owing  to  the  impracticability  of  extirpating 
the    cyst   entire,   recurrence    is  usual,  al- 
though cures  are  reported. 

These  cysts  may  be  either  serous  or 
epithelial.  The  former  are  true  cysts, 
having  a  wall  lined  with  one  or  more 
layers  of  epithelium  (or  rarely  endothe- 
lium), and  enclosing  liquid  contents.  When 
the  wall  is  thin  and  the  liquid  clear,  such 
:i  cysl   may  be  perfectly  transparent  (Fig. 

312).  Fir,.  312.— Serous  cysl  of  the  iri>  nine 

'Pi  •,]    /•    .  ,  ,i  months  after  a   perforating  injury  (from  u 

Ihe   epUhmal    cysts,   on    the    contrary,      patient  of  Dr.  H.Knapp's). 

are  composed  in  the  periphery  of  stratified 

epithelium,  which   toward  the  center  of  the  tumor  gradually  passes  over  into 

an  atheromatous  mass  of  broken-down  epithelium,  fat,  and  cholesterin.     From 

their  appearance  when  cui  these  epithelial  cysts  have  been  culled  pearl  tumors, 

and,  from  their  pathogenesis,  ejjithefiaf  implantation  tumors. 

The  theory  now  accepted  as  adequate  to  explain  the  genesis  of  most  of 

these  tumors,  and  certainly  of  all  those  lined  with  epithelium,  is  thai  epithelial 

particles  from  the  cornea,  lashes,  or  lids  are  carried  by  the  penetrating  body 


490  INTRAOCULAR   GROWTHS. 

into  the  eye,  and,  proliferating  there,  form   a   cyst.     Cysts   may  readily  be 

produced  experimentally  in  this  way. 

For  the  rare  cases  in  which  there  is  no  history  of  perforation  of  the  cornea 

Schmidt-Rim  pier  lias  advanced  the  plausible  theory  that  the  month  of  one  of 

the  crypts  in  the  anterior  surface  of  the  iris  becomes  occluded,  thus  forming  a 

sac  lined  with  the  endothelium   that  normally  covers  the  surface  of  the  iris. 

This  sac,  undergoing  a  progressive  distention  with  liquid,  becomes  a  serous 

cyst. 

(2)   ( h/sts  of  the  pigment-layer  of  tin  iris  occur  in  eye-  with  broad  posterior 

synechia',  and  are  usually  not   discovered  until   the  eye  is  cut  open,  although 

this  condition  has  been  diag- 
uosed  twice  in  life,  the  cyst 
presenting  in  the  pupil  as  a 
pigmented,  vibrating,  translu- 
cent  tumor. 

These  cysts  are  due  to  the 
drawing  apart  of  the  two 
strata  of  cells  making  up  the 

Fig.  313.— Cyst  of  the  pigment-layer  of  the  iris,  due  to      posterior  pigment-layer  of  Lhe 
membraiimis  irido-cyclitis  following  a  perforating  injury  of       •    •  i   ,i    '   en-  '  •.  i    i-       ■  i 

the  cornea  and  lens.  iris,  and  the  tilling  With  liquid 

of    the    cavity    so    produced. 

Although  usually  small,  they   may  involve  the   pigment-layer  in   its  entire 

extent   (Fig.  313). 

Sarcoma  of  the  Iris. — This  is  usually  an  extension  of  sarcoma  from 
the  ciliary  body,  which,  passing  through  the  head  of  the  ciliary  body,  presents 
in  the  angle  of  the  anterior  chamber  (  Fig.  31  1.  D). 

Sarcoma  may,  however,  be  primary  in  the  iris,  and  it  then  appears  in 
middle  life  as  a  very  vascular  tumor,  soon  leading  to  iritis  and  glaucoma. 
It    is  more  common   in   women   than   in   men. 

If  pigmented,  as  it  usually  is,  it  can  only  be  confounded  with  melanoma, 
which  is  uon-vascular  and  non-progressive.'  If  not  pigmented,  sarcoma  may 
be  mi-taken  for  the  irregular  non-vascular  nodules  of  tuberculosis,  which 
develop  with  a  chronic  iritis  in  young  persons  (see  page  339). 

Treatment. — In  the  early  stages,  when  the  growth  is  circumscribed, 
favorable  results  follow  excision  of  the  diseased  portion  of  the  iris  by  means 
of  a  broad  iridectomy.  It  should  l>e  remembered,  however,  that  there  may 
have  been  extension  into  the  ciliary  body,  even  at  a  time  when  the  growth 
still  seems  localized  in  the  iris.  If  this  point  should  be  positively  ascer- 
tained, or  if  extension  should  have  taken  place,  thorough  enucleation  i-  the 
only  remedy. 

Tumors  of  the  Ciliary  Body. — These  are  sarcoma,  myosarcoma, 
primary  and  metastatic  carcinoma,  adenoma,  nevus,  and  cyst.  Sarcoma  is  the 
mosl  common,  and  only  a  few  cases  of  each  of  the  others  have  been  reported. 

Myoma  and  Myo-sarcoma  of  the  Ciliary  Body. — These  are  names 
given  several  times  to  tumors  composed  of  long  fusiform  cells  which  were 
taken  to  be  smooth  muscle-cells  springing  from  the  ciliary  muscle.  The 
differentiation  between  smooth  muscle-cells  and  the  long  fusiform  cells  of 
Barcoma  is  difficult,  and  it  is  not  improbable  that  in  some  of  the  reported 
cases  the  tumor  was  an  ordinary  sarcoma. 

Primary  carcinoma  and  adenoma  of  the  ciliary  body  may  arise  from 
the  proliferation  of  the  cells  of  the  pars  ciliaris  retina',  which  is  of  epithelial 
origin.     The  new  structure  i-  likely  to  be  of  a  glandular  type.    Theoretically, 

Benign  melanoma  here,  as  elsewhere,  may  in  later  life  become  sarcomatous. 


TUMORS  OF  THE  CHOROID.  491 

similar  growths  could  arise  from  the  posterior  pigment-layer  of  the  iris,  and 
such  a  case  has  been  reported  by  ETirschberg,  bul  he  admit- that  the  character 
of  the  growth  was  questionable. 

Cysts  may  be  formed  in  the  ciliary  hud)-  or  choroid,  or  there  may  be 
detachment  of  the  choroid  with  rotation  inward  of  the  ciliary  body.  Such 
'conditions  are  readily  mistaken  for  sarcoma  of  the  ciliary  body.  Oblique 
illumination  of  the  sclera  in  the  ciliary  region  will  show  translucency  in  the 
former  case,  but  opaqueness  if  a  tumor  is  present.  The  tension  is  also  of 
importance. 

Tumors  of  the  Choroid. — These  are  sarcoma,  which  is  the  most 
common ;  metastatic  carcinoma,  which  is  seen  occasionally  ;  and  cyst  and 
in  vus,   which  are   rare. 

I.  Sarcoma  of  the  Choroid  and  Sarcoma  of  the  Ciliary  Body. — 
These  growths  may  be  described  together.  The  course  of  the  disease  has 
been  divided  by  Knapp  into  four  stages. 

Symptoms. — In  the  first  stage,  that  of  latency,  the  patient,  who  is  usually 
past  middle  life,  complains  simply  of  a  defect  in  the  visual  field.  The  media 
are  clear,  and  there  is  seen  a  smooth,  rounded  elevation  of  the  retina,  with- 
out folds,  not  undulating  with  movement  of  the  eye,  not  extending  in  most 
cases  to  the  ora  serrata,  and  with  an  overhanging  margin  in  all  or  most  of 
its  extent.  If  the  sarcoma  is  unpigmented,  its  vessels  may  he  recognized 
beneath  the  retinal  vessels.  Sarcoma  of  the  choroid  usually  appears  of  a  red- 
dish color,  and  sarcoma  of  the  ciliary  body  black.  The  tension  is  normal 
and  the  eye  is  otherwise  healthy. 

While  this  condition  lasts — and  it  may  persist  for  year; — the  disease 
usually  can  be  distinguished  easily  from  spontaneous  detachment  of  tin  retina 
and  from  detachment  of  the  choroid,  the  two  conditions  that  resemble  it. 

Spontaneous  detachment  of  the  retina  i.-  preceded  by  the  perception  of 
muscse  volitantes,  and  comes  on  suddenly.  It  extends  to  the  ora  serrata,  and 
the  folds  into  which  the  retina  is  thrown  undulate  with  every  movement  of 
the  eye.  The  vitreous  is  cloudy,  signs  of  choroiditis  are  usually  found  in 
the  affected  eye  or  the  other,  and  the  tension  is  reduced  (see  page    128  . 

Detachment  of  the  choroid  is  a  very  rare  condition,  of  sudden  onset,  and 
caused,  a-  a  rule,  by  hemorrhage,  and  more  rarely  by  exudation.  Tension 
may  be  increased.  The  characteristic  vessels  of  the  choroid,  however,  can 
usually  be  recognized  beneath  the  vessels  of  the  retina,  thus  establishing  the 
diagnosis  (see  page  357). 

Toward  the  end  of  the  first  stage  of  the  course  of  sarcoma  the  vitreous 
grows  cloudy  and  a  general  detachment  of  the  retina  ensues,  producing  com- 
plete blindness.  Detachment,  however,  is  longer  delayed  w  hen  the  tumor 
is  in  the  ciliary  body  or  near  the  posterior  pole  of  the  eye.  The  tension 
may  still  be  normal  for  a  time,  and  the  diagnosis  will  then  he  exceedingly 
difficult.  This  i-  true  particularly  of  those  rare  cases  in  which  the  tumor  is 
flat,  for  such  a  growth  will  sometimes  perforate  the  globe  posteriorly  before 
it  presents  much  of  a  tumor  in  the  interior  of  the  eye.  The  opaque  tumor 
can,  however,  sometimes  be  made  out  beneath  the  floating  retina  by  using 
intense  illumination,  and  it-  plastic  feature-  may  be  recognized  by  means  "t 
Bellarminoff' 's  device  of  pressing   ;i   moistened   plane  glass  upon  th< 

thus  eliminating  the  refraction  of  th< rnea  and  permitting  objects  in  the 

interior  of  the  eye  to  be  seen  more  nearly  in  their  natural  size  and  relief. 
The  final  tesf  of  tumor  i-  puncture.  If  a  sarcoma  is  present,  blood  will  be 
withdrawn,  but  if  the  condition  i-  merely  one  of  simple  detachment  of  the 
retina,  only  a  scroti-  Liquid   will  appear. 


192 


INTRAOCULAR  0R0WTH8. 


-  i)  after  the  general  detachment  of  the  retina  has  occurred  the  second 
stagt  of  the  disease  is  ushered  in,  that  of  glaucoma.  The  anterior  ciliary 
vein-  are  now  dilated,  more  particularly  on  the  side  corresponding  to  the 
tumor,  the  anterior  chamber  is  shallow,  the  media  are  cloudy,  the  tension  is 
increased,  and  the  eye  is  painful.  There  is  occasionally  hemorrhage  into  the, 
eye,  and  at  times  the  glaucomatous  symptoms  may  mask  every  sign  of  tumor. 
Then  the  fad  that  the  patient  was  blind  before  the  glaucoma  will  arouse 
suspicion  of  tumor,  and  the  coexistence  of  increased  tension  and  detachment 
of  the  retina  i-  almost  pathognomonic.  Cyclitismay  supervene  in  this  stage, 
or  sarcoma  may  develop  in  an  eye  already  shrunken  from  eyelitis;  but  these 
cases  will  l>e  distinguished  from  those  of  uncomplicated  eyelitis  by  the 
increased  ten-ion. 

In  the  third  stage,  that  of  local  extension,  the  growth  spreads  to  parts  out- 
side of  the  eyeball.  When  the  tumor  is  located  in  the  anterior  portion  of  the 
hall,  it  extend-  into  the  ciliary  body,  presenting  in  the  angle  of  the  anterior 
chamber,  and  thence  passes  out  along  the  anterior  ciliary  vessels  to  form 
nodules  in  the  episcleral  tissue.  When  it  is  located  posteriorly,  the  growth 
passes  out  along  the  venae  vorticosse,  or  the  posterior  ciliary  vessels  and  nerves, 
or  the  optic  nerve,  extending  in  the  substance  of  the  latter  or  between  its 
sheaths,  and  then  forms  nodules  in  the  orbit  which  cause  exophthalmos. 

In  the  fourth  stage  metastatic  tumors  develop  in  other  organs,  notably  the 
liver.  Even  when  the  eye  has  been  enucleated  early,  metastases  occur  in 
from  20  to  tO  per  cent,  of  the  cases,  and  death  then  follows,  usually  within 
three  year-. 

Pathological  Anatomy. — The  shape  of  the  sarcomatous  tumor  varies 
with  the  relations  of  the  inner  layers  of  the  choroid,  which  overlie  it  like  a 
capsule.  Rarely  the  tumor  is  diffuse  and  only  slightly  elevated,  but,  as  a 
rule,  it  preserves  a  spheroidal  form  as  long  as  the  choroidal  capsule  is  intact 
(Fig.  31  1,  .1).  When  the  capsule  is  ruptured,  however,  the  tumor  assumes 
the  shape  of  a  sphere  springing  from  a  Matter  base  (Fig.  old,  B),  and  later 
the  entire  ma—  may  again  become  spheroidal  (Fig.  314,  ('). 


/:  C  1) 

Pio.  :a  L— Diagram!  oi  the  uveal  tract,  tin-  heavy  line  representing  the  tumor-capsule. 

\  second  nodule  developing  near  the  first  may  remain  permanently  sepa- 
rated from  the  other  by  it-  capsule  (Fig.  314,  /»').  When  the  tumor  i-  in 
the  ciliary  body,  the  anterior  portion  breaks  through  the  capsule  early  and 
impinges  on  the  lens,  dislocating  and  distorting  it  |  Fig.  314,  D).  The  retina, 
which  in  the  normal  state  i-  but  loosely  attached  to  the  choroid,  may  readily 
undergo  a  total  funnel-shaped  detachment  while  the  capsule  is  still  intact 
(Fig.  :;l  1,  .li.  Bui  when  the  growth  perforate-  the  capsule  the  retina  be- 
comes adherent  at  the  point  of  perforation,  ami  remains  attached  there,  although 
it  may  otherwise  be  detached  entirely  (Fig.  ::i  I,  /.'and  (J). 

The  consistency  of  sarcoma  i-  generally  firm,  although  the  tumor  may  he 


Plate  8. 


Fig.   I.     Vascular  round-celled  sarcoma  of  cboroid. 

Fig.   II.     Non-vascular  spindle-celled  sarcoma  of  choroid. 

Fig.  III.     Metastatic  carcinoma  of  choroid. 


TUMORS  OF  THE  CHOROID.  493 

gelatinous,  and  it   may  undergo  fatty,  myxomatous,  cartilaginous,  or  osseous 
degeneration. 

The  pigmented  variety  (mela/no-sarcoma)  is  much  more  frequent  than  the 
unpigmented  (leukosarcoma).  The  pigment  of  melano-sarcoma  may  lie  only 
in  a  few  cells  along  the  vessels,  or  may  color  single  tracts  of  cells,  or  every 
cell  in  the  tumor  may  be  black  with  pigment.  The  pigmentation  is  usually 
denser  in  the  periphery  of  the  tumor  than  in  the  center. 

Sarcoma  of  the  uveal  tract  may  occur  in  many  of  the  protean  forms  in 
which  sarcoma  is  found  elsewhere,  and  more  than  one  type  of  structure  may 
be  represented  in  the  same  tumor.  The  cells  are  usually  small,  and  the 
spindle-cell  is  commoner  than  the  round.  There  are  all  degrees  of  vascularity, 
from  the  type  in  which  the  tumor  is  made  up  of  thin-walled  vessels,  each  sur- 
rounded by  a  sheath  of  epithelioid  cells  arranged  in  concentric  layers  (Plate 
8,  Fig.  I.)  to  the  type  in  which  tracts  of  spindle-cells  run  in  various 
directions,  and  often  in  a  considerable  field  the  only  trace  of  a  vessel  to  be 
.-ecu  is  a  spot  of  pigment  in  the  center  of  a  tract  cut  transversely,  represent- 
ing the  remains  of  a  previously-existing  vessel  about  which  the  tract  devel- 
oped (Plate  8,  Fig,  II.).  Alveolar  forms  of  sarcoma  are  also  found  occa- 
sionally, and  these  in  former  days  were  sometimes  described  as  carcinoma. 

Prognosis. — If  an  eye  with  sarcoma  of  the  uveal  tract  is  enucleated  befi  ire 
there  are  visible  evidences  of  extension,  the  chances  of  local  return  are  slight  ; 
the  prognosis  as  regards  metastasis,  however,  is  grave.  If  we  take  the  average 
of  the  statistical  tables  that  have  been  published,  it  appears  that  there  is 
eventually  a  fatal  result  in  about  30  per  cent,  of  cases. 

Treatment. — The  treatment  is  prompt  enucleation  as  soon  as  the  diagnosis 
of  sarcoma  is  made.  The  optic  nerve  is  to  be  resected  far  back,  and  evidences 
of  extension  are  to  be  looked  for,  since  the  presence  of  nodules  outside  of  the 
eyeball  usually  calls  for  evisceration  of  the  orbit. 

II.  Metastatic  Carcinoma  of  the  Choroid. — This  growth  has  been  seen 
a  >core  of  times  at  the  posterior  pole  of  the  eye  as  a  broad,  Hat  patch  of 
dull  yellow  mottled  with  white  and  some  spots  of  pigment,  with  fine  vessels 
running  through  it,  elevated  some  millimeters  in  its  central  portion,  and  at 
its  periphery  passing  over  into  the  healthy  choroid  without  a  sharp  line  of 
demarcation.  Not  infrequently  more  than  one  patch  is  present,  and  the 
patches  then  tend  to  coalesce  and  surround  the  optic  disk. 

At  first  glance  carcinoma  might  be  mistaken  for  an  exudation  in  the 
choroid,  but  the  details  of  the  growth  are  too  clearly  defined  for  this,  and 
there  are  wanting  the  congestion  and  edema  of  the  disk  and  retina  that  would 
accompany  an  inflammatory  exudation.  Carcinoma  has  a  slow  progressive 
course,  first  elevating  the  retina  and  producing  hyperopia,  then  interfering 
with  its  function  and  causing  a  scotoma.  Later,  the  retina  is  detached.  In 
nearly  every  case  the  primary  carcinoma  has  been  located  in  the  breast,  and 
in  a  number  of  cases  both  eye-  have  been  affected.1 

The  epithelial  cells  from  the  primary  growth  are  carried  into  the  eve 
through  the  posterior  ciliary  arteries,  and.  lodging  in  the  chorio-capillaris, 
they  proliferate  and  invade  all  the  layers  of  the  choroid   (Plate   8,  Fig.   III.. 

As  with  metastatic  tumors  elsewhere,  nothing  can  !»<•  gained  by  operative 
interference,  although  in  the  glaucomatous  stage  enucleation  has  been  done 
for  the  relief  of  pain. 

Flat  tumors  of  the  choroid  have  proved  in  a  few  instances  to  have  tlu 
character  of  angixyma  or  eavemoma,  and  the  designation  nevus  seems  htt 

1  It  may  be  noted  here  thai  in  the  rare  cases  in  which  Barcoma  of  the  choroid  is 
the  tumor  is  likely  to  assume  this  same  flat  form. 


494  INTRAOCULAR  GROWTHS. 

Tumors  of  the  Retina. — These  are  cyst  and  glioma. 

I.  Cysts  are  found  occasionally  in  the  detached  retinas  of  degenerated 
eyes,  bul   -inc.'  the  media  in  such  eve-  are  cloudy,  the  cysts  are  rarely  dis- 
covered until  after  enucleation.     It  mayhap- 

-    -  pen,  however,  if  the  cysts  lie  far  forward  and 

^tm  -^t  t'"'  '('lls  's  m,t  eE|tirely  opaque,  that  they  niav 

I  **»        ^\  be  indistinctly  seen  in  life,  as  they  were  in  the 

I  j  eye   represented   in   Fig.  315  ;  and    the  cysts 

/  mighl    then   he  mistaken   for   tumors  of  the 

ciliary  body  did  not  the  reduced  tension  and 

WWBII  the  clinical  history  oppose  thai  diagnosis. 

These  cysts  are  due   to  disturbances  of 

circulation  whereby  a  liquid  transuded  from 

Fig.  315     Multiple  cysts  of  t le-      the  retinal  vessels  collects  in  little  cysts  until 

tacned    retina    in   an    eve  with    i>la>tic         .     i         ,i        ,  ..  ,.• 

cyclitis  from  a  non-perforating  injury.      :lt    lengtn    the    retina,    tor    some    distance,    i- 

split   into  two  layers. 

II.  Glioma  of  the  Retina. — This  is  the  most  malignant  tumor  of  the 
eye,  and  i-  sometimes  present  at  birth,  hut  usually  appears  within  the  first 
two  years  of  life  and  never  later  than  the  eleventh  year.  In  one-fifth  of  the 
cases  the  disease  affects  both  eye-. 

Symptoms. — The  clinical  course  of  glioma  may  he  divided  into  four 
stages,  like  that  of  sarcoma  : 

In  the  first  stage  the  attention  of  the  parents  is  attracted  by  a  dilated 
pupil  and  a  whitish  reflex  from  the  interior  of  the  eye.  If  the  glioma  has 
grown  from  the  posterior  surface  of  the  retina  backward  (glioma  exophytum), 
tin'  commoner  form,  it  will  push  the  retina  forward,  so  that  the  latter  will  be 
seen,  with  its  characteristic  vessels,  forming  the  nodular  and  uneven  surface 
of  the  tumor.  Portions  of  the  retina  not  involved  in  the  growth  may  he 
detached  and  undulating.  The  color  of  the  tumor  is  bright  pale  yellow  or 
pink,  with  scattered  spots  of  white.  If  the  glioma  has  grown  from  the  ante- 
rior surface  of  the  retina  forward  (glioma  endophytum),  a  much  rarer  form, 
there  will  he  -ecu  a  number  of  light-colored  nodules  projecting  forward  into 
the  vitreous  in  front  of  the  retina,  which  is  thickened  and  uneven. 

When  the  growth  ha-  reached  a  considerable  size  the  glaucomatous  stage 
come-  on,  with  injection  of  the  eyeball,  shallow  anterior  chamber,  cloudiness 
of  the  media,  and  increased  tension.  In  this  stage  cyclitis  may  supervene, 
causing  a  temporary  shrinking  of  the  ball  and  masking  the  presence  of  the 
growth — a  condition   known  as  crypto-glioma. 

In  the  third  stage  there  i-  extension, usually  first  along  the  optic  nerve, 
and  then  through  the  cornea,  which  i-  destroyed.  The  orbit  thus  becomes 
tilled  with  a  fungoid  ma—,  and  ;it  the  same  time  the  tumor  attacks  the  glands 
of  the  head,  and  -cattered  nodule-  form  on  the  hone-  of  the  skull. 

Finally,  in  the  fourth  stage,  metastases  develop  in  other  organs. 

Diagnosis. — This  is  often  exceedingly  difficult,  hut.  owing  to  the  malig- 
nancy of  the  growth,  enucleation    i-  usually  done  when  there  is  a  reasonable 

assurance  that  the  disease  i-  gli a  ;  consequently,  many  of  the  eyes  enucleated 

with  this  diagnosis  are  found  on  examination  not  to  contain  a  glioma,  but  to 
ppi-e-eiit  one  of  the  -evcnil  condition-;  called  pseildo-glioma. 

Pseudo-glioma  may  consist  in  a  malformation  of  the  anterior  portion  of 
the  vitreous,  with  persistence  of  the  embryonic  hyaloid  artery  and  vascular 
sheath  of  the  leu- — a  condition  whose  nature  can  usually  be  recognized.  It 
may  be  solitary  tubercle,  and  then,  as  in  glioma,  enucleation  is  indicated  if 
the  tuberculosis  i-  limited  to  the  eye  ami  sight  ha-  been  destroyed.     But  in 


TUMORS  OF  THE  RETINA.  495 

the  great  majority  of  cases  pseudo-glioraa  is  an  exudation  into  the  vitreous 
chamber  following  meningitis. 

An  infant  has  fever  with  meningeal  symptoms,  and  shortly  afterward  a 
whitish  reflex  is  noticed  from  the  pupil.  The  iris  is  normal  or  only  atrophied 
in  spots,  hut  its  ciliary  margin  is  retracted  by  cyclitic  membranes,  so  that  the 
periphery  of  the  anterior  chamber  is  very  deep,  while  the  pupillary  margin 
of  the  iris  is  pushed  forward  by  the  lens,  rendering  the  center  of  the  anterior 
chamber  shallow.  The  pupil  is  usually  small,  and  the  iris,  as  a  whole,  has 
the  peculiar  appearance  of  a  truncated  cone,  which  is  characteristic  of  mem- 
branous cyclitis. 

In  the  vitreous  chamber  a  smooth  exudation  will  he  found,  dull  yellow  or 
gray  in  color,  and  without  visible  blood-vessels.  The  tension  is  generally 
reduced.  Later  small  vessels  may  appear  in  the  exudation,  the  retina  may 
become  detached,  and  the  eyeball  may  even  shrink.  This  condition  is 
brought  about  by  a  metastatic  uveitis  or  retinitis  due,  as  a  rule,  to  meningitis, 
hut  also  coming  on  in  pyemia  and  various  other  infectious  diseases.  Syphilis 
ami   penetrating  wounds  may  also  give  rise  to  a  similar  exudation. 

Glioma,  however,  is  distinguished  from  these  condition-  by  the  normal  or 
increased  tension,  the  dilated  pupil,  the  normal  or  uniformly  shallow  anterior 
chamber,  and  by  the  nodular  surface  of  the  growth  with  its  characteristic 
retinal  vessels  (see  also  pages  356  and  400). 

Pathological  Anatomy. — Glioma  of  the  retina  is  a  soft  vascular  tumor, 
composed  of  small  cells  with  a  large  nucleus,  imbedded  in  a  delicate  mesh- 
work  of  cell-processes  and  fibers.  It  readily  undergoes  fatty  and  even 
calcareous  degeneration.  In  the  hardened  specimen  thick  sheaths  of  healthy 
cells  are  seen  surrounding  the  thick-walled  and 
often  degenerated  blood-vessels,  while  the  cells 
farther  from  the  nutritive  supply  are  degenerated  j  (^ 

ant  I   do   not   take  the   nuclear   stains. 

Virchow  first  thought  glioma  to  be  a  prolifera- 
tion of  neuroglia  tissue;  others  have  put  it  in  the 
category  of  sarcoma  ;  and  there  has  been  much 
discussion  as  to  what  layer  of  the  retina  glioma 
really  springs  from,  and  what  is  its  true  nature, 
some  contending  that  a  simple  proliferation  of 
neuroglia  tissue  could  not  have  the  extreme  malig- 
nancy of  glioma,  which  spares  no  tissue  in  the  body. 

Sections  of  glioma  stained  by  the  Golgi-Cajal 

...  '.  .ill'  ii         i  Fig.  316.    Glioma  exophytum. 

silver-impregnation    method    have   recently   shown 

us  that  glioma  is  composed  of  neuroglia-tissue  and  a  few  nerve-cells  of 
various  ~ixe<  (Fig.  317).  Glioma  in  rare  instances  contains  tubules  com- 
posed of  a  thin  elastic  membrane  surrounded  by  long  cylindrical  cells,  each 
sending  a  process  through  the  membrane  into  the  lumen  of  the  tubule.  The 
elements  of  these  tubules  are  histologically  analogous  to  the  cone-nucleus, 
membrana  limitans  externa,  and  cone-body  of  the  normal  retina,  and  such 
tumors  have  been  called   neuro-epitheUoma. 

The  prognosis  of  glioma  is  very  had,  only  about  10  per  cent,  of  the 
patients  being  permanently  cured  by  operation,  the  other--  dying  mostly 
within  a  year,   from    local    recurrence. 

Treatment. — Enucleation  should  be  done  early  and  the  optic  nerve 
resected  far  hack.  If  the  disease  has  extended  into  the  orbital  tissues  behind 
the  eyeball,  only  complete  evisceration  of  the  orbil  with  removal  oi  the 
periosteum  can    he  of  any  avail. 


496 


INTRAOCULAR   GROWTHS. 


Tumors  of  the   Intraocular  Bud  of  the  Optic   Nerve. — These 
include  hyaline  bodies  and  sarcoma. 


Fig.  317.— Glioma  stained  by  Golgi's  method,  showing  neuroglia-tissue  and  scattered  small  nerve-cells. 

I.  Hyaline  bodies  are  found  in  the  optic  disks  of  young  persons  with  eyes 
otherwise  healthy  and  having  normal  vision,  and  also  in  eyes  with  optie  neuritis 

or  with  pigmentary  or  albuminuric  retinitis. 
In   most   eases  a   few   discrete,  lustrous,  pearly 

—         globules  are  seen  in  the  disk,  but  these  globules 

may  be  present  in  such  number  as  to  cover  the 
disk,  and  even  spread  beyond  it  in  a  confluent 
mass  like  frog-spawn   (see  Fig.  265). 

Microscopically,  we  find  laminated  hyaline 
masses  lying  among  the  fiber-bundles.  The 
exact  pathogenesis  of  these  bodies  is  unknown, 
the  old  view,  that  they  are  products  of  the 
ike  the  so-called  colloid  excrescences  on  the 
lamina  vitrea,  now  being  given  up,  since  the  bodies  are  often  present  in  the 
disk  when  the  pigment-epithelium  is  healthy  (Fig.  318),  and  they  are  never 
surrounded  by  pigment  like  the  others  (see  also  page  453). 

II.  Sarcoma  of  the  optic  disk  has  been  seen  a  few  times  as  a  hemispherical 
tumor  involving  the  adjacent  retina  and  projecting  forward  into  the  vitreous. 
It  is  always  an  extension  from  sarcoma  farther  back  in  the  optic  nerve,  and 
it  can  be  differentiated  from  a  tumor  of  the  choroid  overlapping  or  involving 
the  disk  by  the  fad  that  the  retrobulbar  tumor  from  which  it  extended  must 
have  caused  an  exophthalmos  before  the  tumor  appeared  in  the  eye. 


Fig.  318.— Hyaline  b<x 
bead 


in  the  iiLTve- 


vei inal   pigment-epithelium. 


MOVEMENTS   OF   THE   EYEBALLS,  AND  THEIR 

ANOMALIES. 

By  ALEXANDER  DUANE,  M.  D., 

OF    NEW    VoKK    CITY, 


Physiological  Action  of  the  Ocular  Muscles.1 — The  actions  of  the 
external  ocular  muscles,  deduced  partly  from  our  knowledge  of  their  origins 
and  insertions,  partly  from  the  results  produced  by  their  paralysis,  arc  as 
follows  :  - 

The  external  rectus  (abducens)  rotates  the  eye  directly  outward  (abduc- 
tion). 

The  internal  rectus  rotates  the  eye  directly  inward  {adduction). 

The  superior  rectus  carries  the  eye  upward,  adducts  it.  and  rotate.-  the 
upper  end  of  the  vertical  meridian  of  the  cornea  inward  (inward  torsion, 
intorsion).  Its  power  of  producing  adduction  and  torsion  increases  as  the 
eye  is  adducted,  and  decrease--  as  the  eye  is  abducted  ;  its  elevating  power,  on 
the  contrary,  is  greatest  when  the  eye  is  abducted  between  2<»  and  30°,  and 
diminishes  to  zero  as  the  eye  is  adducted. 

The  inferior  rectus  carries  the  eye  downward,  adducts  it,  and  causes  out- 
ward torsion  of  the  vertical  meridian  of  the  cornea  (extorsion).  As  in  the 
case  of  the  superior  rectus,  the  power  of  producing  adduction  and  torsion 
increases  and  the  vertical  action  diminishes  the  more  the  eye  is  carried  in- 
ward ;  and,  contrariwise,  it  acts  most  powerfully  as  a  depressor  (and  not  at 
all  as  an  adductor)  when  the  eye  is  abducted  20°  or  30°. 

The  superior  oblique  (trochlearis)  depresses  the  eye.  abducts  it,  and  rotates 
the  vertical  meridian  inward.  The  power  of  producing  abduction  and  torsion 
increases  and  the  vertical  action  decreases  in  proportion  as  the  eye  is  abducted. 
In  positions  of  adduction,  on  the  contrary,  the  superior  oblique  serves  mainly 
tn  depress  the  eye,  its  action  in  this  regard  increasing  as  that  of  the  inferior 
rectus  diminishes. 

The  inferior  oblique  elevates  the  eye.  abducts  it.  and  rotate.-  the  vertical 
meridian   inward.     The  power  of  producing  abduction  and  torsion  incn 
in  proportion  as  the  eye  is  abducted,  while  the  elevating  action  increases  as 
the  eye  is  adducted,  the  effect  of  the  muscle  in  this  regard  becoming  constantly 
greater  as  that  of  the  superior  rectus  grows  less. 

It  will  be  seen  from  this  that  elevation  and  depression  of  the  eye  are 
effected  mainly  by  the  obliques  when  the  eye  is  adducted  and  by  the  superior 
and  inferior  recti  when  the  eye  i-  abducted  ;  also  that  theadducting  action  of 

1  See  also  pages  41.  12,  and  lee. 

-'I'll.-  researches  of  Volkmann  and  Pacha  upon  the  insertion  of  the  ocular  muscles  have 
Bhown  thai  Blight  variations  from  the  actions  lien-  laid  down  may  occur;  bul  such  variations 
are  inconstant,  and  in  no  case  great  enough  to  invalidate  the  statements  oi  the  I 

:',2  497 


498   MOVEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 

the  superior  and  interior  recti  increases  (and  the  opposing  action  of  the 
obliques  diminishes)  in  proportion  as  the  eye  is  addjicted  ;  and  that  the  ab- 
ducting action  of  the  obliques  increases  (and  the  opposing  action  of  the  recti 
diminishes)  in  proportion  as  the  eye  is  abducted.  Hence,  while  abduction  is 
performed  mainly  by  the  external  rectus,  the  latter  is  reinforced  especially 
toward  the  end  of  its  course  by  the  obliques  ;  and  the  internal  rectus  is  simi- 
larly reinforced  by  the  superior  and  interior  recti,  which,  when  the  eye  is 
already  much  adducted,  will   carry  it   appreciably  farther  in. 

Lastly,  ii  will  be  seen  that,  in  directions  of  the  gaze  up  and  in,  the  tor-ion- 
action  of  the  superior  rectus  will  predominate  ;  in  directions  up  and  out,  that 
of  the  interior  oblique  ;  in  directions  down  and  out,  that  of  the  superior  ob- 
lique  :  and  in  direction-  down  and  in,  that  of  the  inferior  rectus.  Conse- 
quently, when  we  look  up  and  in  or  down  and  out,  the  vertical  meridian  of 
the  cornea  is  tilted  toward  the  nose  ;  when  we  look  n]>  and  out  or  down  and 
in,  it  is  tilted  toward  the  temple.  When  we  look  straight  up  or  straight 
down  (and  also  when  we  look  straight  to  the  right  or  left),  the  torsion  actions 
of  the  oblique  muscles  and  of  the  recti  counteract  each  other,  and  hence 
the  vertical  meridian   remain-  vertical. 

Movements  of  F,ach  Hye. — I>y  the  combined  action  of  two  or  more 
ocular  muscles  the  eve  may  be  moved  in  any  direction  whatever.  Thus  a 
movement  obliquely  upward  and  inward  requires  the  co-operation  of  three 
muscles — i.  i .  of  both  elevators  and  of  the  internal  rectus,  the  latter  (assisted 
by  the  superior  rectus)  carrying  the  eye  inward,  while  the  inferior  oblique 
and,  to  a   moderate  extent,  the  superior   rectus  carry  it   upward. 

In  moving  the  eye  obliquely  up  or  down  three  muscles  are  always  called 
into  play  (viz.  both  elevators  or  both  depressors,  combined  with  either  the 
externa]  or  the  internal  rectus) ;  in  moving  the  eye  straight  upward, four  (/'.  e. 
all  except  the  two  depressors);  in  moving  the  eye  straight  downward,  four 
(all  except  the  two  elevators)  ;  in  moving  the  eye  directly  inward,  five  (all 
except  the  external  rectus)  ;  and  in  moving  it  directly  outward,  five  (all  ex- 
cept the  internal  rectus). 

All  these  movement-  -tart  from  a  position  of  rest,  or  primary  position. 
When  the  eye  is  in  this  position  the  muscles  are  all  balanced — i.e.  if  all  six 
contract  simultaneously  to  an  equal  extent,  they  will  keep  the  eye  fixed 
where  it  i-.  In  all  other  directions  of  the  gaze  {secondary  positions)  the  eye 
i-  so  placed  that  some  one  muscle  or  pair  of  muscles  works  to  greater  advan- 
tage than  the  antagonistic  muscle  or  pair.  In  this  case,  if  all  six  muscles 
contract  simultaneously,  the  muscle  that  work-  to  greater  advantage  will 
exert  a  preponderating  action,  and  will  hence  tend  n>  displace  the  eyeball 
away  from  the  position  it  occupies,  and  in  such  a  manner  always  as  to  carry 
it    back   toward   the  primary  position. 

For  mosl  eye-  the  primary  position  is  that  in  which  the  visual  line  is 
directed  horizontally  or  nearly  so  and  straighl  ahead  (i.e.  is  perpendicular  to 
the  line  joining  the  centers  of  rotation  of  the  two  eye-).1  The  eyes  should 
always  be  placed  in  this  position  when  any  tests  are  made  for  ascertaining 
whether  or   not   the   muscles  are  in   equilibrium. 

Field  of  Fixation. — By  passing  from  the  primary  to  all  possible 
secondary   positions  the  eye  is  enabled  to  fix  a  great  number  of  objects — /'.'■. 

1  The  primary  position  is  more  exactly  defined  ;i-  being  the  only  position  From  which  both 
vertical  and  horizontal  movements  can  be  executed  without  affecting  the  position  of  the  vertical 

meridian  of  the  cornea.     Movements  fron e  secondary  position   to  any  other  in  general 

« -: » 1 1 — « -  a  rotation  of  the  vertical    meridian  (torsion  movement),  \\lii''li   ran  be  de istrated  by 

means  of  the  after-images.  This  fact  is  utilized  in  determining  experimentally  when  the 
primary  position  has  been  reached. 


BINOCULAR    VISION  AND  DIPLOPIA.  499 

bring  the  images  of  these  objects  successively  upon  the  macula.  The  portion 
of  space  occupied  by  all  such  objects  that  can  thus  be  fixed  by  movement  of 
the  eye  alone  without  moving  the  head  is  called  the  field  of  fixation. 

It-  limits  represent  the  limits  of  excursion  of  the  eve  in  all  possible 
directions.  These  limits  can  be  best  determined  by  fixing  the  patient's  head 
upon  the  rest  of  a  perimeter  in  such  a  way  that  the  eye  when  in  the  primary 
position  is  directed  toward  the  zero  of  the  perimetric  arc,  and  then  carrying 
along  the  latter  a  card  with  two  tine  dots  set  close  together  upon  it.  The 
patient  is  told  to  follow  the  dots  with  his  eye  without  moving  his  head.  The 
moment  when  he  fail-  to  do  so  is  evidenced  objectively  by  the  wavering  of 
the  eye,  and  subjectively  by  the  fact  that  the  two  dots  are  no  longer  seen 
distinctly  as  two,  hut  run  into  one.  Then  the  point  on  the  perimetric  arc  to 
which  the  card  has  been  carried  indicates  the  amount  of  excursion  of  the 
eye  in  the  given  direction. 

The  limits  of  the  field  of  fixation  have  been  variously  stated.  My  own 
observations  (37  measurements  of  18  different  subjects)  gave — 

Field  of  Fixation. 

Ud  l'P  UP  Out  In  Down       D(nvn        Down 

Lp-       and  out.    and  in.      UUL  m>         uown.    and  in     and(iut 

Averaee       43°         46°  49°  51°         53°         63°        54°  61° 

Minimum 35°  35°  35°  40°  40°         35°         32°         38° 

Reduction  of  the  excursion  of  the  eye  (contraction  of  the  field  of  fixation) 
to  less  than  30°  in  any  direction  must,  if  substantiated  by  repeated  tests,  be 
regarded  as  distinctly  pathological  (see  also  page  169). 

Binocular  Vision  and  Diplopia. — AYe  ordinarily  use  both  eyes  in 
seeing  (binocular  vision),  and  the  eyes  are  involuntarily  so  adjusted  that  the 
image  of  the  object  looked  at  falls  simultaneously  upon  both  maculae  (binoc- 
ular fixation).  Under  these  conditions  we  see  singly  because  the  two  images 
are  by  our  consciousness  fused  into  one  image,  which  has  somewhat  different 
characters  from  either  of  its  components  [binocular  single  vision).  When  one 
eye  fails  to  fix  simultaneously  with  the  other,  diplopia  generally  results.  But 
diplopia  will  be  absent  if,  as  often  happens,  the  image  formed  in  the  non- 
fixing  eye  is  not  taken  account  of  by  the  consciousness  (monocular  vision  from 
suppression  of  image) ;  and  one  image  maybe  thus  suppressed  even  when 
both  eyes  are  properly  directed — /'.  e.  there  may  be  binocular  fixation,  but 
only   monocular  vision. 

The  diplopia  produced  by  the  fact  that  one  of  the  eyes  deviates  from  the 
object  that  the  other  eye  is  looking  at  i<  directly  proportional  to  the  amount 
of  deviation.  It  may  be  correct,,]  by  an  appropriate  movement  of  the  devi- 
ating eye  Or  by  placing  before  the  eye  a  prism  so  directed  as  to  make  the  rays 
coming  from  the  object  change  their  course  and  fall  upon  the  macula. 

Per  contra,  diplopia  may  be  produced  without  any  deviation  of  the  eyes  by 
putting  before  the  latter  a  prism  which  will  deflect  off  from  the  macula  the 
rays  that  would  otherwise  be  concentrated  upon  it.  In  this  case  the  artificial 
diplopia  may  be  corrected  (or  the  prism  may  bi  " overcomt  ")  by  turning  the 
eye  until   the  1 1 1 : i < ■  ■  1 1 : i    i-  so  directed  as  to  meet   the  deflected  rays. 

When   an   eye  either  is  deflected  to   the  right  or  has  placed  before  it  a 
prism  with  it-  base  directed  to  the  right,  an  object   situated  straight  ahead 
will   form   it-  image  to  the   right  of  the  macula,  instead  of  upon   the  Litter. 
But  experience  and  the  sense  of  touch  continually  teach  us  that  an   <' 
which  forms  its  image  on  the  righl  of  the  macula  i-  itself  situated  to  our  left  ; 


500  MOVEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 

hence,  under  the  conditions  noted  the  object  no  longer  appears  straight  ahead, 
but  deflected  to  the  left,  and  by  as  great  an  amount  a<  the  eye  itself  is  de- 
flected to  the  right.  So  also  when  the  eye  is  deviated  up,  an  object  straight 
ahead  appears  lower  than  it  is  ;  and  in  general,  however  an  eye  may  be 
deflected,  the  apparent  position  of  objects  seen  with  it  is  deflected  in  the 
contrary  way. 

These  facts  may  be  expanded  for  the  particular  cases  as  follows  : 


Varieties  of  Diplopia. 


Name. 


Chajracteb:     '  Caused  i-.y 

n;  '>''  m  \  natural de-    'Jl,   Artlflclallj 

ascompared        '  \i  i'         r  byapnsm 

with  that  of  L.  is  viationoi  piace5,base 


Corrected  by 


(1)  Turning 


Homonymous 
diplopia. 


Heteronymous 
(crossed)  dip- 
lopia. 

Right  diplopia. 


Left  diplopia. 


Homonymous 
torsion- 
diplopia. 

Heteronymous 
torsi'  in- 
diplopia. 


on  i;.  side 

on  L.  side. 

Below. 
Above. 
Tilted  to  R. 

Tilted  to  L. 


Either  eye  in- 
esophor- 
|  ia,  strabismus 
eonvergens 

ESther  eye  out- 
ward (exophor- 
[a,  strabismus 
divergens). 

!;.  .  _\  e  up  or  L. 
eye      down       K. 

hyperphoria  i. 
ft.  eye  down  or 

I.    eye    up    (L. 

hyperphoria). 
ESther     vertical 

meridian  inward 

(convergence 

of  meridians). 
ESther    vertical 

meridian  out- 
ward (divergence 

of  meridians). 


In,  before  either   Both  eyes  out- 
eye,  ward. 

i  Divergence.) 


Out,  before 
tlier  eye. 


Up  before  R. 
eye  or  down 
before  L.  eye. 

Dou  "  before  R. 

eye  or  up  be- 
fore L.  eye. 


(2  Prism  placed, 

base 


Out  before 
ther  eye. 


In  before  either 
eye. 


Both  eyes  in- 
ward. 
(Convergence.) 


R.  eye  down,  and   Down  before   R. 
L.eyeup. (L.sur-      eye  or  up  be- 


umvergence.  I 

K.  eye  up,  and  L. 
ej  e  down.  (ii.  sur- 
miiii\  ergenci 
Both      vertical 
meridians  out 
ward. 
i  Distortion.) 
Both       vertical 
meridians  in- 
ward. 
(<  lontorsion.) 


fore  L.  i  \  e. 
Up  before  K.  eye 
or    down     be- 
fore L.  eve. 


Associated  Movements  of  the  Two  Byes :  Parallel  Movements. 
— As  has  been  stated,  binocular  single  vision  is  attained  only  when  both  eyes 
are  directed  precisely  at  the  objeel  of  fixation,  and  under  normal  conditions 
the  two  eyes  invariably  move  together  in  stum  a  way  as  to  effect  this  end,  and 
that.  too.  at  oner  and  with  the  utmost  precision.  In  the  case  of  a  distant 
object  the  movements  of  the  eyes  must  be  such  as  to  keep  the  two  visual 
lines  strictly  parallel  (associated  parallel  movements).  The  typical  movements 
of  this  class  are  shown  in  the  following  table  : 


Associated   Parallel  Movements. 
[a)   Both  eyes  move  directly  to  I!.  (Dextroversion) 


I!,  eye  carried  to  R.  by  external  rectus, 
assisted,  especially  toward  the  end  of  it-  ex- 
cursion, by  the  two  obliques.  The  latter, 
together  with  the  superior  and  inferior 
recti,  by  their  equal  counter-tractioD  steady 
the  eye,  and  thus  both  maintain  it  in  the 
horizontal  plane  and  keep  it-  vortical  me- 
ridian vertical. 


L.  eye  carried  to  T\.  by  internal  rectus, 
assisted,  especially  toward  the  end  of  its 
course,  by  the  superior  and  interior  recti. 
The  latter,  together  with  the  obliques,  by 
their  equal  counter-traction  steady  the  eye 
and  keep  it-  vertical  meridian  vertical. 


b     B  )th  eyes  move  directly  to  L.  i  Lcevoversion). 

L.  eye  carried  to  L.  by  external  rectus, 
assisted,  especially  toward  the  end  of  its 
course,  by  the  obliques.  The  latter,  to- 
gether with  the  superior  and  inferior  recti, 
by  their  equal  counter-traction  steady  the 
eye  and  keep  it-  vertical  meridian  vertical. 


R.  eye  carried  to  L.  by  internal  rectus, 
I,  especially  toward  i be  end  of  its 
excursion,  by  the  superior  and  inferior 
recti.  Tin-  latter,  together  with  the  ob- 
liques, by  their  equal  counter-traction 
steady  the  eye  and  keep  its  vertical  me- 
ridian  vertical. 


ASSOCIATED  MOVEMENTS  OF   THE    TWO    EYES. 


501 


(c)  Both  eyes  move  directly  up  {Surswnversion). 


R.  eye  carried  up  by  superior  rectus 
and  inferior  oblique.  These  muscles  ex- 
actly neutralize  each  other  in  their  lateral 
tendencies  and  their  action  upon  the  verti- 
cal meridian,  so  that  the  eye  goes  straight 
up  and  the  vertical  meridian  remains  ver- 
tical. The  external  and  internal  recti 
steady  the  eye. 


L.  eye  carried  up  by  superior  rectus 
and  inferior  oblique,  and  steadied  by  exter- 
nal and  internal  recti,  as  in  the  case  of  the 
R.  eye.  Vertical  meridian  remains  ver- 
tical. 


ill)  Both  eyes  mare  obliquely  up  and  to  R. 


R.  eye  carried  up  mainly  by  superior 
rectus  ;  to  R.  mainly  by  external  rectus, 
assisted  by  inferior  oblique.  The  torsion 
action  of  the  latter  preponderating  over 
that  of  the  superior  rectus,  the  vertical  me- 
ridian is  rotated  out  (to  the  R.). 


L.  eye  carried  up  mainly  by  inferior 
oblique;  to  R.  by  internal  rectus,  assisted 
by  superior  rectus.  The  torsion  action  of 
the  latter  preponderating  over  that  of  the 
inferior  oblique,  the  vertical  meridian  is 
rotated  in  (to  the  R.). 


[e)  Both  eye*  move  oblique/;/  up  and  to  L. 


R.  eye  carried  up  mainly  by  inferior 
oblique  ;  to  L.  by  internal  rectus,  assisted 
by  superior  rectus.  The  torsion  action  of 
the  latter  preponderating  over  that  of  the 
inferior  oblique,  the  vertical  meridian  is 
rotated  in  (to  the  L.). 


L.  eye  carried  up  mainly  by  superior 
rectus  ;  to  L.  by  external  rectus,  assisted  by 
inferior  oblique.  The  torsion  action  of  the 
latter  preponderating  over  that  of  the  su- 
perior rectus,  the  vertical  meridian  is  ro- 
tated out  (to  the  L.). 


/)  Both  e;/r.<  //ion  directly  down  [Deorsumversion). 


R.  eye  carried  down  by  inferior  rectus 
and  superior  oblique.  These  muscles  ex- 
actly neutralize  each  other  in  their  lateral 
tendencies  and  their  action  upon  the  verti- 
cal meridian,  so  that  the  eye  goes  straight 
down  and  the  vertical  meridian  remains 
vertical.  The  external  and  internal  recti 
steady  the  eye. 


L.  eye  carried  down  by  inferior  rectus 
and  superior  oblique  and  steadied  by  the 
external  and  internal  recti,  as  in  the  case 
of  the  R.  eye.  Vertical  meridian  remains 
vertical. 


(</)  Both  eyesmove  obliquely  down  and  to  R. 

R.  eye  carried  down  mainly  by  inferior  i  L.  eye  carried  down  mainly  by  superior 

rectus;  to  R.  by  external  rectus,  assisted  by  oblique;  to  K.  by  internal  rectus,  assisted  by 
superior  oblique.  The  torsion  action  of  inferior  rectus.  The  torsion-action  of  the 
the  latter  preponderating,  the  vertical  me-  latter  preponderating,  the  vertical  meridian 
ridian  is  rotated  in  (to  the  L.  I.  |  is  rotated  out  (to  the  L.). 


I ;,     Both  eyes  more  obliquely  down  and  to  I.. 


R.  eye  carried  down  mainly  by  superior 
oblique;  to  L.  by  internal  rectus,  assisted 
by  inferior  rectus.  The  torsion  action  of 
the  latter  predominating,  the  vertical  me- 
ridian is  rotated  out  (to  the   R.). 


L.  eye  carried  down  mainly  by  inferior 
rectus:  to  L.  bj  external  rectus,  assisted  by 
superior  oblique.  The  torsion  action  of 
the  latter  predominating,  the  vertical  me- 
ridian is  rotated  in  (to  the  Et.). 


An  inspection  of  the  foregoing  table  will  show  that  the  twelve  muscles 
that  serve  to  carry  the  two  eyes  in  parallel  directions  may  be  divided  i n t < »  six 
pairs,  one  muscle  of  each  pair  being  in  the  right  eyeand  the  other  in  the  left, 
and  the  two  moving  their  respective  eyes  in  the  same  direction  and  to  the 
same  extent.     The  muscles  constituting  such  a  pair  are  called  associ 

t  <!(/(, II)  si*. 


502  movements,  of  the  eyeballs,  and  their  anomalies. 

Associated  .  I  ntagonists. 


K   eye 

l.    eye. 

External 

Internal 

rectus. 

Internal 

rectus. 
External 

rectus. 

Superior 

rectus. 

rectus. 
Inferior 
oblique. 

Inferior 
oblique. 

Superior 
rectus. 

Inferior 
rectus. 

Superior 
oblique. 

Superior     Inferior 
oblique.       rectus. 


Moves  eye  to  which  it  belongs— 


To  R.  (dextroduction  ).      No  vertical  nor  torsion  action. 
To  L.    Ifevoduction  .     No  vertical  nor  torsion  action. 

Up,  to  L.  flsevoduction),  and  rotates  vertical  meridian  to  I.  (lsevotor- 
sion).  Elevating  action  increases  as  eyes  are  carried  to  R. ;  lateral  and 
torsion  movements  increase  as  eyes  are  carried  to  L. 

Op, to  H.  (dextroduction),  and  rotates  vertical  meridian  to  K.  (dextro- 
torsion).  Elevating  action  increases  as  eyes  are  carried  to  L.  ;  lateral 
and  torsion  action-  increase  as  eyes  are  carried  to  R. 

Down,  to  1..  lsevoduction), and  rotates  vertical  meridian  to  R.  (dextro- 
torsion  .  Depressing  action  increases  as  eves  are  carried  to  R.;  lateral 
and  torsion  actions  increase  as  eves  are  carried  to  L. 

Down,  to  K.  i  dextroduction',  and  rotates  vertical  meridian  to  L.  (laevo- 
torsion).  Depressing  action  increases  as  eves  are  carried  to  L.  ;  lateral 
and  torsion  actions  increase  as  eves  are  carried  to  R. 


The  amount  of  excursion  in  every  direction  made  by  a  pair  of  eyes  in 
following  a  more  or  less  distant  object  which  they  simultaneously  fix  deter- 
mine- the  field  of  binocular  fixation  ;  and  the  amount  of  excursion  that  they 
can  make  and  yet  preserve  parallelism  of  their  axes,  so  that  no  diplopia 
ensues,  determines  the  field  of  binocular  single  vision.  This  latter  extends 
not  less  than  40°  (normally  from  40°  to  50°)  in  every  direction  from  the 
primary  position;  and  diplopia,  occurring  uniformly  when  the  eyes  have 
been  carried  less  than  30°  from  the  primary  position,  is  distinctly  path- 
ological. 

The  tendency  to  maintain  parallelism  of  the  visual  lines  is  so  great  as  to 
persisl  even  when  one  eve  is  excluded  by  blindness  or  by  being  covered  with 
a  screen  ;  so  that  one  eye  keep-  moving  with  the  other,  and  binocular  fixation 
i-  maintained  in  all  direction-  of  the  gaze,  although  only  one  eye  sees  the 
object  fixed.  Upon  this  fad  depends  the  test  by  alternate  covering  (screen 
test). 

The  associated  parallel  movements  are  apparently  governed  by  a  nervous 
mechanism  distinct  from  the  nuclei  that  supply  the  nerves  for  the  ocular 
muscles;  and  each  of  the  typical  movements  (dextroversion,  sinistroversion, 
sursumversion,  deorsumversion,  and  perhaps  the  oblique  inurement*  also)  seems 
to  have  its  separate  center.  The  precise  location  of  these,  centers,  however, 
has   not   yet   been  satisfactorily  determined. 

Movements  of  Convergence. — By  means  of  the  associated  parallel 
movements  both  eye-  can  We  simultaneously  directed  at  any  distant  objed  sit- 
uated within  the  limits  of  the  field  of  fixation.  To  direct  them  both  at  once 
ai  some  near  object  requires  a  greater  or  less  degree  of  convergence  of  the  visual 
line-,  and  this  js  effected  by  a  simultaneous  equal  contraction  of  the  two 
interni.  Tin-  movement,  which  under  normal  conditions  takes  place  invari- 
ably, immediately,  ami  with  the  utmost  precision,  and  which,  as  in  the  case 
of  the  associated  parallel  movements,  takes  place  even  when  one  eye  is 
excluded  from  seeing,  is  apparently  governed  by  a  nerve-center  distind  from 
the  nerve-nuclei  of  the  internal   recti. 

When  the  object  looked  at  i-  situated  not  straight  ahead,  but  to  one  side 
or  above  or  below,  binocular  fixation  is  effected  by  a  <• bination  of  conver- 
gence with  an  associated  parallel  movement.     Tim-,  in  looking  at  an  object 

-itnaled    near  the    eye-    ami     15      to  the    right    of    the    median    line,   tile  two  eves 

fir-t  move,  each,  15    to  the  right  by  a  simultaneous  equal  contraction  of  the 


MO  I  'EM i;X TS  OF  SI  *liS CM\  EB GENCE.  503 

right  externus  and  the  left  internus  (dextroversion) ;  then  by  a  simultaneous 
equal  contraction  of  the  righl  internus  and  the  left  internus  (convergence)  the 
right  eye  is  turned  somevvhal  to  the  left  again  and  the  left  eye  somewhat 
farther  on   to  the   right,   until    both   visual    lines  are  properly  directed. 

Even  without  being  adjusted  for  near  objects,  the  eyes  tend  to  converge 
somewhat  when  directed  downward. 

The  amount  of  convergence  is  measured  by  the  distance  from  the  nose 
of  the  point  (convergence  near-point,  !'<■)  upon  which  the  eyes  can  by  the 
utmost  effort  be  made  to  converge.  This  should  be  from  1  to  l|  inches  from 
the  nose.  The  convergence  is  also  measured  by  the  degree  of  prism,  placed 
base  out  before  the  eyes,  which  the  latter  can  overcome  by  turning  inward 
(prism-convergence,  improperly  called  the  adduction).  The  prism-conver- 
gence, when  a  distant  test-object  is  used,  is  represented  by  prisms  of  60°  to 
90°  total  refracting  angle  (      a  convergence  of  the  visual  lines  of  35°  to  00°). 

The  maximum  amount  that  each  eye  turns  inward  in  performing  conver- 
gence (convergence-adduction  )  is  about  30°— 35°.  It  is  somewhat  less,  therefore, 
than  the  amount  (40°-50°)  by  which  each  eye  can  turn  inward  when  moving 
parallel  with  its  fellow  (associated  adduction  or  adduction  proper). 

Movements  of  Divergence. — In  passing  from  the  consideration  of 
near  objects  to  those  more  remote  the  eyes  diverge  from  each  other.  They 
can  even  diverge  beyond  parallelism  (i.e.  become  absolutely  divergent),  as, 
for  example,  when  they  look  at  a  distant  object  through  a  prism  placed,  base 
in,  before  them,  and  then  >vercome  the  diplopia  which  the  latter  produces. 
The  amount  of  this  absolute  divergence  or  diverging  power  (  prism-divergence, 
improperly  called  the  abduction)  is  from  6°  to  <S°  prism  (=  an  actual  separa- 
tion of  the  visual  lines  of  only  3°  to  4°).  The  absolute  diverging  power 
(divergence-abduction)  of  each  eye,  therefore,  amounts  to  only  2°.  It  must 
not  be  confounded  with  the  abduction  proper  (associated  abduction),  or  abso- 
lute degree  of  rotation  of  each  eye  outward  in  performing  associated  parallel 
movements,  which   is  40°-50°. 

The  movement  of  divergence  consists  either  in  a  simultaneous  equal 
relaxation  of  the  two  interni,  or,  more  probably,  in  a  simultaneous  equal 
contraction  of  the  two  extend.  It  is  often  combined  with  associated  parallel 
movements.  Thus,  if  a  prism  of  8°  is  placed,  base  in,  before  the  left  eye, 
each  eye  will  turn  out  through  an  angle  of  2°  in  order  to  i'u^o  the  double 
images  (divergence);  then,  in  order  to  bring  the  imago  on  the  macula'  of 
the  two  eyes,  each  eye  will  turn  2°  to  the  left  (sinistroversion),  so  that  the 
right  eye  is  directed   straight   ahead,   the   left   eye  4°  to  the   left. 

A  slight  divergence  of  the  visual  lines  occurs  normally  when  both  eyes 
are  directed  upward. 

Movements  of  Sursumvergence.  —  Divergence  of  the  visual  line-  in 
a  vertical  plane,  so  that  one  rises  above  the  other,  is  called  sursumvergence? 
and  this,  again,  is  denoted  as  right  or  left  according  as  the  right  or  left  < ; 
the  higher.  Right  and  left  sursumvergence  arc  normally  equal,  but  arc  very 
limited  in  amount  (=  only  2°  prism,  or  1°  of  actual  separation  of  the  visual 
lines).  The  movement  is  undoubtedly  distributed  equally  between  the  two 
eyes,  so  that  a  movement  of  right  sursumvergence  is  the  same  thin-  as  a 
movement  of  left  deorsumvergenc< — i.e.  in  both  cases  the  right  visual  line 
moves  up  and  the  left  visual  line  moves  down,  and  each  move-  to  an  equal 
extent.  Neither  the  upward  movement  of  one  visual  line  nor  the  downward 
movement  of  the  other  can    be  regarded    as   a    measure  of  the   power   ol    the 

1  Usually  called  Biirsnmduction,  bul  this  term  is  properly  applied  to  mean  tin-  absolute 
degree  of  movement  of  either  eye  upward — :i  movement   "i  -  '>>'     10    in  extent. 


504  MOVEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 

elevators  and  depressors  of  the  eye,  which  is  determined  rather  by  the  sur- 
sumduction  (in  the  proper  sense  of  the  term) — i.e.  the  absolute  ability  of 
either  eve  to  move  upward  (  about  40°),  and  the  deorsumduction,  or  ability 
of  either  eye  to  move  downward  (=  50°-60°). 

Right  sursumvergence  is  measured  by  the  degree  of  prism  placed  base 
down  before  the  right  eye  (or  base  up  before  the  left  eye),  and  left  sursum- 
vergence by  the  prism  placed  base  down  before  the  left  eye  (or  base  up  before 
the  riirht  eve),  which  the  eves  can  overcome. 


VARIETIES,  CLASSIFICATION,  ETIOLOGY,  AND  GENERAL  SYMPTOMS 
OF  MUSCULAR  ANOMALIES. 

Varieties  of  Deviations. — All  the  movements  of  the  eyes,  described 
above,  may  be  deranged  pathologically,  and  the  derangemenl  may  take  the 
form  of  over-action,  under-action,  or  perverted  action,  'flic  result  of  these 
derangements  is  that  binocular  fixation  and  binocular  single  vision  are  inter- 
fered with,  so  that  one  of  the  eyes  deviates  or  tends  to  deviate  from  the  object 
looked  at. 

Strabismus  and  Heterophoria. — A  marked  deviation  which  the 
patient  cannot  in  general  overcome  is  called  asquint  or  strabismus  (hetero- 
topia, manifest  deviation!;  one  which,  being  moderate  in  amount,  is  habit- 
ually overcome  by  muscular  effort,  and  hence  is  elicited  only  by  special  tests, 
is  called  a  heterophoria  or  insufficiency  (latent  squint,  latent  deviation). 

A  deviation  is  further  classed  as  constant,  if  present  all  the  time;  in- 
termittent, if  sometimes  present,  sometimes  absent  ;  ami  periodic,  if  regu- 
larly recurring  under  certain  conditions  (e.  g.  if  the  accommodation  is 
used ). 

Measurement  of  Deviations. — 'Fhe  magnitude  of  the  deviation  may  be 
measured  directly  by  ascertaining  either  how  far  the  deviating  eye  stands 
in  or  out  when  the  other  eye  is  looking  straight  ahead,  or  how  far  it  has  to 
turn  in  or  out  in  order  to  perform  fixation  when  the  other  eye  is  screened 
(sci'een-test).  The  amount  of  this  deflection  or  of  this  movement  may  be 
gol  at  by  taking  a  linear  measurement  along  the  edge  of  the  lower  lid,1 
or  it  may  be  determined  directly  in  degrees  by  means  of  a  perimeter  or  a 
tangent  scale.  Objective  measurement  performed  in  this  way  is  termed 
strabometry. 

Indirectly,  the  amount  of  a  deviation  is  determined  by  the  amount  of 
diplopia  which  it  produces,  this  latter,  again,  being  measured  either  by  the 
actual  distance  between  the  double  images  or  by  the  strength  of  the  prism 
required   in  order  to  unite  them   (see  Table  <>J  I)'ii>I<>i>J<i,  p.  500).     When   no 

diplopia  exists  ~\ taneously,  the  artificial  diplopia  produced  by  the  various 

forms  of  phorometer  and   the    amount   of  parallactic  displacement    that    the 

object   looked  at   undergoes  when  a  screen  is  shifted  froi !  eye  to  the  other, 

serve  as  a  precise  measure  of  the  deviation. 

It  frequently  happens,  especially  in  constant  and  periodic  squint,  that  the 

deviation   is  confineal le  eye,  the  other  performing  fixation  all  the  time. 

In  this  case  the  non-fixing  eye  is  apt  to  be  amblyopic  ;  but  whether  the  poor 
sight  i-  congenital  and  gives  rise  to  the  deviation,  or  whether  it  is  itself  the 
result  of  the  latter  and  springs  from  the  habitual  suppression  of  the  visual 
image  (amblyopia  from  disuse,  amblyopia  exanopsia)  or  from  the  injurious 
effects  of  the  diplopia  upon  the  squinting  eye,  is  not  certain. 

In  many  cases,  especially  in  intermittent  squint,  and  almost  always  in 
Each  millimeter       about  I'    actual  deviation. 


STBA  BISMUS  AND  IIETKHOI'IloltlA. 


505 


heterophoria,    fixation    is    performed    by    each    eve   alternately    (rdternaiing 
deviation). 


Fin.  319.— Measurement  of  squint  with  a  perimeter: 

The  deviating  eye  R  is  placed  at  the  center  of  the  graduated  arc  of  the  perimeter  P  P, 
the  arc  lying  on  the  plane  of  the  deviation.  The  patient  is  then  required  to  fix  with  his  two 
eyes  a  distant  object,  A, situated  alone'  the  central  radius  R  o  A.  This  is  the  direction  which  the 
deviating  eye  should  have  in  the  normal  condition.  The  point  n  to  which  the  eye  in  reality 
is  directed  should  now  be  determined  ;  the  angle  0  R  n,  formed  by  the  deviating  line  of  sight 
n  with  the  normal  line  of  sight  A  o  /.'.  is  the  angle  of  the  strabismus.  In  order  to  obtain  this 
angle,  it  would  be  necessary  only  to  determine  the  precise  direction  of  the  line  of  sight  of  the 
deviating  eye.  As  this  is  not  an  easy  matter,  it  is  sufficient  in  practice  to  determine  the  direc- 
tion of  the  corneal  axis:  this  differs  from  the  former  only  by  a  small  angle,  which,  in  com- 
parison with  the  large  angle  of  the  strabismus,  may  be  neglected.  The  Same  of  a  candle  is 
moved  along  the  arc  of  the  perimeter  until  its  reflection  is  in  the  center  of  the  pupil.  This 
will  occur  when  the  flame  is  at  n.  The  corneal  axis  has  now  been  found,  and  the  size  of  the 
angle  of  strabismus  may  be  read  off. 

Deviations  are  also  classed  according  to  the  direction  of  the  deviating  eve, 
as  follows : 


Deviating  eye 
turns 


In, 

Out. 
Up. 

Down. 


Deviation  apparenl  or  manifest  (squint, 
strabismus). 


Deviation  latent  (elicited  only  l >y  special 
tests) :  eyes  usually  perform  binocular 
fixation. 


Strabismus      convergens     (convergent 

squint,   esotropia  . 
Strabismus  divergens  (divergenl  squint, 

exotropia  . 
Strabismus  sursumvergens ;  hypertropia 
(I!,  or  L.,  according  as  R.  or  I-.  visual 
line  is  higher 

Strabismus deorsumvergens;  hypertropia   Hyperphoria!  I.',  or  L., according  as 
I  R.  or  I...  according  .-is  R.  or  L.  visual        R.  or  L.  visual  line  is  higher), 
line  is  higher  . 


Esophoria. 
Exophoria. 

Hyperphoria  1 1!,  or  I-.,  according  as 

II.  or  L,  visual  1  i 1 1< -  is  higher). 


The  condition  in  which  there  is  no  tendency  to  deviation  in  the  primary 
position  is  called  orthophoria. 

Etiology  of  Ocular  Deviations ;  Etiological  Classification.— 
Ocular  deviations  may  be  grouped  according  to  their  etiology,  as  follows: 


506  MOVEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 

(  Jlassification. 

I.  Anomalies  (if  the  individual  muscles: 

(a)    Under-action,  due   to  faults  in  (1)  structure,  (2)  insertion,  and 

(3)  innervation. 
(/>)   Over-action,  due  to  faults  in  (1 1  structure,  (2)  insertion,  and  (3) 
innervation. 
II.  Anomalies  of  the  association-centers  for  parallel  movements: 

(a)    Under-action,  producing  an  impairment  of  the  movements  of 
both    eves   either  (1)    up,  ('_!)   down,):!)   to    the    right,  (4)  to 
the   left,    or  (5)   obliquely  [associated  paralysis,  conjugate 
paralytic  deviation  \ 
(6)   Over-action,  producing  an   equal  excessive  movement  or  equal 
spastic  deviation  of  both  eyes  in  the  same  direction  (associ- 
ated spasm,  conjugate  spastic  deviation). 
(c)   Perverted  action,  clonic  spasm  of  associated  movements  (nystag- 
mus). 
III.  Anomalies  of  the  center  for  convergence  movements  : 

(a)    Under-action,  convergence-insufficiency,  either  (1)  accommoda- 
tive or  (2)  non-accommodative. 
(6)   Over-action,  convergence-excess,  either  (1)  accommodative  or  (2) 
non-accommodative. 
IY.  Anomalies  of  divergence  movements: 

(a)    Under-action,  divergence-insufficiency. 
(6)   Over-action,  divergence-excess. 
Y.   Anomalies  of  sursumvergence  : 

(a)  I  rnder-action,  sursumvergence-insufficiency. 

(b)  Over-action,  sursumvergence-excess. 

Summary. 

I.  Associated  parallel  deviations  (conjugate  deviations)  may  he  due  to — 

(a)  Under-action   of  one  of  the  centers   for   producing   associated 

parallel  movements  (conjugate  paralysis). 
(A)  Over-action    of  one   of    the   centers    for    producing    associated 
parallel  movements  (conjugate  spasm). 
II.   Convergent  deviations  (esophoria,  convergent   strabismus)  may  be  due 
to— 
("i  Over-action  of  one  or  both  internal  recti  or  of  the  other  adduc- 
tors of  the  eye  (superior  and  inferior  recti). 

(b)  Under-action  of  the  external    rectus  or  of  the  other  abductors 

(the  obliques). 

(c)  I  Fnder-action  of  divergence  movements  (divergence-insufficiency). 

(d)  Over-action  of  the  center  for  producing  convergence  movements 

(convergence-excess,  which  in  turn    may  or  may  not   be  due 
to  excessive  accommodative  action). 

(<  )  Two  or  more  of  the  above  cause-  combined. 
III.   Divi  r>/<  iii  ill  fin  I  in, is  (exophoria,  divergenl  strabismus)  may  be  due  to — 

(a)  Under-action  of  the  internal  rectus  or  of  the  other  adductors 
i superior  and  inferior  recti ). 

(A)  Over-action  of  the  external  rectus  or  of  the  obliques. 

(<•)  Under-action  of  the  center  for  producing  convergence  move- 
ments (convergence-insufficiency,  which,  in  turn,  may  or 
may  not   be  due  to  insufficiency  of  accommodative  action). 


COMITANT  AND   NON-COMITANT  DEVIATIONS.  507 

{(I)  Over-action  of  divergence  movements  (divergence-excess). 
(e)  Two  or  more  of  the  above  causes  combined. 
IV.    Upward  and  dovmward  deviations  (hyperphoria,   strabismus  sursum- 

vergens  and  deorsumvergens)  may  be  < Iim-  to — 
(a)  Over-action  of  an  elevator  or  depressor  muscle. 
(6)  CJnder-action  of  an  elevator  or  depressor  muscle. 
(r)  CJnder-action  or  over-action  of  sursumvergence. 
{(I)  Two  or  more  of  the  above  causes  combined. 
V.  Mixed  forms  (hyperphoria    combined   with    exophoria,     hyperphoria 

combined   with    esophoriaj  and    esophoria    in  one  part  of 

the  field    of   view    combined  with    exophoria    in    another) 

arc  frequent. 

Comitant  and  Non-comitant  Deviations. — Ocular  deviations  are 
divided  into  comitant*  and  non-comitant.  In  the  former,  one  eye,  even  when 
deviating  from  the  other,  always  deviates  by  the  same  amount,  so  that  the 
two  eyes  in  all  their  excursions  maintain  the  same1  angle  with  each  other. 
The  most  typical  example  of  comitant  deviations  is  afforded  by  the  anoma- 
lies of  the  associated  parallel  movements  (associated  paralysis,  associated 
spasm,  nystagmus). 

The  ordinary  forms  of  divergent  and  convergent  squint  are  also  generally 
comitant  when  they  come  under  observation,  although  probably  for  the  most 
part  non-comitant  in  their  origin,  the  comitancy  in  this  case  having  developed 
as  a  result  of  the  evolutionary  tendency,  described  in  the  next  section,  by 
which  new  compensatory  conditions  arc  gradually  superadded  to  the  old  ones. 

In  iioit-coiiiittfiif  deviations  the  deflection  of  the  non-fixing  eye  keeps 
varying  as  the  direction  of  the  gaze  is  shifted,  so  that  the  angle  between  the 
two  visual  lines  is  continually  changing.  The  most  marked  examples  of 
non-comitance  are  furnished  by  disorders  (under-action  and  over-action)  of 
the  individual   muscles. 

Anomalies  of  convergence  and  divergence,  when  uncomplicated,  occupy 
a  middle  ground  between  the  comitant  and  the  non-comitant  deviations. 
They  are  comitant  in  that  for  any  one  distance  the  deflection  remains  the 
same  whether  the  eye-  are  carried  up  or  down  or  from  side  to  side,  but  arc 
non-comitant  in  that  the  deflection  changes  in  amount  in  proportion  as  the 
object  looked  at  is  brought  nearer  to  the  eyes  or  away  from  them.  They 
are,  however,  usually  classed  as  comitant. 

The  differential  diagnosis  between  comitant  and  non-comitant  deviations 
may  be  thus  stated  : 

Comitant  Deviations.  Non-comitant  Deviations. 

Due  to  some   condition   affecting  the  Due  to   seine    condition    affecting  the 

movements  of  both  eyes  equally.  movements  of  one  eye  more  than  the  other. 

Hence,  if  simple,  an-  due  to  derange-  Due  to  an    anomaly   in    structure  or 

ment  of  one  of  the  centers  which  effect  the  insertion  of  the  muscles  of  one  eye.  or  to 

movements  of  both  eye-  together  (associa-  an  anomaly  of  the  nerves  ami  nerve-nuclei 

tion-centers,  centers  governing  divergence  which   supply  these  muscles    and    which 

and  convergence  movements  .  subserve  uniocular  movement. 

Often  complex,  ami   then  due  to  com-  Usually  simple. 
pensatory  changes  [contractures,  etc.)  grad- 
ually developing  in  an  eye  that   was  for- 
merly the  seat  of  a  non-comitant  deviation. 

1  The  term  "comitant,"  already  used  by  others, has  been  adopted  here    al  the  sug»  3tion  of 
Dr.  H.  Knapp  .  instead  of  the  more  usual  "concomitant,"  which  is  less  wieldy,  and  also 
well  formed  from  an  etymological  point  of  view. 


508  MO  VEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 


<  'militant  I>i  vialioru. 

Deviating  eye  follows  the  other  in  all 
its  movements,  maintaining  the  same  angle 
with  it.  The  total  range  of  excursion  and 
total  extent  of  the  field  of  fixation  of  one 

eye  equal  those  of  the  other,  but  in  the 
deviating  eye  both  are  limited  in  some  one 
direction,  and  are  increased  to  a  like 
amount  in  the  opposite  direction. 


Diplopia  often  absent,  or,  if  present, 
readily  ignored.  Patient  often  fails  to 
recognize  double  images  produced  by 
jirisms. 

Deviation  behind  sereen,  parallax, 
deviation  measured  by  the  phorometer, 
diplopia  (if  present  i.  and  other  symptoms 
same  in  amount  in  all  directions  of  the 
gaze. 

Deviation  behind  screen  of  the  deflect- 
ed eye  equals  that  of  the  non-deflected  eye. 


Non-comitant  Deviations. 

Deviating  eye  lags  behind  or  shoots 
ahead  of  the  other  for  certain  directions 
of  the  gaze.  The  angle  of  deviation  keeps 
continually  changing.  The  range  of  ex- 
cursion and  held  of  fixation  of  the  devi- 
ating eye  are  either  abnormally  large  or 
abnormally  small  in  some  one  direction  of 
the  gaze,  and  in  other  directions  are 
normal.  Total  range  of  excursion  abnor- 
mally large  or  small. 

Diplopia  usually  present  and  apt  to 
persist. 


Deviation  behind  screen,  parallax,  de- 
viation measured  by  the  phorometer,  di- 
plopia, and  other  symptoms  increase  mark- 
edly and  progressively  as  the  eyes  are 
carried  in  some  one  direction,  and  dimin- 
ish when  the  eyes  are  carried  in  the  oppo- 
site direction. 

Deviation  of  the  two  eyes  behind  the 
screen  unequal,  that  of  the  sound  eve 
being  the  greater  if  the  affected  eye  is 
paretic  or  otherwise  limited  in  action,  and 
that  of  the  affected  eye  being  the  greater 
if  the  affected  eye  is  the  subject  of  spasm 
or  over-action. 


Conversion  of  Non-comitant  into  Comitant  Deviations. — In 
non-comitant  deviations  the  deflection  is  marked  for  some  directions  of  the 
gaze,  while  for  other  direction-  the  conditions  are  normal.  If,  now,  some 
new  condition  is  superadded  by  which  the  deflection  is  made  equally  marked 
for  all  directions  of  the  gaze,  the  deviation  will  become  comitant.  This,  in 
fact,  is  what  tends  to  take  place  naturally  in  all  non-comitant  anomalies.1 
Thus,  a  paresis  of  the  right  external  rectus  produces  an  inward  deflection  of 
the  right  eye,  which  at  the  outset  is  marked  only  when  the  eyes  are  directed 
to  the  right.  After  a  time,  however,  spastic  contracture  of  the  right  interims 
develops,  which  causes  an  inward  deflection  of  the  right  eve  when  the  eyes 
are  directed  to  the  left,  as  well,  so  that  ultimately  a  condition  is  produced 
closely  simulating  a  comitant  strabismus  convergens.2  Again,  an  exophoria 
due  in  a  convergence-insufficiency  is  :it  firsl  present  only  when  the  eyes  are 
directed  at  near  points  ;  |,nt  after  this  condition  has  persisted  for  :i  long  time 
the  action  of  divergence  tor  distance,  hitherto  normal,  becomes  excessive 
(divergence-overaction),  and  the  exophoria  becomes  marked  for  distance  also. 
So,  too.  a  periodic  convergent  squint,  in  which  the  eves  are  straight  for  dis- 
tance. Inn,  owing  to  convergence-overaction,  converge  excessively  when 
directed  ;it  near  objects,  is  finally  converted  into  a  constant  squint — i.e. 
becomes  marked  l'<>v  distance,  too.  through  the  development  of  an  insufficiency 
of  the  diverging  power  or  perhaps  of  an  insufficiency  of  the  external  recti. 
In  this  way  a  deviation  that  was  comitant  only  for  one  range  becomes  comi- 
tant  for  all. 

Subjective  Symptoms  of  Deviations. — Tin  subjective  symptoms 
produced  by  ocular  deviations  are  -i  I  (diplopia  and  blurring  of  sight,  (2)  false 
projection    and   apparent   motion  of  objects,  (3  J  vertigo,  (I)  asthenopia,  (5) 

'  Except  in  cases  nf  congenital  paralysis  or  absence  of  a  muscle. 

•'  In  fact,  probably  :i  number  of  cases  of  comitanl  Bquinl  are  produced  in  this  very  way. 


SUBJEi  TI I '/;  SYMPTOMS  OF  DE  \  7. 1  TIONS.  509 

pain  in  the  eyes  with  conjunctival  irritation  ami  blepharitis,  (6)  headache  and 
neuralgia,  and  (7)  other  reflex  disturbances,  including  backache,  uausea,  im- 
pairment of  nutrition  and  energy  (sometimes  considerable  in  amount),  chorei- 
form spasms,  and  occasionally  graver  conditions,  such  as  epilepsy. 

1.  Diji/'ijiin  is  homonymous,  heteronymous,  or  vertical  (right  or  left) 
according  as  the  deviation  is  convergent,  divergent,  or  vertical  (right  or  left 
hyperphoria)  (see  ante,  Tabh  <>f  I>ij>/"/>i<i).  It-  amount,  measured  in  degrees, 
is  equal  to  the  amount  of  the  deviation  present  at  the  time.  In  ordinary 
comitant  squint  (insuperable  deviation)  it  is  usually  absent,  because  the  image 
formed  by  the  Qon-fixing  eye  is  either  too  indistinct  to  be  noticed  or  is 
actually  suppressed  ;  '  in  non-comitant  squint  it  is  usually  present,  at  least  in 
the  earlier  stages  of  the  affection  ;  and  in  superable  deviation-  (heterophoria) 
it  is  present  at  times,  although  generally  overcome  by  appropriate  forced 
movements  of  the  eye-  (see    Table  of  Diplopia). 

In  -light  deviation-  the  amount  of  diplopia  is  just  sufficient  to  cause  over- 
lapping of  the  double  images,  producing  thereby  a  considerable  blurring  of 
the  object  looked  at.  This  is  particularly  marked  for  reading,  in  which  the 
letters,  as  they  double,  become  superimposed,  and  hence  appear  run  together. 
This  confusion  of  sight  is  distinguished  from  that  clue  to  an  error  of  refrac- 
tion by  the  fact  that  it  disappears  as- soon  a-  either  eye  is  covered. 

In  general  the  slighter  degrees  of  diplopia,  and  especially  those  that  can  be 
corrected  by  voluntary  effort,  are  less  readily  negligible  than  is  a  diplopia  of 
larger  amount,  and  hence  give  rise  to  more  confusion  and  trouble. 

2.  False  projection  of  objects  (i.e.  the  seeing  of  objects  in  the  wrong 
place)  is  particularly  noticeable  in  deviation  due  to  paresis  or  spasm  of  an 
ocular  muscle.  In  this  case,  when  the  eye  has  to  use  the  affected  muscle  in 
order  to  look  toward  an  object,  the  amount  of  energy  put  forth  by  the  muscle 
is  out  of  proportion  to  the  amount  of  nerve-impulse  sent  to  it,  and  hence  the 
patient  feels  as  if  the  eye  had  moved  much  farther  or  much  less  than  it  really 
has.  Thus  a  patient  with  a  paresis  of  the  right  externus  when  looking  at  an 
object  situated  to  his  right  would  regard  the  object  as  much  farther  to  the 
right  than  it  really  is.  because  he  has  to  make  a  very  great  effort  with  the 
paretic  muscle  to  move  the  eye  as  far  as  he  needs  to  do;  and  this  excessive 
effort  corresponds  in  his  experience  to  an  excessive  movemenl  of  the  eye  to 
the  right — i.  e.  to  the  act  of  looking  at  an  object  that  i-  situated  very  far  to 
the  right.  The  same  thing  would  take  place  if  he  had  a  paresis  of  the 
dextro version-center  (the  association-center  for  turning  both  eye-  to  the 
right).  On  the  contrary,  if  he  had  a  spasm  of  the  right  externus  (or  of  the 
dextroversion-center),  an  object  situated  on  hi-  right  would  appear  less  far  to 
that  side  than  it  really  i>. 

One  consequence  of  tlii-  false  projection  is  that  objects  whose  place  is 
thus  wrongly  conceived  of  appear  l<>  mnr,  when  the  eye-  are  turned  or  when 
the  patient  approaches  them.  The  reas >f  this  i-  that  the  amount  of  dis- 
placement of  an  object  from  it-  true  situation,  produced  by  false  projection, 
varies  with  the  different  positions  of  the  eye-,  so  that  when  we  change  the 
position  (by  turning  the  eye-  or  by  approaching  the  object)  the  objeel  appear- 
to  be  at  one  moment  in  it-  true  place,  at  the  next  moment  out  of  it — /.  • . 
appeal'.-   to   have   moved    from   one   place   to  another. 

This  apparent   movement  of  object-,  together  with   the  diplopia  and   the 
nnequal   -train  put  upon  the  eye-muscles,  is  the  cause  of  the  vertigo  that 
often  accompanies  ocular  deviations. 

'Suppression  implies  that  the  image  produces  its  proper  impressi  n  upon  the  sensorium, 
but  that  the  patient  by  some  mental  process  excludes  1 1 1 1  —  impression  fi 


510  MOVEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 

If  binocular  single  vision  is  lost,  the  power  of  appreciating-  depths  and 
distances  is  necessarily  much  impaired  {loss  of  stereoscopic  vision). 

3.  The  remaining  symptoms  (asthenopia,  headache,  eye-pain,  and  the 
various  reflex  disturbances)  arc  due  to  the  .-train  imposed  upon  the  muscles 
when  overcoming  a  deviation.  They  are  hence  more  pronounced  in  heterophoria 
and  in  squint  of  low  degree  and  in  intermittent  squint  (in  all  of  which  con- 
ditions the  patient  tries  with  more  or  less  success  to  overcome  the  deviation), 
than  in  a  marked,  con-taut  strabismus,  in  which, as  the  deviation  is  insuper- 
able, the  patient  makes  no  attempt  to  overcome  it.  Furthermore,  the  amount 
of  asthenopia  and  reflex  disturbance  i-  roughly  proportional  to  the  amount  of 
effort  that  the  patient  has  to  exert  in  overcoming  tne  deviation.  Hence  these 
troubles  are  more  marked  in  cases  of  insufficiency  than  of  over-action  ;  '  and 
in  cases  requiring  exercise  of  the  comparatively  weak  diverging  power  (e.  </. 
cases  of  divergence-insufficiency),  and  of  the  still  weaker  sursumverging 
power  ((.  </.  case-  of  hyperphoria),  than  in  ease-  such  as  those  of  divergence- 
excess,  that  demand  exercise  of  the  strong  converging  action  for  their  com- 
pensation. In  general,  asthenopia  is  a  marked  feature  of  convergence-insuf- 
ficiency, and  eye-pain,  with  conjunctival  irritation  and  blepharitis,  is  apt  to 
be  associated  with  the  same  affection  ;  while  headache,  neuralgia,  nausea,  and 
disturbances  of  digestion  and  general  nutrition  are  particularly  prone  to  occur 
in  connection  with  divergence-insufficiency  and  the  vertical  deviations. 

CHARACTERS  AND  DIAGNOSIS  OF  THE  INDIVIDUAL  ANOMALIES. 

Affections  of  Individual  Ocular  Muscles  (Paretic  and  Spastic 
Squint). — Etiology. — Over-action  or  under-action  of  an  ocular  muscle  may 
be  due  to  three  causes. 

(")  Over-development  or  under-development  of  the  muscle  itself  (struct- 
ural squint  and  heterophoria).  Thus,  congenital  non-development  of  the 
externa]  rectus  occurs,  producing  a  convergent  deviation;  also  congenital 
non-development  of  the  superior  rectus,  producing  a  downward  deviation  of 
the  eye,  which  may  or  may  not  lie  associated  with  ptosis.  Again,  over- 
growth of  the  externus,  combined  or  not  with  non-development  of  the 
internus,  is  at  the  bottom  of  a  number  of  cases  of  divergent  squint  or  of 
exophoria  ;  and  a  similar  preponderance  in  muscular  development  of  the 
internal   recti  accounts  lor  many  cases  of  convergent  squint. 

{/>)  Faulty  insertion  of  the  tendon  of  the  muscle,  causing  undue  laxity  or 
tension  of  the  latter,  and  giving  a  point  of  application  for  the  muscular  force, 
which  is  more  advantageous  or  is  less  advantageous  than  normal  (insertional 
squint  or  heterophoria).  Examples  of  this  an — (1)  the  deflection  produced 
by  a  tenotomy  or  an  advancement  ;  (2)  the  over-action  of  the  antagonist  of 
a  paralyzed  muscle  after  structural  changes  (true  contracture)  have  taken 
place  in  the  former ;  and  (3)  the  exophoria  or  divergent  squint  that  develops 

in  diildl d  as  a   result   of  increasing  divergence  of  the  orbits,  a   process 

which  gives  the  externus  a  more  favorable  area  of  application  than  the 
interim-.  This  process,  which  is  a  normal  feature  of  development  in  child- 
hood, may,  if  occurring  in  children  that  originally  have  the  orbits  set  very 
close  together,  abrogate  a  convergent  squint,  or  even  cause  the  latter  to  pass 
gradually  into  a  strabismus  divergens. 

I--)  Paresis  or  spasm  "fa  muscle  due  to  an  affection  of  it-  nerve  or  nerve- 
nucleus  (innervational  anomalies,  paretic  and  spastic  squint,  and  heterophoria). 

1  Because  in  insufficiency  compensation  i-  effected  by  means  of  weakly-acting  muscles,  and 
in  over-action  by  means  of  normal  muscles;  and  ii  is  harder  to  bring  weak  muscles  up  to  the 
normal  than  t<>  make  normal  muscles  act  with  extra  energy. 


DIAGNOSIS  OF  INDIVIDUAL   ANOMALIES.  511 

Tl  if  common  causes  of  paresis  Eire  tertiary  syphilis  and  its  consequences  (espe- 
cially tabes),  meningitis  (especially  tuberculous),  pachymeningitis, tumors  of  the 
brain  and  skull,  abscess  and  hemorrhage  of  the  brain,  exposure  to  cold 
called  rheumatic  paralysis),  traumatism,  and  hysteria.  Paresis  may  also, 
although  rarely,  be  due  to  diphtheria,  diabetes,  influenza,  whooping-cough, 
and  the  action  of  ]>< >i><  >u- :  and  slight  impairment  of  power  occurs  in  neuras- 
thenia and  other  condition-  of  nervous  depression.  Spasm,  which  i-  much 
less  frequent  than  paralysis,  is  due  to  irritative  lesions  (meningitis,  etc.), 
chorea,  epilepsy,  and  hysteria  ;  rarely  is  idiopathic.  Spasm  also  occur- 
sooner  or  later  in  the  antagonist  of  a  paralyzed  muscle,  and  ultimately  leads 
to  structural  changes  in  the  latter  (contracture).  A  false  or  apparent  spasm 
is  the  over-action  which  regularly  occurs  in  the  associated  antagonist  of  a 
paralyzed  muscle  when  an  attempt  i.-  made  to  move  the  latter;  the  over- 
action  in  this  case  being  the  result  of  the  excessive  stimulus  imparted  to  both 
muscles.  Thus,  a  patient  with  a  paralysis  of  the  right  externus  who  tries  to 
look  to  the  right  makes  an  excessive  effort,  which  effort  causes  the  right  eye 
to  move  to  the  right  feebly  and  the  left  eye  to  move  to  the  righl  very  greatly 
and  in  an  apparently  spasmodic  way,  although,  of  course,  spasm  in  the  true 
sense  of  the  word  is  nol  present  here  at  all,  since  the  eye  is  simply  reacting 
normally  to  an  excessive  stimuli!-. 

One  or  severe/  muscles  may  he  affected.  In  insertional  and  structural 
deviations  isolated  affections  are  frequent,  and  the  muscles  most  apt  to  be 
involved  are  the  external,  internal,  and  superior  recti.  In  innervational 
deviations,  if  but  one  muscle  is  affected,  this  is  usually  the  external  rectus 
(abducens  paralysis  or  spasm),  although  isolated  paralysis  of  the  superior 
oblique  (trochlear  paralysis)  is  not  uncommon.  Isolated  paralysis  of  the 
other  muscles  is  less  often  met  with,  hut  combined  paralysis  of  some  or  all  of 
the  muscles  supplied  by  the  third  nerve  (oculomotor  paralysis)  is  frequent. 
Complete  oculomotor  paralysis  causes  loss  of  power  in  four  out  of  the  six- 
exterior  muscles  of  the  eyeball,  and  also  in  the  levator  palpebral  (causing 
ptosis),  the  sphincter  iridis  (iridoplegia),  and  the  ciliary  muscle  (myeloplegia). 
In  some  cases,  caused  generally  by  syphilis  or  by  the  action  of  poisons  such 
as  atropin,  the  paralysis  is  confined  to  the  sphincter  iridis  and  the  ciliary 
muscle  (ophthalmoplegia  inf<n<<t)  ,•  in  other-  to  the  sphincter  iridis,  producing 
mydriasis  without  any  other  symptoms;  in  other-,  especially  when  due  to 
diphtheria,  to  the  ciliary  muscle,  producing  paralysis  of  accommodation  alone  ; 
and  in  -till  other  cases  these  muscles  are  exempt,  but  some  or  all  of  the  ex- 
terior muscles  of  the  eyeball  are  paralyzed  (ophthalmoplegia  externa).  In 
rare  cases  all  the  muscles  of  the  eyeball,  exterior  and  interior,  arc  paralyzed 
at  the  same  time  (ophthalmoplegia  /<>fa/is). 

Symptoms. — The  symptoms  of  muscular  under-action  and  over-action 
an — (1)  limitation  or  excess  of  movement  of  the  affected  eye  in  some  one 
direction — i.  e.  a-  the  two  eyes  move  together  in  that  direction  one  of  the 
two  lags  more  and  more  behind  the  other,  producing  a  constantly  increasing 
deviation.  This  symptom  gives  rise  to  all  the  others — namely.  2)  diplopia, 
(3)  false  projection  of  objects  seen  with  the  affected  eye.  |  I)  apparent  move- 
ment of  Such  object-  when  the  patient  approach.-  them,  and  (5)  \< 
The  explanati t'  these  symptoms  has  already  been  given.  The  character- 
istic feature  about  all  of  them  i-  that  they  increase  a-  the  eye-  are  carried  in 
-nine  one  direction — increase,  namely,  in  that  position  of  the  ' ;  es  in  which  the 
affected  muscle  when  normal  acta  most  effectively  in  moving  the  ey< 
Table,  \<.  502),  and  decrease  a-  the  eye-  are  carried  in  Hi-  contrary  direction. 
For  example,  in  an  affection  of  the  right  superior  oblique  the  diplopia,  vei 


512  MOVEMENTS  OF  Till:  EYEBALLS,  AND  THEIR  ANOMALIES. 

etc.  are  absent  when  the  patient  looks  up,  begin  to  appear  when  he  Looks 
down,  increase  rapidly  when  he  looks  down  and  to  the  left,  and  are  much 
less  marked  when  he  looks  down  and  to  the  right  ;  because,  in  the  first  place, 
the  superior  oblique,  being  a  depressor,  acts  normally  only  when  the  eyes  are 
directed  down,  and  because,  in  the  second  place,  it  acts  much  more  energeti- 
cally as  a  depressor  when  the  eyes  arc  directed  down  and  in. 

This  characteristic  feature  of  these  condition-  gives  rise  to  another  symp- 
tom— (6)  namely,  altered  position  of  the  head,  the  patient  in  each  instance 
holding  it  in  such  a  way  as  to  prevent  the  development  of  diplopia,  etc. 
Thus,  if  the  deviation  i-  such  that  diplopia  occurs  when  the  eyes  are  turned 
to  the  right,  he  gets  over  the  difficulty  by  turning  his  head  to  the  right,  so 
that   the  eye-   themselves  are  directed   to   the   left. 

The  symptoms  vary  in  intensity  from  a  slight,  transient  diplopia,  elicited 
only  by  the  different  tests  for  heterophoria,  to  the  complete  immobility  pro- 
duced by  total  paralysis. 

In  ophthalmoplegia  interna  (7)  mydriasis  and  (8)  paralysis  of  accommo- 
dation will  occur  j  and  in  complete  oculomotor  paralysis  both  these  symp- 
toms tog-ether  with  (9)   ptosis. 

Course  and  Prognosis. — Structural  deviations,  particularly  if  congenital, 
show  little  tendency  to  increase  or  decrease,  [nsertional  deviations  are  apt 
to  increase,  except  when  the  result  of  a  tenotomy  or  advancement,  in  which 
case  they  usually  decrease  because  of  the  contraction  that  takes  place  in  the 
process  of  healing. 

Paretic  or  spa-tic  deviations  may  recover  spontaneously  or  as  the  result 
of  treatment.  This  is  always  the  case  in  hysterical  affections,  and  is  the  rule 
in  the  cycloplegia  due  to  diphtheria.  On  the  other  hand,  in  diphtheritic 
paralyses  of  the  external  muscles  and  in  paralyses  due  to  exposure  to  cold 
the  condition  often  persists  for  a  long  time  or  even  permanently  ;  and  oph- 
thalmoplegia interna,  except  when  due  to  the  action  of  drug-,  i-  usually  incu- 
rable. 

In  chronic  paralyses  the  prognosis  is  uncertain,  the  condition  being  some- 
times recovered  from,  often  remaining  stationary,  and  in  yet  other  ea>es 
advancing  progressively.  The  tendency  to  advance  is  particularly  marked 
in  the  slowly  developing  paralyses  of  unclear  origin  affecting  isolated  muscles, 
and  especially  in  the  variety  of  paralysis  known  as  ophthalmoplegia  externa 
(see  page  511).  In  these  cases  one  muscle  after  another  is,  in  the  course  of 
months  or  years,  successively  involved  (progressive  ophthalmoplegia),  the 
process  often  extending  to  other  center-  besides  the  nuclei  of  the  eye-muscles, 
and  causing  death  through  involvement  of  the  respiration  or  other  vital 
action. 

Paralyses  of  sudden  development,  on  the  other  hand,  do  not  usually  show 
this  tendency  in  advance,  and  often  indeed  disappear  completely.  It  i-.  how- 
ever, to  he  remarked  that  those  cases  that  get  well  rapidly  and  spontaneously 
are  particularly  apt  to  be  the  precursors  of  tabes,  disseminated  sclerosis,  and 
general  paresis. 

'I'n  two  classes  of  acutely  developing  ophthalmoplegia,  however,  this 
grave  prognosis  does  not  apply.  In  one  (recument  ophthalmia  migraine)  a 
total   oculomotor   paralysis,   preceded    usually   by  violent    migraine,  recurs  at 

more  or  less  periodical  intervals,  and,  after  lasting  for  a  day  or  two  in  - ■ 

cases  and  two  or  three  i ths  in  others,  disappears  almost  or  quite  com- 
pletely. In  the  other  (transient  bilateral  ophthalmoplegia)  a  paralysis,  usually, 
but  not  always, affecting  all  the  ocular  muscles  and  always  bilateral,  develops 
rapidly,  and  disappears  completely  after  lasting  one  or  two  month-. 


DIAGNOSIS  OF  INDIVIDUAL  ANOMALIES. 


513 


Under-action  of  an  ocular  muscle,  whether  due  to  paralysis  or  not,  after 
lasting  for  a  time  leads  to  over-action,  and  finally  to  permanent  contracture 
of  the  opposing  muscle  in  the  same  eye.  In  like  manner,  continuous  oxer- 
action  of  a  muscle  leads  to  enfeeblenient  of  its  antagonist.     The  deviation  in 

both  instances  is  thus  gradually  converted  into  a  comitanl  one  (see  page  508). 
Contracture  of  the  opponent  does  not,  however,  usually  take  place  in  con- 
genital paralysis. 

The  symptoms,  especially  the  false  projection  and  vertigo,  gradually 
grow  less  pronounced  as  the  patient  accommodates  himself  to  his  new  expe- 
riences. The  diplopia  often  remains  for  a  very  long  time,  and  may  even 
persist  after  the  deviation  has  become  comitant. 


v         F  h  g  E  B 

Fig.  320.— 1,  right  external  rectus ;  2,  right  internal  rectus. 


Fig.  321. — 1,  right  inferior  rectus  ;  2,  right  superior  oblique. 


Fig.  322.— l.  right  superioi  rectus ;  2.  right  Inferior  oblique. 

Figs.  320-822     -■  h<  me  "t  double  Images  in  paralysis  of  tl cular  muscles  (modified  from  Mauthner  mul 

Berry):  A  <;  II  1>,  field  of  binocular  single  vision  of  normal  eyes     Bhaded  area,  A  BCD,  : 
binocular  single  vision  in  complete  paralysis:  unshaded  area,  BQHC,  field  of  double  vision  in 
complete  paralysis  ;  area,   i  E  F  l>.  field  of  single  \  ision  in  partial  paralysis :  area,  E  0  u  /•',  field  of 
double  vision  in  partial  paralysis.    Shaded  image  is  that  belonging  to  th< 


514  MOVEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 


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coxvi:i!(ii:yr  deviations.  515 

Diagnosis. — The  diagnosis  of  the  muse/,  ujj',<-f<,l  may  in  the  case  of  I  1  | 
under-action  or  over-action  of  a  sin;//'  muscle  be  made  from  the  double 
images  by  means  of  the  table  on  page  514.    (See  also   Figs.  320—322.) 

2.  A  diplopia  increasing  in  more  than  one  direction  indicates  an  affection 
of  more  than  one  muscle,  the  diagnosis  of  the  specific  muscles  being  made 
from  the  table.  K.  g.  a  right  diplopia  increasing  both  in  looking  up  and 
to  the  left  and  up  and  to  the  right  indicates  weakness  of  the  left  superior 
rectus  and  the  left  inferior  oblique  :  and  a  left  diplopia  increasing  in  looking 
up  and  to  the  right,  combined  with  a  right  diplopia  increasing  in  looking 
up  and  to  the  left,  indicates  a  paralysis  of  both  superior  recti  or  a  paralysis 
of  one  superior  rectus,  combined  with  spasm  of  the  inferior  oblique  in  the 
same  eye. 

3.  Crossed  diplopia  (with  the  image  of  the  affected  eye  somewhat  below), 
combined  with  inability  of  the  eye  to  move  upward,  inward,  or  to  any  great 
extent  downward,  although   it  can  still  move  out  well,  indicates  oculomotor 

paralysis.     The  latter  is  complete  if  there  are  also  ptosis,  mydriasis,  and 
paralysis  of  accommodation. 

Convergent  Deviations ;  Esophoria  and  Convergent  Squint. — 
A  convergent  deviation  may  exist  in  all  degrees,  from  an  esophoria  of  2°  or 
-3°,  elicited  only  by  careful  tests  with  the  photometer,  to  a  constant  converg- 
ent squint.     In  any  case  it  may  be  due  to — 

1.  Weakness  of  one  or  both  externi  or  over-action  of  one  or  both  intemi, 
or  to  both  these  causes  combined  (muscular  deviation).  The  weakness  or 
over-action,  which  may  be  structural,  insertional,  paretic,  or  spastic  in  origin, 
produces  a  more  or  less  non-comitant  deviation  having  the  characters  already 
given  of  a  purely  muscular  anomaly  (see  pages  510  and  511).  Briefly  stated, 
these  characters  are  as  follows  : 

Outward  movements  of  one  or  both  eyes  diminished,  or  inward  movements 
of  one  or  both  increased,  the  increase  in  the  latter  case  being  equally  marked 
whether  the  eye  turns  inward  in  obedience  to  a  convergence-impulse,  or  in 
performing  an  associated  parallel  movement  with  the  other  eye.  In  per- 
forming associated  parallel  movements  the  restriction  of  outward  movement 
and  the  increase  of  inward  movement  are  marked  for  distance  as  well  as  for 
near.  The  amount  of  restriction  or  increase  usually  differs  for  the  two  eyes, 
and  the  sum  of  the  inward  and  outward  movements,  or  total  range  of  excur- 
sion, is  greater  in  one  eye  than  in  the  other,  and  in  one  eye,  at  least,  is  abso- 
lutely greater  or  less  than  normal  (enlargement  or  contraction  of  the  field  of 
fixation).  Degree  of  convergence  or  esophoria  (as  measured  by  the  diplopia, 
deviation  behind  the  screen,  parallax,  and  phorometer)  is  not  materially 
different  for  distance  ami  near,  but  changes  noticeably  as  the  eyes  are  moved 
to  the  right  or  to  the  left.  Near-point  of  convergence  usually  closer  to  the 
eyes  than  normal,  bin  often  nearer  when  the  objed  looked  at  is  carried  from 
one  side  obliquely  inward  toward  the  nose  than  when  it  i<  carried  inward 
from  the  other  side. 

The  determination  of  the  specific  muscle  affected  can  by  means  of  the 
table  on  page  514  be  deduced  from  the  direction  of  the  gaze  in  which  the 
diplopia  or  deviation  increases  the  most. 

2.  Convergence-excess. — The  -i-n-  of  this  are — 

For  distance,  convergence  or  esophoria  less  than  for  near,  and  usually 
slight.  Prism-divergence  (so-called  abduction)  normal  oral  leasl  nol  dispro- 
portionately low  [/.  >.  with  an  esophoria  of  3°-4°,not  below  1°).  Prism-con- 
vergence (adduction)  readily  performed.  Associated  parallel  movements  nor- 
mal and  equal  in  the  two  eyes.    Total  range  of  excursion  normal  in  both  e 


516  MOVEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 

For  near-points,  convergence  or  esophoria  marked  (by  all  tests).  Con- 
vergence  near-point  excessively  close  to  the  nose,  and  equally  so  whether  the 
object  looked  at  is  carried  toward  the  aose  from  the  right  or  from  the  left. 
Eye  moves  farther  inward  in  response  to  a  convergence-impulse  than  when 
executing  a  parallel  movement  in  conjunction  with  the  other  eye.  Excess  of 
inward  movement  same  for  each  eve. 

( lonvergence-excess  is  often  due  to  excessive  accommodative  action  exerted 
to  overcome  hyperopia  or  astigmatism,  the  association  between  accommo- 
dation and  convergence  being  so  intimate  that  one  function  can  hardly  be 
brought  into  play  without  bringing  in  the  other  with  it.  In  this  accommo- 
dative convergence-excess  the  signs  above  enumerated  will  tend  to  disappear 
upon  the  instillation  of  atropin  and  the  continuous  wearing  of  the  proper 
correcting  glasses,  lint  cases  of  non-accommodative  convergence-excess  also 
occur,  and  in  these  glasses  afford  no  relief 

3.    Dinrr/ciicc-iiisuj/iciciici/. — The  signs  of  this  are — 

For  distance,  convergence  or  esophoria  marked.  Prism-divergence  (ab- 
duction) disproportionately  low,  absent,  or  even  negative  (/.  e.  there  is 
homonymous  diplopia  that  the  patient  cannot  overcome,  except  when  prisms, 
base  out,  are  placed  before  the  eye).  Prism-convergence  (adduction)  normal 
or  often  subnormal.  Associated  parallel  movements  and  range  of  excursion 
equal  in  both  eyes,  and  normal  or  nearly  so. 

For  near-points,  convergence  or  esophoria  slight  or  absent  or  even  replaced 
by  exophoria.  Convergence  near-point  not  abnormally  close  to  the  nose,  and 
about  equally  far  from  the  latter  when  the  object  looked  at  is  carried  inward 
from  the  right  or  from  the  left. 

In  rare  cases  the  insufficiency  may  be  so  great  as  to  constitute  an  actual 
divergenee-paralysis  (  Parinaud,  Uhthoff,  Straub).  These  cases  are  character- 
ized by  homonymous  diplopia  for  distance,  with  marked  convergent  squint 
when  the  eve-  are  directed  straight  ahead  ;  both  the  diplopia  and  the  con- 
vergence diminishing  progressively  as  the  eyes  are  carried  to  the  right  or  to 
tin'  left.     Such  cases  may  be  secondary  to  an  abducens  paralysis. 

1.  A  convergence-excess  which  has  lasted  a  long  time  is  regularly  followed 
by  a  divergence-insufficiency,  and  a  divergence-insufficiency  of  long  standing 
is  followed  by  a  convergence-excess.  The  mixed  form  thus  produced  is  cha- 
racterized by  marked  esophoria  (and  often  by  homonymous  diplopia)  for  both 
distance  and  near,  excessive  approximation  of  the  convergence  near-point, 
and  limited,  absent,  or  negative  prism-divergence  (abduction).  The  constant 
over-action  of  the  convergence  seems  to  lead  to  actual  over-development 
of  the  intend,  and  the  under-action  of  the  divergence  to  actual  insufficiency 
of  the  externi,  thus  causing  still  further  increase  of  the  deviation.  When 
the  deviation  becomes  too  great  for  the  patient  to  overcome,  SO  that  binocular 
vision  can  no  longer  be  maintained,  a  squint  develops,  which,  at  first  inter- 
mittent, afterward  becomes  constant. 

This  conversion  of  an  esophoria  into  a  convergent  squint  is  favored  by 
the  presence  of  any  condition  (amblyopia  of  one  eye,  anisometropia)  which 
renders  binocular  vision  of  Little  value. 

A  convergent  squinl  thus  developed  is  prone  to  increase.  But  in  children 
Buch  a  squinl  often  diminishes  and  sometimes  disappears,  owing  to  the  tendency 
that  the  eyes  have  to  become  divergent  during  the  aire  of  growth  (see  pa  ire 
510). 

flu-  symptoms  of  convergent  deviations  ar< — homonymous  diplopia  (espe- 
cially in  cases  thai  are  passing  from  the  3tate  of  :i  heterophoria  to  that  of  :i 
squint) ;  unilateral  amblyopia  and  loss  of  stereoscopic  vision  (in  true  squint) ; 


DI }  rER  ( ii:X  T  I)  E I  rL  1  TIO NS.  5 1 7 

and  asthenopia,  headache,  neuralgia,  and  nutritive  disturbances  in  esophoria 
proper  (especially  in  divergence-insufficiency). 

Divergent  Deviations ;  Exophoria  and  Divergent  Squint.— 
A  divergent  deviation,  whether  a  slight  exophoria  or  a  marked  divergent 
squint,  may  be  due  to — 

1.  Weakness  of  one  or  both  interni  or  over-action  of  one  <>r  both  externi, 
or  to  both  these  causes  combined  (muscular  deviation).  The  weakness  or 
over-action  may  be  structural,  insertional,  or  innervational,  and  produces, 
particularly  when  unilateral,  a  more  or  less  non-comitant  deviation  having 
the  following  character-,  indicative  of  a  purely  muscular  anomaly  (see  pages 
510  and  511). 

Outward  movements  of  one  or  both  eyes  increased  or  inward  movements 
of  one  or  both  diminished,  the  diminution  in  the  latter  case  being  equally 
marked  whether  the  eye  turn-  inward  in  obedience  to  a  convergence-impulse 
or  in  performing  an  associated  parallel  movement  with  the  other  eye.  In 
performing  associated  parallel  movements  the  restriction  of  inward  move- 
ment and  the  increase  of  outward  movement  are  marked  for  distance  as  well 
as  for  near.  The  amount  of  restriction  or  increase  usually  differs  for  the 
two  eyes  ;  and  the  sum  of  the  inward  and  outward  movements,  or  total  range 
of  excursion,  is  greater  in  one  eye  than  in  the  other,  and  in  one  eye.  at  least, 
is  absolutely  greater  or  absolutely  less  than  normal.  Degree  of  divergence 
or  exophoria  (as  estimated  from  the  diplopia,  deviation  behind  the  screen, 
parallax,  and  phorometer)  not  materially  different  for  distance  and  near,  but 
changes  noticeably  as  the  eves  are  carried  to  the  right  or  to  the  left.  Near- 
point  of  convergence  often  more  remote  from  the  eye  than  normal,  but  may 
be  much  farther  when  the  object  looked  at  is  carried  from  one  side  obliquely 
inward  toward  the  nose  than  when  it  is  carried  obliquely  inward  from  the 
other  side. 

The  determination  of  the  specific  muscle  affected  may  be  deduced  (by 
means  of  the  table  on  page  514)  from  the  direction  of  the  gaze  in  which  the 
crossed  diplopia  or  the  exophoria  increases  the   most. 

2.  ( 'onvergencer-insitfficii  ncy. — The  signs  of  this  are — 

For  distance,  but  slight  divergence  or  perhaps  orthophoria.  Prism- 
divergence  (abduction,  so  called)  not  usually  above  10°  and  often  subnormal 
(6°).  Prism-convergence  (adduction)  often  performed  with  difficulty  even 
after  a  number  of  trials.  Associated  parallel  movements  and  total  range  of 
excursion  normal  or  nearly  so,  and  equal  in  both  eyes. 

For  near-points,  exophoria  of  6C  and  upward  and  divergence  marked  (by 
all  tests).  Convergence  near-point  over  •">"  (often  from  6"  to  10")  from  the 
nose,  and  equally  distant  from  the  latter  whether  the  object  looked  at  is 
carried  toward  the  nose  from  the  right  or  from  the  left.  Maintenance  of 
convergence  for  more  than  a  moment  difficult.  Eyes  turn  farther  inward  in 
performing  associated  parallel  movements  than  in  performing  convergence 
movements  (i.  e.  when  the  convergence  near-point  is  reached  either  eye  can 
turn  -till  farther  inward,  but  the  oilier  eye  will  then  diverge).  Limitation 
of  movement  inward  same  for  each  eye. 

In  some  cases  the  insufficiency  i-  so  greal  ;i-  to  constitute  an  actual  con- 
vergence-paralysig  (Parinaud,  A.  Graefe).  The  characteristic  sign  of  this  is 
that,  while  either  eye  can  move  inward  to  a  normal  degree,  provided  the  other 
eye  moves  outward,  it  cannot  move  inward  at  all  in  response  to  an  impul- 
convergence.  Hence,  the  convergence  near-point,  instead  of  receding  to  only 
6"  or  7".  i-  situated  a  yard  or  more  from  the  eyes,  and  when  the  object  looked 
at  i-  brought  nearer  than  tin.-,  insuperable  crossed  diplopia  develops. 


518  MOVEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 

Owing  to  the  intimate  relation  existing  between  accommodation  and  con- 
vergence, those  who  use  their  accommodation  but  little  in  looking  at  near- 
points  will  tend  to  converge  less  than  they  should.  Hence,  convergence- 
insufficiency  oeeui's  in  myopes  who  wear  no  glasses  fof  near,  and  also  in 
hyperopes  and  presbyopes  who  wear  too  strong  convex  glasses  for  near. 
This  accommodative  insufficiency  will  disappear  if  the  myope  is  made  to  wear 
concave  glasses  for  near,  and  it',  in  the  other  conditions,  the  strength  of  the 
convex  glass  is  lessened.  Bui  a  non-accommodative  convergence-insuf- 
ficiency, not   corrigible  in  any  such  way,  also  exists. 

3.  Divergence-excess. — The  signs  of  this  are — 

For  distance,  exophoria  or  divergence  marked.  Often  spontaneous 
crossed  diplopia.  Prism-divergence  (abduction)  high  (in  pure  cases  dispro- 
portionately so — i.e.  with  an  exophoria  of  4°  or  5°  there  maybe  a  prism- 
divergence  of  13°  or  15°).  Prism-convergence  (adduction)  usually  normal. 
Associated  parallel  movements  and  range  of  excursion  equal  in  both  eyes  and 
normal  or  nearly  so. 

For  near-points,  exophoria  or  divergence  slight.  Convergence  near-point 
and  power  of  maintaining  convergence  normal.  Convergence  near-point 
same  whether  the  object  looked  at  is  carried  from  the  right  or  from  the 
left   obliquely  toward  the  nose. 

1.  A  convergence-insufficiency  which  has  lasted  a  long  time  is  regularly 
followed  by  a  divergence-excess,  and  a  divergence-excess  which  has  lasted  a 
long  time  by  a  convergence-insufficiency.  The  mixed  form  thus  produced  is 
characterized  by  marked  exophoria  (or  divergent  squint)  and  often  by  crossed 
diplopia  for  both  distance  and  near,  excessive  prism-divergence  (abduction), 
and  marked  recession  of  the  convergence  near-point.  Here,  as  in  esophoria, 
the  constant  over-action  of  the  divergence  produces  apparently  an  actual 
over-development  of  the  extend,  and  the  under-action  of  the  convergence 
an  actual  insufficiency  of  the  interni,  thus  causing  still  further  increase  of 
the  deviation.  Here  also,  when  the  deviation  becomes  too  great  for  the 
patient  to  overcome,  so  that  binocular  vision  can  no  longer  be  maintained,  a 
squint  develops,  at  lir<t  intermittent,  afterward  constant.  As  in  the  case  of 
the  convergent  deviations,  the  presence  of  anisometropia  or  unilateral  ambly- 
opia favors  this  conversion  of  an  exophoria  into  a  divergent  squint. 

A  divergent  squint  thus  developed  usually  increases. 

The  syniptoin>  of  divergent  deviations  are — crossed  diplopia  (especial  lv  in 
ea~e~  that  are  passing  from  the  state  of  a  heterophoria  to  that  of  a  squini  )  : 
unilateral  amblyopia  and  loss  of  stereoscopic  vision  in  cases  of  confirmed 
squint  ;  and  asthenopia  and  conjunctival  irritation  with  pain  in  the  eyes  in 
exophoria  (particularly  in  convergence-insufficiency).  Headache  is  less  fre- 
quenl  and  other  symptoms  are  rather  rare. 

Vertical  Deviations  ;  Hyperphoria  and  Vertical  Squint. — Ver- 
tical deviations,  whether  superahle  i  hyperphoria )  or  productive  of  an  actual 
squint,  are  cither  comitanl  or  uon-comitant. 

I.  Non-comitani  hyperphoria  is  occasioned  by  under-action  or  over- 
action  of  one  or  more  of  the  elevators  or  depressors.  As  in  this  case  the 
deviation  (determined  by  the  vertical  diplopia,  deflection  behind  the  screen, 
parallax,  ami  phorometer)  varies  noticeably  in  differenl  directions  of  the  gaze, 

the   diagnosis    of  the    Specific  muscle   affected    can    readily   he    made    from    the 

table  on  page  51  1.    In  a  number  of  these  cases  the  hyperphoria  is  apparently 

due  t<.  spasmodic  action  of  the  muscles,  since  it  changes  in  amount  from  one 
examination  to  another,  and  after  a  time  disappears  altogether. 

■_'.    In  a  comitant  hyperphoria  the  deviation  (determi I   by  the  diplopia. 


ASSOCIATED   PARALLEL  DEVIATIONS.  519 

deflection  behind  the  screen,  parallax,  and  phorometer)  remains  sensibly  the 
same  in  all  directions  of  the  gaze.  Sonic  of  these  cases  may  be  due  to  a  ver- 
tical separation  of  the  visual  axe-,  due  to  excessive  sursumvergence,  bu1  mosf 
arc  probably  example-  of  a  aon-comitant  hyperphoria  which  ha-  become 
comitant  through  the  agencies  already  described  (see  pages  508,513).  In 
this  case  the  diagnosis  of  the  muscle  affected  is  usually  no  longer  possible. 

The  deviation  i-  often  slight  (only  1°  or  2°).  When  slighl  it  can  be 
overcome  by  the  action  of  sursumvergence.  In  well-marked  cases  it  will 
generally  be  found  that  there  is  a  difference  of  1  or  more  between  the  righl 
and  left  sursumvergence,  the  former  predominating  in  right  hyperphoria  and 
the  latter  in  left  hyperphoria. 

Hyperphoria  does  not,  in  general,  -how  any  great  tendency  to  increase, 
and  cases  of  actual  vertical  squint — i.  e.  of  a  vertical  deviation  so  great 
that  binocular  fixation  can  no  longer  be  performed,  and  hut  one  eye  fixe- — are 
rare.  Such  a  squint  is  called  a  strabismus  sursumvergens  if  the  deviating  eye 
stands  higher,  and  strabismus  deo?'Sumvergens  if  it  stands  lower,  than  the  one 
which  regularly  performs  fixation. 

The  symptoms  of  vertical  deviations  are  vertical  diplopia,  blurring  of 
binocular  vision,  asthenopia,  headache,  neuralgia,  nausea,  vertigo,  disturbance 
of  nutrition,  choreiform  twitchings,  and  other  evidences  of  reflex  trouble. 
The  symptoms  in  general  arc  more  frequently  present,  more  varied  in 
character,  and  more  severe  in  this  form  of  ocular  deviation  than  in  any 
other. 

Associated  Parallel  Deviations. — Associated  parallel  deviation- 
comprise — 

1.  Associated  Paralysis  and  Spasm. — Paralysis  of  the  movements  of 
both  eyes  to  the  right  or  of  both  eyes  to  the  left  frequently  occurs  in 
destructive  lesions  of  the  brain,  and  especially  in  apoplexy.  This  condi- 
tion is  not  due  to  paralysis  of  the  externus  of  one  eye  and  the  internus  of 
the  other,  since  the  internus  may  still  act  in  movements  of  convergence,  but 
it  is  due  to  the  involvement  of  the  higher  (association)  center  governing  the 
movement  of  both  eye-  to  the  right  or  to  the  left  (dextroversion  and  sinistro- 
version).  Paralysis  of  the  movements  of  both  eyes  up  and  of  both  eyes 
down   has  also  been  observed,  but   i-  rare. 

Spasm  of  the  associated  parallel  movements  occurs  in  irritative  lesions  of 
the  brain  involving  the  association  center-  or  tracts,  and  also  in  hysteria.  It 
produce-  a  spastic  deviation  of  both  eyes  in  the  same  direction  (right,  left,  up, 
down,  or  obliquely). 

2.  Nystagmus. — Nystagmus  consists  in  a  very  rapid  oscillating  move- 
ment of  the  eye  in  some  one  direction.  Almost  invariably  both  eye-  take 
part  in  the  movement,  the  oscillations  of  the  two  being  equal  and  in  the  same 
sense.  According  to  the  direction  of  the  movement  nystagmus  is  called 
horizontal,  vertical,  rotary  (when  both  eyes  roll  like  wheels  in  the  same 
direction),  or  mixed  (when  oscillations  of  two  different  kind-  are  combined). 
Horizontal  nystagmus  is  much  the  most  frequent  form. 

Nystagmus  is  due  to  alternate  discharges  from  the  association  centers  for 
parallel  movements.  For  example,  in  horizontal  nystagmus  there  i^  6rs1  ;i 
discharge  from  the  center  for  turning  both  eye-  to  the  right  (dextroversion 
center),  followed  at  once  by  ;i  discharge  from  the  center  for  turning  th<  • 
to  the  left  (sinistroversion  center).  In  those  who  are  subject  t"  it  it  i-  often 
set  up  by  the  attempt  to  fix  the  eyes  on  an  object  or  to  turn  them  in  - 
special  direction.      It  occurs — 

(a)  A-  a   re-ult  ot*   visual  defects  (such  as  cataract,  opacities  of  thi 


520  MOVEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 

nea,  diseases  of  the  retina  and  choroid,  and  albinism),  which,  being  either 
congenita]  or  acquired  soon  after  birth,  have  prevented  the  patient  from  ever 
seeing  well  or  from  learning  to  direci  his  eves  properly-. 

(6)  As  a  late  acquired  affection  in  disseminated  sclerosis,  in  hereditary 
ataxia,  and  in  hemorrhage,  degeneration,  inflammation,  and  tumors  of  the 
meninges,  cord,  and  brain  (especially  the  cerebellum).  A  special  acquired 
form  occurs  in  miners  (miner's  nystagmus),  who  work  by  a  bad  light  and 
with  their  eves  in  a  strained  position.  Nystagmus  may  also  be  produced  by 
a  rapid  rotation  of  the  body  or  any  other  cause  affecting  the  functions  of  the 
semicircular  canals  (auditory  disease).1 

In  some  of  the  forms  acquired  late  in  life,  particularly  miner's  nystag- 
mus, the  oscillation  of  the  eye-  produces  an  apparent  movement  of  objects 
looked  at,  with  consequent  vertigo.  Otherwise  the  disease  causes  no  symp- 
toms. 

Nystagmus  occasionally  disappears  spontaneously  or  as  a  result  of  the 
removal  of  the  optical  defect  that  caused  it  ;  and  miner's  nystagmus  may 
disappear  on  removal  of  the  patient  from  the  hurtful  conditions  under  which 
he  lives.     ( Otherwise  the  condition  is  not  susceptible  of  amelioration. 

Treatment  of  Ocular  Deviations.— The  first  indication  to  be  fulfilled 
where  possible  is — 1,  to  ration'  the  cause  of  the  deviation.  Hence  in  paralysis 
or  spasm  due  to  syphilis,  meningitis,  periostitis,  and  exudative  processes  in 
general  we  use  iodids  and  mercurials;  in  rheumatic  paralyses  we  employ  the 
iodids,  salicylates,  and  diaphoresis;  in  diabetic  paralyses,  the  appropriate 
diet;  and  in  miner's  nystagmus  we  remove  the  patient  from  his  hurtful 
surroundings. 

2.  The  next  indication  to  he  fulfilled  in  all  cases  causing  symptoms  is  to 
correct  tin-  refraction.  Such  correction  will  in  many  cases  (e.  </.  those  of 
accommodative  convergence-excess  and  insufficiency)  remove  the  deviation 
it-eli':  in  others,  while  having  no  effect  upon  the  deviation,  it  will  do  away 
with  the  symptoms.  In  esophoria  (particularly  in  convergence-excess)  the 
total  amount  of  hyperopia  and  astigmatism  (determined  under  a  mydri- 
atic) should  he  prescribed  and  the  glasses  worn  constantly.  In  exophoria 
(particularly  convergence-insufficiency)  the  myopia  present  should  be  fully 
corrected,  and  the  concave  glasses  worn  for  near  as  well  as  for  distance.  On 
the  other  hand,  it  i-  often  propel-  to  more  or  less  under-correct  hyperopia  or 
presbyopia  coexisting  with  convergence-insufficiency. 

In  ophthalmoplegia  interna  it  is  often  necessary  to  prescribe  a  convex 
glass  for  the  affected  eye  to  supplement   its  lost  accommodation. 

3.  Exercise,  tonics,  and  other  corroborant  measures  are  frequently  re- 
quired in  debilitating  affections,  neurasthenia  and  hysteria,  which  by  causing 
a  temporary  enfeeblement  of  the  muscles  either  produce  a  deviation  directly 
or,  in  case  one  i-  already  present,  interfere  with  its  proper  compensation. 

I.  'I  he  bromids  may  he  of  use  in  certain  cases  of  spasm.  <  >ther  remedies, 
such  a-  strychnin,  electricity,  etc.,  which  are  supposed  to  act  directly  upon  the 
muscles  or  nerves,  are  of  little  value,  excepl  in  so  far  a-  they  improve  the 
genera]  nutrition.  The  same  may  he  -aid  with  even  more  force  of  electricity 
and  eserin  in  ophthalmoplegia  interna. 

5.  Exercise  of  the  prism-convergence  (so-called  adduction)  with  prisms, 
base  out,  is  often  useful  in  exophoria  (particularly  convergence-insufficiency), 
hut  often  fail-.     Exercise  with  prisms,  base  in,  in  esophoria  i-  of  qo  service. 

1  Nystagmus-like  twitchings  of  a  muscle   especially  a  paretic  muscle)  may  ale icur  when 

the  lattei  is  carried  u>  the  extreme   limit  of  it-  excursion,  but  tlii-  is  not  nystagmus  in  tin- 
proper  sense  of  the  term. 


TREATMENT  OF  OCULAR  DEVIATIONS.  52] 

Prisms  for  continuous  wear  may  be  useful,  particularly  in  slight  and 
stationary  vertical  deviations.  Their  employment  in  lateral  deviations  is  to 
be  avoided,  except  as  a  temporary  measure,  since  prisms,  base  in,  tend  to  pro- 
duce convergence-insufficiency,  and  prisms,  base  out,  a  convergence-excess,  so 
that  in  both  cases  they  ultimately  increase  the  deviation  which  they  are 
designed  to  correct. 

6.  The  muscles  may  be  exercised,  not  only  by  means  of  prisms,  but  also 
by  making  forced  movements  of  the  eyes  in  different  directions,  up,  down, 
right,  and  left;  by  making  forced  movements  of  convergence  in  looking  at 
near  objects  ;  by  forcing  the  eyes  to  overcome  a  natural  diplopia  of  small 
amount;  and  by  forcing  the  eves  to  move  so  as  to  unite  the  images  of  two 
objects  which  are  some  distance  apart.  These  orthoptic  exercises,  as  they  are 
called,  should  not  be  kept  up  for  more  than  a  few  minutes  at  a  time,  Inn 
may  be  repeated  several  times  a  day. 

7.  An  operation  is  to  be  done  only  when  the  symptoms  are  marked  and 
when  it  is  apparent  that  all  other  measures  will  fail.  In  structural  and  inser- 
tional  muscular  anomalies  an  operation  is  generally  indicated,  and  doc-  good 
service.  In  paretic  and  spastic  deviations  it  is  indicated  only  when  we 
are  assured  that  the  condition  has  become  stationary.  In  convergence  and 
divergence  anomalies  it  is  usually  indicated  when  the  deviation  is  marked 
and  when  correction  of  the  refraction  after  long  trial  has  afforded  no  relief. 
In  all  cases  the  rule  is  to  perform  tenotomy  of  an  over-acting  muscle  and 
advancement  of  one  that  is  under-acting,  provided  always  that  the  latter  is 
capable  of  acting  at  all.     The  specific  operations  to  be  employed  are — 

(a)  In  esophoria  (or  convergent  squint),  when  due  to  over-action  of  one 
or  both  interni  or  to  convergence-excess,  tenotomy  of  one  or  both  interni  ; 
when  due  to  weakness  of  the  externi  or  to  divergence-insufficiency,  ad- 
vancement of  one  or  both  externi  combined,  especially  if  there  is  oxer- 
action  of  convergence  or  over-action  of  the  interni,  with  tenotomy  of  the 
latter. 

(b)  In  exophoria,  when  due  to  over-action  of  one  or  both  externi  or  to 
divergence-excels,  tenotomy  of  the  externi  ;  when  due  to  convergence- 
insufficiency  or  to  actual  insufficiency  or  paresis  of  one  or  both  interni, 
advancement  of  the  latter,  combined,  if  necessary,  with  tenotomy  of  the 
externi. 

(c)  In  non-comitant  hyperphoria,  when  due  to  weakness  of  the  superior  or 
inferior  rectus,  advancement  of  the  weak  muscle  ;  when  due  to  over-action  of 
the  superior  or  inferior  rectus,  tenotomy  of  the  over-acting  muscle  ;  v\  hen  due 
to  weakness  (paresis)  of  the  superior  oblique,  tenotomy  of  the  inferior  rectus 
of  the  other  eye  ;  when  due  to  over-action  of  the  superior  oblique,  advance- 
ment of  the  inferior  rectus  of  the  other  eye;  when  due  to  weakness  of 
the  inferior  oblique,  tenotomy  of  the  superior  rectus  of  the  other  eye:  and 
when  (\\\c  to  over-action  of  the  inferior  oblique,  advancement  of  the  superior 
rectus  of  the  other  eve.  A  comitanf  hyperphoria  i>  generally  besl  remedied 
by  tenotomy  of  the  superior  rectus  of  the  higher  eye. 

In  performing  either  a  tenotomy  or  an  advancement  the  precise  amount 
of  the  deviation  should  be  measured  (when  possible  by  the  phorometer)  before 
and  during  the  operation,  the  latter  being  done  in  successive  Steps,  and  its 
effect  gradually  increased  until  just  the  desired  amounl  of  correction  i-  ob- 
tained. As  the  ultimate  effect  is  somewhat  less  than  the  primary,  it  is 
advisable  in  operations  upon  the  lateral  muscles '  (especially  advancements) 

1  <  ^Derations  upon  the  superior  and  inferior  recti,  if  carefully  performed,  >i"  ool  n<  i  ■!  t<>  l*e 
overdone. 


522   MOVEMENTS  OF  THE  EYEBALLS,  AND  THEIR  ANOMALIES. 

to  produce  an  over-effect  of  about  30.1  An  exception  [s  in  the  convergent 
squint  of  young  persons,  in  which  we  prefer  to  leave  a  slight  amount  of 
convergence,  so  as  to  prevent  a  possible  over-correction  later,  and  in  large 
deviations,  in  which  the  best  plan  is  to  divide  the  operation  between  the  two 
eyes. 

In  the  author's  experience  the  best  results  are  secured  if  the  tenotomy  is 
performed  by  the  open  method,  the  incision  being  made  in  the  middle  of  the 
tendon,  near  it-  insertion,  and  carried  gradually  up  and  down  until  the  tests 
show  that  the  fibers  are  sufficiently  detached.  '  A  bandage  is  not  applied  in 
the  case  of  a  simple  tenotomy,  and  the  patient  is  encouraged  to  use  his  eves  for 
distant  vision  directly  after  the  operation,  for  then  the  directive  influence  of 
binocular  fixation,  exerted  upon  the  tissues  when  they  are  still  plastic,  tends 
to  mala'  the  eyes  assume  their  proper  position  with  regard  to  each  other.2  In 
advancement  a  bandage  i-  required  to  prevent  sudden  movement-  of  the  eye, 
which  would  produce  loosening  of  the  sutures. 

If  an  excessive  over-correction  is  produced,  the  surplus  should  be  at  once 
removed  by  inserting  a  suture  and  making  the  proper  traction. 

1  The  operation,  however,  should  not  be  carried  so  far  as  to  reduce  the  diverging  power 
(abduction)  to  below  5°  or  increase  it  to  above  12°. 

2This  tendency  may  be  reinforced  by  exercises  with  prisms  performed  systematically  while 
tin-  i issues  are  healing. 


INJURIES  AND  DISEASES  OF  THE  ORBIT. 


r.v    I\  BULLEB,,  M.  D., 

OF    MONTREAL,    CANADA. 


CONQENITAL  ANOMALIES. 

Congenital  faults  in  the  development  of  tlie  orbits  have  been  described 
in  all  degrees,  from  trifling  defects  in  limited  portions  of  their  bony  walls  tc 
complete  absence  of  these  cavities,  one  or  both;  in  the  latter  case  the 
structures  they  are  designed  to  enclose  are  also  wanting.  Jn  the  Lesser 
defects  the  orbital  contents  may  be  modified  in  various  way-.  Such  modifica- 
tions as  affect  the  eyeballs  are  of  special  interest.  Of  these  there  are  four 
well-known  conditions.  They  are — anophthalmos,  microphthalmos,  megal- 
ophthalmos,  and  cyclopia.  The  first  three  of  these  are  not,  however,  neces- 
sarily associated  with  anomalies  in  the  construction  of  the  orbits.  Although 
congenital  defects  of  this  class  are  usually  bilateral,  one-sided  faults  are  by 
no  means  uncommon. 

Anophthalmos. — Congenital  absence  of  both  eyes  is  a  rare  condition 
(still  more  rarely  is  this  condition  unilateral — monophthalmos).  In  most  of 
these  cases  the  palpebral  fissure  has  been  found  closed  or  very  narrow,  the 
conjunctival  sac  small,  of  a  pale-red  color,  and  the  eyeball  totally  absenl  or 
only  represented  by  a  soft,  irregular  flesh-like  mass.  Several  or  all  of  the 
extrinsic  ocular  muscles  have  been  found  in  connection  with  this  rudimentary 
mass.  The  orbital  cavities  are  always  smaller  than  normal,  and  the  adnexa 
of  the  eye,  when  present,  are  -mall  and  ill-developed.  The  faulty  develop- 
ment in  these  cases  is  not  confined  to  the  orbits  and  their  content-,  buf 
involves  also  the  chiasma,  optic  tracts,  corpora  quadrigemina,  and  sometimes 
adjacent  parts  of  the  cerebrum. 

A  few  instances  of  monolateral  anophthalmos  have  been  observed.  In 
one  of  these  the  single  eye  was  normally  developed.  This  anomaly  i<  ex- 
plained by  failure  of  the  primary  optic  vesicle  to  bud  from  the  anterior 
primary  encephalic  vesicle,  or,  having  budded,  it  has  failed  to  form  a  sec- 
ondary optic  vesicle.  In  every  case  the  eye  was  properly  situated,  even  when 
very  imperfect — a  feature  which  justifies  the  use  of  the  term  monophthalmos 
in  describing  tlii-  deformity,  and  distinguishes  it  from  the  more  common 
monstrosity  known  a-  cyclopia. 

Cyclopia. — Tin-  anomaly  is  a  fusion  of  both  orbit-  and  their  contents, 
with  a  single  eyeball  situated  in  the  middle  line  just  above  the  ordinary  posi- 
tion of  the  root  of  the  nose.  This  single  eye  may  be  larger  or  smaller  than 
normal  for  the  general  development,  but  always  show-  unmistakable  evidence 

of  an  imperfect  I'u-i f  the  two  eye-.    The  same  is  true  of  the  adnexa  of  t  lie 

eye.  In  all  -ucli  cases  ill1,  ethmoid  is  absenl  or  only  rudimentary.  The  olfac- 
tory nerve-  are  wanting,  and   the  cerebrum   is  -o  imperfectly  formed  that, 


524 


INJURIES  AND   DISEASES  OF  THE  ORBIT. 


although  sonic  cyclops  have  been  living  when  horn,  all  that  the  writer  has 
been  able  to  find  records  of  have  died  within  a  very  short  time  alter  birth. 

Microphthalmos. — Eyes  which  at  birth  are  considerably  smaller  or 
larger  than  normal  are  seldom,  if  ever,  sufficiently  normal  in  other  respects 
to  admit  of  useful  vision.  These  peculiarities  are  probably  the  result  of 
some  pathological  process  in  utero,  rather  than  a  mere  arrest  or  excess  of 
development.     Either  condition  may  be  found  in  one  or  both  eves. 

In  microphthalmos  the  whole  globe  is  uniformly  spherical,  sometimes  flat- 
tened below  ;  the  cornea  is  usually  very  much  smaller  than  normal,  its  margins 
ill-defined,  and  curvature  of  the  same  radius  as  the  adjacent  sclerotic;  the 
anterior  chamber,  iris,  and  pupil  are  correspondingly  diminished.  The  pal- 
pebral fissure  is  narrow,  and  the  lids,  unsupported  by  the  globe,  are  partly 
deprived  of  their  ordinary  functions.  The  changes  in  the  interior  of  the 
globe  have  not  been  fully  studied.  According  to  Manz,  they  are  often  of  a 
degenerative  character,  such  as  occur  in  phthisis  bulbi  from  other  causes.  In 
the  higher  grades  of  microphthalmos  vision  is,  of  course,  entirely  wanting. 

Megalophthalmos  is  a  rare  congenital  anomaly  in  which  the  cornea 
and  anterior  chamber  are  larger  than  normal (hydrophthahnos anterior).  The 
explanation  of  this  is  probably  to  be  found  in  some intra-uterine  pathological 
condition  in  which  the  intra-ocular  tension  has  been  increased  at  a  time  when 
the  cornea  possessed  less  resisting  power  than  the  sclerotic,  and  therefore 
became  distended,  whilst  the  posterior  segment  of  the  eyeball  remained 
relatively  unaffected  in  its  development  (see  also  pages  32*9  and  385). 


DISEASES  OF  THE  ORBIT. 


A  glance  at  Fig.  323  show-  that  the  eyeball  is  rather  loosely  slung  in  the 
conical  bony  cavity  of  the  orbit,  well  toward  its  anterior  part.     The  bony  walls 


X*  iv.  supraorb. 


-  Frontal. 


_  Orbicul. 


Supercil. 
Septum  orbit. 


Septum  orbit. 
Obliqu.  inf. 


It  mm. 

Pig  -      ttal  Bection  "i  orbil    !>•■  Wecker  and  Landolt). 

of  this  hollow  cone  are  - yielding  that  any siderable  augmentation  of  its 

contents  or  encroachment  from  without  will   have  the  effect  of  displacing  the 


PERIOSTITIS.  525 

eyeball.  The  displacement  will  naturally  be  greatest  in  the  direction  of 
Least  resistance,  which,  in  a  general  way,  is  obviously  forward. 

General    Symptoms    of  Orbital    Disease. — Most    of   the    pathological 

conditions  met  with  in  the  orbit  either  increase  its  contents  or  <• •  from 

encroachment  upon  sonic  part  of  its  walls;  hence  a  more  or  less  forward 
displacement  of  the  eyeball — proptosis — is  the  most  usual  sign  of  disease 
of  the  orbit. 

In  the  normal  state  the  eyeball  is  freely  movable  in  every  direction  by 
means  of  the  three  pairs  of  ocular  muscles,  each  one  of  which  is  situated 
entirely  within  the  orbit,  and  therefore  liable  to  Loss  of  function  from 
changes  in  the  tissues  surrounding  them;  hence  another  common  -inn  of 
orl)ital  disease  is  alteration  in  the  mobility  of  the  eye.  Inflammatory  proci  ss<  - 
or  morbid  growths,  which  cause  infiltration  of  the  tissues  surrounding  the 
muscles,  are  especially  liable  to  result  in  fixation  of  the  eyeball.  Periostitis, 
even  of  a  limited  extent,  at  the  apex  of  the  orbit  may  have  a  similar  effect 
by  pressure  upon  the  motor  nerves  as  they  pass  through  the  Sylvian  fissure, 
thus  causing  a  paralytic  immobility. 

On  the  other  hand,  a  high  degree  of  proptosis,  caused  by  non-infiltrating 
growths  arising  within  the  orbit  or  projecting  into  it  from  adjacent  parts,  is 
compatible  with  free  mobility  of  the  eyeball,  as  in  certain  orbital  cyst-  and 
other  encapsuled  new  growths.  Only  in  case  of  one-sided  exophthalmos  can 
a  fairly  accurate  estimate  of  the  displacement  be  made  by  comparison  with 
the  position  of  the  eyeball  in  the  normal  orbit.  If  the  displacement  is 
bilateral,  its  degree  is  a  matter  of  conjecture,  and  allowance  must  be  made  for 
the  fact  that  a  wide  palpebral  fissure  simulates  exophthalmos,  whilst  a  narrow 
fissure  may  simulate  the  opposite  condition  or  enophthalmos. 

The  differential  diagnosis  of  orbital  disease  will  be  greatly  facilitated  by 
a  careful  consideration  of  the  following  less  constant  signs  : 

(1)  Redness,  swelling,  and  edema  of  the  lids,  especially  conspicuous  in  the 
inflammatory  affections  of  the  cellular  tissue  of  the  orbit. 

(2)  Chemosis  of  the  conjunctiva,  cither  general  or  localized,  over  a  certain 
portion  of  the  globe  nearest  the  area  of  disease. 

(3)  Fluctuation  is  likely  to  be  present  when  an  abscess  of  the  orbit  has 
formed,  but  cannot  always  be  nnule  out  with  certainty. 

(4)  Pain,  intensified  when  the  patient  attempts  to  rotate  the  eyeball  or 
when  it  is  pressed  backward,  and  the  surroundings  are  palpated  by  the  sur- 
geon. Tenderness  on  pressure  of  the  orbital  margins  is  a  common  sign  in 
periostitis  of  the  orbit,  and  frontal  headache  is  often  intense  during  the  acute 
stages  of  inflammation  in  the  orbital  tis-ucs,  or  of  the  frontal  -inns. 

(5)  Disturbance  <<{  vision  is  often  absent,  but  becomes  a  valuable  sign 
when  associated  with  changes  in  the  fundus  oculi,  such  as  papillitis,  pallor 
of  the  optic  nerve,  or  retinal  hemorrhages.     Diplopia  is  also  common. 

Periostitis. — Periostitis  of  the  orbit  occurs  in  two  form-,  acute  and 
chronic.  The  term-  circumscribed  and  diffuse  are  applicable  according  to  the 
supposed  periosteal  area  involved  in  either  variety. 

Etiology. — (  tertain  diathetic  states  predispose  to  tin-  disease.  They  an  — 
scrofula,  syphilis,  and  rheumatism.  Injuries  and  sudden  changes  ol  tem- 
perature are  recognized  exciting  causes,  but  in  many  cases  tin'  exciting  cause 
cannot  be  positively  determined. 

This  disease  attacks  by  preference  the  margin  of  the  orbit  (especially  the 
outer  margin),  and  extend-  more  or    less  widely;  suppuration  (abscess 
prone  to  occur. 

Symptoms. — The   symptoms   of  an   ordinary  acute    marginal    periostitis 


526  INJURIES  AND  DISEASES  OF  THE  ORBIT. 

are — swelling,  edema,  and  redness  of  the  lids;  chemosis  of  the  conjunctiva, 
commencing  at  the  equator  of  the  globe  \  pain  and  tenderness  on  pressure  at 
the  part  of  the  orbital  margin  affected.  Sometimes  a  highly  sensitive,  tense 
spot  may  be  discovered  with  the  finger,  or  fluctuation  if  pus  has  formed. 

^Iculi  parietal  (deep-seated)  orbital  periostitis  is  difficult  to  distinguish 
from  cellulitis.  The  symptoms  are  violent  and  severe — intense  headache, 
pyrexia,  sometimes  nausea,  vomiting,  and  great  prostration.  The  local  symp- 
toms arc — swelling  of  the  Lids,  chemosis,  pain,  increased  when  the  eyeball  is 
pressed  backward,  and  more  or  less  displacement  and  immobility  of  the 
eyeball. 

Chronic  orbital  periostitis  is  far  more  frequent  than  the  acute  form, 
and  is  nearly  always  distinctly  circumscribed.  Its  course  is  tedious,  lasting 
for  months  or  year-.  All  the  symptoms  are  less  intense,  though  similar  in 
other  respects,  except  that  the  swelling  of  the  lids  is  more  a  simple  edema 
and  the  patient  complains  of  a  dull  pain,  usually  worse  at  night.  It  com- 
monly  results  in  abscess  of  the  orbit,  occasionally  in  gradual  resolution. 
Whenever  pus  has  formed  beneath  the  periosteum  caries  or  necroses  of  the 
bone  are  liable  to  occur,  and  there  is  always  danger  of  extension  to  the 
cranial  cavity  or  septic  infection,  particularly  when  the  disease  is  parietal. 
If  the  consecutive  bone-disease  involves  the  orbital  margin,  adhesion  and 
retraction  of  the  adjacent  skin  may  cause  eversion  and  distortion  of  the  eye- 
lids.     This  result  is  very  common  in  children. 

Prognosis. — This  must  be  based  chiefly  on  a  recognition  of  the  foregoing 
facts,  and,  in  acute  cases,  on  the  immediate  effects  of  treatment. 

Treatment. —  If  the  ease  is  seen  before  pus  has  formed,  leeches  applied 
to  the  temple,  cold  compresses  over  the  eyelids,  and  other  antiphlogistic 
measures  may  arrest  the  inflammation.  If  pus  is  present  or  its  formation 
seems  to  be  inevitable,  hot  applications  may  be  used,  but  incision  should  not 
be  long  delayed  (see  Operations  on  the  Orbit);  and  in  no  case,  acute  or 
chronic,  should  an  abscess-formation  in  the  orbit  be  allowed  to  undergo 
spontaneous  rupture.  Alter  an  opening  has  been  established  suitable  drainage 
and  careful  daily  cleansing  will  be  required  so  long  as  the  discharge  continues 
from  the  opening. 

Appropriate  remedies  for  the  underlying  constitutional  cause  must  be 
administered  in  all  cases.  If  syphilitic,  the  judicious  use  of  mercury  and 
iodid  of  potassium  may  be  expected  to  give  excellent  results.  In  rheumatic 
or  strumous  cases  constitutional  treatment, although  undoubtedly  beneficial,  is 
not  so  distinctly  curative. 

Caries  and  necrosis  of  the  orbit  are  probably  always  preceded  by 
periostitis,  of  which  they  are,  therefore,  common  sequels. 

<  laries  affects  by  preference  the  lower  outer  orbital  margin,  but  may  attack 
any  pari  of  the  orbital  walls,  when  deep-seated  brain-complications  are  not 
unlikely  to  occur.  It  is  seldom  .-ecu  in  adult  life;  often  in  children.  A 
fistulous  opening,  surrounded  by  granulations,  lend-  to  an  area  of  softened 
bone,  which  may  be  detected  by  careful  use  of  a  probe.  Retraction  of  the 
skin  and  deformity   of  the   lid,   usually  ectropion,  ensues  in   most  cases. 

Necrosis  is  far  less  frequenl  than  caries,  ami  belongs  to  adult  life.  It  is 
apt  to  follow  denudation  of  a  large  area  of  hone  from  periostitis,  or  a  frag- 
ment of  bone  detached  by  traumatism  from  the  orbital  margin  may  become 
necrosed  |  Fig.  32  1 1. 

Treatment.— The  li-tuloii-  opening  and  sinus  should  be  gently  cleansed 
two  or  three  times  daily  with  some  antiseptic  Quid.  Mineral  acids  may  be 
cautiously   employed    locally   for  the   purpose  of    gradually   dissolving  the 


CKL1A  LITIS. 


527 


diseased  bone.  Meddlesome  surgery  and  the  injudicious  use  of  probes  are 
harmful,  and  may  induce  orbital  cellulitis  or  an  extension  of  the  disease. 
Removal  of  diseased  bone  may  only  he  undertaken  when  near  the  surface 
or  obviously  completely  detached;  when  the  roof  of  the  orl.it  i-  the  part 
affected,  the  surgeon  should  he  extremely  careful  in  the  use  of  instruments. 
This  disease  is  essentially  chronic,  and,  besides  the  local  treatment, 
appropriate  constitutional   remedies  will  be  in  order  until  a  cure   i-  effected. 


Fig.  324.— Syphilitic  caries  of  the  inner  wall  of  the  orbit. 

The  case  represented  in  Fig.  324  recovered  without  a  trace  of  deformity,  after 
a  course  of  mercurial  inunctions  followed  by  potassium  iodid  in  large  doses. 

Cellulitis  {Phlegmon  of  the  Orbit). — This  disease  doc-  not  always  present 
the  same  clinical  picture.  In  all  its  forms  the  soft  tissue  surrounding  the  eye- 
ball is  inflamed,  but  the  inflammation  may  be  acute,  subacute,  or  chronic,  mono- 
lateral  or  bilateral.  The  inflammatory  process  may  terminate  in  resolution, 
hut  commonly  leads  to  suppuration  and  abscess. 

In  mild  cases  the  symptoms  are — moderate  swelling  of  the  lid-,  some 
exophthalmos,  diplopia,  dull  pain,  and  little  or  no  constitutional  disturbance. 

Acute  phlegmonous  orbital  cellulitis  conic-  on  with  chills,  pyrexia,  and  deep- 
seated   pain,  aggravated  by  movements  of  the  eye-.     Intense  headache  i-  a 

common  symptom.     Loss  of  mobility  of  the  eyeball   may  he iplete.      The 

lids  become  greatly  swollen,  red,  and  edematous  ;  the  conjunctiva  i-  chemosed 
and  hyperemic,  suggesting  a  violent  purulent  conjunctivitis  or  a  panophthal- 
mitis; hut  the  absence  of  profuse  suppuration  of  the  conjunctiva  and  the 
preservation  of  ;i  normal  red  reflex  from  the  pupil  will  prevent  such  an  error 
of  diagnosis  (Fig.  325).  Vision  may  he  unaffected  for  some  time,  hut  it  i- 
not  unusual  for  neuro-retinitis  to  appear,  and  this,  in  turn,  may  pass  over  into 
atrophy  of  the  optic  nerve  and  blindness.  The  pressure  on  the  eyeball  may 
cause  dilatation  of  the  pupil,  anesthesia,  or  ulceration  of  the  cornea,  and,  occa- 
sionally in  had  cases,  panophthalmitis. 

In  certain  cases  of  an  erysipelatous  typ<  extensive  intra-ocular  changes  have 


528 


INJURIES  AND  DISEASES  OF  THE  OR  JUT. 


Fig.  325.— From  a  photograph  of  a  patient  in 
the  Philadelphia  Hospital,  under  the  care  of  I»r. 
>lr  Schweinitz,  suffering  from  double  orbital  cel- 
lulitis the  result  of  erysipelas. 


been  observed,  due  probably  to  arrest  of  the  circulation  in  the  retinal  blood- 
vessels, and  consequenl  edematous  exudation  and  hemorrhages  in  the  retina. 

Finally,  an  abscess  forms,  with  characteristic  fluctuation,  usually  below 
the  inner  portion  of  the  supra-orbital   ridge.     Sometimes  the  inflammation 

leading  to  abscess-formation  is  of  a 
more  chronic  character,  and  may  not 
involve  the  entire  orbital  cellular  ti>- 
sue,  as  where  the  disease  originates  in 
the  bone  or  periosteum  in  scrofulous 
subjects,  or  in  the  vicinity  of  a  foreign 
body  imbedded  in  the  orbit. 

Etiology. — When  orbital  cellulitis 
cannot  be  traced  to  any  definite  cause, 
it  is  said  to  be  idiopathic.  Among  the 
many  recognized  causes  are — exposure 
to  excessive  changes  of  temperature, 
certain  febrile  conditions,  such  as  scar- 
latina, typhoid  fever,  meningitis,  and 
facial  erysipelas.  The  last  disease  is 
responsible  for  the  most  violent  types 
of  orbital  cellulitis,  which  is  then  apt 
to  be  bilateral.  Diseased  teeth  and 
suppuration  in  adjacent  cavities  have 
been  known  to  cause  the  affection.  It 
occurs  as  a  metastasis  in  pyemia  and  in 
puerperal  septicemia,  and  in  all  cases  of 
acute  panophthalmitis  there  is  more  or  less  diffuse  inflammation  of  the  tissues 
surrounding  the  eyeball. 

Prognosis. — This  is  favorable  in  mild  cases  and  those  of  a  more  chronic 
character,  and  recovery  is  likely  to  be  perfect  when  the  disease  terminates  in 
resolution. 

Although  purulent  collections  in  the  orbit  usually  tend  toward  the  surface, 
there  is  always  a  liability  to  cerebral  complications,  which  almost  certainly 
terminate  fatally.  These  an — meningitis,  cerebral  abscess,  and  the  extension 
of  phlebitis  of  the  orbital  veins  to  the  cerebral  sinuses.  In  this  way  the 
other  orbil  may  become  involved  through  the  intervention  of  the  cavernous 
Ejinus.  In  double  cases  of  this  nature  a  fatal  issue  is  to  be  expected.  If 
orbital  cellulitis  originates  from  pyemia  or  septicemia,  the  chances  of  recovery 
are  of  course  exceedingly  limited. 

The  danger  to  vision  is  to  be  estimated  by  the  character  and  extent  of  the 
ocular  complications  already  mentioned. 

Treatment. — Absolute  rest  in  bed  is  essential.  In  the  early  stage  of  acute 
inflammation  cold  compresses,  leeches  to  the  temple,  aconite,  and  derivatives 
may  be  employed.  If  these  measures  arc  not  effective  in  a  short  time,  a 
change  musl  be  made  to  hoi  fomentations  and  general  supporting  treatment, 
or  tlii—  plan  must  be  adopted  at  the  outset  if  there  is  evident  depression  of 
the  vital  forces. 

If  there  is  reason  to  believe  thai  suppuration  has  taken  place,  do  time  is 
to  be  lost  in  making  one  or  more  incisions  deep  enough  to  reach  the  suspected 
pus.  [ncisions  arc  besl  made  with  a  Graefe  knife,  through  the  conjunctiva,  the 
il.-it  of  the  blade  facing  the  eyeball.  If  pus  is  discovered,  drainage  musl  be 
maintained  by  mean-  <>f  rubber  tubing  or  strips  of  iodoform  gauze,  and 
systematic  cleansing  of.  the  cavity  with  antiseptic  solutions  will  be  necessary 


TUMORS  OF  THE  ORBIT.  529 

until  all  suppuration  has  ceased.  Ocular  complications  which  threaten  loss 
of  vision  demand  operative  interference  even  when  there  is  no  positive  evi- 
dence of  suppuration. 

Inflammation  of  the  Ocnlo-orbital  Fascia  (  Tenonitis). — As  a  pri- 
mary affection  tin-  disease  i>  exceedingly  rare,  and  i-  supposed  t<>  lie  an 
inflammatory,  serous  exudation  into  Tenon's  capsule  <>f  rheumatic  origin,  but 
a  few  cases  have  l»een  observed  in  connection  with  diphtheria  ami  during 
attacks  of  influenza. 

Its  characteristic  feature  is  a  watery  chemosis  of  the  ocular  conjunctiva, 
partial  or  complete,  and  out  of  proportion  to  other  local  manifestations  of 
disease.  There  i-.  however,  more  or  less  edema  of  the  eyelid-,  some  loss 
of  mobility  of  the  eye.  perhaps  diplopia,  exophthalmos,  and  a  feeling  of  ten- 
sion about  the  eye,  and  pain  when  its  ordinary  movements  are  attempted. 

The  treatment  consists  in  hot  fomentations  and  the  administration  of 
potassium  iodid,  salicylates,  or  the  subcutaneous  injection  of  pilocarpin. 

A  secondary  tenonitis,  with  more  -olid  exudation.  i>  associated  with  any 
violent  inflammation  of  the  eyeball,  and  occasionally  follows  certain  trauma- 
tism-;, such  as  squint-operations  performed  without  antiseptic  precautions. 

Thrombosis  of  the  cavernous  sinus,  as  already  stated,  may  result 
from  phlebitis  of  the  orbital  veins  during  phlegmonous  inflammation  of  the 
orbit,  or  it  may  be  of  intercranial  origin,  as  in  caries  of  the  petrous  portion 
of  the  temporal  bone  resulting  from  middle-ear  disease,  with  infection  of  the 
superior  petrosal  and  cavernous  sinus. 

A  letid  discharge  from  the  ear,  with  or  without  edema  over  the  mastoid, 
and  evidences  of  an  orbital  cellulitis  and  grave  cerebral  symptoms,  are 
characteristic  of  this  condition,  which  probably  always  terminates  fatally. 

Tumors  of  the  Orbit. — The  scope  of  this  article  admits  only  of  a  brief 
outline  of  this  extensive  subject,  which,  for  convenience,  may  be  arranged 
according  to  the  following  headings  : 

1.  Tumors  of  the  tissues  of  the  orbit  ; 

2.  Tumors   arising   from   the    periosteum  or  bony  walls  of  the  orbit 

(exostosis,  etc.) ; 

3.  Tumors  arising  in  the  cavities  or  tissues  close  to  the  orbit  ; 

4.  Pulsating  exophthalmos. 

Xew  growths  originating  within  the  eyeball  are  not  classified  as  orbital 
tumors,  except  when   met  with  as  local  recurrences  after  removal  of  the  eye. 

The  terms  primary,  metastatic,  congenital,  malignant,  and  benign,  as 
applied  to  tumors  of  the  orbit,  have  the  same  significance  as  in  other  depart- 
ment- of  surgery,  and  are  intended  to  convey  an  idea  as  to  the  nature  of  the 
growth. 

All  orbital  tumor-  that  have  attained  appreciable  dimensions  are  likely  to 
cause  displacement  of  the  eyeball.  When  confined  within  the  funnel  of  the 
straight  muscles  the  proptosis  i-  in  a  forward  direction  :  displacement  in  any 
other  direction  will  depend  upon  the  size  and  position  of  the  tumor  accord- 
ing to  the  position  or  point  of  origin  of  the  growth.  Special  symptoms  in 
any  case  will  depend  upon  the  size,  position,  nature,  and  density  of  the 
growth.     As  the  eyeball  becomes  pushed  out   of  it-  natural   position,  the  lids 

be< e  distended  and  apparently  enlarged  ;  occasionally,  in  high  degrees  oi 

proptosis,  they  fail  to  close  over  the  eyeball,  and  sometimes  even  recede  Ley  mid 
it-  equator. 

Prognosis. — This  depends  on  the  nature,  position  and  size,  density,  rate 
of  growth,  and  possibility  of  successful  surgical  interference  and  its  comp 
removal. 

34 


530 


INJURIES  AND  DISEASES  OE  THE  ORBIT. 


!26. — Fibroma  of  the  optic  nerve.  The  morbid  growth  in  this  case  extended  into  the  optic  fora- 
men, tit  \\  bich  point  chlorid-of-zinc  paste  was  applied  alter  removal  of  the  eyeball  and  growth  without 
exenteration.    Ten  years  later  there  had  been  n<>  recurrence. 

Treatment. — In  most  cases  treatment  should  consist  in  complete  removal 
of  the  growth   by  operations  conducted  on  general  surgical  principles.     Cer- 


Lymphangioma  of  i  he  orbit. 


t;iin  growths  originating  in  some  vascular  disease  cannol  !><•  safely  extirpated. 
Benign   tumors   may  often   be  removed  without   sacrificing  the  eyeball,  but 


TUMORS  OF  THE  ORBIT.  531 

those  of  a  distinctly  malignant   type  call   for  complete  exenteration  of  the 
orbit. 

I.  Tumors  Originating-  in  the  Tissues  of  the  Orbit. — Of  these  the 
cystic  formations  supply  a  large  contingent.  They  arc  sebaceous,  serous, 
blood  and  dermoid  cysts,  echinococci  and  cysticerci.     Besides  these  there  are 


Fig.  328.— Lipoma  of  both  orbits,  stationary  for  many  years.    Patient  died  at  an  advanced  age;  orbital 

condition  unchanged. 

simple  and  cavernous  angiomas,  lymphangiomas  (Fig.  327),  lipomas  (Fig. 
328),  enchondromas,  lymphomas,  and  a  variety  of  sarcomata  which  may  take 
their  origin  from  fibrous  or  connective  tissue  anywhere  within  the  orbital 
cavity  (Fig.  330). 

Carcinoma  as  a  primary  tumor  has  been  met  with  in  connection  with  the 
lachrymal  gland.  Tumors  originating  in  the  lachrymal  gland  are,  however, 
mostly  of  the  adeno-sarcomatous  type  and  non-malignant. 

The  differential  diagnosis  is  not  always  an  easy  matter,  but  can  generally 
be  achieved  by  a  careful  study  of  all  the  signs  and  symptoms. 

Treatment. — Cysts  with  fluid  contents  may  lie  cured  by  simple  incision 
followed  by  astringent  or  irritant  injections. 

Dermoid  cysts  should  be  thoroughly  evacuated  and  the  lining  of  the 
cavity  destroyed  with  strong  pigment  of  iodin  or  with  nitrate  of  silver: 
excision  of  deep-seated  cysts  should  never  be  attempted,  since  the  cyst-walls 
can  readily  be  destroyed  by  either  of  the  drugs  just  named  without  damaging 
other  structures.  Many  of  the  solid  <_rrowths  can  lie  shelled  out  without  much 
disturbance  of  the  surrounding  tissues. 

Electrolysis  has  been  found  efficient  in  treating  orbital  angiomas.  Some  ot 
them  are  sufficiently  circumscribed  to  admit  of  removal  by  careful  dissection. 

II.  Tumors  which  Arise  from  the  Periosteum  or  Bony  Walls  of. 
the  Orbit. — These  comprise  the   following  : 

(1)  Sarcomataor  fibro-sarcomata  occasionally  spring  from  the  periosteum. 


532 


INJURIES  AND   DISEASES  OF  THE  ORBIT. 


I  i       29—1  ibro-sarcoma  of  both  ortitn 


Figure  •">_!!>   represents  a   case  of  the  latter  occurring  in  a  boy  of  fourteen,  in 
whom  the  entire  periosteum  of  both  orbits  became  involved.     Some  months 


ginating  in  the  i  issues  of  the  apes 

after   removal   of    these   growths  death   resulted   from   metastatic  formations 
elsem  here. 

Thickening  of  tlu  periosteum  of  an    inflammatory  nature   sometimes 


TUMORS  OF  TllK  OR B IT. 


533 


simulates  a  neoplasm,  especially  if  Idealized  and  associated  with  hyperos- 
tosis of  the  underlying  bone. 

(3)  Exostoses  are  a  somewhat  rare  form  of  orbital  tumor,  characterized  by 
slowness  of  growth,  extreme  hardness,  and  evident  continuity  with  the  adja- 
cent hone.  They  may  attain  so  large  a  size  as  to  occasion  great  deformity. 
Most  of  these  growths  spring  from  the  periosteum  at  or  near  the  orbital  mar- 
gin or  from  neighboring  cavities.  They  consist  of  an  outer  layer  of  ivory- 
like hardness  ami  an  inner  more  spongy  structure.  Some  are  of  congenital 
origin,  others  may  be  traced  to  injury,  or  there  may  be  no  discoverable  cause. 

Treatment. — The  only  effective  operation  for  exostoses  is  ablation  by 
means  of  drill,  hammer,  and  chisel.  This  operation  is  likely  to  be  difficult 
and  dangerous  if  the  growth  involves  the  roof  of  the  orbit. 

III.  Tumors  'which  Arise  in  the  Cavities  or  Tissues  close  to  the 
Orbit. — These  are — 

(1)  Encephalocele  or  meningocele  is  an  exceedingly  rare  form  of  tumor, 
containing  cerebro-spinal  fluid,  with  or  without  a  hernial  protrusion  of  brain- 
substance.  It  is  of  congenital  origin,  the  result  of  defective  ossification  at 
some  part  of  the  orbital  wall,  by  preference  the  anterior  part  of  the  fronto- 
ethmoidal  suture,  and  appearing  as  a  smooth,  fluctuant,  sometimes  pulsating 
swelling,  not  adherent  to  the  skin,  and  existing  since  birth  at  the  upper 
inner   angle    of   the   orbit,   is  liable   to    be    mistaken    for   a    dermoid    cyst. 


f^r' 

JH 

1  i 

jFHH 

£ 

Ik 

Fig.  331.— Ethmoidal  mucoci  ' 

Unlike  the  latter,  it  is  not  amenable  to  any  form  of  operation  or  treatment. 
A  correct  diagnosis  is  therefore  of  paramount  importance  if  an  operation  is 

contemplated. 

(2)  Nevi,  lupus,  and  epithelioma,  originating  in  the  -kin  of  the  eyelid-  or 
face,  may  extend  into  the  orbit. 

(3)  Polypoid  growths,  originating  in  the  nasal  cavities,  sarcomatous,  can- 
cerous, or  osteoid  growths  in  the  frontal,  sphenoidal,  or  maxillary  sinuses, 
ethmoidal    mucocele   (Fig.    331),    or,    even    distention    of    these   cavities    by 


534  INJURIES  AND   DISEASES  OF  THE  ORBIT. 

fluid  secretion,  may,  by  invasion,  simulate  orbital  tumors.  An  exact 
diagnosis  may  be  difficult  or  impossible.  The  character  of  the  proptosis, 
the  condition  of  adjacenl  parts,  and  a  careful  consideration  of  all  the  signs 
and  symptoms  present  will,  however,  usually  reveal  the  true  nature  of 
the  affection  (see  page  454 l). 

Pulsating  exophthalmos  is  a  form  of  orbital  tumor  which  results 
from  some  vascular  disease  within  the  orbital  cavity,  the  primary  lesion  being 
commonly  situated  within  the  cranial  cavity  immediately  behind  the  orbit. 

Symptoms. — The  ordinary  signs  of  pulsating  exophthalmos  ar< — pro- 
trusion of  the  eyeball  (occasionally  both),  and  pulsation,  which  may  some- 
times  be  both  seen  and  felt.  The  stethoscope  reveals  a  distinct  bruit  when 
placed  upon  the  brow  or  closed  eyelid.  There  are  swelling  and  a  passive 
hyperemia  of  the  latter  and  of  the  subconjunctiva,  sometimes  presenting  an 
appearance  not  unlike  that  of  orbital  cellulitis.  The  retinal  veins  arc  usually 
distended  and  tortuous,  and  there  may  be  retinal  hemorrhages,  optic  neuritis, 
and  more  or  less  impairment  of  vision.  The  protrusion,  fulness  of  the  ves- 
sels, and  pulsation  are  increased  by  stooping  the  head. 

The  subjective  symptoms  are  pulsating  tinnitus  or  noises  in  the  head,  and 
pain,  likewise  increased  by  stooping,  and  diminished  by  compression  of  the 
carotid  artery. 

This  assemblage  of  symptoms  is  nearly  always  due  to  the  formation  of 
aneurysmal  varix  in  the  cavernous  sinus,  the  internal  carotid  thus  directly 
pumping  blood  into  the  orbital  veins.  The  initial  lesion  is  in  most  cases 
caused  by  traumatism,  such  as  falls  or  severe  blows  upon  the  head  or  face; 
not  very  rarely,  however,  especially  in  women,  the  arterio-venous  communi- 
cation (rupture  of  the  carotid  in  the  sinus)  has  occurred  spontaneously. 

Some  other  lesions,  so  rare  as  to  constitute  pathological  curiosities,  have 
been  known  to  cause  pulsating  exophthalmos:  they  are — aneurysm  of  the 
ophthalmic  artery  within  or  behind  the  orbit,  or  of  the  carotid  in  the  sinus, 
pulsating  angioma,  and  medullary  osteo-sarcoma  of  the  orbital  walls. 

Treatment. — Spontaneous  cure  is  possible:  so  long,  therefore,  as  there 
are  no  urgent  symptoms,  such  as  severe  pain,  attacks  of  epistaxis,  or  impair- 
ment of  vision,  with  extensive  or  increasing  intra-ocular  changes,  there  is  no 
nece— ity  for  active  interference.  Rest  in  bed,  full  doses  of  potassium  iodid, 
and  intermittent  but  frequent  compression  of  the  common  carotid  may  arrest 
the  disease;  but  in  the  presence  of  urgent  symptoms  ligation  of  the  common 
carotid  should  not  be  delayed.  The  results  of  this  operation  have  been  satis- 
factory in  a  large  percentage  of  eases  so  treated. 

Exophthalmic  Goiter  i  Basedow's  Disease,  Graves's  Dist  ase}  Cardiac 
Exophthalmos). — This  disease  comes  rather  more  appropriately  within  the 
domain  of  general  medicine,  since  the  ocular  symptoms  are  but  a  local  mani- 
festation of  ;i  more  serious  general  disturbance  or  form  of  debility,  which  is 
associated  not  only  with  exophthalmos,  but  also  with  enlargement  of  the 
thyroid  eland  and  increased  action  of  the  bearl  (tachycardia).  Any  one  of 
tin-  trio  of  symptoms  may  be  in  abeyance  or  may  predominate  over  the 
Other  two.  for  tin-  reason  there  is  a  lack  of  uniformity  in  the  si<j-ns  which 
indicate  the  presence  of  this  disease. 

Symptoms. — With  regard  to  the  ocular  symptoms,  the  exophthalmos, 
almost  always  bilateral,  Is  much  greater  in  some  cases  than  in  others,  is  subject 
to  .1  certain  amounl  of  spontaneous  variability,  and  may,  in  the  early  stages 
at  least,  lie  temporarily  diminished  by  pressure.     The  eyeballs  are  pushed 

1  For  m  detailed  description  <>i  tlii-  class  of  tumors  the  reader  is  referred  to  an  article  l>y 
<  has.  -   Bull  in  the  New  York  Medical  Journal  for  Dec.  1'.',  L891. 


EXOPHTHALMIC  GOITER.  535 

straight  forward;  their  mobility  is  not  impaired.  In  extreme  cases  the  lids 
may  not  sufficiently  cover  them  to  secure  adequate  protection,  and  damage  to 
the  cornea  may  ensue. 

Vision  is  unimpaired,  and  intra-ocular  changes  have  not   been  observed, 

except  occasionally  visible  pulsation  of  the  central  artery  of  the  retina,  and 
sometimes  the  retinal  arteries  appear  relatively  larger  than  they  should  be  as 
compared  with  the  veins. 

The  exophthalmos,  even  when  slight,  is  characterized  by  a  peculiar  staring 
appearance  of  the  eyes,  giving  the  patient  an  astonished  or  frightened  look. 
This  is  due  to  a  retraction  of  the  organic  levator  of  the  lid.  The  resulting 
widening  of  the  palpebral  fissure  is  known  as  Dalrymple's  sign. 

On  looking  downward  the  upper  lids  do  not  perfectly  follow  the  move- 
ments of  the  eyeballs,  as  in  health  ;  consequently  the  sclera  above  the  corneal 
margin  becomes  visible  (v.  Graefe's  sign).  This  symptom  is  not  always 
present,  and  it  may  exist  without  exophthalmos  in  the  early  stage,  or  be 
persistent  after  the  latter  has  disappeared  if  a  cure  has  been  effected.  Di- 
minished or  imperfect  winking  movements  of  the  lids  are  often  noticeable 
(SteUwag's  sign).  These,  together  with  the  widened  palpebral  fissure,  may 
induce  a  tendency  to  desiccation  of  the  cornea,  and  probably  account  for 
the  sense  of  heat  and  discomfort  in  the  eyes  of  which  these  patients  often 
complain. 

The  enlargement  of  the  thyroid  body,  primarily  due  to  enlargement  of  its 
blood-vessels,  may  be  slight  or  very  considerable.  As  a  rule,  it  is  evenly 
distributed,  but  there  are  some  marked  exceptions  to  this  rule ;  in  these  the 
right  side  is  apt  to  be  the  larger.  The  enlarged  thyroid  feels  soft  and  elastic 
in  most,  but  not  in  all,  cases.  The  chief  point  of  distinction  between  exoph- 
thalmic and  other  forms  of  goiter  is  that  in  the  former  the  hand  detects  a 
whirring  sensation  and  strong  pulsatory  movement  with  each  cardiac  impulse. 
These  circulatory  phenomena  are  associated,  as  might  be  expected,  with  a  loud 
rasping  bruit. 

The  carotids  are  probably  distended  and  pulsate  strongly.  This  pulsa- 
tion is  visible,  as  wrell  as  audible,  along  the  course  of  these  arteries,  and  the 
patient  often  complains  of  a  beating  sensation  communicated  to  the  head. 
Signs  of  engorgement  of  the  large  cervical  veins  are  also  often  present.  Pul- 
satory phenomena  sometimes  also  exist  in  the  thorax  and  abdomen.  The 
action  of  the  heart  is  increased  both  in  frequency  and  intensity  ;  the  pulse, 
never  less  than  100,  becomes  considerably  accelerated  by  the  slightest  exer- 
tion or  mental   excitement. 

Some  enlargement  of  the  heart,  especially  of  the  left  ventricle,  is  not 
uncommon,  and  variable  cardiac  murmurs  maybe  present;  but  if  recovery 
take-  place,  these  signs  disappear:  they  are  therefore  assumed  to  be  of  a  func- 
tional character. 

Persons  suffering  from  Basedow's  disease  are  often  irritable  and  excitable  ; 
most  of  them  are  anemic,  some  chlorotic  ;  a  tendency  to  emaciation  even  when 
the  appetite  and  digestion  arc  unimpaired  has  often  been  observed. 

Etiology. — Tins  disease  belongs  almost  exclusively  to  adult  life,  and  in 
women  rarely  develops  after  the  menopause.     The  male  sex  is  comparatively 
exempt   from   it.      As  recognized   exciting  causes  may  be  mentioned  dis< 
of  the  genital  organs,  worry,  mental  excitement,  anxiety,  and  fright. 

Although  exophthalmic  goiter  has  been  known  to  come  on  suddenly,  tin- 
is  the  exception  ;  as  :i  rule,  the  onsel    is  gradual — first   palpitation,  later  en- 
largement  of  the  thyroid,  still  later  exophthalmos;  often  month-  or  \ 
elapse  before  the  disease  is  fully  developed.      Innumerable  functional  nervous 


536  INJURIES  AND   DISEASES  OF  THE  ORBIT. 

disturbances,  often  of  an  hysterical  type,  come  and  go  during  the  course  of 
the  disease.  After  a  long  period  of  sameness  a  gradual  improvement  may 
take  place,  ending  in  recovery,  or  there  may  be  indefinitely  repeated  periods 
of  improvement,  and  relapse  or  gradual  exhaustion,  with  intercurrent  com- 
plications, may  end    in   death. 

Prognosis. — The  prognosis  is  said  to  be  least  favorable  when  the  disease 
attack-  elderly  persons  of  the  male  sex.  As  far  as  vision  is  concerned,  the 
source  of  danger  has  already  been  alluded  to.  An  excessive  exophthalmos, 
with  imperfect  closure  of  the  lids,  may  lead  to  keratitis  e  lagophthalmo,  and  the 
resultant  corneal  opacity  «>r  ulceration  may  lead  to  partial  or  complete  blind- 
ness of  one  or  both  eyes  (see  also  page  .">17). 

In  the  absence  of  definite  and  constant  pathological  lesions  discoverable 
after  death,  we  are.  for  the  present,  constrained  to  class  exophthalmic  goiter 
as  a  functional  disease  which  seems  to  depend  upon  a  disturbance  of  inner- 
vation, especially  that  of  the  sympathetic.  The  present  tendency  i<  to 
regard  certain  parts  of  the  central  nervous  system  (medulla  and  upper  part 
of  the  spinal  cord)  as  the  primary  seat  of  this  strange  disease. 

Treatment. —  For  the  general  treatment  the  reader  will  find  this  part 
of  the  subject  elaborately  discussed  in  most  of  the  standard  works  on 
general  medicine  and  neurology.  The  ophthalmic  surgeon  may,  however, 
be  called  upon  to  deal  with  corneal  complications.  Undue  exposure  of  the 
cornea  may  he  obviated  by  an  operation  tor  narrowing  the  palpebral  fissure 
(tarsorrhaphy,  sec  page  547).  Slight  degrees  of  corneal  irritation  may  be 
relieved  by  the  use  of  a  carefully  adjusted  compressive  bandage  and  by 
soothing  applications,  such  as  vaselin,  or  mucilaginous  collyria  containing  a 
-mall  quantity  of  sodium  biborate  or  boric  acid.  Refractive  error  should 
always  be  corrected. 

INJURIES  OF  THE  ORBIT. 

Injuries  may  be  limited  to  the  soft  parts  or  involve  the  bony  walls  as  well. 
The  danger  of  such  injuries  depends  upon  their  nature  and  extent.  It  is 
often  impossible  to  estimate  either  of  these  factors  exactly,  except  in  the 
light  of  subsequent  events. 

With  injury  of  the  soft  parts  there  may  be  more  or  less  damage  to  the 
lid-  and  eyeball.  The  appearance  of  orbital  fat  in  the  wound  is  proof  posi- 
tive that  the  orbit  has  been  penetrated.  Extravasation  of  blood  with  ecchy- 
moses  of  the  conjunctiva  and  integument,  and  exophthalmos,  are  commonly 
present.  Paralysis  of  ocular  muscles  and  loss  of  vision  from  damage  to  the 
optic  nerve  are  significant.  Foreign  bodies  of  considerable  size  remaining 
in   the  orbit    may   displace,   or  even   completely    luxate,   the  eyeball. 

Foreign  bodies  thrust  into  the  orbit  may  be  difficult  to  discover,  and 
when  aseptic  have  been  known  to  remain  for  an  indefinite  period  without 
creating  serious  reaction.  Small  foreign  bodies — e.g.  shot-graim — not  readily 
discoverable  by  ore  I  in;  icy  examination,  may  be  located  by  mean-  of  the  r-ravs 
Appendix,  page  607).  Pointed  or  blunt  objects  withdrawn  after  pene- 
tration not  infrequently  have  pierced  the  cranial  cavity,  the  gravity  of  the 
lesion  only  being  discoverable  when  cerebral  complications  occur. 

Injuries  to  the  bones  of  the  orbital  margins  are  a  common  result 
of  crushing  blow-  upon  this  part.  The  diagnosis  is  not  difficult  if  the 
injured  hone  i-  sufficiently  displaced  to  cause  distinct  unevenness  of  if  a 
portion  of  the  margin  is  detached.  Mere  sensitiveness  to  pressure  is  no! 
diagnostic  of  fracture,  though  always  coincident  with  it.  The  marginal 
fracture  may  extend  ;i~  ;i  fissure  to  any  part  of  the  orbit,  even  to  the  optic 


DISLOCATION  OB   LUXATION  OF  THE  EYEBALL.         537 

foramen;  in  the  latter  case  blindness  may  result  from  laceration  of  the  « >j>tic 
nerve  or  hemorrhage  into  its  sheath,  or  fissure  of  the  orbital  walls  may 
occur  from   fractures  of  the  base  of  the  skull. 

Emphysema  of  the  lids  and  orbital  tissues  is  quite  common  even  where 
the  violence  has  not  been  great,  and  indicates  fissure  of  the  thin  walls 
between  the  nasal  or  ethmoidal  cavities  and  the  orbit  :  a  suddenly  developed 
elastic  and  crepitant  swelling  i>  quite  characteristic  of  tin.-.  Exophthalmos 
due  to  this  condition  can  be  reduced  by  pressure  with  the  finger.      It'  due  to 

extravasation  of  bl I.  a-  it  often  is  in  orbital  fractures,  the  swelling  cannot 

be  reduced  in  this  way. 

Injuries  of  the  orbit  may  rec  iver  perfectly  after  absorption  of  extravasated 
blood  or  air,  but  lesions  of  the  eyeball,  the  optic  or  the  third  nerve,  or  the 
ocular  muscles,  often  cause  permanent  impairment  of  function  ;  or  phlegmon 
of  the  orbit,  with  its  attendant  danger,  may  set  in;  or  the  content- of  the 
cranial  cavity  may  be  involved  directly  or  become  so  in  consequence  of  the 
extension  of  septic  inflammation  following  the  injury.  A  fatal  issue  i-  then 
to  be  expected. 

Treatment. — In  recent  injuries  of  the  orbit,  if  there  be  an  open  wound 
it  must  be  carefully  and  thoroughly  cleansed  and  disinfected.  Exploration 
for  suspected  foreign  bodies  is  a  matter  which  can  only  be  left  to  the  judg- 
ment and  skill  of  the  surgeon.  Exploration  with  the  finger,  when  prac- 
ticable, is  always  to  be  preferred.  Small  and  probably  aseptic  foreign  bodies 
should  on  no  account  be  searched  for.  Suitable  provision  for  drainage  of 
the  wound  may  be  required,  and  an  antiseptic  dressing  is  to  be  applied. 
Should  suppuration  ensue,  the  treatment  will  be  that  of  orbital  cellulitis. 
Rest  in  bed  is  essential   if  the  injury  is  still  severe. 

Hemorrhage  into  the  orbit  when  at  all  abundant  causes  an  immediate 
exophthalmos,  later  ecchymoses  of  lids  and  conjunctiva  ;  this  latter  may  be 
the  only  sign  of  atrophic  hemorrhage-,  it  is  a  common  result  of  severe 
injuries  of  the  orbit,  often  occurs  with  fracture  of  the  skull  implicating  the 
orbital  roof,  occasionally   without    this  lesion. 

Spontaneoibs  orbital  hemorrhages  have  occasionally  been  seen  in  scorbutus, 
hemophilia,  and  during  violent  paroxysms  of  coughing.  A  copious  bleed- 
ing into  Tenon's  capsule  is  an  accident,  fortunately  rare,  in  operation  for 
squint. 

Injury  of  the  Optic  Nerve. — Laceration  of  the  optic  nerve  may  occur, 
as  has  been  stated,  in  connection  with  fracture  of  the  bony  wall-  of  the  orbit. 
But,  independently  of  such  an  association,  the  optic  nerve  may  be  injured  by 
a  -harp  -tick,  as  in  a  case  reported  by  NToyes,  by  a  knife-thrust,  or  by  a  bullet. 
Atrophy  of  the  nerve  and  blindness  are  the  results  of  such  accident-,  which 
are  not  frequent,  twenty-one  cases  having  been  collected  by  Aschman  in  1884. 

Laceration  of  the  nerve  ami  the  central  retinal  bl l-vessels  may  be  followed 

by  retinitis  proliferans,  a-  in  the  case  recorded  by  < '.  Zimmermann. 

Dislocation  or  luxation  of  the  eyeball  exists  when  the  eyeball  has 
1 ii  pushed  -o  far  forward  that  the  lid-  remain  contracted  behind  it. 

Traumatisms,  such  as  when  a  large  foreign  body  has  been  driven  into  the 
orbit  from  the  outside,  the  use  of  an  assailant's  thumbs  in  certain  brutal 
assaults — the  so-called  gouging — and  a  similar  self-mutilation  by  insane  per- 
sons, have  been  known  to  cause  tin-  condition,  which  would  probably  be  less 
rare  if  the  eyeball  did  not  usually  rupture  at  the  time  of  injury.  Traumatic 
dislocation  is  apt  to  cause  blindness  from  rupture  or  laceration  of  the  optic 
nerve. 

The    luxation-   that    readily  occur  during  the  continuance  of  any  morbid 


538 


I.X.Uh'II.s   A  XI)   DISEASES  OF  THE  ORBIT. 


condition  attended  with  excessive  exophthalmos  arc  a  mere  complication  of  a 
more  serious  condition. 

Treatment. — 'Flic  eyeball  should  be  replaced  as  soon  as  possible.  To 
effecl  this  division  of  the  outer  canthus  may  be  necessary.  After  reposition 
acompressive  bandage  may  be  required,  and  in  the  second  class  of  eases 
tarsorrhaphy  (page  547)  may  be  done  to  prevent  recurrence. 

Enophthalmos   [Idiopathic   and    Traumatic). — A    condition    in  which 

the  appearance  of  the  eye  is  the  opposite  of  ex- 
ophthalmos, the  eyeball  being  retracted,  is  met 
with  under  various  circumstances,  as  in  wasting 
diseases  "with  extreme  emaciation  and  absorption 
of  orbital  fat;  in  Asiatic  cholera  because  the 
enormous  waste  of  fluids  causes  shrinkage  of 
the  orbital  as  well  as  other  tissues ;  as  one  of 
the  symptoms  of  paralysis  of  the  cervical  sym- 
pathetic; iu  neurotic  anesthesia  of  the  face,  as 
in  lepra  ansesthetica  ;  and,  finally,  in  a  form 
distinctly  traumatic  in  its  origin. 

In  some  cases  immediately — in  others  weeks 
or  months — after  traumatism,  such  as  a  blow 
upon  the  upper  margin  of  the  orbit  without 
direct  injury  to  the  eye,  enophthalmos  appears, 
and  may  be  due  to  paralysis  of  (Midler's) 
retractor  of  the  lids — i.  e.  a  local  lesion  of  the 
sympathetic — or  to  trophic  disturbance  with 
atrophy  of  the  orbital  tissues.  It  has  also  been 
ascribed  to  fracture  with  depression  of  the  orbital  floor,  and  to  cicatricial 
contraction  of  the  orbital  tissues  following  certain  injuries  (Fig.  332). 


/ 


7 


Fig.  332.— Traumatic  enophthal- 
mos, patient  li ..  .kiii'-r  straight  for- 
ward; sunken  appearance,  resem- 
bling u  badly-fitting  artificial  eye, 
well  shown  (de  Schweinitz). 


OPERATIONS. 


PREPARATION  OF  THE  REGION  OF  OPERATION,  THE 
INSTRUMENTS,  AND  THE  DRESSINGS;   ANESTHESIA. 

By  G.  E.  de  SCHWEINITZ,  A.  M.,  M.  L)., 

OF  PHILADELPHIA. 


All  the  principles  of  clean  surgery  and  the  main  practices  of  aseptic 
surgery  are  necessary  in  all  ophthalmic  operations. 

1.  Preparation  of  the  Hands  of  the  Operator. — Scrub  the  hands 
thoroughly  with  soap  and  warm  water ;  then  clean  the  spaces  beneath  and 
around  the  nails;  soak  the  hands  in  95  per  cent,  alcohol  for  not  less  than  one 
minute  ;  on  removing  them  place  them  without  drying  in  a  solution  of  1  :  1000 
corrosive  sublimate,  and  allow  them  to  remain  there  for  at  least  one  minute. 

2.  General  Preparation  of  the  Patient. — Necessarily,  each  patient 
preceding  an  operation  should  be  placed  in  the  best  possible  physical  and 
mental  condition.  Usually  a  laxative  is  advisable.  The  author  is  accustomed 
to  give  calomel  on  the  night  preceding  the  operation  and  a  saline  in  the 
morning. 

The  nares  of  patients  requiring  corneal  section  should  be  sprayed  either 
with  a  mixture  of  listerin  and  Dobell's  solution  or  with  equal  parts  of 
water  and  the  peroxid  of  hydrogen,  which  flushes  out  the  passages  and 
probably,  largely  by  mechanical  effect,  gets  rid  of  infectious  material. 
Independently  of  the  fact  that  chronic  bronchitis  by  virtue  of  the  cough 
which  it  produces  is  a  complicating  circumstance,  it  is  perfectly  possible 
that  pathogenic  germs  may  migrate  from  the  lower  respiratory  tract  and 
destroy  the  effects  of  an  operation.  Under  these  circumstances  it  has  been 
advised  to  administer  capsules  of  oil  of  eucalyptus,  which  i-  a  good  stimu- 
lating expectorant  and  plays  the  part  of  a  mild  antiseptic.  It  is  almost 
needle--  to  point  out  the  necessity  of  ridding  the  patient  of  any  inflam- 
mation of  the  conjunctiva,  margins  of  the  lids,  or  lachrymal  passages  pre- 
ceding operative  interference  on  the  ocular  tissues.  Tf  there  is  dacryocys- 
titis, the  usual  treatment  of  this  affection  is  indicated  (page  268).  Ilaab  has 
recommended  sealing  the  lachrymal  puncta  with  a  galvano-cautery  needle. 
The  inner  corner  of  the  eye  may  be  covered  with  sterile  iodoform  powder  to 
prevent  access  of  infected  fluid  from  the  lachrymal  passages  to  a  corneal 
incision. 

3.  Preparation  of  the  Skin  of  the  Region  of  Operation.— The 
skin  should  be  treated  firsl  with  soap  and  water,  then  with  alcohol,  and  finally 
with  corrosive  sublimate,  1  :  2000.  These  irritating  substances  must  nol  enter 
the  conjunctival  sac,  but  the  face,  surface  of  the  closed  lids,  eyebrows,  brow, 


540  OPERATIONS. 

and  scalp  should  be  tluis  prepared.  The  ciliary  margins  should  be  cleansed 
with  soap  and  water  followed  by  bichlorid  of  mercury  1  :  5000.  The  parts 
should  be  kept  covered  with  a  compressof  lint  soaked  in  a  bichlorid  solution, 
1  :  5000,  which  should  remain  in  place  for  at  least  one  hour  before  the  operation 
begins.1 

4.  Preparation  of  the  Conjunctival  Cul-de-sac  and  the  Ciliary- 
Margin. — The  method  to  be  employed  depends  upon  the  nature  of  the 
operation.  In  enucleation,  for  example,  the  ordinary  rules  of  antiseptic  sur- 
gery are  applicable,  and  the  same  is  true,  for  instance,  in  an  advancement, 
save  only  that  the  strength  of  the  bichlorid  solution  commonly  employed  by 
general  surgeons  must  be  decreased.  A  solution  of  a  grain  to  the  pint  is 
quite  sufficient.  Numerous  investigations  have  demonstrated  that  it  is  impos- 
sible to  sterilize  the  conjunctival  sac.  Therefore  the  object  is  to  reduce  the 
vitality  of  the  microbes  that  cannot  be  washed  away,and  the  mechanical  effect 
of  the  fluid  used  is  quite  as  potent  as  any  germicidal  value  which  it  may 
exercise.  Strong  germicidal  solutions  are  likely  to  be  deleterious  to  the  deli- 
cate epithelium  of  the  corneal  tissue.  For  irrigating  purposes  the  surgeon 
may  employ,  provided  the  fluid  reaches  all  portions  of  the  conjunctival  cul- 
de-sac  and  thoroughly  scours  out  the  folds  of  the  conjunctiva,  boric  acid,  4 
per  cent.,  or  physiological  salt  solution,  which  may  he  prepared  by  adding  a 
heaping  teaspoonful  of  salt  to  a  pint  of  sterilized  water,  bichlorid  of  mer- 
cury, 1 :  10,000,  or  any  of  the  other  antiseptics  mentioned  in  the  footnote. 
The  author  prefers  either  the  physiological  salt  solution  or  the  solution  of 
boric  acid.  As  a  final  precaution  the  lids  should  be  turned  and  gently 
mopped  with  a  pledget  of  cotton  soaked  in  the  antiseptic  solution,  especial 
care  being  particularly  taken  to  cleanse  the  region  of  the  inner  canthus. 

The  experiments  of  Bernheim,  Stroschein,  and  many  others  have  demon- 
strated the  impossibility  of  completely  sterilizing  the  ciliary  margin  ;  hence 
careful  cleansing  with  soap  and  water,  followed  by  the  salt  solution  or  one 
of  the  antiseptics  mentioned,  accomplishes  the  only  practical  result — namely, 
diminution  of  the  vitality  and  number  of  the  cocci.  All  of  these  prepara- 
tions should  be  made  immediately  preceding  the  operation  (see  also  page  575). 

5.  Preparation  of  the  Instruments. —  All  coarse  instruments,  such 
as  hook-,  scissors,  etc..  should  be  cleansed  first  with  soap  and  water,  then 
boiled,  and  finally  placed  in  an  antiseptic  bath,  where  they  remain  until 
required,  and  they  should  be  covered  with  this  fluid  for  not  less  than  twenty 
minutes  before  the  operation.  The  antiseptic  bath  may  be  carbolic  acid, 
1  :  l'ii.  or  absolute  alcohol,  preferably  the  latter.  Immediately  preceding  the 
operation  the  instruments  may  be  removed  from  the  antiseptic  bath  and 
placed  in  a  dish  of  sterile  water.  Sharp  instruments — cataract-knives,  kera- 
tomes,  cystotomes,  etc. — must  be  cleansed  with  great  caution,  lest  damage 
be  done  to  their  edges.  First,  the  edge  of  the  instrument  is  inspected  with 
a  magnifying-glass ;  then  the  instrument,  wrapped  in  cotton,  is  pul  in  the 
boiling  water,  and  from  this  transferred  to  a  dish  containing  absolute  alcohol. 
When  the  operator  i-  ready  the  knife  is  removed  from  this  fluid  and  the 
blade  freed  from  alcohol  by  dipping  it  momentarily  in  a  vessel  containing 
boiling  water.  Stroschein  and  others  believe  that  antisepsis  is  secured  if 
the    blade    is    rubbed    with    cotton    wool    soaked    in   a    mixture    of  equal    parts 

1  In  place  "i'  Bubliraate  solution  tin-  following  antiseptics  have  been  recommended,  espe- 
cially in  ophthalmic  work:  aqua  chlorinata;  trichlorid  of  iodin,  1  :2 :  cyanurel  of  mer- 
cury, 1  :  1" :  oxycyanid  of  mercury,  l     I ;  and  especially  formaldehyd,  1  :  2000.     Of  this 

list  the  cyanurel  of  mercury  and  formaldehyd  have  most  i"  commend  them,  the  latter  substance 
i  .in-  n  most  efficient  ocular  antiseptic,  and  the  author  has  been  mosl  favorably  impressed  with 
it-  value. 


DBJSSSIJVGS. 


•Ml 


of  absolute  alcohol  and  ether,  to  which  a  few  drops  of  ammoniac  have  been 
added.  Subsequently  the  knife  may  be  washed  in  a  5  per  cent,  solution 
of  carbolic  acid,  [nstead  of  placing  the  instruments  in  absolute  alcohol 
or  carbolic  acid,  it  i-  the  practice  of  some  surgeons  to  put  them  in  a  physi- 
ological .-air  solution  or  in  sterile  water;1  or  they  may  be  used  directly  after 
removal  from  the  boiling  water.  Perfect  sterilizati f  non-cutting  instru- 
ments made  of  platinum  may  be  secured  by  bringing  them  to  a  white  heat 
in  the  Same  of  a   lamp  jusl   before  the  operation  (Gruening). 

Dr.  E.  A.  ile  Schweinitz  recommends  sterilization  of  instruments  with  the 
vapor  of  formaldehyd.  The  practical  value  of  formaldehyd  in  the  disinfec- 
tion of  small  instruments  has  also  been  demonstrated  by  II.  O.  Reik  ami 
\\  .  J.   Watson,2  who  have  designed  a  special  sterilizing  apparatus. 

ii.  Dressing's. — These  must  be  modified  according  to  circumstances. 
In  plastic  operations  aboul  the  lids  the  ordinary  antiseptic  dressing  i-  usually 
applied — protective  and  antiseptic  gauze  covered  by  a  wet  or  dry  bichlorid 
roller.  Iodoform  is  also  used  under  these  circumstances,  although  some 
surgeons — for  example.  Noyes — -do  not  consider  it  an  advantage.  Dressings 
impregnated  with  antiseptic  substances  bought  ready  made  from  the  various 
shops  are  not  satisfactory.  Sterilization  with  steam  is  the  proper  method. 
If  a  wet  dressing  i-  desired,  the  fabric  may  he  soaked  in  our  of  the  anti- 
septic fluids,  usually  bichlorid,  1  :  5000,  or  in  a  physiological  -alt  solution 
which  has  been  sterilized  by  boiling.  Bits  of  gauze  prepared  by  sterilization 
with  steam  are  much  more  desirable  than  cotton  for  removing  Mood,  etc. 
from  the  area  of  operation.  If  the  lighter  forms  of  cataract  dressing  art; 
employed,  such  a-  isinglass  plaster  or  -mall  wad-  of  cotton  held  in  place  by 
-trips  of  surgeon's  isinglass  plaster,  these  should  he  properly  disinfected 
before  application. 

When  the  eye    is   bandaged,  either  the   single  (Fig.  333)  or   the  double 


!  f-eight  of  fine  eye. 


i  l.— Figure-of-eighl  "f  both  eyes 


bandage  (Fig.  334)  i-  employed,  or  a  modification  of  Liebreich's  bandage 
(Fig.  335).  In  mosl  cases  ;i  dry,  absorbenl  material — for  example,  gauze 
sterilized  by  heat,  i-  most    useful,  although  there   i-  no  objection  i"  a  flannel 

1  For  a  valuable  paper  entitled  "  Absolute  Alcohol  as  :i   Disinfectant  for  Instrument 

Robert  L.  Randolph,  < suit  Transactions  of  (he  American   Ophtl  vii.  part 

631. 
-  Johns  Hopkins  Hospital  Bulletin,  No.  81,  Dei 


542 


OPERATIONS. 


roller,  if  it  is  desired,  when  this  is  placed  over  a  properly  applied  antiseptic 
pad.  The  dressings  applicable  to  the  different  operations  vary  according  to 
the  desire  of  the  surgeon.  Cataract  dressing  is  described  on  page  581.  In 
addition  to  the  dressing  recommended  there,  Ring's  ocular  mask  (Fig.  336), 
which  covers  the  bandage,  and  which  may  he  understood  by  a  reference  to 
the  figure,  is  of  great  advantage. 

Sutures. — These  may  be  of  catgut  or  silk.     The  latter  is  usually  Mack, 
ordinarily  known  as  iron-dyed,  although  for  delicate  sutures  in  the  conjunctiva 


Fig.  335.— Modified  Liebreich's  l>anclage. 


Fn;.  336. — Ring's  ocular  mask. 


the  white  silk — such,  for  example,  as  comes  in  Stevens's  tenotomy  case — is 
of  great  advantage.  These  sutures  should  be  soaked  in  an  antiseptic  bath 
preparatory   tit   their  use. 

Catgut  specially  prepared  by  the  instrument-maker  may  be  purchased, 
but  it  is  better  for  the  surgeon  to  prepare  this  for  himself.  The  author  is 
accustomed  to  use  a  delicate  sulpho-chromic  surgical  gut,  which  is  kept  in 
a  solution  of  bichlorid  of  mercury  in  alcohol,  1  :  KXK).  If  sponges  are 
used  in  plastic  operations  or  in  enucleations,  they  should  be  properly  disin- 
fected by  the  ordinary  processes.  Generally,  the  area  of  operation  may  he 
kept  clean  by  gently  touching  it  with  cotton  soaked  in  bichlorid  solution,  or 
by  gauze   which    has  been   sterilized   by   heat. 

General  Anesthesia. — The  indications  for  general  anesthesia  in  oph- 
thalmic surgery  are  limited.  In  children  or  in  very  nervous  adults,  and  for 
enucleations,  blepharoplastic  operations,  occasionally  in  advancements,  and 
usually  in  cases  of  glaucoma,  general  anesthesia  is  necessary.  The  surgeon 
must  decide  between  ether  and  chloroform.  The  author  prefers  the  former, 
believing  it  safer  than  chloroform  or  the  A..  C.  E.  mixture.  Bromid  of  ethyl 
has  been  recommended  and  much  employed,  but  the  author  has  not  been 
favorably  impressed   with   its  value. 

I,ocal  Anesthesia. — -When  local  anesthesia  is  required,  usually  hydro- 
chlorate  of  cocain  is  employed  in  2  or  I  per  cent,  solution  (some  surgeons  use 
a  Hi  per  cent,  solution).  Various  fungi  grow  readily  in  solutions  of  this 
alkaloid,  and,  indeed,  in  solutions  of  any  of  the  alkaloids  commonly  used  in 
ophthalmic  practice.  A  number  of  methods  of  sterilization  are  employed — 
namely,  sterilization  by  heat,  by  the  addition  of  an  antiseptic  (1  :  5000  solu- 
tion  of  bichlorid   of  mercury,    1    per  cent,   of  boric  acid,   formaldehyd,  as 


LOCAL   ANESTHESIA. 


543 


recommended  by  Valude,  or  trikresol,  1  :  1  <><»<>,  as  recommended  by  E.  A.  de 
Schweinitz  of  Washington),  or  by  ;i  combination  of  these  two  methods.  The 
most  satisfactory  procedure  is  to  l><>il  the  solution.  A  number  of  convenient 
flasks  for  this  purpose  arc  iu  the  market,  among  the  best  being  those  intro- 
duced by  Stroschein  of  Wurzburg  (  Fig.  337),  and  the  one  devised  by  Llewel- 


FlG.  337.— Stroschein's  flasks 


Fig.  338. — Flask  for  sterilizing  collyria. 


lyn  of  Philadelphia  (Fig.  338).  The  Stroschein  flask  may  be  understood  by 
a  reference  to  the  figure.  The  solution  is  placed  in  the  Llewellyn  flask  and 
boiled.  After  the  liquid  is  cool  and  ready  for  use  the  warmth  of  the  hand 
causes  the  fluid  to  drop  from  the  end  of  the  pipette.  If  it  is  desired  to  pre- 
serve the  solution  after  boiling,  a  portion  of  one  of  the  antiseptic  substances 
previously  mentioned  may  be  added. 

In  order  to  avoid  the  drying  and  roughening  of  the  corneal  epithelium 
caused  by  cocain  the  lids  should  be  kept  closed  after  each  instillation.  The 
drug  should  not  be  used  too  freely  or  it  may,  according  to  Mellinger,  prevent 
closure  of  the  corneal  wound.  Three  instillations  of  a  4  per  cent,  solution, 
five  minutes  apart,  are  sufficient  for  a  corneal  section.  Gelatin  disks  impreg- 
nated with  cocain,  as  recommended  by  some  surgeons,  have  no  advantage 
over  the  solution,  and  general  anesthesia  is  preferable  to  strong  solution-  of 
cocain,  which  have  been  recommended  in  the  operation  of  curetting  Lupus 
and  similar  growths. 

In  addition  to  cocain,  a  number  of  other  substance-  (for  example,  tropa- 
cocain)  have  from  time  to  time  been  recommended  as  local  ocular  anes- 
thetics, but  without  establishing  claims  to  special  favor.  Three  may  be 
briefly  described  : 

(1)  HydrocMorate  of  eucain  "A,"  like  cocain,  is  a  local  anesthetic,  and 
may  be  employed  in  2  per  cent,  solution.  Its  application  is  followed  by 
very  considerable  smarting  and  conjunctival  congestion.  It  has  little  or  do 
effect  upon  the  pupil,  and  is  said  not  to  cause  drying  of  the  corneal  epithelium. 
The  anesthesia  begins  in  a  few  minutes  and  lasts  from  ten  to  fifteen  minute- 
The  author  has  been  unable  to  see  in  what  way  it  possesses  any  advant  • 
over  cocain. 

(2)  HydrocMorate  of  eucain  "  B"  is  related  to  eucain  "  \."  and  also  to 
cocain  and  tropacocain.     It  is  nol  decomposed  by  boiling,  and  i-  less  irritating 
than  the  older  eucain,  according  to  Silex.     A  ■_'  per  cent,  solution  caus<  - 
anesthesia  in  from  one  to  three  minutes,  which   lasts  about  fifteen  minutes. 


544  OPERATIONS   UPON   THE  EYELIDS. 

It  does  ii"!  dilate  the  pupil,  apparently  does  not  decrease  intra-ocular  tension 
nor  cause  clouding  of  the  corneal  epithelium. 

Holocain  (p-didthoxyathenyl  diphenylamidin),  introduced  into  ophthal- 
mic  therapeutics  by  Hirschberg  and  Gutmann,  and  originally  known  as 
■•auiidin."  is  an  active  local  anesthetic  closely  allied  in  its  general  properties 
to  phenacetin.  A  1  per  cent,  solution  causes  anesthesia  in  from  fifteen  seconds 
to  one  minute,  which  lasts  for  ten  minutes,  preceded  by  a  moderate  burning 
sensation.  ETasket  Derby  considers  it  advantageous  because  it  does  not 
enlarge  the  pupil,  does  not  affect  the  accommodation,  does  not  increase  intra- 
ocular tension,  and  is  itself  bactericidal.  Holocain  is  highly  recommended 
by  II.  V.  Wurdemann. 

Infiltration-anesthesia. — In  lid-operations  cocain  solution,  2-4  per 
cent.,  is  sometimes  injected  beneath  the  skin,  hut  a  more  efficacious  and  safer 
procedure  is  the  so-called  infiltration-anesthesia  introduced  by.  C  L.  Schleich.1 
Tin-  consists  of  an  intracutaneous  (not  subcutaneous)  injection,  with  a  hypo- 
dermic syringe  or  with  one  specially  devised  for  the  purpose,  of  a  \  per  cent, 
solution  of  sodium  chlorid,  which  i-  reinforced  by  the  addition  of  from  y^-g- 
to  -jJLy  per  cent,  of  cocain.  The  fluid  injected  produces  edema,  and  the  anes- 
thesia  is  strictly  limited   to  the  edematous   area. 

Eucain  has  been  much  employed  hypodermically,  and  also  by  the  infiltra- 
tion method.  The  general  toxic  effects  which  sometimes  follow  hypodermics 
of  eucain  do  not  appear  with  eucain,  but  sloughing  of  the  tissues  has  been 
reported. 


OPERATIONS    UPON   THE   EYELIDS. 
By  f.  c.  hot/,  m.  d., 

OF    CHICAGO. 

The  operations  upon  the  eyelids  may  be  divided  into  two  groups.  The 
first  group  embraces  a  number  of  surgical  procedures  which  every  practitioner 
having  a  general  training  in  surgery  may  easily  employ.  The  second  group 
embraces  those  operations  requiring  a  degree  of  dexterity  and  judgment  which 
can  be  acquired  only  by  special  training. 

MINOR  OPERATIONS. 

1.  The  Removal  of  Eyelashes. — The  simplesl  procedure  for  remov- 
ing eyelashes  is  (a)  epilation  by  means  of  a  cilium-forceps. 

With  the  Bngers  of  the  left  hand  a  gentle  steady  pressure  is  made  upon  the  lid,  and 
with  tli.-  forceps,  held  in  the  righl  hand,  the  eyelash  is  seized  as  near  a-  possible  to  the 
-kin  and  drawn  out  with  a  steady  traction.     Jerkingmusl  be  avoided,  lesl  the  hair-shaft 
ilso  not  more  than  one  eyelash  must  be  grasped  at  one  time,  because  extrac- 
tion of  several  eyelashes  togi  ther  i-  very  painful. 

Eyelashes  so  removed  usually  grow  again  :  epilation,  therefore,  is  the 
proper  procedure  only  where  a  temporary  removal  of  cilia  is  indicated.  It  a 
permanent   removal  is  desired,  we  mus1  have  recourse  to  electrolysis  or  the 

scalping  operation. 

1  For  a  full  consideration  of  this  method  "f  inducing  local  anesthesia,  together  with  the 
various  formulae  suitable  for  inj<  ction,  tip    reader  is  referred  toa  lecture  by  Schleich,  published 

in  the  /"'  '  .  1  395,  vol.  ii.  5th  seri<  b. 


i:\<  av/o.v  of  cilia  i:y  r.<>i;i>i:i;. 


545 


{h)  Electrolytic  removal  of  cilia  requires  a  mild  galvanic  currenl  and 
an  electrolytic  nceillo  set  in  a  convenient  handle. 

The  eyelid  being  well  steadied  in  the  manner  described  above,  the  point  of  the 
needle  connected  with  the  negative  pole  of  the  battery  is  inserted  along  the  shaft  ol  the 
eyelash  until  it  reaches  the  root,  about  •">  nun.  under  the  surface.  The  other  electrode, 
represented  by  a  moist  sponge,  is  placed  upon  the  temple  or  the  hand  of  the  patient; 
this  closes  the  circuit,  and  at  once  a  whitish  froth  makes  its  appearance  around  the 
needle.  After  a  lew  seconds  the  needle  is  withdrawn,  the  eyelash  seized  with  forceps, 
and  extracted.  If  it  offers  tin'  slightest  resistance,  the  electrolytic  needle  should  he  re- 
inserted, lor  only  if  the  eyelash  is  perfectly  loose  are  we  sure  of  the  complete  destruction 
of  its  root. 

This  procedure  is  quite  painful  ;  hence  if  a  great  Dumber  of  cilia  are  to  We 
removed,  it  is  advisable  to  treat  three  or  lour  eyelashes  only  at  one  sitting 
and  to  repeat  the  operation  at  intervals  of  a  few  days.  As  the  operation  pro- 
duces no  sears,  it  does  not  disfigure  the  lid.  In  this  respect  it  is  far  preferable 
to  the  extirpation  of  the  cilia  by  the  scalping  operation. 

{<■)  Scalping-  consists  in  the  excision  of  the  whole  ciliary  border.  The 
instruments  required  for  tin-  operation  are  a  line  scalpel, forceps, small  curved 
needles,  a  needle-holder,  fine  silk,  and  a  lid-plate  made  usually  of  shell  or 
hard   rubber. 

The  surgeon,  putting  the  thumb  of  his  left  hand  upon  the  lid  supported  by  a  plate, 
makes  a  slight  pressure  upon  it  to  turn  the  lid-border  into  full  view.  With  the  scalpel 
in  his  right  hand  he  then  makes  an  incision  all  along  the  lid-border  just  behind  the  eye- 
lashes (Fig.  339),  and  deepens  this  incision  by  repeated  strokes  pf  the  scalpel  until  the 


Fig.  339.— Making  the  IntermarginaJ  Incision. 

bulbs  of  the  cilia  are  exposed  as  -mall  black  dots  in  the  anterior  margin  of  the  wound. 
This  incision  i-  known  as  the  intermarginal incision.  It-  correcl  execution  requires  a 
steady  hand  and  watchful  eye.  for  it  is  essential  that  no  hair-bulbs  -hall  remain  behind 
in  the  posterior  margin  of  the  incision. 

The  next  step  consists  of  a  transverse  incision  through  the  -kin,  made  just  behind 
the  eyelashes ;  at  both  ends  this  incision  is  continued  into  the  intermarginal  inch 
the  two  incisions  thus  including  a  long  and  narrow  -trip  containing  all  eyelashes.     This 

35 


54  6 


OPERATIONS  UPON  THE  EYELIDS. 


strip  is  seized  with  fine  forceps,  and  dissected  up  by  deepening  the  cutaneous  wound 
until  it  meets  the  intermarginal  incision  belaud  the  hair-bulbs.  Alter  a  careful  inspec- 
tion has  convinced  the  operator  that  no  hair-bulbs  are  left  behind,  the  wound  is 
thoroughly  cleansed  and  elosed  by  line  silk  sutures,  which  are  removed  alter  three 
days. 

In  former  years  scalping  was  frequently  performed,  but  since  the  intro- 
duction of  electrolysis  and  improved  modern  operations  for  entropion  it  is 
seldom  required,  and  fortunately  for  the  patients,  as  it  produces  a  very 
hideous  and  permanent  disfigurement  of  the  eyelid. 

Abscesses  of  the  /id  are  opened  by  a  transverse  incision  through  the  skin 
and  treated  according-  to  the  general   principles  of  surgery. 

Hordeolum  (or  stye)  is  opened  by  a  small  incision  ami  it-  contents  arc 
expelled  by  gentle  pressure. 

2.  Removal  of  a  chalazion  (tarsal  tumor,  Meibomian  cyst)  can,  in 
the  majority  of  cases,  be  performed  by  an  incision  through  the  conjunctiva; 
but  it'  it  is  very  large,  causing  a  decided  protuberance  of  the  skin,  it  is  more 


Fig.  340.— Knapji's  lid-clamp. 

convenient  to  attack  the  tumor  through  the  external  integument.  In  either 
case  the  use  of  the  lid-clamp  (Fig.  340)  is  very  advantageous,  as  it  makes 
the  operation  practically  bloodless. 

If  the  surgeon  decides  to  remove  the  chalazion  by  incision  through  the  skin,  the  lid 
i-  secured  in  a  clamp  and  the  tumor  is  exposed  by  a  transverse  incision  through  skin 
and  muscular  layer,  and  is  cut  open  from  within  outward  by  transfixing  its  base  with 
the  narrow  blade  of  ;i  small  scalpel.  The  contents  of  the  cyst  are  removed,  and  each 
half  of  its  wall  is  successively  seized  by  a  tine  forceps  and  excised  by  -mall  curved 
scissors.  Upon  the  removal  of  the  lid-clamp  there  is  a  free  oozing  of  blood,  which, 
however,  i-  easily  checked  by  pressing  a  compress  gently  upon  the  lid;  next  the  lid  is 
cleansed  and  the  wound  covered  with  iodoform  ;  a  bandage  is  not  necessary.  As  these 
transverse  incisions,  following  the  natural  creases  of  the  lid-skin,  have  no  tendency  to 
.  it  is  not  strictly  necessary  n>  use  sutures;  but  if  the  wound  is  very  large,  it  is  per- 
fectly proper  to  close  it  by  one  or  two  sutures. 

li  the  chalazion  is  to  be  removed  by  an  incision  through  the  conjunctiva,  the  posi- 
tion of  the  lid-clamp  is  reversed,  its  plate  being  put 
upon  the  outer  side  and  it-  ring  upon  the  conjunc- 
tival side  of  the  lid  (Fig.  841). 

If  the  chalazion  i-  very  small,  the  clamp  may  be 
omitted,  and  the  operation  still  be  made  almost 
bloodless  if  the  lid  j-  everted  and  firmly  pressed 
against  the  handle  of  a  scalpel  or  the  nail  of  an 
assistant's  finger. 

The  clamp  being  screwed  down  the  lid  is  everted  ; 
the  cyst,  marked  by  a  'lark  red,  prominent  patch  in 
the  conjunctiva,  i-  opened  by  an  incision;  a  small 
curet  is  introduced  and  the  contents  are  scraped 
out.  Overhanging  i'\^<~  of  the  cartilage  may  he 
trimmed  "if  without  tear  of  producing  a  contraction 
and  malformation  of  the  tarsus.  The  cartilaginous  walls  of  the  chalazion  often  contain 
small  pockets  filled  by  tie  same  granulation-tissue;  th<  se  side-pocki  t-  should  always  b< 


Pig, 


■i  of  chalazion. 


OPERATIONS  roll  MAKING  A    SEW  CANTHUS. 


547 


searched  for  and  thoroughly  scraped  out,  for  if  overlooked  they  form  the  nucleus  of  a 
new  tumor,  and  often  account  for  the  recurrence  of  the  chalazion  at  the  site  of  the 
operation. 

When  the  clamp  is  removed  the  cyst-cavity  fills  with  blood,  producing  more  or  less 
tumefaction  of  the  lid;  but  in  a  few  days  the  blood  is  absorbed  and  the  fid-swelling  is 
gone.  No  special  dressing  is  needed,  except  perhaps  the  application  of  a  warm  wel 
compress  for  a  few  hours  to  allay  pain. 

l>r.  Agnew's  method  of  removing  the  contents  of  the  chalazion  through  an  Inter- 
marginal  incision  has  no  material  advantage  over  the  other  methods. 

To  remove  chalky  deposits  in  the  Meibomian  glands,  the  lid  is  everted 

and  the  conjunctiva  over  the  white  deposit  is  punctured,  and  the  chalky  grain 
picked  np  on  the  point  of  a  Graefe  cataract-knife. 

Polypoid  granulations  on  the  conjunctiva,  warty  excrescences  at  the  lid- 
borderland  similar  growths  are  excised  with  curved  scissors;  if  necessary, 
the  small  wound  is  touched  with  liquid  chromic  acid  at  the  end  of  a  probe. 

3.  Operations  for  Making  a  New  Canthus;  Canthoplastic 
Operations. — The  object  of  these  operations  is  either  to  reduce  or  to 
increase  the  transverse  diameter  of  the  palpebral  aperture. 

(a)  The  Operation  for  Shortening-  the  Palpebral  Fissure  (Tarsorrhaphy 
or  Blepharorrhaphy). — This  accomplishes  its  object  by  uniting  the  opposing 
lid-borders  for  a  short  distance  at  the  outer  or  inner  canthus  {external  or 
internal  tarsorrhaphy).  The  operation,  as  applied  to  the  outer  canthus,  is 
performed  as  follows: 

The  surgeon  seizes  the  border  of  the  lower  lid  with  a  forceps  near  the  outer  canthus, 
and  transfixes  it  with  a  narrow  scalpel  2  mm. 
below  the  eyelashes  in  such  a  manner  that  the 
back  of  the  blade  is  turned  toward  the  canthus 
and  its  point  emerges  from  the  intermarginal 
surface  of  the  lid-border  just  in  front  of  the 
orifices  of  the  Meibomian  glands;  pushing 
the  blade  along  the  lid-border  by  a  steady 
sawing  movement,  the  operator  cuts  from  it 
a  narrow  strip,  from  4-6  mm.  in  length,  which 
must  contain  all  the  eyelashes.  In  the  same 
way  a  similar  flap  is  removed  from  the.  oppo- 
site border  of  the  upper  lid;  the  two  opposing 
denuded  surfaces  (Fig.  342)  are  carefully  united 
by  two  or  three  fine  silk  sutures,  and  the  lids  are 
kept  immobilized  by  a  bandage  for  two  or  three  days,  when  the  sutures  are  removed. 

Internal  Tarsorrhaphy. — Tn  a  case  of  paralysis  of  the  orbicularis  muscle, 
causing  eversion  of  the  lower  tear-point,  Dr.  Aril  '  has  relieved  the  trouble- 
some epiphora  by  a  tarsorrhaphy  at  the  inner  canthus.  From  the  tear-points 
toward  the  inner  canthus  a  narrow  strip  of  cutis  was  pared  off  and  the 
wounds   were   united   by   two  sutures. 

Dr.  II.  I ).  Noyes 2  operated  for  the  same  purpose  in  the  following  man- 
ner: "I  dissected  up  a  parallelogram  of  skin  above  and  below  the  canaliculi 

for  a  space  which  reached  from  the  commissure  to  3  mm.  bey 1  the  puncta. 

I  turned  the  raw  surfaces  of  the  little  Haps,  raised  from  the  respective  lids. 
against  each  other  and  stitched  through  them.  The  puncta  were  thus  turned 
inward  and  out  of  sight." 

(h)  The  operation  for  enlarging-  the  palpebral  fissure  (canthotomy  or 
blepharotomy)  is  performed  at  the  external  canthus  only. 

[f  the  enlargemenl  of  the  fissure  is  required  only  temporarily  for  reliev- 
ing the  eyeball  of  the  pressure  of  excessive  lid-swelling  in  acute  blennorrhea, 

1  Graefe  and  Saemisch  :  Handbook,  vol.  iii.  p.  M6. 

2  Text-book  of  Ophthalmology,  189  I,  p.  28  l. 


Fig.  S42. — External  tarsorrhaphy 


548 


OPERATIONS   UPOX   THE  EYELIDS. 


or  for  the  removal  of  an  enlarged  globe  or  a  retrobulbar  tumor,  the  operation 
consists  simply  in  a  horizontal  incision  through  the  commissure,  the  wound 
being  allowed  to  close  up  again  {temporary  canthotomy). 

But  it'  the  enlargement  of  the  fissure  is  to  be  permanent,  the  reunion  of 
the  wound-edges  mus1  be  prevented  by  lining  them  with  conjunctiva  [perma- 
n< at  canthotomy).     The  steps  of  the  operation  are  as  follow- : 

An  assistant  draws  the  temporal  portions  of  the  lids  apart  to  make  the  external 
commissure  stand  out  as  a  firm  vertical  ridge.     The  surgeon  inserts  the  one  blade  of 

blunt-pointed  straight  scissors  between 
the  commissure  and  globe,  and  pushes  it 
in  a  horizontal  direction  toward  the  wall 
of  the  orbit  ;  next  the  scissors  are  shut, 
and  with  one  firm  stroke  the  entire 
thickness  of  the  commissure  i>  cut 
through.  The  bleeding  is  usually  pro- 
fuse, but  easily  controlled  bypressure; 
sometimes,  however,  it  is  necessary  to 
use  torsion  upon  a  small  artery.  Owing 
to  the  traction  of  the  assistant  upon  the 
eyelid-,  the  transverse  incision  is  imme- 
diately changed  to  a  vertical  rhomboid 
wound  (Fig.  343), whose  temporal  side  is 
represented  by  the  skin  and  the  bulbar 
side  by  the  conjunctiva.  Skin  and  con- 
junctiva are  then  united  by  sutures  to 
keep  the  palpebral  fissure  permanently 
enlarged.  Three  sutures  are  applied — 
one  uniting  the  center  of  the  wound 
where  the  new  canthus  i-  to  lie,  and  one 
suture  above  and  one  below  it. 

Before  these  sutures  are  passed  it  is 
necessary  to  loosen  the  conjunctiva  from 
the  underlying  tissues.  Seizing  the  conjunctival  border  of  the  wound  with  forceps,  the 
surgeon  draws  upon  it  until  lie  distinctly  feel-  the  resistance  of  the  ligament  ;  then, 
passing  the  closed  blades  of  curved  scissors  into  the  wound,  he  feel-  fur  the  ligament, 
and  when  he  ha-  found  it  opens  the  scissorsjusl  far  enough  to  get  the  ligament  between 
the  Made-,  and  out-  it  by  one  quick  stroke.  As  soon  as  the  ligamenl  is  cut  the  con- 
junctiva i-  so  movable  thai  it  can  easily  be  united  with  the  skin-borders  of  the  enlarged 
fissure.  The  sutures  should  be  tied  rather  loosely,  lesl  they  cul  through  the  swollen 
tissue  too  soon.  Bandaging  i-  not  necessary.  On  the  third  or  fourth  day  the  sutures 
can  be  removed. 

Operation  for  Epicanthus. — The  host  results  are  obtained  by  the  modified 
v.  Am mon's  operation,  devised  by  I>r.  Knapp1  in  1ST.'!. 

A  rhomboidal  piece  of -kin.  over  an  inch  in  length  and  nearly  two-thirds  of  an  inch 
in  width  at  it-  broadest  part,  is  excised  on  the  root  of  the  nose.  The  skin  at  both  -ides 
of  the  wound  is  carefully  undermined,  and  when  the  bleeding  has  subsided  the  wound  is 
united  by  silk  sutures.  Dr.  Knapp  cover-  the  wound  with  plaster  -trips  to  protect  it 
from  the  child'-  hand-,  for  immediate  union  is  of  the  greatesl  importance  to  avoid 
unsightly  -car-  on  the  nose. 


Fig.  343.— Canthotomy. 


MAJOR   OPERATIONS. 

This  group  comprises  operations — 

1.  For  the  correction  of  nialpositii 1'  the  eyelids  (entropion  and  ectro- 
pion :  '_'.  For  the  reconstruction  of  the  partly  or  totally  destroyed  lid; 
•  !.   For  the  relief  of  ptosis. 

I.  Operations  for  Entropion  and  Trichiasis.-' — Instruments. — 
small  scalpels,  curved  scissors,  mouse-toothed  forceps,  needle-,  needle-holder, 

1    1  chives  of  Ophthalmology,  vol.  iii.  \<.  53. 

'•  'I  he  so-called  trichiasis  represents  merely  the  most  advanced  stage  of  entropiuni. 


OPERATIOXS  FOR  EXTROPIOX  AX/)    TRICHIASIS.        549 

and  silk  Nos.  1  and  ■"».  The  lid-clamp  and  lid-plate  arc  nut  absolutely 
required,  though  used  by  many  operators. 

The  chief  object  of  all  entropion-operations  is  to  remove  the  offending 
eyelashes  from  contacl  with  the  eyeball.  This  can  be  accomplished  in  two 
way-:  either  the  whole  inverted  lid-border  i.-  turned  up  and  secured  in  its 
normal  position  by  a  permanent  tension  from  a  fixed  point  above,  or  the  eye- 
lashes alone  are  turned  up  to  their  normal  direction  and  supplied  with  a 
support  below  to  prevent   their  reinversion. 

1.  The  principle  of  relieving  entropion  by  permanent  ten-ion  upon  the 
lid-border  finds  its  most  correct  and  successful  application  in  the  operation  of 
AnagnostaJds  and  lint-.} 

The  operation  i-  performed  on  the  upper  lid  a-  follows  : 

While  an  assistant  fixes  the  -kin  at  the  supra-orbital  margin  the  operator,  seizing 

the  center  of  the  lid-border  with  ringers  or  forceps,  draws  the  lid  downward  to  put  its 
skin  well  on  a  stretch,  and  makes  a  transverse  incision  through  -kin  and  orbicularis 
muscle  from  a  point  2  or  3  mm.  above  the  punctum  lachrymale  to  a  point  2or  3  mm. 
above  the  external  canthus.     This  incision  (Fig.  344,  A)  divide-  the  lid-skin  iu  a  line 


Figs.  344,  345.— J  and  B,  operation  of  Anagnostakis  ami  Hotz. 


parallel  to  and  a  little  below  the  upper  border  of  the  tarsal  cartilage,  and  is  therefore 
from  4  to  X  mm.  distant  from  the  free  border  in  the  center  of  the  lid.  The  -kin  and 
muscular  layer  are  now  dissected  from  the  incision  down  to  the  r>>ut-  of  the  eyelashes, 
and.  while  an  assistant  is  holding  the  edges  of  the  wound  well  separated,  the  operator 
seizes  with  forceps  and  excises  with  curved  scissors  the  muscular  fibers  running  trans- 
versely across  the  upper  border  of  the  tarsus.  Next  the  sutures  are  inserted.  Three 
suture-  are  usually  sufficient  -one  in  the  center  of  the  wound  and  one  at  each  side  of  the 
central  suture.     The  curved  needle,  armed  with  black  -ilk  No.  '■>.  is  firsl  passed  through 

1 'I'm  the  0 inner  belongs  tin-  credit  of  having  been  the  firsl  (Annates  <T Oculist 
declare  that  in  order  to  be  effective,  uniform,  ana  lasting  the  skin-tension  applied  to  the  lid- 
border  must  proceed  from  a  fixed  point  so  located  thai   ir   maintains  tin  same  distance  from  the 
lid  border  in  all  the  various  positions  and  movements  of  the  lid,  and  the  only  point  which  mltils 
these  anatomic  conditions  is  the  opposite  border  of  the  tarsal  cartilage.     But  this  valuabh 
gestion  and  the  operation  based   upon  it  did  nol  find  among  the  oculists  the  recognition  they 
deserved.     Twenty  years  later  Dr.  Hotz  was  led  by  lib  own  independenl  inv<  stigatii 
the  same  view-     Arch.qf  Ophth.,  viii.  p.  249),  and  to  saggesl  an  operation  in  its 
identical  with  that  of  Anagnostakis. 


.>»<> 


OPEHATIOXS   UPOX   THE   EYELIDS. 


the  wound-border  of  the  lid-skin  (Fig.  344,  a) ;  then  it  is  thrust  through  the  upper 
border  of  the  tarsus  and  returned  through  the  tarso-orbital  fascia  just  above  this  border ; 
and  finally  il  is  carried  through  the  upper  wound-border  (Fig.  344,  b).  When  these 
sutures  are  tied  the  skin  is  drawn  upward  and  fixed  to  the  upper  tarsal  border  (Fig. 
345,  B),  and  this  slight  traction  is  sufficient  to  turn  the  inverted  lid-border  and  eyelashes 
to  their  normal  position;  and,  as  the  skin  becomes  firmly  united  with  the  tarsal  border, 
the  tension  thus  produced  upon  the  lid-border  is  permanently  secured. 

The  sutures  should,  of  course,  not  he  tied  until  all  bleeding  has  ceased  and  the 
wound  is  thoroughly  cleansed;  they  may  be  removed  on  the  third  day,  Under  aseptic 
dressings  the  wound  heals  by  first  union,  even  if,  as  sometimes  occurs, secondary  hemor- 
rhage or  edema  causes  considerable  swelling  lor  several  days.  Should,  however,  suppura- 
tion occur,  the  sutures  should  at  once  be  taken  out  to  give  free  exit  to  the  pus ;  audit' 
the  suppuration  is  promptly  subdued,  a  fair  result  may  still  be  hoped  for,  because  the 
contraction  of  the  cicatrix  unite-  the  skin  with  the  tarsal  border. 

This  operation  can  be  performed  also  on  the  lower  lid  ;  only  that  on 
account  of  the  small ness  <d*  the  tarsus  the  sutures  are  passed  entirely  below 
it   through  the  tarso-orbital  fascia. 

In  the  higher  degrees  of  entropion  (trichiasis)  additional  surgical  meas- 
ures arc  often  necessary  :  if  the  palpebral  fissure  is  abnormally  contracted. 
canthotomy  should  be  done  in  connection  with  the  entropion  operation  ;  and 
it'  the  tarsus  is  much  shrunken  and  rigid,  the  reposition  of  the  lid-border 
cannot  be  accomplished  without  grooving  the  cartilage  (Streatfeild— Snellen's 
operation ). 

Just  above  the  roots  of  the  eyelashes  a  transverse,  narrow  wedge-shaped  strip  is 
removed  from  the  cartilage;  the  resulting  groove  makes  it  easy  Cor  the  lid-border  to 
turn  up  under  the  traction  of  the  skin  when  it  is  sutured  to  the  upper  border  of  the 
tarsus. 

2.  The  second  principal  method  of  relieving  entropion  may  be  called  the 
reconstruction  of  the  lid-margin.  Tt  consists  in  turning  up  the  inverted  eye- 
lashes alone,  and  supporting;  them  in  their  normal  position  by  a  new  lid- 
margin.  This  operation,  first  suggested  in  1S7.">  by  Spencer  Watson's  com- 
plicated double-transplantation,  has  gone  through  numerous  changes  before 
it  was  evolved  into  the  present  simple  procedure. 

The  inverted  lid-border  is  split  by  the  intennarginal  incision,  great  care  being  taken 
that  all  cilia  are  contained  in  the  anterior  layer.  This  incision  is  deepened  so  much  that 
the  anterior  layer  with  the  lashes  can  easily  be  everted,  thereby  converting  the  inter- 
marginal  incision  into  a  gapingwound  (Fig.  346)  several  millimeters  in  depth. 


Fig  346     Reconstruction  of  Ud-border, 


This  groove   is  to  be  filled  either  by  a  strip  of  mucous  membrane  or  a  skin-graft. 
'I  he  grafi  musl  be  of  the  Bame  length  and  width  as  the  intennarginal  wound. 

The  >trip  of  mucous  membrane  is  cut  oul  with  a  few  clips  of  a  pair  of  curved 

3ci880rs  from  the  inner    surface   of  the    Under    lip,  and  placed  :it    once  on  the  wound  and 

pr<  mi  'I  into  position  with  a  pledgel  of  cotton  wool  or  gauze. 

The  skin-graft  is  cul  out  from  the  integ enl   behind  the  ear,  the  incisions  pene- 
trating obliquely  just   into  the  corium.     It  is  at  once  transported  to  the  lid  and  pressed 

into  tin-  groove.      If  the  grafl  should  be  too  large,  it  should  be  trimmed  down  with  a  pair 

of  small  curved  scissors  until  its  edges  are  even  with  the  margin  of  the  wound.  Sutures 
are  unnecessary,  but  both  eve-  should  be  bandaged  lor  twenty-four  or  forty-eighl  hours, 
until  the  idherent. 


OPERATIONS   FOR    ECTROPION. 


551 


The  writer  prefers  skin-grafts,  because  the  normal  intermarginal  space  is 
lined  by  skin,  nol  by  mucous  membrane;  because  skin-grafts  are  less  likely 
to  mortify  ;  and  because  filling  the  entire  depth  of  the  wound  makes  a  more 
substantia]  new  lid-border.  The  use  of  skin-grafts  is  often  objected  toon  the 
ground  thai  the  fine  hairs  in  the  transplanted  strip  would  irritate  the  eye,  but 
it'  the  grafts  are  cut  as  described  above,  they  never  grow  any  hairs.  If  sub- 
sequently any  hairs  are  found  in  the  newly-made  lid-margin,  a  careful  inspec- 
tion will  prove  that  they  grow  from  the  posterior  edge  of  the  lid-margin,  or, 
in  other  words,  they  are  cilia  which  the  operator  when  making  the  intermar- 
ginal incision  has  left  in  the  posterior  margin  of  the  wound. 

The  two  methods  of  entropion-operation  here  described  can  relieve  all 
degrees  of  entropion  ;  in  the  worst  forms  the  West  results  are  obtained  by  the 
combination  of  both  methods. 

This  latter  plan  is  certainly  superior  to  the  Jaesche-Arlt  operation,  in 
which  also  skin-tension   is  combined   with   the   transplantation  of  the  cilia. 

The  Lid-margin  is  split  by  the  intermarginal  incision;  next  a  second  incision  is 
made  5  mm.  above  and  parallel  to  the  ciliary  edge,  and  a  third  incision  is  carried  in  a 
curve  from  one  end  of  the  second  incision  to  the  other  end,  and  the  semilunar  piece  of 
skin  is  removed.  The  bridge  containing  the  eyelashes  is  detached  from  the  underlying 
cartilage  by  careful  dissection,  so  that  when  the  margins  of  the  gaping  skin-wound  .ire 
drawn  together  by  tine  sutures  the  bridge  is  shifted  upward.  This  produces  along  the 
lid-margin  a  gap  which  is  covered  by  a  piece  of  skin  (Waldauer's  modification). 

The  objectionable  features  of  this  operation  are  that  the  new  intermarginal 
space  is  abnormally  broad,  and  that  the  excision  of  the  lid-skin  seriously  dis- 
turbs the  natural  appearance  and  movements  of  the  lid.  In  many  instances 
the  shortening  of  the  lid-skin  has  made  the  closure  of  the  lids  impossible. 

Burow,  Green,  and  others,  believing  in  an  incurvation  of  the  tarsus  as  the  chief 
factor  in  the  production  of  entropion,  practise  a  transverse  incision  from  the  conjunc- 
tival side  through  the  entire  thickness  of  the  tarsus  to  straighten  the  supposed  incurva- 
tion. These  operations  are  seldom  permanently  successful,  and  leave  on  the  conjunctival 
surface  a  thick  scar  which  is  often  the  source  of  a  persistent  irritation  to  the  eye. 

II.  Operations  for  Ectropion. — The  eversions  of  the  lid  calling  for 
operative  correction  are  the  senile  ectropion  and  the  various  forms  of  (-ver- 
sion from  the  contraction  of  cicatrices  following  extensive  tissue-destruction 
in  the  lid  and  its  vicinity  {cicatricial  ectropion). 

Senile  ectropion  occurs  only  in  the  lower  lid  from  a  relaxation  of  its 
tissues  associated  with  a  lengthening  of  its  free  border.  Unless  the  lid-border 
is  shortened,  the  reposition  id'   the  everted   lid  ^-.      „-._ 

cannot  be  successfully  accomplished.  This  ac- 
counts for  the  unsatisfactory  results  attained  by 
the  suture-operations  (Snellen,  Argyll-Robert- 
son, and  others)  which  attempt  to  overcome  the 
eversion  by  the  traction  id'  sutures  carried  from 
the  conjunctiva  near  the  fornix  through  the 
entire  thickness  of  the  lid.  and  tied  upon  the 
cheek  over  a  piece  <'f  small   rubber  tubing. 

Shortening  the  lid-border  is  accomplished  by 
Adams's  operation  : 

A  wedge-shaped  piece  is  excised  from  the  entire  thickness  of  the   lid    and  the  mar- 
gins of  the  wound  drawn  together  by  sutures.     If.  as  originally  practised,  the  pie< 
excised  from  the  center  of  the  lid,  the  contraction  of  the  scar  produces  an  unsightly 
notch   in  the  lid-border:  this  disfiguration  is  avoided   by  making  the  excision  at  the 
external  canthus  I  Fig.  ::  17 1. 


*v 


Fig.  :a: 


-Shortening  of  the  li'l 
bordi 


552 


OPERATIONS   UPON   THE  EYELIDS. 


Tin  Kuhnt-Mvller  Operation. — A  very  neat  operation  for  the  same  pur- 
pose was  designed  by  Prof.  Kuhnt  in  L883,  and  modified  by  L.  Muller  in 
1893. 

A  deep  incision  is  made  by  an  iridectomy-knife  into  the  center  of  the  lid-margin 
to  split  tlif  lid-substance  into  two  portions — the  one  portion  containing  the  conjunctiva 
and  tarsus,  and  tin-  other  portion  containing  the  soft  tissues  and  the  skin.  From  the 
firsl  portion  a  triangular  piece  is  dissected  out  by  two  incisions  (Fig.  348,  A,  ac  and  be) 
converging  toward  the  fornix.  The  two  portions  of  the  lid  are  further  separated  toward 
the  external  canthus  by  carrying  the  lance  from  and  under  the  margin  be  toward  it. 
Now  the  V-shaped  wound  of  the  tarsus  is  closed  by  one  or  two  sutures,  and  then  the 
long  stretch  of  the  skin-margin  (da  |  is  "  gathered  up  "  with  the  much  shorter  margin  db 
of  the  tarsus  by  sutures;  the  proper  mode  of  their  application  is  best  understood  by 
a  reference  to  Fig.  348,  />'.  Where  these  sutures  are  tied  the  skin  puckers  a  little  be- 
tween each  suture,  hut  the  process  of  cicatrization  will  efface  every  trace  of  this  uneven- 
ncss  and  restore  a  perfectly  smooth  lid-margin. 


Fig.  348.— A,  shortening  of  lid-border  after  manner  of  Kuhnt  and  Muller  ;  D,  Kuhnt-Muller  operation, 

final  stage. 

In  the  operations  for  cicatricial  ectropion  the  first  step  should  always  be 
to  liberate  by  careful  dissection  the  everted  lid  from  till  cicatricial  adhesions 
so  thoroughly  that  its  reposition  is  possible  without  the  least  restraint  or 
resistance. 

Cicatricial  ectr'opion  of  the  lower  lid  presents  two  problems: 
1.  Its  border,   being;   stretched    and    abnormally    lengthened,   must    be 
reduced  to  the  proper  size. 


Fig.  849,    .i.  Aril  cl  ropion  of  Lower  li'i  i  /.'.  final 

•_!.  The  replaced  lid  must  be  provided  with  a  solid  supporl  below  to  hold 

it    in    it-    normal    position. 


OPERATIONS  FOR  ECTROPION. 

In  many  instances  these  problems  can  be  successfully  solved  by  ArWa 
operation  (Fig.  349,  .1  and  11). 

The  incisions  ab  and  bd  are  made  so  that  they  form  at  6  an  acute  angle.  These 
incisions  are  carried  right  through  the  cicatricial  tissues ;  the  flap  abd  is  carefully  dis- 
sected up  to  the  lid-border,  and  the  lid  released  from  all  cicatricial  restraints,  so  that  it 
can  easily  be  brought  into  its  normal  position.  Next  the  lid-border  is  shortened  at  the 
external  canthus  by  removing  the  piece  coed,  making  an  incision  co  along  the  edge  just 
behind  the  eyelashes  on  the  conjunctival  side  and  the  crosscuts  cd  and  or.  If  now  the 
Lid-border  is  lifted  up  into  its  proper  position,  the  wound-margins  or  and  cd  are  brought 
in  apposition  and  held  together  by  two  sutures. 

The  reposition  of  the  lid  leaves  below  it  the  open  wound  abdg  (Fig.  M4'.>,  /.'),  which  must 
be  filled  with  some  solid  material  to  furnish  a  good  support  to  the  lid  according  to  the 
second  indication  stated  above.  If  the  adjacent  integument  is  sound  and  elastic,  the 
support  of  the  replaced  lid  can  be  furnished  by  drawing  the  margin  ag  and  gd  together 
from  g  upward,  and  by  uniting  also  a  portion  of  the  margin  ag  with  ah  and  gd  with  bd 
to  a  Y-shaped  cicatrix. 

If  this  plan  cannot  be  adopted,  U rolfe's  method  of  grafting  a  skin-flap 
without  a  pedicle  upon  the  wound  should  be  practised. 

The  edges  of  the  lower  and  upper  eyelids  are  united  by  three  ligatures,  and  the  ends 
of  the  ligatures  are  drawn  up  and  fixed  upon  the  forehead  by  strips  of  adhesive  plaster. 
The  shape  and  size  of  the  skin  required  must  be  carefully  cut  out  in  lint.  A  piece  of 
lint  is  then  laid  upon  the  forearm  and  the  shape  traced  by  the  point  of  the  knife,  making 
it  one-third  larger  all  around  to  allow  for  shrinking.  This  flap  is  excised  and  spread  out 
on  the  left  forefinger  to  remove  from  it  with  sharp  scissors  all  areolar  tissue  to  leave  a 
white  surface.  The  flap  so  prepared  is  put  upon  the  wound  and  moulded  into  position. 
No  sutures  are  used  ;  several  pieces  of  lint  or  gauze  wrung  out  of  hot  water  are  laid  upon 
the  flap  and  secured  by  a  bandage.  The  e>/e  should  not  be  disturbed  for  the  first  three  days, 
after  which  the  dressing  should  be  carefully  removed,  the  last  layer  being  well  soaked 
with  hot  water  in  order  that  it  may  be  removed  easily  without  deranging  the  flap.  It 
may  then  be  dressed  every  twenty-four  hours.  The  ligatures  of  the  eyelids  should  not 
be  removed  before  six  weeks. 

This  operation  is  superior  and  preferable  to  all  the  numerous  ingenious 
methods  of  transplanting  flaps  with  pedicles  from  the  face,  for  it  is  free  from 
the  serious  disadvantage  they  possess — to  wit,  that  if  the  flap  sloughs  the  dis- 
figuration of  the  face  is  worse  after  the  operation  than  before. 

Operation  for  cicatricial  ectropion  of  the  upper  eyelid  presents  an  additional 
problem  of  great  interest — namely,  to  restore  its  mobility.  On  this  account 
the  selection  of  a  proper  material  to  replace  the  lost  skin  of  the  lid  is  of  the 
greatest  importance  This  material  should  be  so  thin  as  to  mould  itself  to 
the  surface  of  the  lid,  and  so  light  and  pliable  as  not  to  impede  the  movements 
by  its  weight  and  thickness.  For  these  reasons  the  transplantation  of  skin- 
flaps  from  the  temporal  region  cannot  be  recommended.  Wolfe's  (lap-  have 
been  used  with  fairly  good  results,  but  the  lid  always  looks  heavy  and  cannot 
be  elevated  to  the  full  extent. 

Thiersch's  method  of  shin-grafting  yields  better  cosmetic  results. 

The  lid,  being  completely  liberated  from  the  cicatricial  adhesions,  is  drawn  down 

and  fastened  to  the  cheek  by  three  Ligatures  passed  through  the  lid-border.  The  wound 
is  temporarily  covered  with  a  gauze  compress  wrung  out  of  a  warm  solution  of  -odium 
chlorid  (}  per  cent.)  while  the  grafts  arc  being  cut  from  the  flexor  side  of  the  arm.  The 
-in-con  grasps  the  arm  between  the  thumb  ami  fingers  of  the  Left  band  to  draw  the  skin 

tense,  and,  holding    the    razor    in    his    right   hand.be   lavs   it<   blade  tlat    upon   the  well- 
wetted  surface  of  the  arm,  and  presses  it  down  just  enough  to  make  it-  3harpedge  bite 
into  the  -kin,  but  no  deeper  than  the  papillary  layer.     By  slow  and  shorl  sawing  mo- 
tions the  blade  i<  Bteadily  pushed  on  in  the  papillary  layer  until  a  piece  of  epiderm 
the  desired  size  bas  been  gathered  on  the  razor-blade. 

During  this  " shaving  process "  an  assistant  drops  -alt  solution  upon  the  blade  and 

pushes   with   a   probe   the   -kin  -having   back    from    the   ,,|        ,.|    the   razor.      To    cut    the 


554 


OPERATIONS   Cl'O.X    THE  EYELIDS. 


shaving  nil',  the  edge  of  the  knife  is  turned  up,  while  the  assistant  presses  the  probe  Bat 
down  upon  the  shaving  near  the  edge  of  the  razor-blade.  Now  the  compress  i>  removed 
from  the  lid,  the  wound  is  carefully  cleansed  of  all  coagulated  blood,  and  the  skin- 
shaving  is  transferred  directly  from  the  razor  to  the  lid-surface.  For  this  purpose  plenty 
of  salt  solution  is  dropped  on  the  razor  to  keep  the  graft  floating:  if,  now,  the  edge  of 
"he  razor  near  its  point  is  brought  in  contact  with  the  border  of  the  wound,  the  BOlution 
will  run  oil'  from  the  razor  and  carry  the  graft  with  it  ;  hut  as  soon  as  the  solution  begins 
to  How  and  the  edge  of  the  graft  has  come  in  contact  with  and  clings  to  the  wound- 
border,  tlie  razor  is  drawn  from  under  the  graft  across  the  wound,  by  which  maneuver 
the  skin-graft  floating  from  the  razor  i>  at  once  spread  out  smoothly  over  the  lid-snrfaee. 
It  i-  not  difficult  to  cut  shavings  from  1'  to  z  inches  in  length  and  from  1  to  1^  inches 
in  width  if  only  the  knife-blade  is  operated  by  a  steady  hand  and  moved  in  the  same 
plane.  When  the  whole  wound  is  well  covered  with  these  skin-shavings  two  layers  of 
strips  of  silk  protective,  moistened  with  the  salt  solution,  are  placed  in  position.  They 
should  be  half  an  inch  wide  and  Long  enough  to  lap  over  the  wound-border  on  both 
sides  ;  one  la\  er  is  placed  in  a  transverse  direction  and  the  second  layer  in  a  longitudinal 
direction.  These  strips  are  covered  with  a  compress  which  is  to  be  kept  wet  with  salt 
solution.     The  sound   eye  should  also  be  bandaged. 

This  first  dressing  should  remain  undisturbed  for  two  days.  To  remove  it  the  com- 
presses and  strips  of  protective  are  thoroughly  soaked  with  salt  solutions  ;  the  grafts  are 
rinsed  with  the  same  solutions,  and  fresh  strips  and  compresses  are  applied.  After  four 
or  live  days  the  bandage  may  be  removed  from  the  sound  eye,  at  the  end  of  one  week 
the  Ligatures  may  be  cut,  and  during  the  second  week  the  grafted  lid  needs  only  to  be 
daily  rubbed  over  with  iodoform  ointment.  Alter  the  second  week  no  further  treatment 
is  required.  The  grafted  skin  undergoes  a  gradual  contraction  of  about  one-fourth  of  its 
area,  but  if  this  shrinkage  has  been  anticipated  by  the  operator,  it  will  not  affect  the 
perfect  cosmetic  success  of  the  operation. 

Transplantation  of  Cicatricial  Skin  to  Replace  the  Integument  of  the  Lid. — 
For  cases  where  the  eyebrow  is  partially  destroyed  and  the  supraorbital  region 
largely  covered  by  cicatricial  tissue  the  author  has  made  the  new  skin  of  the 
replaced  lid  from  this  cicatricial  skin. 

In  case  of  complete  ectropion  of  the  upper  lid  (Fig.  350)  the  procedure 
was  as  follows  :l 

The  border  of  the  everted  upper  lid  of  the  left  eye  was  drawn  up  and  fixed  to  the 
temporal  portion  of  the  supraorbital  margin,  and  above  it  a  large  stretch  of  cicatricial 
skin  extended  far  into  the  frontal  and  temporal  region.     The  absence  of  the  temporal 


Show  ing  n  Btoration  "i  the  upper  lid. 

half  of  the  brow  made  the  following  operation  possible:  From  a  point  [a,  Fig.  351  j  aear 

the  inner  canthus  an  incision  was  carried  obliquely  upward  past  the  end  of  the  eyebrow, 

1  Case  reported  to  the  American  Medical  Association  in  L896. 


OPERATJOXS  FOR    THE  RESTORATION  OF   THE  LID.     555 

well  up  into  the  cicatricial  skin  above  the  supraorbital  margin,  and  then  continued  al 
i  considerable  distance  from  the  lid-border  in  a  curved  line  downward  to  a  poin 
about  6  mm.  from  the  external  canthus.     The  large  skin-flap  (abc)  mapped  oul  by  this 


Pig.  351.— Hotz's  transplantation  of 
cicatricial  flap. 


Pig.  352. — Second  stage  of  Hotz's  transplantation  of  cica- 
tricial Bap. 


Fig.  353.— Final  stage  of  Hotz's  transplantation  of  cicatricial  flap. 


incision  was  carefully  dissected  from  the  underlying  scar-tissue  down  to  the  lid-border, 
with  which  it  was  left  connected.  The  lid  then  was  released  from  all  cicatricial  adhe- 
sions and  replaced  in  its  normal  position. 

The  cicatricial  skin-flap  (abc,  Fig.  351)  contracted  considerably  as  soon  as  it  was 
detached  from  its  basis;  but  as  this  shrinkage  was  anticipated  by  cutting  the  flap  of 
very  large  dimensions,  it  was  still  sufficiently  large  to  cover  the  whole  surface  of  the  lid. 
It  was  spread  over  this  surface,  and  its  margin  (ac,  Fig.  352)  was  fixed  by  four  sutures 
to  the  upper  border  of  the  tarsus,  and  the  resultant  wound  (abc)  above  the  lid  was 
covered  by  a  skin-Hap  (bed)  from  the  temporal  side,  the  margin  be  being  united  to  "//. 
and  dc  to  the  margin  ac,  Fig.  353. 

The  great  advantage  of  this  operation  lies  in  the  fixation  of  the  new  lid- 
skin  to  the  upper  tarsal  border.  This  union  makes  the  new  skin  an  integral 
part  of  the  lid,  and  constitutes  a  protective  barrier  to  prevent  tissue-eon- 
traction,  which  may  take  place  in  the  supratarsal  region,  from  disturbing  the 

position  of  the  lid. 

III.  Operations  for  the  Restoration  of  the  Lid  (  Blepharoplasty).- 

If  the  lid  is  partly  or  totally  destroyed  (by  injuries,  extirpation  of  tumors, 
ulcerations,  etc.),  the  defect  is  repaired  by  the  transplantation  of  skin-flaps 
from  the  vicinity.  The  operative  procedures  are  as  numerous  as  the  lesions 
vary  in  character  and  extent,  and  each  case  must  be  studied  well  to  designate 
the  method  host   suited   for  its  conditions.     In  general,  il   maybe  said  that 

the  results  of  blepharoplasty  present  a  far  better  appearanc* paper  than 

in   flesh. 

The  following  method-  may  serve  a-  working  patterns  : 

Eversbusch's  Method  for  Making  an  Entin    New  Lid.     A  skin-flap  of  suitable  shape 

and  >ize  is  cul  in  the  vicinity,  and  the  wound  as  well  as  the  undersurface  of  the  flap  is 
covered  with  Thiersch  skin-shavings.     A  piece  of  -ilk  protective  being  placed  upon  the 


556 


OPERATIONS  UPON  THE  EYELIDS. 


wound,  tlic  flap  is  put  back  in  it.-  original  place,  and  left  there  under  proper  aseptic 
dressings  until  the  Thiersch  grafts  are  adherent.  Then  the  cicatrix  along  the  orbital 
margin  is  excised,  and  the  skin-flap  being  laid  across  the  eyeball,  its  edge  (which  has 
been  previously  freshened  up)  is  sutured  to  the  wound  along  the  orbital  margin. 

[f  a  portion  of  the  conjunctiva  is  preserved,  this  is  carefully  dissected  up  from  the 
cicatricial  adhesions  and  used  for  lining  the  transplanted  flap. 

For  the  reconstruction  of  the  upper  lid  a   tongue-shaped  Hap  is  taken 
from  the  temporal  region — Frickefs  method  (Fig.  .'554). 


Fig.  354.— Fricke's  method  of  blepharoplasty.       Fig.  355.— Dieffenbach's  method  of  blepharoplasty. 

The  lower  lid   can  he  restored  by  Dieffenbach's  method  of  sliding  a  flap 
taken  from  the  cheek  upon  the  triangular  wound  (Fig.  355),  or  by 

A  B 


Figs  57.— Landolt's  method  of  blepharoplasty. 

Landolt's  Method  I  Figs.  356,  357). — Two  parallel  incisions  (ab  and  cd),  which  at  both 
<nd-  reach  a  few  millimeters  beyond  the  eantbi.  are  made  through  skin  and  orbicularis 
of  the  upper  lid.  and  this  bridge,  being  dissected  from  the  tarsus,  is  drawn  down  to  take 
the  place  of  the  lost  lower  eyelid.  The  lower  edge  of  the  Hap  is  sutured  to  the  skin 
along  the  infraorbital  margin,  and  its  upper  edge  is  muted  with  the  conjunctiva.  Alter 
union  has  taken  place  t  he  connections  of  the  skin-bridge  with  the  upper  lid  are  divided. 

[f  only  a  portion  of  the  lower  lid  is  lost,  the  remaining  portion  may  be 
moved  over  into  the  defect,  and,  if  the  defect  is  very  largo,  a  skin-flap  can  be 
drawn  over  from  the  opposite  side  to  be  joined  with  the  nan-planted  lid- 
portion —  Knapp's  method  |  Fig.  358). 

For  partial  destruction  of  i  be  upper  lid  Landoll  has  devised  the  following 
ingenious  method  |  Fig.  359)  : 

The  nasal  portion  of  the  upper  lid  being  lost,  the  Burgeon  splits  the  remaining  lid- 
portion  in  its  entire  extent  into  two  layers,  the  anterior  layer  containing  the  skin  and 
muscle,  the  posterior  layer  containing  the  tarsus  and  conjunctiva.     An  incision  made 


OPERATIONS  FOB  PTOSIS. 


557 


through  the  anterior  layer  from  the  external  canthus  obliquely  upward  to  the  eyebrow 
allows  the  anterior  layer  to  be  shitted  toward  the  nasal  side,  where  it  is  united  hy 
sutures  with  the  nasal  margin  of  the  original  lid-defect ;  sutures  are  also  pul   into  the 


sz^fe-,. 


Fig.  358.— Knapp's  method  of  blepharoplnsty. 


Fig.  359. — Landolt's  restoration  of  a  partially 

destroyed  upper  lid. 


lid-margin  from  c  to  </  to  reunite  the  transplanted  anterior  layer  with  the  posterior 
layer.  The  triangular  wound  {abc)  resulting  from  the  sliding  of  the  anterior  layer  is 
covered  by  Thierseh's  skin-grafts. 

Operations  for  Coloboma  of  the  Lid. — Congenital  and  traumatic  colo- 
bomata  of  moderate  extent  can  usually  he  rectified  by  a  careful  union  of  the 
freshened  edges.  Extensive  lacerations  of  the  lid,  however,  often  produce 
so  great  a  displacement  of  the  severed  lid-portion  that  its  reposition  requires 
a  regular  transplantation,  as,  for  instance,  in  the  following  ease  : 

In  September,  18N6,  a  young  man  received  a  deep  cut  by  a  piece  of  gla.-s,  completely 
dividing  the  temporal  third  of  the  upper  lid  of  the  left  eye.  In  November  he  presented 
himself  with  a  long  oblique  scar  in  the  upper  lid,  with  its  temporal  portion  so  displaced 
that  its  edge  ran  straight  upward.  To  relieve  this  deformity  the  scar  was  excised  from 
a  to  c,  and  a  flap  was  formed  by  the  deep  incisions  ce  and  eg.     This  flap,  being  well 


s        1/71,.  ,/.^y/ 


Fig.  360.— Replacement  of  lacerated  lid  according       Fig.  361.— Result  of  replacement  of  Laci  rated  lid. 
to  H  otz. 


mobilized,  was  then  turned  so  as  to  bring  the  lid-edge  be  into  its  normal  position  ; 
the  wounds  were  then  closed  by  uniting  the  edges  c<  with  ac  and  the  neighboring  skin 
with  ge.     The  result  was  very  satisfactory. 

I  V.  Operations  for  Ptosis. — Patients  suffering  from  paralysis  of  the 
levator  palpebrarum  instinctively  learn  to  elevate  the  lid  to  a  certain  degree 
by  the  aid  of  the  frontalis  muscle,  [ts  contractions,  drawing  the  eyebrow 
and  the  integumenl  between  the  brow  and  eyelid  upward,  exert  indirectly  a 
traction  upon  the  lid  by  which  a  moderate  elevation  of  the  lid  is  accom- 
plished. To  increase  tlii-  vicarious  action  of  the  frontalis  muscle  upon  the 
upper  lid  is  the  aim  of  the  following  ptosis  operations: 


55S 


OPERATIONS  UPON  THE  EYELIDS. 


Panas'a  Operation.  The  upper  lid  being  stretched  upon  a  horn  plate,  a  transverse 
incision,  following  the  furrow  above  the  lid,  is  made  through  skin  and  muscle  to  expose 
the  tarso-orbital  fascia.  From  mar  either  extremity  of  this  incision  a  vertical  incision 
(Fig.  362)  i>  carried  downward  to  a  point  2  or  3  mm.  below  the  upper  border  of  the 
tarsus,  where  the  one  incision  is  continued  in  a  horizontal  direction  to  terminate  near 
the  tear-point,  and  the  other  one  horizontally  outward  to  terminate  near  the  external 
eanthus.  The  rectangular  flap  thus  mapped  out  is  dissected  up  from  above  downward, 
-..  a-  to  expose  the  upper  tarsal  border.  Next  a  transverse  incision,  slightly  convex 
upward  ind  about  2  cm.  in  length,  is  made  just  above  the  eyebrow.  This  incision  is 
carried  through  all  the  tissues  down  to  the  periosteum.  The  cutaneous  bridge  between 
the  two  horizontal  incisions  above  and  below  the  brow  is  undermined,  and  the  rectan- 
gular skin-flap  is  pushed  under  this  bridge  upward  and  attached  by  suture-  to  the  upper 
edge  of  the  upper   incision.     In  order  that   the  traction  of  these  sutures  shall  not  pro- 


^    ,    *    r    « 


Fig.  362. — Panas's  operation  for  ptosis. 


Fig.  363.— Panas's  operation  concluded. 


-duce  ectropion,  an  additional  suture  is  applied  at  each  side.  These  lateral  sutures  are 
passed  through  the  tarso-orbital  fascia  and  conjunctiva  near  the  upper  tarsal  border, 
hut  do  not  include  the  skin,  and  carried  under  the  skin  upward  to  emerge  from  the 
upper  margin  of  the  frontal  incision.  The  wound  is  dressed  with  antiseptic  dressing, 
and  the  sutures  are  removed  after  four  or  five  days. 

The  effeel  of  the  operation  depends  on  the  length  of  the  rectangular  h!;i|>. 
It'  it  is  too  long,  the  elevation  of  the  lid  will  be  insufficient;  if  too  short,  a 
marked  degree  of  lagophthalmos  is  produced. 

Winder's  Operation  (Fig.  364). — Dr.  W.  II.  Wilder  of  Chicago  has  in  a 


64     Wilder's  operation  for  ptosis :  a,  lower  li|>  "f  wound  draw  n  dow  a,  exposing  b  tarsus  and 
■  Ital  fascia,  in  which  gathering  stitches  are  placed;  d,  orhital  margin;  e,  upper  lip  ol  wound, 
into  the  deep  parts  of  which  Butures  are  finally  passed 

number  of  cases  relieved  the  ptosis  by  folding  upon  itself  the  tarso-orbital 
fascia  ("the  suspensory  ligamenl  of  the  upper  lid")  and  by  establishing  a 
firm  adhesion  between  the  fascia  and  frontalis  muscle: 


OPERATIONS  FOB   PTOSIS.  559 

An  incision  \\  inches  in  Length  is  made  a  little  above  and  parallel  with  the  orbital 
margin  through  all  the  tissues  down  to  the  periosteum,  and  should  be  so  placed  thai  the 
resulting  sear  will  he  concealed  by  the  eyebrow.  Retractors  being  used  to  drawdown 
the  lower  Lip  of  the  wound,  the  skin  and  orbicularis  muscle  are  separated  from  the  fascia 
by  careful  dissection  until  the  tarsus  is  broughl  into  view.  Two  fine  sutures  of  steril- 
ized catgut  or  silk,  armed  at  each  end  with  a  curved  needle,  are  then  passed  in  the 
following  manner:  the  needle  is  introduced  deep  enough  into  the  tarsus  to  secure  a  firm 
hold  at  a  point  about  at  the  junction  of  the  outer  and  middle  third  and  a  little  distance 
from  it-  upper  edge.  It  is  then  drawn  through,  and  several  gathering  stitches  are  taken 
upward  in  the  tarso-orbital  fascia,  after  which  the  needle  is  made  to  pass  through  lie' 
muscle  and  connective  tissue  of  the  upper  lip  of  the  wound.  The  other  needle  on  the 
same  suture  traverses  a  parallel  course  in  the  same  manner,  entering  the  tar-us  about 
3  mm.  from  the  point  of  entrance  of  the  first,  and  emerging  in  the  tissue  above,  thus 
making  a  loop  by  which  the  lid  may  he  drawn  up.  The  second  suture  is  passed  in  the 
same  way,  making  a  loop  at  the  junction  of  the  middle  and  inner  thirds  of  the  tarsus. 
The  requisite  elevation  of  the  lid  may  he  now  secured  by  drawing  on  the  loop>  and 
tying  the  sutures,  after  which  the  ends  may  he  cut  oil'.  The  lower  lip  of  the  wound  is 
now  replaced  and  united  to  the  upper  with  fine  sutures.  The  slight  scar  that  remains 
after  healing  is  almost  entirely  hidden  when  the  eyebrow  grows  again.  As  the  buried 
sutures  become  capsulated  additional  strength  is  given  to  the  bands  that  hold  up 
the  lid. 

The  various  operations  aiming  tit  increasing  the  effect  of  the  frontalis 
muscle  by  subcutaneous  ligatures  are  unreliable  and  uncertain  in  their  effect, 
like  all  operations  done  in  the  dark.  But  the  excision  of  an  oval  piece  of 
skin  should  never  be  practised  for  this  purpose,  because  it  produces  a  hideous 
Jagophthalmos. 

If  the  action  of  the  levator  muscle  is  not  entirely  lost,  the  principles  of 
tendon  advancement  and  tendon  resection  as  practised  in  squint  operations 
may  be  employed,  and  tire  made  the  basis  of  the  methods  of  Eversbusch, 
Snellen,  and  Wolff. 

In  Eversbusch's  operation  the  advancement  is  produced  by  folding  the 
tendon  upon   itself,  like  the  advancement  of  Tenon's  capsule. 

Midway  between  the  lid-margin  and  the  eyebrow  a  horizontal  incision  is  made 
through  all  the  tissues  down  to  the  fascia.  The  edges  of  the  wound  are  dissected  up  to 
-expose  well  the  tendon,  which  there  is  blended  with  the  tarso-orbital  fascia.  Four  mm. 
above  the  upper  border  of  the  tarsus  a  small  vertical  fold  of  the  center  of  the  tendon  is 
then  taken  up  in  the  loop  of  a  double-armed  thread,  and  both  needles  are  passed  verti- 
cally downward  between  the  tarsus  and  orbicularis,  brought  out  at  the  lid-margin  2  mm. 
from  each  other,  and  tied  over  a  small  bit  of  rubber  tubing.  A  similar  suture  is  passed 
through  the  nasal  and  temporal  portions  of  the  tendon  respectively;  the  skin-wound  is 
closed  by  sutures  before  the  tendon-sutures  are  tied. 

Snellen's  operation  '  is  a  tendon  resection. 

The  upper  border  of  the  tarsus  i-  exposed  by  a  transverse  incision  and  the  orbicu- 
laris libers  are  pushed  upward  and  downward.  The  exposed  fascia  is  then  incised  at 
some  distance  above  the  tarsal  border,  and  three  or  four  needles  are  thrust  through  the 
tendon  and  passed  from  above  downward  to  emerge  again  through  the  upper  border  of 
the  tar-us.  But  before  the  needles  arc  drawn  out  the  piece  of  tendon  between  the  tarsal 
border  and  the  point  of  entrance  of  the  needles  is  excised.     Then  the  needles  are  drawn 

through  and  the  threads  t  ied. 

Wolff's  operation  2  combines  tendon  resection  with  tendon  advancement. 
and  is  a  decided   improvement   over  Snellen's  method. 

The  surgeon  make-  an  incision  through  all  the  tissues  along  the  upper  border  of  the 

tarsus,  and,  lifting  up  in  a  vertical  fold  the  central  portion  of  the  tendon  expansi >n 

the  anterior  surface  of  the  tar-us,  he  cuts  at  cadi  -idea  vertical   buttonhole,  through 

1  Report  of  the  German  Ophthalmol  Society,  al  Heidelb  r 

ll.nl..   1896 


560 


OPERATIONS   UPON  THE  EYELID8. 


which   two  strabismus-hooks  arc  slipped   under  the   tendon,  so  that   the  one  hook  is 
placed  close  to  the  insertion  aud  the  other  hook  so  fax  above  it  that  the  distance  between 


Fig.  365.— Wolffs  operation. 

the  two  hooks  represents  the  piece  of  tendon  to  be  resected.  Two  double-armed  catgut 
sutures  being  put  through  the  tendon  just  below  the  upper  hook,  the  tendon  is  cut 
transversely  below  the  sutures.  Both  ends  of  each  suture  are  then  carried  behind  the 
tendon-stump  and  passed  through  the  line  of  insertion,  lied,  and  cut  short;  the  skin- 
wound  is  closed  over  them  by  silk  sutures. 

The  success  of  the  operation  depends  upon  the  accurate  dosage  of  the  tendon- 
resection;  the  resected  piece  should  measure  exactly  as  many  millimeters  as  the  vertical 
diameter  of  the  palpebral  aperture  of  the  affected  eye  is  smaller  than  that  of  the  normal 

eve. 

Operation  of  Ptosis  Adiposa  or  Atonica. — in  this  affection  the  lid 
shows  neither  any  superabundance  of  adipose  tissue  nor  any  imperfect  action 

of  the  levator  muscle  ;  but  the  skin  lias  losl  its 
connection  a\  itli  the  aponeurosis  and  the  upper 
border  of  the  tarsus,  and  therefore  is  nut  drawn 
hack  with  the  tarsus  when  the  lid  is  opened,  but 
falls  down    ever  the  lid-border   like  a   heavy 
curtain    (Fig.    366).      To   relieve   the  deformity 
by  cutting  away  tin's  skin-curtain   would   he  a 
grave  mistake,  because  it  would  leave  the  skin 
so  short  that  the  lid  could  not    he  closed.      lint 
the  deformity  can  he  perfectly  relieved   by  reattaching  the  skin  to  the  upper 
border  of  the  tarsus  by  means  of  the  sutures  employed  in  the  author's  opera- 
tion for  entropion  (see  page  -"'I!)). 


Fig.  360.— Operation  for  ptosis  adiposa. 


OPERATIONS  UPON  THE  CONJUNCTIVA,  CORNEA,  AND 
SCLERA;    ENUCLEATION  AND  EVISCERATION. 


By   CHARLES  W.    KQLLOCK,   M.  D., 

OF    CHARLESTON,    S.    C. 


Thk  conjunctiva,  being  a  highly  vascular  membrane,  heals  rapidly  after 
injury,  and  so  loosely  is  it  attached  to  the  eyeball  that  an  extensive  loss  may 
be  replaced  by  dissecting  it  from  the  ball  in  the  vicinity  of  a  wound  and 
drawing  the  flaps  together  by  sutures.     No  evil  effects  are  produced  by  this 

procedure,  and  in  many  eases  no  visible  cicatrix  remains.  With  the  con- 
junctiva of  the  lids,  however,  less  liberty  can  be  taken,  for  a  loss  of  the 
covering  in  this  part  may  result  in  entropion,  or  perhaps  a  narrowing  of  the 
palpebral  fissure.  Large  wounds  of  the  conjunctiva,  after  thorough  cleansing, 
should  be  closed  by  sutures,  and  require  but  little  after-treatment  beyond 
cleanliness  and  protection  by  closing  the  lid. 

Foreign  bodies  that  pass  through  the  conjunctiva  are  often  difficult  to 
remove  on  account  of  their  entanglement  in  its  meshes,  and  when  a  sharp 
instrument  is  used  in  the  attempt  to  remove  them  subconjunctival  hemorrhage 
generally  occurs  and  obscures  the  Held  of  operation.  This  is  especially  the 
case  with  grains  of  powder.  The  easiest  method  of  dealing  with  such  cases 
is  to  seize  the  body  with  forceps  through  the  conjunctiva  and  snip  off  the 
entangling  part,  which  causes  but  a  small  loss  of  tissue,  and  the  wound  heals 
without  leaving  a  scar.  Grains  of  powder  may  be  removed  in  this  way  when 
not  too  numerous;  otherwise  by  electrolysis,  as  advised  by  E.Jackson  (see 
also  page  368). 

Operations  for  Pterygium. — The  instruments  \\<vd  in  these  operations 
are  a  stop-speculum,  fixation-  and  dissecting-forceps,  sharp-pointed  knife, 
small  scissors,  strabismus-hook  or  probe,  needles,  needle-holder,  sutures,  etc. 

Operation. — The  anesthesia  produced  by  cocain  is  sufficient  for  this  operation,  which 
is  performed  as  follows :  (1  |  Thorough  removal  of  the  corneal  portion  of  the  growth  may 
be  accomplished  by  shaving  or  dissecting  it  away  with  a  sharp  knife,  and  then  scraping 
(Deschamps)  off  the  remnants  carefully,  or  by  destroying  them  with  the  fchermo-cautery 
or  by  the  application  of  pure  carbolic  acid  (Alt  |.  The  method  advised  by  Prince  is  also 
effective,  and  consists  in  grasping  the  growth  with  forceps  near  the  corneal  attachment. 
and  by  a  series  of  slight  jerks  its  rout-  or  prolongations  are  withdrawn  from  beneath 
Bowman's  membrane  and  even  from  between  the  corneal  layers.  No  opacity  remains 
when  this  is  carefully  done,  nor  does  the  cornea  become  inflamed.  Next  to  divulsion, 
the  method  of  scraping  the  remnants  from  the  cornea  with  a  knife  is  preferable  to  the 
use  of  the  cautery,  as  it  is  difficull   to  limit   the  action  of  the  latter  agent. 

The  next  step  is  the  disposition  of  the  body  of  the  growth.  It  may  be  separated  at 
its  borders  from  the  conjunctiva  proper  as  far  hack  as  the  caruncle,  ami  then  excised;  or 
it  may  be  transplanted  beneath  the  conjunctiva,  loosened  for  this  purpose  either  above 
or  below,  and  fixed  in  it-  new  position  by  a  suture  passing  through  the  growth  and  its 
conjunctiva  ;  or  it  may  be  split  from  apex  to  base,  and  one-half  transplanted  above  and 
the  other  below  the  opening,  as  advised  by  Knapp. 

Others  (Boeckmann,  Hotz    advise  unfolding  and  spreading  out  the  growth  after 
separating  it  from  the  cornea,  first  removing  all  subconjunctival  tissue;  which  i-  a  i 
important  step  in  any  procedure.      Boeckmann  fastens  the  reposed  conjunctiva     pt< 
ium)  to  the  head  of  the  internal  rectus  muscle  by  a  suture,  and  leave-  the  small  tri- 

36  661 


562 


OPEHATIOXS    CPOX   THE  CONJUNCTIVA. 


Fig.   :"!tV7.— Showing    position    of  graft, 
narrower  than  wound,   but   Long   enough 

to  reach  across  it. 


angular  and  denuded  space  near  the  cornea  to  heal  by  cicatrization,  which,  he  contends, 
will  prove  an  effectual  harrier  to  a  future  growth.     Hot/.,  alter  reposition,  covers  the 

denuded  spot  with  a  graft  taken,  alter  the  method 
of  Thiersch,  1'rom  the  inner  surface  of  the  fore- 
arm or  from  behind  the  ear.  This  graft  is  cut 
slightly  smaller  than  the  area  to  be  covered,  and 
is  placed  in  position  with  or  without  sutures 
according  to  circumstances. 

Ilobbs  and  others  advise  removal  by  means 
of  the  electro-cautery.  The  growth  is  grasped  by 
forceps  near  the  cornea  and  lifted  from  the 
sclera  ;  a  curved  needle  or  probe  is  passed 
beneath  it,  and  then  the  neck  is  burned  through 
with  the  cautery-tip  at  a  cherry-red  heat.  The 
subconjunctival  tissue  is  drawn  out  and  excised, 
and  the  corneal  end  is  scraped  away  or  touched 
by  the  cautery.     A  cross-stitch  unites  the  conjunctiva  near  the  cornea. 

In  all  cases  of  removal  or  transplantation  of  the  growth  the  conjunctiva  should  be 
loosened  above  and  below  and  the  edges  closely  united  by  sutures. 

Dressing. — After  thorough  cleansing  with  warm  bichlorid  or  boric-acid  solution  the 
eve  is  closed  with  sterilized  gauze  and  cotton,  which  are  held  in  place  by  any  form  of 
light  bandage  or  by  adhesive  strips.  The  dressing  may  be  renewed  every  day,  and 
sutures  should  remain  as  long  as  they  do  not  irritate,  which  is  usually  four  to  five  days. 
When  removing  sutures  it  is  advantageous  to  have  the  eye  under  the  inlluence  of  cocain, 
lor  a  sudden  movement  may  cause  the  edges  of  the  wound  to  separate.  The  simple 
introduction  of  the  speculum  may  also  cause  this  accident,  so  that  whenever  possible  it 
is  safer  to  have  the  lids  held  apart  by  the  fingers  of  an  assistant  or  even  by  the  patient 
if  he  is  not  too  nervous.  After  the  removal  of  the  sutures  the  dressing  may  be  left  off, 
and  the  eye,  which  is  often  quite  sensitive,  protected  by  tinted  glasses. 

Complications  arc  fare  after  this  operation.  Ulceration  of  the  cornea 
has  occurred,  and  should  be  treated  by  the  usual  methods.  Occasionally  a 
small  growth  of  granulation-material  springs  from  the  wound,  but  it  is  easily 
snipped  off  with  scissors  or  it  may  be  contracted  by  astringent  solutions. 
When  the  growth  has  extended  well  over  the  cornea  a  hazy  spot  is  apt  to 
remain  after  its  removal.  Pterygium  often  returns,  and  may,  under  ordinary 
circumstances,  be  again  removed. 

Symblepharon. — Instruments   necessary  for  the  operation   an — stop- 


!•"[...  :;r,-      'I'.-mIi-"-  operation  for  svniblepharon. 


speculum,  vulcanite  spatula,  fixation-  and  dissecting-forceps,  probe,  scissors, 
sutures,  needles,  needle-holder,  etc. 

For  the  simpler  operations  cocain  may  be  used,  bul  when  the  adhesions 
are  extensive  ether  or  chloroform   is  more  satisfactory. 

Operations. — The  slighl  form-  of  symblepharon  known  as  symblepharon 
anterius  an-  easily  cured  by  separating  the  attachment  and  preventing  its 
recurrence  by  the  frequent  passage  of  a  probe  between  the  point-.  Pooley 
and  Senile-  each  report  a  case  in  which  the  formation  of  symblepharon  was 
prevented  by  using  a  glass  or  rubber  shield  which  fitted  over  the  globe 
between  the  lids,  and  which  was  left  in  place,  excepl  during  shorl  intervals 
for  cleansing,  until  healing  took   place. 


OPERATIONS  FOB   TRACHOMA.  563 

There  are  several  methods  of  operating  when  adhesions  arc  extensive  and 
involve  the  fornix  {syitiblepharon  posterius).    Symblepharon  is  often  incurable. 

(1)  The  lid  is  separated  from  the  ball  and  the  dissection  is  carried  well  back  to  the 
fornix  (Arlt).     A  suture  armed  with  two  needles  is  passed  through  the  separated  end ; 

the  needles  are  then  passed  from  the  bottom  of  the  cul-de-sac  through  the  lid  to  the 
cheek.  Tightening  the  suture  draws  the  flap  down  and  brings  the  conjunctival  surface 
next  to  the  raw  surface  of  the  ball.  The  ends  of  the  .suture  are  tied  over  a  piece  of 
cork  or  drainage-tube. 

i  2)  Teale's  Operation. — Sliding  flaps  from  the  adjacent  conjunctiva  are  brought  over 
the  denuded  portions  and  sutured  in  position  (Noyes  and  Teale).  The  operation  is 
readily  comprehended  by  attention  to  the  accompanying  illustrations  (Fig.  368). 

(3)  Riverdin  covers  denuded  surfaces  with  small  pieces  of  mucous  membrane  taken 
from  the  mouth. 

(4)  Harlan  ha-  devised  the  following  operation  where  there  is  extensive  adhesion 
to  the  lower  lid:  The  adhesion  is  freely  dissected  until  the  upward  movement  of  the 
ball  is  entirely  unimpaired,  and  an  external  incision,  represented  at  All  in  the  accom- 
panying cut,  along  the  margin  of  the  orbit  is  carried  through  the  whole  thickness  of  the 
lid,  which  is   tints  separated   from    its   connections 

except  at  the  extremity.  A  thin  flap,  CD,  is  then 
formed  from  the  skin  below  the  lid,  care  being  taken 
to  leave  it  attached  at  its  base-line  by  the  tissue  just 
beneath  AB,  as  well  as  at  the  extremities.  On  this 
attachment  it  is  turned  upward  as  on  a  hinge,  bring- 
ing its  raw  surface  in  contact  with  the  inner  surface 
of  the  lid,  and  its  sound  surface  presenting  toward 
the  ball,  and  held  in  this  position  by  suturing  its 
edge  to  the  margin  of  the  lid.  In  dissecting  up  the 
flap  the  incisions  are  carried  more  deeply  into  the  Fig.  369.— Lines  of  incision  in  Harlan's 
orbicularis  muscle  when  the  base-line  AB  is  nearly  operation  for  symblepharon. 

reached,  to  enable  it  to  turn  more  readily.     The  bare 

space  left  by  the  removal  of  the  strip  of  skin  is  nearly  covered  without  strain  by  mak- 
ing a  small  horizontal  incision,  DE,  at  its  outer  extremity  and  forming  a  sliding  flap 
(Fig.  369). 

(5)  For  very  extensive  adhesions  an  opening  maybe  made  below  the  attachment 
and  a  piece  of  lead  wire  inserted,  which  is  left  until  a  fistulous  opening  is  formed,  when 
one  of  the  above  operations  may  be  performed  (Himly). 

(6)  Large  raw  surfaces  from  extensive  adhesions  may  also  be  covered  by  skin-grafts 
after  Thiersch's  method  (Hotz). 

Dressings. — After  minor  operations  it  is  sufficient  to  bandage  the  eye.  and  it  should 
be  kept  closed  until  the  sutures  are  removed.  After  transplantations  the  eye  should 
not  be  disturbed  for  three  or  four  days,  unless  there  are  signs  of  irritation,  and  both 
eyes  should  be  bandaged. 

Complications  are  due  to  the  failure  of  grafts  to  unite  ami  to  renewal 
of  adhesions. 

Symblepharon posterius  due  to  trachoma  is  scarcely  amenable  to  surgical  treatment. 

Transplantation  of  Rabbit's  Conjunctiva. — Wolfe  firsi  suggested 
this  mode  of  dealing  with  extensive  adhesions  between  the  li<l  and  eyeball, 
and  several  operators  have  performed  the  operation  with  beneficial  and  even 
surprising  results.    General  anesthesia  is  necessary,  ;i-  the  operation  Is  tedious. 

The  eye  and  appendages  are  cleansed  and  the  adhesions  are  divided.  Bleeding  is 
controlled  by  pledgets  of  absorbenl  cotton  saturated  with  hot  water  and  placed  in  the 
cul-de-sac.  Two  rabbits  are  anesthetized,  in  case  any  accidenl  should  happen  to  one. 
The  size  of  the  graft  having  been  calculated,  four  sutures  are  introduced  al  its  coi 
before  it  i<  separated,  because  after  removal  it  rolls  upon  itself  ami  it  i-  rather  difficult 
to  recognize  the  proper  surface.  The  graft  having  been  separated,  it  is  rapidly  trans- 
ferred to  the  denuded  area  and  carefully  stitched  in  position. 

Ankyloblepharon  is  readily  relieved  when  the  edges  of  the  lids  only 
are  united,  but  when  the  adhesions  involve  the  ball  also,  treatment  i<  of  little 
avail. 

Operations  for   Trachoma. — Expression  of  trachomatous  bodi 


504 


OPERATIONS   UPON  Till:  CONJUNCTIVA. 


performed  in  various  ways  by  different  surgeons  and  according  to  the  gravity 
and  duration  of  the  case.     The  roller-forceps  devised  by  Knapp  (Fig.  o70) 


Fig.  370.— Knapp's  roUer-foreeps. 

and   the   modifications    of   this   instrument   have   aided   very   much    in   the 
thorough  performance  of  this  operation. 

Where   follicles    are  discrete,   as  in    follicular    disease,   they   are  easily 
expressed    between   the    thumb-nails,  or    preferably   by   dissecting-forceps. 


Fig.  371.— Noyes's  trachoma-forceps. 

General  anesthesia    is  desirable  for    the    surgical   treatment  of    trachoma, 
though  there  are  those  who  prefer  to  operate  under  the  influence  of  cocain. 

Operation  of  Expression. — The  lid  is  grasped  with  forceps  near  the  ciliary  horder 
and  rolled  upon  itself  until  the  conjunctival  surface  is  well  exposed.  The  roller-forceps 
are  then  used  as  follows :  one  blade  is  pushed  well  up  into  the  retrotarsal  folds  while 
the  other  is  placed  near  the  ciliary  edge.  The  morbid  material  in  the  conjunctiva  is 
then  thoroughly  expressed  by  a  milking  process,  each  portion  being  subjected  to  the 
squeezing.  The  retrotarsal  folds  may  be  treated  separately  by  still  further  everting  the 
lid  and  drawing  them  out.  When  the  conjunctiva  near  the  edge  of  the  lid  is  to  be 
expressed,  one  Made  should  be  placed  upon  the  cutaneous  surface.  The  surgeon  should 
wear  protecting  glasses,  as  the  expressed  material  often  Hies  out  suddenly  and  to  a  con- 
siderable distance. 

After-treatment.— After  careful  cleansing  with  warm  bichlorid  solution  iced  com- 
presses are  applied  to  the  lids  for  several  hours  to  prevent  pain  and  swelling.  The  con- 
junctiva is  not  as  much  mutilated  as  might  be  expected  by  this  rough  handling,  and  hut 
little  reaction  follows.  Adhesions  are  very  apt  to  form,  and  should  be  broken  down  by 
the  daily  passage  of  a  probe  through  the  cul-de-sac.  The  subsequent  treatment  of  t  he  case 
requires  the  application  of  a  solution  of  nitrate  of  silver  (gr.  v-f^j),  and  later  that  of  a 
crystal  of  sulphate  of  copper. 

George  Lindsay  Johnson  1ms  described  the  following  operatiou  for 
trachoma  : 

The    lid    is   everted   over    a  vulcanite   spatula   and    held    teii>e   in  this   position   by  a 

double  hook  inserted  mar  its  edge.     With  a  tri-bladed  scalpel  the  conjunctiva  is  incised 
parallel  to  the  free  horder  of  the   lid  from  end  to  end.     The  instrument    is  then   moved 


Fig,  372     i  hree  bladed  Bcarifler. 


BO  that  the  lasl  blade  shall  pass  through  the  foremost  cut,  and  so  on  until  the  entire  sur- 
face baa  been  incised.  The  thicker  the  lid  the  deeper  the  cuK  and  vice  versd.  Bleed- 
ing is  controlled  by  cotton  compresses  saturated  with  hoi  water.  An  electrolizer,  con- 
nected with  a  Stirrer's  battery  of  twenty  cells  and  having  two  platinum  blades,  i-  nexl 
used.    The  blades  pass  through  the  incisions  made  by  the  scalpel.     Aboul  thirty  milli- 


OPERATIONS  FOB   TRACHOMA. 

amperes  are  used,  and  a  thick  loamy  cream  at  once  arises  about  the  blades,    strong 
current-  should  be  avoided.     The  lids  are  then  washed,  sprinkled  with  a  ~>  per  cent, 
solution  of  cocain,  dusted  with  calomel,  and  smeared  with  an  ointment  of  bydronaphthol 
and  vaselin,  1  to  sun.     Inflammation  and  swelling  are  controlled  by  iced  compn 
There  is  considerable  discharge  and  sloughing  for  forty-eight  hours.     Care  should 
taken  not  to  injure  the  cornea. 

The  after-treatment  consists  in  using  boric-acid  wash  and  the  ointment  of  beta-* 
naphthol  and  vaselin.     No  entropion  or  ectropion  has  resulted. 

Crrattage  is  an  operation  recommended  for  trachoma  by  Abadie,  Darier, 
and  other  French  surgeons.  As  the  operation  is  necessarily  quite  painful, 
ether  or  chloroform  should  be  used. 

The  lid  i>  everted  and  held  by  force].-  Fig.  373  .  as  in  the  operation  for  expression, 
and  t lie  conjunctiva  is  freely  incised  from  the  ciliary  border  to  the  fornix,  and  from  end 
to  end  of  the  lid,  by  the  tri-bladed  scarificator  (Fig.  37:2)  or  a  similar  instrument.    The 


Fig.  373.— Forceps  for  grattage. 

incised  surface  is  next  thoroughly  scrubbed  with  a  nail-brush  that  has  been  saturated  in  a 
strong  solution  (1  :  5<mi)  of  bichlorid  of  mercury.  By  this  proceeding  all  trachomatous 
material  is  washed  out,  and  the  lids  are  then  treated  by  cold  applications,  a-  described 
on  page  564.     The  same  care  must  be  exercised  to  prevent  the  formation  of  adhesions. 

Excision  of  the  Cul-de-sac. — This  method  of  treatment  is  very  old,  but 
Galezowski   in  1874  brought    it   again    prominently  before  the    profession. 

Stephenson  also  advocates  its  performance  in  certain  cases,  and  report-  a 
number  of  successful  operations.     The  operation  advised  by  him  is  as  follow- : 

The  lid  is  everted,  and  two  moderately  strong  suture-  are  passed  through  the 
extremities  of  the  fold.  The  sutures  are  held  by  anassistant,  who  by  their  manipulation. 
keeps  the  parts  "  on  the  stretch."  An  incision  is  now  made  along  the  attachment  of  the 
fornix  to  the  tarsal  conjunctiva  with  blunt-pointed  scissors,  but  should  never  go  beyond  the 
anterior  layer  of  tie'  fold.  4 'his  layer  i-  freed  from  its  attachment-,  and  the  dissection  into 
the  subconjunctival  layer  i-  carried  a-  far  back  as  i-  deemed  necessary.  The  operation 
is  completed  by  cutting  transversely  through  the  posterior  layer  of  the  cul-de-sac,  which 
comes  away  with  the  sutures.  Bleeding  i-  often  profuse,  but  may  be  arrested  by  twist- 
ing the  vessels.  Sutures  are  never  employed  to  close  the  wound.  The  eye  is  cleansed 
and  closed,  and  i-  not  inspected  for  five  or  six  days,  unless  complications  arise. 

Complications  are  of  two  kind- — viz.  wound-granulations  and  ptosis. 
The  former  should  be  -nipped  off  with  scissors.  The  latter  may  be  due  to 
the  swelling  of  the  lid  which  naturally  follow-,  and  will  soon  disappear,  or  to 
interference  with  the  tarsal  insertion  of  the  levator  palpebral  muscle. 
Stephenson  always  excises  the  upper  cul-de-sac,  as  it  i-  more  difficult  to  reach 
for  treatment  than  the  lower,  and  never  advocates  the  operation  tor  cases  that 
can  1)0  cured  by  other  means. 

Choice  .of  an  Operation. — Expression  i-  especially  valuable  in  cas 
spawn-like  granulation-  ami  diffuse  hyaline  infiltration.  Tt  may  be  used  in 
cicatricial  trachoma  with  patches  of  hyaline  infiltration.  Grattage  may  be 
employed  in  cicatricial  trachoma  and  in  cases  characterized  by  sclerotic 
masses  of  trachomatous  tissue.  It  i-  inferior  to  expression  preceded  by  scari- 
fication.     The  indications  for  excision  of  the  cul-de-sac  have  been  given. 


5to 


OPERATIONS   UPON   THE  CORNEA. 


Peritomy,  or  syndectomy,  is  performed  forgetting  rid  of  a  thick  pannus. 
A  narrow  strip  of  conjunctiva  '1  to  4  nun.  in  width  is  removed  from  around 
the  cornea,  and  all  vessels  going  to  the  cornea  are  divided. 

Kenneth  Scott  proposes  a  substitute  for  peritomy.  as  he  believes  the  latter 
operation  i»  rarely  a  success,  in  cases  of  vascular  cornea.  By  the  aid  of  a 
magnifying-glass  he  is  enabled  to  divide  with  a  Graefe  knife  every  vessel 
passing  to  the  cornea.  He  slits  them  throughout  their  entire  length,  which 
destroys  the  vessel  and  further  anastomosis  is  prevented. 

Subconjunctival  Injections  of  Germicides. — After  thorough  conjunctival  anti- 
sepsis and  anesthesia  have  been  secured,  a  fold  of  conjunctiva  is  seized  with  a  pair  of 
forceps  about  8  nun.  from  the  corneal  margin, and  the  point  of  a  hypodermic  or  Pravaz 
syringe  charged  with  the  germicide  is  introduced,  very  much  in  the  same  manner  as 
when  an  ordinary  hypodermic  injection  is  given,  and  '2  to  4  minims  i>i  the  fluid  are 
injected.  The  strength  of  the  solution  varies  with  diflerenl  operators.  Of  bicblorid 
1  :  2000  or  1 :  4000  may  be  employed.  Trichlorid  of  iodin  and  cyanure  t  of  mercury  may 
be  used  in  the  same  way. 

Precisely  the  same  results  follow  similar  injections  of  physiologic  salt 
solution,  and  it  i-  probable  that  all  of  these  injections  act  by  stimulating  the 
lymph-channels,  and  therefore  promoting  absorption.  They  act  favorably  at 
times  in  iritis,  irido-cyclitis,  scleritis,  and  corneal  ulceration.  They  have  also 
been  recommended  in  diseases  of  the  retina  and  optic  nerve,  but  the  author 
doubts  their  value  under  these  circumstances. 

OPERATIONS  UPON  THE  CORNEA. 

Foreign  Bodies  in  the  Cornea. — Small  particles  of  dust,  cinders, 
iron,  steel,  emery,  stone,  etc.  frequently  adhere  to  or  become  partially  or 
wholly  imbedded  in  the  cornea. 

When  simply  adherent  to  the  corneal  surface  or  but  slightly  imbedded  the  foreign 
body  is  easily  wiped  off  with  a  wisp  of  cotton  or  scraped  away  by  a  sharpened  match- 
stick  or  clean  wooden  toothpick.  Such  means  are  preferable  to  steel  instruments  in 
these  cases,  as  they  are  less  liable  to  injure  the  cornea.  When  the  body  is  more  firmly 
fixed  however,  it  is  necessary  to  use  the  ordinary  steel  spud  or  cataract  needle  (Fijr. 


Pig.  374.— Spud. 


Fig.  375.— Angular  lance-knife. 


Pig.  376     Lance-knife. 


874  .     Bodies  which  have  sunk  below  the  Burface  are  by  no  means  easy  to  extract,  for  a 
.-lie-lit  pressure  suffices  to  force  them  into  the  interior  chamber. 


Fin.  877.— Johnson's  magnet  for  removing  foreign  bodies  from  cornea. 

When,  therefore,  Bucb  a  condition  exists,  a  small  lance  knife  (Figs.  375,876)  Bhould 
be  entered  beneath  the  body  to  prevent  its  going  nearer  the  chamber.    It  is  then  cul  down 


APPLICATION  OF  THE  ACTUAL   CAUTERY.  567 

upon  and  grasped  by  forceps  or  pushed  from  its  position  with  a  small  probe  or  spud. 
\V.  l'>.  Johnson  lias  devised  a  magnet  for  such  cases.      Cocain  anesthesia  is  sufficient. 

After-treatment. — Especial  care  should  be  taken  in  the  after-treatment  of  these 
corneal  wounds,  for  it  not  infrequently  happens  thai  poisonous  germs  are  introduced 
and  infectious  ulcers  follow,  causing  abscess  and  loss  of  vision  from  resulting  leukoma 
or  loss  of  the  entire  eye  from  panophthalmitis.  Alter  removal  of  the  body  the  wound 
and  eve  should  be  carefully  cleansed  with  an  aseptic  solution,  atropin  instilled,  and  the 
eye  closed  by  a  bandage  to  prevent  reinfection  from  the  air;  all  instruments  should  be 
carefully  sterilized. 

Removal  of  Gunpowder  Grains  from  the  Cornea. — E.  Jackson 
treat-  these  cases  by  the  galvano-cautery,  as  follows  : 

A  small  cautery-tip,  such  as  is  used  for  cauterizing  corneal  ulcers,  is  brought  to  a 
white  heat  and  the  imbedded  powder-grains  are  touched  in  rapid  succession,  sufficient 
time  being  allowed  for  destroying  tissue.  The  resulting  scars  are  not  worse  in  appear- 
ance than  the  stains.  When  possible  the  operation  should  be  done  early  and  before 
diffusion  of  the  carbon  takes  place  (see  page  368). 

Paracentesis  of  the  Cornea. — The  instruments  required  for  this 
operation    are   a    stop-speculum  or  elevator,   fixation-forceps,    paracentesis- 

needle,  and  a  small  spatula. 

Operation. — The  anesthesia  of  cocain  is  sufficient,  except  with  children,  tor  whom 
ether,  chloroform,  or  bromid  of  ethyl  should  be  used.  The  eye  is  lixed  by  grasping 
the  conjunctiva  with  the  forceps  as  near  the  point  to  be  opened  as  is  possible,  because 
by  this  means  the  eye  can  be  held  more  firmly,  the  opening  made  gradually,  and  a 
sudden  evacuation  of  the  aqueous  humor  prevented.     The  needle  is  entered  within  the 


Fig.  378.— Paracentesis-needle. 

corneo-scleral  border  at  right  angles  to  the  surface,  and  as  the  blade  is  pushed  onward 
the  handle  is  slightly  depressed  in  order  to  avoid  wounding  the  iris  and  lens-capsule. 
Next  the  needle  is  gently  withdrawn,  allowing  at  the  same  time  a  gradual  escape  of  the 
aqueous,  so  that  the  iris  shall  not  be  swept  into  or  against  the  wound.  Careful  cleans- 
ing, the  instillation  of  atropin  or  eserin,  as  the  case  may  be,  and  a  light  bandage,  which 
should  be  worn  two  or  three  days,  generally  comprise  all  measures  needful  in  the  way 
of  treatment.     The  operation  may  be  repeated  when  necessary. 

Complications. — Prolapse  of  the  iris  into  the  wound  may  occur,  and  when 
it  cannot  he  replaced  with  the  spatula,  it  should  he  excised,  unless  the  prolapse 
is  very  small  or  the  iris  rests  against,  rather  than  falls  into,  the  incision. 

Curetting  the  Cornea. — A  -mall  curette  or  spud  mav  he  used  for  this 
operation,  which  is  done  for  indolent  or  spreading-  ulcers. 

By  the  aid  of  a  curette  the  necrosed  tissue  is  carefully  scraped   from  the  sides  and 
bottom  of  the  ulcer,  after  which    the   ordinary  treatment   for  corneal   ulceration   is   fol- 
lowed.   De  Wecker  and  Santarnecchi  (Cairo)  advise  what  is  called  " hydraulic  curetting''1 
as  a  substitute  for  the  ordinary  method-  and   the  use  of  the 
cautery.      A  syringe   having  a  small  nozzle  is   filled  with  a 
solution    of    bichlorid    of   mercury      1  :    1000),    which    is    then 
thrown  in  a  steady  stream  upon  the  ulcer  and  gradually  washes 
away  the  necrosed  tissue.     Santarnecchi  claim-  that  it  is  more 
thorough  and  less  dangerous  than  ordinary  curetting  and  the 
use  of  the  cautery,  as   injury  to  the  sound  tissues   is  much    lc<< 
likely  to  occur. 

Application  of  the  Actual  Cautery.  —  I'm-  tins 
purpose  a  platinum-tipped  probe  of  the  galvano-cauterv 

may  he  used. 

• 

The  point,  having  been  broughl   to  a  red  heat,  is  lightly 

applied  to  the  floor  and  sides  of  the  ulcer,  care  being  taken  not  to  perforate  the  anterior 
chamber.  The  area  to  be  cauterized  is  colored  green  by  dropping  upon  it  a  solution 
of  fluorescin  isee  page  145). 


568  OPERATIONS   UPON  Till:  COHXEA. 

The  after-treatment  consists  in  the  use  of  atropin  and  mild  aseptic  washes,  such 
as  boric  acid  and  salt.  The  application  of  a  bandage  depends  upon  the  quantity  of  the 
discharge. 

Saemisch's  Section. — The  instruments  necessary  arc  a  stop-speculum, 
fixation-forceps,  v.  Graefe  knife,  spatula,  and  perhaps  a  small  syringe. 

Operation. — The  pupil  should  be  dilated  as  much  as  possible,  and  if  the  patient  is 
a  child  general  anesthesia  is  necessary.  The  eye  is  steadied  by  grasping  the  conjunctiva 
with  the  forceps  while  the  knife  is  entered,  edge  out,  in  the  healthy  tissue  near  the 
ulcer.  The  point  is  passed  through  the  anterior  chamber  and  emerges  at  a  corre- 
sponding spot  beyond  the  ulcer,  when  the  intervening  corneal  tissue  is  cut  through, 
allowing  the  pus  and  aqueous  humor  to  escape. 

Sometimes  the  pus  is  caught  between  the  li|>-  <it'  the  wound,  but  is  easily  removed 
with  a  spatula  or  iris-forceps, or  by  washing  out  the  chamber  with  any  specially  devised 
syringe  charged  with  normal  salt  solution.  The  iris  should  be  replaced  a-  well  as  pos- 
sible,  but  synechias  are  likely  to  result. 

The  after-treatment  consists  in  cleanliness,  the  instillation  of  atropin,  and  the 
application  of  a  bandage  until  the  cornea  has  healed.  The  operation  may  he  repeated 
a-  often  as  the  pus  re-forms. 

Complications  are  synechia?  and  the  resulting  leukoma,  which  latter  is 
•  hie  to  the  ulceration  rather  than  the  incision.  Panophthalmitis  and  entire 
destruction  of  the  cornea  mav  result  if  the  ulceration  is  not  checked. 

Conical  Cornea ;  Staphyloma  Pellucidum. — There  are  various 
operation-  for  this  deformity,  all  of  which  have  lor  their  object  the  removal 
of  the  cone.  Vim  Graefe  shaved  off  the  apex  of  the  cone  and  applied  the 
solid  nitrate-of-silver  stick  to  the  wound,  which,  as  it  healed,  caused  contrac- 
tion and  diminution  of  the  cone.  Bowman  accomplished  the  same  result  by 
means  of  a  trepan,  and  Knap])  has  devised  a  special  point  for  the  galvano- 
cautery,  with  which  the  cone  is  cauterized  as  deep  as  Descemet's  membrane, 
avoiding,  if  possible,  entrance  into  the  anterior  chamber  (Fig.  380). 

Fig.  380.— Knapp's  cautery-point  for  conical  cornea.  F"'  381.— Tattooing-needle. 

A.fter  healing,  arj  iridectomy  is  usually  necessary.  'Flic  scar  left  by  the 
cautery  may  be  tattooed — a  procedure  which  not  only  improves  the  appear- 
ance of  the  eye,  but  also  the  vision,  by  excluding  unnecessary  light.  It  may 
be  necessary  to  repeal  the  operation,  which  is  preferable  to  running  the  risk 
of  destroying  the  eye  by  attempting  too  much  at   first. 

Tattooing  the  Cornea. — The  instruments  required  area  stop-speculum, 
fixation-forceps,  and  tattooing-needle  (Fig.  381). 

Operation.  -Thorough  anesthesia  of  the  cornea  is  essential  in  order  thai  the  ink 
may  be  driven  well  into  its  layer-.  The  India  ink  should  be  of  the  consistency  of  paste 
and  plentifully  applied  to  the  leukoma,  as  it  soon  fades  when  thinner.  The  pigment 
i-  then  pricked  into  the  cornea  over  the  area  to  be  covered,  after  which  the  excess  is 
washed  away  by  a  boric  acid  solution.  Atropin  i-  next  instilled  and  a  light  bandage  is 
applied.  The  reaction  subsides  within  a  few  days,  and  the  operation  may  be  repeated, 
it  necessary,  after  all  inflammation  has  disappeared.  Different  colored  ink-  may  he 
used  to  match  the  varying  color-  of  the  irides.  Tattooing  is  also  useful  for  covering 
colobomata  which  admit  too  much  lighl  to  the  eye. 

Wounds  of  the  Cornea. — rncised  wounds  usually  heal  without  trouble, 
it   being    simply  necessary  to  cleanse   the  eye  carefully,    to  bring   the    lips 

of  the    w ul  accurately  together,    to   replace    (lie   iris    if  it    has    fallen    into 

the  wound,  and  to  apply  a  bandage.     Eserin  or  atropi ay  be  used  accord- 


SCLEROTOMY. 

ing  to  the  position  of  the  wound.  Ef  the  prolapse  continues  and  cannol  be 
replaced,  it  should  be  excised.  Large  gaping  wounds,  whether  incised  or 
lacerated,  may  be  closed  with  sutures,  which  should  be  composed  of  very  fine 

silk. 

De  Wecker  has  advised  the  following  method  for  closing  and  protecting 
large  wounds  of  the  cornea  :  The  conjunctiva  is  dissected  from  the  corneal 
limbus  and  beyond  the  attachments  of  the  recti  muscles.  A.  suture  is  then 
passed  in  and  out  near  its  a\^(\  which,  when  tightened  like  a  string  ;ii  the 
mouth  of  a  bag,  draws  the  conjunctiva  over  and  entirely  covers  the  cornea. 
It  should  remain  until  the  cornea  has  healed,  when  it  may  be  dissected  loose. 
Adhesions  do  not  take  place,  except,  perhaps,  in  the  line  of  the  wound,  and 
these   arc    readily  freed. 

Von  Hippel's  Operation   for  Transplanting  the   Cornea. — In 

eases  of  central  leukoma  von  Ilippel  has  transplanted  a  graft  from  the  cornea 
of  a  rabbit,  but  the  results  have  not  been  very  satisfactory,  because  the  trans- 
planted cornea  has  also  finally  become  opaque.  He  restricted  the  operation 
to  those  cases  where  the  entire  corneal  thickness  was  not  involved — in  other 
words,  where  the  leukoma  was  not  totally  adherent. 

Operation. — A  general  anesthetic  should  be  used  for  patient  and  rabbit.  Tin-  eve 
having  been  prepared,  the  trepan  is  gauged  so  that  it  shall  not  enter  the  anterior  cham- 
ber. It  is  placed  accurately  over  the  center  of  the  cornea,  and  by  touching  the  spring 
the  cut  is  quickly  made.  The  plug  is  lifted  out  by  the  aid  of  special  forceps  and  cut  oil' 
with  a  Graefe  knife.  In  a  like  manner  the  plug  is  cut  from  the  rabbit's  eye  and  quickly 
transferred  to  the  patient's.  After  cleansing,  both  eyes  should  be  bandaged  and  the 
patient  kept  quiet  in  bed  for  a  few  days. 

Complications  may  be  ulceration  of  the  cornea  and  general  infection  of  the  eye. 

Operations  for  Closing  Scleral  Wounds. — Wounds  of  the  sclera 
are  common  near  the  corneal  border,  over  the  ciliary  body,  and  on  the  upper 
surface  id'  the  ball.  Owing-  to  the  frequent  involvement  of  the  ciliary  body, 
extreme  care  must  be  exercised  in  their  management. 

Small  punctured  wounds  require  no  special  care  beyond  the  usual  anti- 
septic precautions;  but  if  exposed,  they  should  be  covered  with  the  conjunctiva. 
Small  incised  and  lacerated  wounds,  when  inclined  to  gape  or  when  their  edges 
are  separated  by  a  bead  of  vitreous  humor,  should  be  closed,  after  the  pro- 
lapsed vitreous  has  been  excised,  with  small  animal  sutures  introduced  through 
the  outer  layers  in  order  to  avoid  wounding  the  inner  coats  id'  the  eye.  The 
conjunctiva  is  to  be  sutured  over  the  scleral  wound  with  animal  or  silk 
sutures.  Large  scleral  wounds  may  at  times  be  approximated  -imply  by 
closing  the  conjunctiva  over  them,  but  it  i>  probably  safer  to  suture  the  sclera 
to  avoid  the  danger  of  staphyloma.  Care  musl  be  taken  that  the  ciliary  body 
and  choroid  are  not  imprisoned  in  the  wound.  The  subsequent  treatment 
requires  cleanliness  and   bandaging   until   healing  is  complete. 

Complications  arise  from  injuries  to  the  ciliary  body,  choroid,  and  retina, 
which  may  cause  sympathetic  ophthalmia  and  separation  of  the  retina,  Pro- 
lapse  of  the  vitreous  interferes  with  healing. 

Sclerotomy. — The  instruments  for  this  operation  are  a  stop-speculum, 
fixation-forceps,  Graefe  knife,  and  spatula. 

Operation. —  A  Graefe  knife  is  entered  in  the  sclera  aboul  1  nun.  from  the  cornea, 
arid,  passing  through  the  anterior  chamber,  emergea  at  a  corresponding  point  on  the 
opposite  side.  The  cm  b  made  upward  by  a  to-and-fro  motion,  as  in  the  operatic 
removing  cataract,  until  a  narrow  bridge  is  left  connecting  the  sclera  with  the  cornea. 
The  knife  ia  then  withdrawn  carefully  to  prevent,  it'  possible,  tin'  prolapse  of  the  iris, 
which  i>  apt  to  occur,  and  which  should  then  be  excised  1 1 


570 


OPERATIONS   VPOX  THE  SCLERA. 


Fig.  382. — Lines  of  incision  in  sclerotomy. 


This  operation  is  not  as  effective  as  iridectomy,  and  Fuchs  says  should 
only  be  performed  under  the  following   conditions:     1.  Glaucoma  simplex, 

with  a  dcej)  anterior  chamber  and  without 
distinct  elevation  of  tension.  2.  Inflamma- 
tory glaucoma,  when  the  iris  through  atrophy 
has  become  so  narrow  that  one  cannot  hope 
to  perform  excision  of  the  iris  that  would  be 
according  to  rule.  3.  Hemorrhagic  glau- 
coma. 4.  Hydrophthalmos.  5.  Instead  of 
a  second  iridectomy  in  those  eases  of  glau- 
coma in  which  the  increase  of  tension  returns  in  spite  of  an  iridectomy  per- 
formed according  to  rule  (compare  with  page  078). 

Posterior  Sclerotomy. — The  incision  should  be  placed  so  as  notto  wound  the  ocular 
muscles  or  endanger  the  ciliary  body,  and  should,  therefore,  not  approach  the  cornea 
nearer  than  ti  or  7  nun.  The  cut  is  made  with  a  Graefe  knife  from  behind  forward,  SO 
as  to  correspond  with  the  direction  of  the  scleral  libers.     There  is  probably  less  danger 

from  infection  it'  the  incision  in  the  sclera  i-  not  directly  under  that  in  the  conjunctiva. 
When  it  is  desired  to  produce  a  fistulous  opening  the  incision  should  be  made  near  the 
equator,  as  healing  is  less  likely  to  take  place  here  than  farther  forward. 

Posterior  sclerotomy  is  indicated  in  cases  where  the  anterior  chamber  has 
been  obliterated  and  iridectomy  or  anterior  sclerotomy  cannot  be  performed, 
for  separation  of  the  retina,  for  staphyloma,  and  for  those  cases  in  which 
reduction  of  tension  is  indicated  and  other  operations  are  not  available.  In 
cases  of  corneal  staphyloma  it  may  be  necessary  to  repeat  the  operation  a 
number  of  times  before  satisfactory  results  arc  obtained. 

Sclerectomy,  as  described  by  II.  Parinaud,  is  for  the  purpose  of  obtain- 
ing less  resistance  from  the  sclera,  more  efficacious  drainage,  and  the  forma- 
tion of  a  staphyloma  when  desired. 

Operation. — At  a  point  mar  the  equator  a  curved  needle  is  plunged  into  the  exter- 
nal layers  of  the  sclera,  which  are  then  slightly  elevated.  With  a  Graefe  knife,  held 
Parallel  to  the  needle,  a  flap  is  cut,  at  the  bottom  of  which  the  choroid  should  be  visible, 
t  is  advisable  not  to  cut  entirely  through  the  sclera,  though  this  may  be  punctured 
later  if  thought  uecessary. 

Operations  for  Staphyloma. — Small  staphylomata  of  recent  formation 
may  frequently  be  cured   by   pressure  from   well-applied    bandages,   which 

should  be  kept  in  place  until  the  cornea 
has  regained  its  tonicity.  When  this 
proves  unsuccessful  an  iridectomy  may 
be  performed  at  or  near  the  point  of 
bulging;  after  this  the  eye  must  be 
bandaged  until  healing  is  complete  and 

the  part:-  are  Btrong. 

A  staphyloma  involving  the  entire 
cornea  is  difficult  to  treat  successfully, 
and  many  methods  of  operating  have 
been  devised.  Probably  the  most  ef- 
fective is  entire  excision  of  the  growth  ; 
though     the    safer,    hut     more     tedious 

method,  which  sometimes  succeeds  ad- 
mirably, is  by  posterior  sclerotomy. 

For  the  operation  1>\  excision  the 
following  instruments  are  necessary  :  a 

stop  speculum,    fixation-forceps,  Beer's   knife,  scissors,  needles,  and  sutures. 

Ether  or  chloroform  should  !><■  administered. 


I,.  Wecker's  operation  for  staphyloma. 


ENUCLEATION  OF  THE  EYEBALL. 


571 


De  Wecker  and  Critchett  both,  after  having  inserted  needles  «>r  sutures 
through  the  base  of  the  staphyloma  to  prevent  loss  of  vitreous,  excise  the 
staphyloma  with  the  knife  and  scissors  and  allow  the  lens  to  escape.  !><■ 
Wecker  closes  the  wound  by  drawing  the  conjunctiva  together  over  it,  while 
(Yitchett  passes  the  sutures  through  the  sclera  and  draw-  its  edges  aceurately 
together.  The  conjunctiva  is  then  closed  over  the  scleral  wound.  Reference 
to  the  figures  will  make  the  steps  of  these  operation-  evident,  which  are  not 
now  much  practised,  as  evisceration  with  insertion  of  artificial  vitreous  is 
preferable  (Figs.  383-385). 

After-treatrnent. — The  eve  is  dressed  and  kepi  closed  for  several  days 
unless  there  are  symptoms  of  inflammation.     Healing  is  slow. 

Complications. — Wounding  the  ciliary  body  may  cause  sympathetic 
ophthalmia,  and  a  general  infection  may  be  followed  by  panophthalmitis. 


FlG.  384.— Critchett's  operation  for  staphyloma. 


Fig.  385.— Stump  after  Critehett's  operation  for 
staphyloma. 


Enucleation  of  an  Eyeball. — Most  operators  prefer  general  anesthesia 
for  this  operation,  but  there  are  a  few  who  advise  cocain.     J.  J.  Chisolm 


FlG.  386.— Enueleat  ion-scissors. 

speaks  highly  of  bromid  of  ethyl.  The  instruments  required  are  a  stop- 
speculum,  fixation-  and  dissecting-forceps,  strabismus-hook,  ami  enucleation- 
scissors  (  Fig.  386). 

Operation — Bonnet's  Method. — The  conjunctiva  is  grasped  by  the  forceps  near  the 
cornea,  and  with  the  scissors  is  loosened  entirely  around  the  latter  and  as  near  t<>  it  as 
possible.  The  dissection  is  then  carried  well  back  in  every  direction.  The  recti  luna- 
cies are  next  caught  up  separately  by  a  strabismus-hook  and  their  tendons  divided 
close  to  the  ball.  The  scissors  are  new  pressed  close  to  the  ball  and  dissect  it  from  the 
orbital  ti>~nes  on  .■very  side.  The  enucleation-scissors  are  then  passed  well  hack  into 
the  orbit  until  the  points  touch  the  optic  nerve,  when  they  are  separated  ami  the  nerve 
i-  Bevered  as  tar  hack  as  possible.  The  scissors  may  he  entered  from  the  nasal  "i-  tem- 
poral side.  Care  should  he  taken  not  to  divide  the  nerve  too  close  to  the  hall  or  the 
sclera  may  be  perforated. 

Vienna   Method.— By  this  method  the  operation  i<   much  more  quickly 
performed,  but    there   is    greater  Loss  of  orbital  tissue,  which   prevents  the 


572  OPERATIONS   UPON  THE  EYEBALL. 

accurate  fitting  <>t'  an  artificial  eve.  This  operation,  however,  is  to  be  recom- 
mended when  for  any  reason  a  quick  manipulation  is  necessary. 

The  conjunctiva  is  opened  near  the  outer  or  inner  margin  of  the  cornea  and  dis- 
sected away  over  the  attachment  of  the  rectus  muscle,  which  is  caught  up  and  divided. 
The  scissors  arc   then   passed   rapidly  around  the  ball,  dissecting  it   from  the  orbital 

tissues  until  the  nerve  is  reached  and  divided.  The  anus  of  the  speculum  are  opened 
and  prosed  hack  to  force  the  hall  from  tin'  socket.  The  conjunctiva,  muscles,  and 
orhital  tissues  are  then  easily  divided  by  rotating  the  hall.  If  hemorrhage  is  profuse 
alter  enucleation,  it  should  lie  checked  at  once  by  hot  water  to  prevent  the  orhital 
tissues  from  becoming  infiltrated.  The  hot  water  is  best  applied  by  saturating  halls  of 
absorbent  cotton  and  forcing  them  into  the  orbit.  Some  operators  suture  the  edges  of 
the  conjunctiva,  though  this  is  unnecessary. 

After  bleeding  has  ceased  the  orbit  should  be  flooded  with  hot  bichlorid  solution 
(1:5000).  A  piece  of  sterilized  gauze  is  placed  next  to  the  lids,  upon  this  a  good- 
sized  pad  of  absorb) snl  cotton  (sterilized),  and  over  these  a  roller  bandage  is  tightly 
applied,  care  being  taken  to  make  the  turns  from  below  upward,  so  that  the  compress 
shall  be  forced  into  the  orbit. 

After-treatment. — When  possible  the  dressing  should  be  changed  a  few  hours 
after  its  application,  as  it  adds  much  to  the  comfort  of  the  patient.  The  eye  should  he 
dressed  every  day.  and  the  orbil  thoroughly  Hooded  with  warm  bichlorid  solution.  Rest 
in  bed  tor  two  or  three  days  after  the  operation  is  a  safe  plan  to  follow,  though  many 
surgeons  do  not  require  it.  After  three  or  four  days  the  roller  bandage  may  be  replaced 
by  a  lighter  form. 

Complications. — Secondary  hemorrhage  rarely  occurs,  and  may  be  controlled  by 
applying  hot  water  and  tightening  the  bandage.  Cellulitis,  meningitis,  acute  mania, 
and  tetanus  have  followed  enucleation.  In  cases  of  cellulitis  and  meningitis  deep 
incisions  should  be  carried  to  the  back  of  the  orbit,  hot  applications  should  be  made  to 
the  lids,  and  a  free  evacuation  from  the  bowels  should  be  encouraged. 

Exenteration  or  Evisceration. — This  operation  should  under  no 
circumstances  be  performed  upon  an  eye  that  may  be  capable  <d'  causing 
sympathetic  ophthalmitis,  and  is  therefore  applicable  to  but  a  few  eases.1 


Fir;.  387.— Scoop  for  evisceration. 

The  instruments  required  are  a  stop-speculum,  fixation-forceps,  Beer's 
knife,  small  scissors,  curette  or  s< p,  needles,  sutures,  etc. 

Opt  ration. — The  conjunctiva  having  been  dissected  to  the  equator  of  the  eyeball,  the 
cornea  i-  excised  bypassing  a  Beer's  knife  through  the  corneo-scleral  juncture  from 
Bide  to  side  and  cutting  ou1  above,  then  reversing  the  knife  and  cutting  down,  or  after 
the  first  incision  with  the  knife  the  remaining  Hap  is  removed  with  the  scissors.  The 
contents  of  the  globe  are  evacuated  and  the  inner  coats  scraped  away  with  scoop  or 
curette.  Hemorrhage  is  controlled  by  hoi  water  and  the  cavity  cleansed  with  hot 
bichlorid  solution  (1  :  2 or  3000).  It  is  very  essential  that  every  portion  of  the  con- 
tents should  be  thoroughly  removed  and  hemorrhage  completely  controlled,  for  under 
these  condition-  healing,  which  is  necessarily  slow,  progresses  more  favorably.  Prince 
advises  cauterizing  the  scleral  cavity  with  95  per  cent,  carbolic  acid  to  relieve  pain  and 
to  hasten  bealing.  The  edges  of  the  sclera  are  approximated  accurately  with  catgut 
sutures,  and  the  conjunctiva  is  closed  with  silk  sutures. 

/'  •    and  the  after-treatment  are  the  same  as  for  enucleation,  but  the  period  of 

reco\ .  iy  i-  more  protracted. 

Evisceration  of  the  Eyeball,  with  Insertion  of  an  Artificial 
Vitreous  (Mules? 8  Operation). — Mr.  Mules  has    modified  the  operation  of 

1  In  tie-  "pinion  of  the  Editor,  die  sphere  of  evisceration  i-  by  no  means  so  limited, 
although  if  in  a  case  of  sympathetic  ophthalmitis  or  irritation  already  developed  it  was  decided 
io  n  move  tie  exciting  eye,  he  would  perform  enucleation. 


EVISCERATION  OF  THE  EYEBALL. 


573 


evisceration  by  the  introduction  of  a  glass  ball  into  the  cavity  of  the  sclera. 
In  general  terms  the  operation  is  performed  in  the  same  manner  as  an  ordi- 
nary  evisceration,  but  certain  special  precautions  require  to  be  ooted. 

The  conjunctiva  having  been  dissected  from  the  corneo-scleral  attachment  in  all 
directions  to  the  equator  of  the  eyeball  without  disturbing  the  muscles,  evisceration  is 
performed,  after  abscission  of  the  cornea,  in  the  ordinary  manner.  A  perfectly  clean 
white  scleral  cavity  must  be  secured,  and  hemorrhage  absolutely  controlled  by  packing 
the  cavity  with  sterilized  gauze  saturated  with  a  hot  solution  of  bichlorid  of  mercury, 
1:2000,  ami  by  frequently  irrigating  it  with  a  tepid  solution  of  tin-  same  drug 
times  tlic  hemorrhage  is  more  readily  controlled  with  repeated  dry  packings  of  sterilized 
•ran/''  than  witli  hot  solutions.  A  glass  sphere  i  Fig.  •'X|  .  of  such  size  that  it  may  be  in- 
troduced within  the  scleral  cup  without  difficulty,  is  selected, 
its  introduction  being  facilitated  by  slitting  the  sclera  verti- 
cally for  about  4  mm.  at  the  upper  and  lower  corneo-scleral 
margins.  The  introduction  of  the  sphere  is  further  facili- 
tated by  the  use  of  an  instrument  specially  devised  for  this 
purpose  (Fig.  388).  The  concluding  steps  of  the  operation 
consist  in  stitching  the  sclera  vertically,  the  conjunctiva 
horizontally,  dusting  iodoform  within  the  socket,  and  apply- 
ing a  full  antiseptic  dressing.  Indeed,  the  greatest  care 
should  be  exercised  to  secure  absolute  antisepsis  during  the 
operation  and  at  the  subsequent  dressings. 

After-treatment. — The  patient  should  be  confined  to 
bed  for  at  least  three  days,  and   both  eyes  should  be  band- 


I  !     388.— Instrument  for  introducing  the  glass  sphere. 


Fig.  389.— Glass  balls  for  intro- 
duction into  scleral  cupafter  evis- 
ceration. 


aged  for  forty-eight  hours.  At  the  end  of  this  time  there  may  be  a  daily  dressing, 
and  at  the  end  of  five  or  six  days,  or  at  most  at  the  end  of  a  week,  the  patient  may 
be  discharged  from  his  room.  Usually  an  artificial  eye  can  be  worn  at  the  expiration 
of  two  weeks. 

Complications. — Severe  reaction  occasionally  follows,  with  mark  edema 
of  the  lids  and  chemosis  of  the  conjunctiva.  The  chemotic  conjunctiva  may 
be  incised,  and  the  reaction  controlled  by  continuous  iced  compresses. 

Early  absorption  of  the  sutures,  if  catgut  is  used,  may  cause  the  scleral 
wound  to  separate  and  the  glass  ball  to  extrude.  Should  this  happen,  the  hall 
may  be  removed  and  the  operation  converted  into  an  ordinary  evisceration,  or 
a  still  smaller  ball  may  be  placed  in  position  and  the  scleral  wound  once  more 
closed  with  catgut  sutures. 

The  stum])  after  a  successful  Mules's  operation  is  so  superior  to  thai  fur- 
nished by  any  other  method  that,  if  no  contraindication  exists,  there  should 
be  no  hesitancy  in  performing  this  operation  :  for  even  it'  the  accidenl  of 
extrusion  of  the  ball  should  take  place,  the  remaining-  stump  is  far  preferable 
to  any  that  could  be  formed  after  an  ordinary  enucleation.  The  danger  that 
the  glass  ball  may  be  broken  is  remote,  although  thi<  accidenl  has  happened. 

Other  Operations  for  Support  of  Artificial  Bye. — Claiborne  and 
Belt  advise  sponge-grafting  in  the  orbit  for  the  support  of  an  artificial 
After  removal  of  the  eye  a  globe  of  sponge,  aboul   three-fourths  the  size  >>\ 
the  eyeball,  is  inserted  into  the  socket  or  Tenon's  capsule.     The  recti  muscles 
are  then   united  over  it  and  the  conjunctiva  over  all.     Suker  prepares  the 


574  OPERATIONS  OX  IRIS  AND   CRYSTALLINE  BODY. 

stump  for  an  artificial  eye  by  suturing  the  recti  muscles  together  with  catgut 
and  the  conjunctiva  with  >ilk. 

L.  W.  Fox  describes  an  operation  for  irrvplardiitg  a  glass  ball  in  an  orbit 
from  which  the  globe  has  been  enucleated  at  some  previous  date.  A  hori- 
zontal incision  is  made  through  the  conjunctiva  and  tissues  of  the  orbit,  which 
should  be  slightly  less  than  the  diameter  of  the  ball  to  be  inserted.  The 
upper  lip  of  the  conjunctival  wound  is  raised  and  dissected  away  by  sharp 
SClSSOrs  until  a  pouch  is  made  for  the  ball,  which  is  inserted  after  bleeding  is 
controlled,  and  the  opening  closed  by  sutures.  This  operation  i>  practically 
identical  with  the  suggestion  of  Frost  and  Lang  to  introduce  a  Mules's  sphere 
into  Tenon's  capsule  after  ordinary  enucleation,  and  close  the  muscles  and 
conjunctiva  over  it  in  the  usual  way. 

Optico-ciliary  Neurectomy. — This  operation,  like  evisceration,  was 
proposed  as  a  substitute  for  enucleation,  but  has  not,  for  two  reasons,  filled 
the  place  to  which  it  was  assigned  :  1.  It  does  not  replace  enucleation,  because 
the  danger  of  infection  from  such  an  eye  is  by  no  means  prevented,  as  cases 
of  sympathetic  ophthalmia  have  occurred  after  its  performance.  2.  The 
operation  is  rather  difficult  to  perform,  and  has  been  followed  by  softening 
and  atrophy  of  the  globe. 

Operation. — An  opening  is  made  between  the  superior  ami  external  recti  muscles, 
and  the  scissors,  pressed  close  to  the  hall,  divide  the  tissues  until  the  optic  nerve  is 
found.  This  is  caught  by  a  strabismus-hook  as  far  back  as  possible  ami  divided.  The 
optical  end  is  then  seized  by  forceps  or  hook  and  drawn  to  the  opening.  The  nerve  and 
all  surrounding  tissues  are  then  cut  close  to  the  ball.  There  is  considerable  hemorrhage, 
and  it  is  difficult  to  replace  the  ball.  There  is  some  prominence  of  the  ball  for  a  time, 
but  it  usually  resumes  its  normal  position  after  a  shorter  or  longer  period. 

After-treatment  consists  in  cleanliness  and  bandaging  the  eye  until  healing  is 
complete. 

Complications. — Abscess  of  the  orbit  and  meningitis  may  follow  from 
infection  during  the  operation. 


OPERATIONS  ON  THE  IRIS  AND  THE  CRYSTALLINE 

BODY. 

By  HERMAN   KNAPP,  M.  D., 

Ml      Ni:\V    YORK. 

General  Precautions. — The  patient  should  be  five  from  acute  disease 
and  from  exacerbations  of  chronic  general  disease.  The  time  of  the  year 
makes  a  difference  only  in  so  far  as  constitutional  infirmities  are  influenced 
by  it  :  for  instance,  I'm  persons  should  avoid  the  hoi  season,  patients  with 
pulmonary  and  kidney  disease  the  coldesl  winter  months,  etc.  Cleanliness 
of  the  -kin  and  hair,  a-  well  a-  regularity  of  the  bowels,  should  receive  due 
attention. 

Dhe  operations  on  the  iris  and  lens  can  be  most  conveniently  performed 
on  mi  operative  chair,  which  can  be  moved  (on  casters),  so  thai  the  besi 
illumination  of  the  eye.  either  by  day  or  by  artificial  light,  can  be  readily 
secured  mid  disturbing  reflexes  avoided.  For  cataract-extraction  it  is  of 
advantage  to  operate   on    the    patient    in    his  lied,  if  the    bed  can   be  moved  to 

tin-  source  of  light,  because  the  patient  will  not   be  disturbed  by  taking  him 


OPFJIATIOXS  ON   THE  IBIS. 


575 


from  the  chair  t<>  his  bed.  This  advantage  is  counterbalanced  by  the  greater 
ease  the  surgeon  and  his  assistant  enjoy  when  the  patienl  is  placed  upon 
a  chair. 

The  patient  should  keep  ;is  quiet  as  he  can  during  the  firs!  twenty-four 
hours  after  the  operation,  tor  quietness  is  an  important  factor  in  obtaining 
primary  union  of  the  wound,  lie  may,  however,  sit  up  in  bed  for  hi>  meals 
and  gel  up  for  calls  of  nature.  In  case  he  is  not  nervous  and  his  attendance 
good,  the  degree  of  success  of  the  operation  will  lie  greater  if  for  one  or 
several  days  both  eyes  are  bandaged  ;  otherwise,  the  non-operated  <vc  may 
be  covered   with  a  patch  which  the  patient   occasionally   may   raise. 

Xo  septic  condition  should  he  present  in  any  organ  of  the  patient  at  the 
time  of  the  operation ;  in  particular,  the  conjunctiva  and  the  lachrymal  sac 
must  he  free  from  suppuration.  Chronic  non-snppnrative  disease  of  these 
parts  is  no  absolute  counter-indication. 

The  operations  should  be  done  under  aseptic  conditions  as  perfect  as  we 
can  have  and  make  them.  Immediately  before  the  operation  the  eye  and  its 
surroundings  are  washed  with  soap,  then  with  a  1  :  5000  solution  of  corrosive 
sublimate,  with  which  also  the  edges  and  mucous  surfaces  of  the  everted  eye- 
lids are  washed  by  means  of  pledgets  of  absorbent  cotton. 

Cocain-anesthe<ia  is  sufficient  and  preferable  in  most  cases  ;  only  in  chil- 
dren, nervous  and  unruly  adults,  and  in  cases  of  high  eyeball  tension,  com- 
plete general  anesthesia  should  be  administered. 

Besides  a  nurse,  the  operator  should  have  at  his  disposal  two  or  three 
trained  assistants — one  to  take  charge  of  the  instruments,  the  second  to  hold 


Fig.  390.— Eye-speculum. 

the  fixing-forceps  and  cleanse  the  wound,  the  third  to  throw  day  or  artificial 
light  on  the  eve  with  a  hand-lens,  which  is  indispensable  in  at  least  50  per 
cent,  of  the  operations. 

The  eyelids  are  kept  open  by  a  wire  speculum  that  does  not  press  on  the 
eyeball,  and  is  strong  enough  to  prevent  the  spasmodic  closure  of  the  lids. 

The  eyeball  is  steadied  with  fixing-forceps,  the  teeth  of  which  are 
numerous  and  large  enough  to  be  firmly  inserted  into  the  episclera.     They 


I  ra  391.    Fixing-forceps. 

arc  provided  with  a  catch  that  closes  them  fast,  yel  can  lie  opened  without 
a  jerk. 

OPERATIONS    ON    THE    IRIS. 

I.  Iridectomy  -I.  e.  Excision  of  a    Piece  of   the   Iris. —  It-  indications 

arc   twofold. 

I .  To  Make   a  New   Passage  for  the  Rays  of  Light. — Artificial  or 
Optical  Pupil. — This  is  done 


576        OPERATIONS  OS  THIS  AND   CRYSTALLINE  BODY. 

(a)  When  the  natural  pupil  is  more  or  less  occluded  by  malformation  or 

disease. 

(b)  When  the  axial  portions  of  cornea  or  lens — /.  e.  those  situated  right 
before  or  behind  the  pupil — are  so  opaque  or  misshaped  as  to  intercept  the 
ray-  of  lighl  <>r  casl  on  the  retina  a  Less  defined  image  than  would  be  formed 
by  light  passing  through  a  peripheric  portion  of  the  cornea  and  lens.  This 
i-  the  case  in  closure  of  the  pupil,  and  opacities,  or  abnormities  of  curva- 
ture in  the  center  of  the  surfaces  of  the  cornea  and  lens  (keratoconus  and 
lenticonus).  An  artificial  pupil  should^  however,  never  he  made  before  an 
examination  with  a  stenopeic  apparatus  by  dilated  pupil  has  positively 
demonstrated  thai  the  new  pupil  will  afford  better  sight  than  the  old.  This 
precaution  applies  particularly  to  maculae  cornea*. 

2.  To  Relieve  and  Cure  Inflammations  of  the  Eye  and  their  Sequels. 
— Antiphlogistic  or  Curative  Pupil. — This  is  done — 

(a  In  chronic  recurrent  iritis,  when  broad  or  circular  synechia'  impede  or 
prevent  the  current  of  the  aqueous  humor  from  the  posterior  to  the  anterior 
chamber.  The  strongest  indication  for  an  iridectomy  is  furnished  by  the  so- 
called  crater-shaped  pupil,  which  when  left  alone  will  not  only  cause  blind- 
ness, but  the  ruin  of  the  eye  by  irido-cyclo-choroiditis,  and  may  even  have  a 
prejudicial  effect  on  the  other  eye. 

A)    In  all  affections  in  which   prolonged  increase  of  eyeball  tension  is  a 
pronounced  symptom — i.  e.  in  primary  and  consecutive  glaucoma. 

(c)  '/'"  remove  /minus  (cysts,  sarcomata,  etc)  and  foreign  /><,<tics  if  they 
an  located  in  the  anterior  part  <f  the  eye,  and  cannot  be  removed  without 
sacrificing  a  piece  of  the  iris.  Foreign  bodies  in  the  iris  formerly  were 
never  removed   without  excising  the  piece  in  which  they   lay   imbedded. 

(di  As  <i  step  in  ripening  immature  cataract,  <m<l  as  a  preliminary  <>p<  ra- 
tion fur  subsequent  extraction  of  cataract  (see  later). 

(e)  T<>  remove  prolapses  of  flu  iris  after  injuries  and  operations.  When 
a  patient  consults  us  with  a  fresh  wound  through  which  iris  protrudes,  it 
may  be  left  alone  if  the  lens  is  not  injured  and  the  wound  is  not  situated  in 
the  ciliary  region  near  to  and  concentrically  with  the  border  of  the  cornea. 
In  prolapses,  which  happen  frequently  after  cataract  extraction,  the  protruded 
iris  is  apt  to  swell,  become  cystic,  and  in  all  cases  produce  a  high  degree  of 
astigmatism.  In  such  instances  clean  removal  of  the  prolapse,  and,  if  the 
latter  i-  not  fresh,  deep  excision  of  the  iris,  is  the  best  treatment.  Also  in 
recent  prolapses  of  the  iris  through  a  corneal  wound  a  clean  iridectomy,  if  it 
i-  -till  possible,  can  appropriately  be  done.  II'  the  iris  cannot  be  disentan- 
gled from- the  wound  and  the  prolapse  is  let  alone,  we  frequently  see  an 
undisturbed  recovery,  with  permanently  good  sight,  follow  the  natural,  clean 
elimination  of  the  protruded  iris  by  a  process  of  constriction  of  the  base  and 
snaring  oil'  of  the  protruded  part. 


Lance  sbaped  knife. 


v  Graefe'e  knife, 


The  special  instruments  for  iridectomy  arc — a  lance-shaped  (Fig.  392)  or 
a  Bmall  (v.  Graefe)  cataract-knife  (Fig.  393) ;  an  ordinary  iris-forceps,  curved 


IRIDECTOMY. 


577 


■fc— i- 


i  [i ,    394.    ( Jurved  iris-forceps. 


l- 1  ■ . .  395.     Mathieu's  iris-forceps. 


Fig.  3%.    I  lurved  iris-scissi  irs. 


397.— Grooved  spatula  and  probe. 


— J>g^ 


Fig.  398- Tyrrell's  hook. 

(Fig.  394),  or  its  modification  by  Mathieu  (Fig.  395)  ;  a  pair  of  curved  |  Fig. 
396)  or  straight  iris-scissors;  a  metal  spatula  and  flexible  probe  (Fig.  397)  • 
a  blunt  hook  (Tyrrell's)  (Fig.  398). 

EXECUTION  OF  THE  OPERATION. 

1.  Opening  of  the  Anterior  Chamber. — Suppose  that  the  surgeon  has  to  perform 
an  upward  iridectomy,  the  most  frequent  case.  The  patient  is  reclining  on  the  operating- 
chair  near  a  window  or  an  Argand  gas-lamp.  An  assistant  throw-  light  on  the  eve  with 
ahand-lens.  The  operator,  standing  behind  the  head  of  the  patient,  separates  the  eyelids 
with  a  wire  speculum,  steadies  the  eyeball  with  the  fixing-forceps,  which  he  holds  in  his 
right  hand,  the  thumb  near  the  button  of  the  catch,  the  second  and  third  fingers  on  the 
other  branch  of  the  forceps  opposite  the  catch.  With  the  lance-shaped  knife,  which  he 
holds  in  the  same  way  as  the  forceps,  he  makes  an  incision  in  the  upper  part  of  the 
cornea  at  or  near  its  transparent   margin  (the  limbus). 

The  point  of  the  lance,  applied  at  a  point  directly  opposite  to  the  implantation  of 
the  forceps,  is  thrust  through  the  cornea,  al  first  somewhat  perpendicularly,  then,  when 
it  has  entered  the  anterior  chamber,  which  is  recognized  by  the  brighl  luster  the  blade 
assumes,  it  is  pushed  forward  in  a  direction  parallel  to  the  plane  of  the  iris  as  deeply  as 
the  intended  size  of  the  incision  requires.  Now  it  is  withdrawn  slowly,  advancing  the 
point  toward  the  cornea  as  the  aqueous  escapes.  Tins  maneuver  should  be  executed 
with  a  steady  hand,  so  that  the  blade  of  the  knife  advances  as  it'  moved  by  machinery, 
and  avoids  injuring  the  iris  and  the  lens-capsule  on  the  one  band  or  the  cornea  on 
the  other.  Wounding  the  capsule  would  produce  cataract,  and  grating  the  posterior 
surface  of  the  cornea  mostly  leaves  an  indelible  streak. 

It  is  necessary  that  the  tip  of  the  knife  he  -harp  and  flexible,  otherwise  we  may 
have  difficulty  in  pushing  it  through  the  tough  lamellae  of  the  cornea.  Afraid  or 
wounding  the  iris,  we  have  a  tendency  to  lower  the  handle  of  the  knife:  the  tip,  if 
flexible,  becomes  curved,  with  the  concavity  toward  the  iris,  and  can  only  with  undue 

force  be  moved  forward. 

2.  Excision  of  the  Iris. — The  operator,  entrusting  the  fixing-forceps  to  the  hand  of 
an  assistant,  take-  a  pair  of  scissors  in  the  right  and  the  iris- forceps  in  the  lefl  hand.     II 
(doses  the  forceps  and  introduces  their  branches  into  the  anterior  chamber  as  far  as  the 
pupillary  edge  of  the  iris.     He  opens  the  forceps,  the  iris  passes  between  the  brand 
the  operator  closes  the  forceps  a'jain  and  draws  the   iris  out  0     thi    ■'     md  (more  01 


578        OPERATIONS  ON  TRIS  AND   CRYSTALLINE  BODY. 

of  it  according  as  a  larger  or  smaller  portion  is  to  be  removed),  and  cute  it  off  close  to 
the  cornea,  the  blades  of  the  scissors  parallel  to  the  wound,  or,  if  he  want-  to  make  a 
small  incision,  at  right  angles  to  it.     In  most  cases  the  cutting  can  be  done  with  one 

stroke;  in  some  we  ma\  ent  in  two  or  three  successive  strokes. 

The  iris-forceps  should  be  delicate ;  the  tips  of  the  branches  should  close  nicely  and 
remain  closed  when  the  branches  are  pressed  together.  Some  forceps  close  at  the  tip 
when  only  moderate  pressure  is  applied,  but  under  stronger  pressure  they  close  at  a 
posterior  point  and  diverge  at  the  tip.  This  i-  a  great  fault,  for  the  instrument,  after 
having  seized  the  iris,  Loses  it  again  when  the  operator  presses  the  branches  more  firmly 
together. 

The  tips  of  the  branches  should  be  carefully  rounded  off.  They  frequently  have 
sharp  edges,  which  make  the  points  liable  to  engage  in  the  tissue  of  the  iris,  drag  it 
along,  and  produce  irido-dialysis  and  hemorrhage.  Hemorrhage  may  also  he  produced 
it',  while  drawing  the  iris  out.  we  exert  not  a  straightforward,  meridional  traction,  but 
a  lateral  one.  which  causes  dialysis  and  rupture  of  the  large  arterial  circle  of  the  iris. 

o.  Adjustment  of  the  Lips  of  the  Wound. — No  foreign  substance,  in  particular 
no  iris-tissue,  must  he  left  in  the  wound.  It  disturbs  the  healing,  and  may  cause,  in 
consequence  of  the  angular  entanglement  of  the  iris,  very  unpleasant  irritative  proc- 
i  sses  — cystoid  scar,  corneal  fistula,  glaucoma,  suppurative  iritis,  irido-cyclitis,  and  sym- 
pathetic ophthalmia. 

The  adjustment  of  the  lips  of  the  wound  can  he  made  satisfactorily  in  most  eases  by 
passing  a  spatula  over  the  wound,  flat  and  at  right  angles  to  the  line  of  the  section,  so 
that  the  columns  of  the  coloboma  are  moved  hack  into  the  anterior  chamber.  Should 
we  fail  to  accomplish  this  by  outward  pressure,  we  must  pass  the  spatula  through  the 
incision,  push  the  stump  of  the  iris  hack  of  the  wound,  and  particularly  stroke  the  iris 
out  of  the  corners,  so  that  the  sphincter  is  clear  in  the  anterior  chamber  at  a  good 
distance  from  the  wound. 

During  and  after  the  operation  a  few  drops  of  a  mild  antiseptic  may  he  dropped 
over  the  line  of  incision  and  the  cornea,  as  the  latter,  owing  to  the  action  of  the  cocain, 
becomes  dry. 

4.  Dressing". — Both  eyes  are  covered  with  pieces  of  corrosive-sublimate  gauze,  upon 
which  are  placed  pads  of  absorbent  cotton,  which  are  held  in  position  by  the  classic 
binoculus  (double  figure-of-eight  bandage  .  and  the  patient  is  put  to  bed. 

The  recovery  in  the  great  majority  of  cases  is  without  disturbance.  The  eye  is 
inspected  every  twenty-four  hours,  hut  need  not  he  opened  each  time,  unless  some 
irregularity  takes  place.  The  patient  is  discharged  in  from  seven  to  fourteen  days, 
which,  of  course,  does  not   mean  that   he  shall  have  his  full   liberty  SO  early. 

Different  Methods  of  Performing  Iridectomy  called  for  by  Special 
Morbid  Conditions. — (")  Oj,/i<-<i/  pupils  should  be  small.  The  incision  is  sit- 
uated 2  inn),  from  the  limbus  in  the  clear  cornea,  and  is  3  t<>  -4  mm.  in  length  ; 

the  iris  is  seized  with  a  Mathieu  forceps  (Fig.  395)  or  :i  blunt  1 k  (Fig.  :'>!»*), 

and  only  the  central  portion  excised.  The  coloboma  should  lie  situated  where 
the  optical  conditions  of  the  cornea  as  to  curvature  and  clearness  are  best. 
If  we  have  the  choice,  the  situation  nasally  and  a  little  downward  gives  the 
besl  sight. 

(6)  The  glaucoma  pupil  should  be  large  and  peripheric,  1  mm.  at  least 
behind  the  limbus.  In  acute  glaucoma  with  high  tension  cocain -anesthesia 
i-  mostly  insufficient  ami  perilous  ;  because  the  diffusion-currents  being 
directed  peripherally,  prevent  the  cocain  from  penetrating  into  the  eye 
sufficiently  to  produce  much  effect.  If  the  cornea  be  made  tolerably  insen- 
sible by  it,  the  iris  i-  not  affected  at  all.  The  patient  does  not  feel  the  corneal 
incision  very  much,  but  as  soon  as  the  forceps  touch  the  sensitive  iris  he  is 
apt  to  give  a  sudden  jerk  with  his  head,  which  may  drive  the  tip  of  the  iris- 
forceps  into  the  lens.     General  anesthesia  is  to  be  preferred  in  these  cases. 

If  one  iridectomy  in  glaucoma  gives  only  temporary  relief,  a  subsequent 
one  is  better  than  a  sclerotomy  (compare  with   page  "»7<M. 

Glaucoma  occur-  in  about  1  per  cent,  after  extraction  of  primarv  or 
discission  of  secondary  cataract.  If  instillations  of  a  myotic — eserin  I  per 
cent,  solution  or  pilocarpin  2  per  cent. — do  not  cure  the  attack,  an  iridectomy 
i-  -me  to  succeed  ( probably  also  ;i  paracentesis  of  the  anterior  chamber).    The 


OPERATIONS  ON  THE  CRYSTALLINE  BODY.  579 

iris  in  such  cases,  as  in  all  aphakia!  eyes,  frequently  escaping  the  ordinary 
forceps,  should  be  seized  with  Mathieu's  or  other  forceps  the  teeth  of  which 
are  at  the  lower  surface  near  the  tip,  not  straighl  at  the  tip.  11'  even  these 
(capsule)  forceps  fail,  a  blunt  hook,  passed  Into  the  pupil,  will  grasp  the 
pupillary  portion  of  the  iris  and  draw  it  out  of  the  anterior  chamber,  where 
it  can  l»e  abscised. 

II.  Other  operation-  performed  mi  the  iris  arc — 

1.  Iridotomy  [g  practised  when,  after  a  cataract  operation,  the  pupil  is 
closed  and  drawn   toward  the  scar   left    by  the  wound. 

The  so-called  pince-ciseaux  of  De  Wecker  (Fig.  399),  a  kind  <>t'  cutting  forceps,  are 
introduced  into  the  anterior  chamber  through  a  small  corneal  incision.  The  sharp- 
pointed  branch  is  thrust  through  the  iris,  the  other  remains  in  the  anterior  chamber, 


and  in  this  way  one  or  two  incisions  are  made  through  the  iris  and  pseudo-membranes 
that  may  be  adherent  to  it.     If  successful,  an  artificial  pupil  can  be  obtained. 

The  author's  personal  experience  is  not  sufficient  to  pass  judgment  on  the 
value  of  this  operation.  After  several  trials,  which  were  not  very  sat i  — 
factory,  he  has  returned  to — 

2.  Irido-cystectomy  in  such  cases,  which  have  become  very  rare  in  his 
practice. 

An  incision  is  made  with  a  Beer's  cataract-knife  (Fig.  400)  through  the  cornea,  iris, 
and  the  adherent  thickened  lens  capsule:  next  a  Tyrrell's  hook,  or  one  branch  of  a 
pair  of  capsule-forceps  (Mathieu's,  Fig.  395)  is  passed  into  the  opening  in  the  iris ;  the 


Fig.  400.— Beer*s  cataract-knife. 


edge  of  the  iris  is  seized,  drawn  out  of  the  wound,  and  cut  off  close  to  the  cornea.     The 
results  of  this  procedure  have  in  general  proved  successful. 

3.  Corelysis  (syneehiotomy),  the  detachment  of  posterior  (Streatfeild)  or 
anterior  (Lang)  synechia',  has  not  been  found  sufficiently  beneficial  to  he 
regarded  as  a  standard  operation. 

4.  The  iridencleisis  of  earlier  surgeons  and  the  iridodesis  of  George 
Critchett,  by  which  pieces  of  the  iris  were  healed  into  a  corneal  wound,  and 
thus  the  iris  drawn  away  from  a  central  opacity,  have  been  abandoned  in 
favor  of  the  easier  and  less  hazardous  iridectomy. 

OPERATIONS  ON  THE  CRYSTALLINE  BODY. 

The  crystalline  body,  consisting  of  the  lens  and  its  capsule,  gives  occasion 
for  two  kind-  of  operative  procedures  which,  as  to  delicacy  and  precision  ,,t 
execution  and  to  brilliancy  of  results,  are  excelled  by  no  other  department 
of  surrrorv. 

A.  Operations  on  the  Lens. — When  the  [ens  becomes  opaque  in  - 
way  or  other,  either   partially  or  totally,   it    intercepts   the   rays  of  liLdit   on 
their  wav  through  the  pupil.     If  the  leu-  is  removed  from  behind  the  pupil, 


580 


OPERATIOXS  OX  JlilS  AXD    CRYSTALLINE  BODY. 


(lone    hv  (ii 


splacement, 


the  objecl  of  the  surgeon  is  obtained.     This  can  be 
by  extraction,  or  by  solution. 

I.  Displacement  at  the  present  time  is  only  exceptionally  practised — 
namely,  for  certain  forms  of  shrunken  or  secondary  cataract.  It  is  described 
by  Celsus,  and  was  used  long  before  him.  It  was  practised  in  two  ways — 
(u)  by  depression  (keratonyxis).  A  broad  needle  was  introduced  through  the 
lower  part  of  the  cornea  into  the  upper  part  of  the  pupil,  where  by  the  raising 
of  the  handle  it  dislocated  the  lens  into  the  lower  pan  of  the  vitreous.  (6)  by 
reclination  (couching,  scleronyxis).  The  needle  was  introduced  through  the 
sclerotic  and  lateral  pari  of  the  lens  into  the  upper  part  of  the  pupillary  area, 
from  where,  by  a  curvilinear  movement,  it  turned  the  lens  hack  and  down 
into  the  vitreous. 

The  immediate  results  of  displacement  were  often  brilliant,  but  in  most 
cases  sight  was  subsequently  lost  by  ascension  of  the  lens,  or  by  irido-cho- 
roiditis  and  glaucoma. 

II.  Extraction  also  seems  to  be  an  old  method,  hut  has  been  system- 
atically practised  only  since  the  French  surgeon  Jaques  Daviel  in  1845  re- 
discovered it.  It  soon  obtained  favor,  and  for  the  last  forty  years  has  been 
the  chief  operation  for  cataract. 

'flic  following  instruments  are  required  :  A  wire  speculum  (see  fig.  390); 
fixing-forceps  (Fig.  391  I,  a-  for  iridectomy  ;  a  narrow  (v.  Graefe,  Fig.  893) 
or  a  triangular  (Beer,  Fig.  400)  knife,  with  a  linn,  non-flexible  point,  which, 
like  the  cutting  inl^e,  is  of  the  utmost  sharpness;  a  cystotome,  the  shaft  of 
which  may  he  straight  or  bent  at  an  obtuse  angle,  in  which  case  two  are 
necessary — one  for  the  right,  the  other  for  the  left,  eye  (Fig.  401),  and  the 
point  of  which,  with  its  short  cutting  a]^'  very  line  and  sharp,  is  to  be 
cautiously  handled  in  cleansing  and  sterilizing;  a  Daviel  spoon, flexible  (Fig. 
40.')) ;  a  blunt  (olive-tipped  i  flexible  probe  (  Fig.  397) ;  a  curved,  flexible,  and 
slightly  grooved  spatula  (Fig.  -".'.'T),  and  a  wire  loop,  curved  like  a  spoon 
(Fig.  MM). 


Fig.  401.    Etighl  and  lefl  cystotomes. 


g.tiema«nsj:9. 


--v 


Pig.  102.— Cystotome  and  spoon. 


l  i'.    103.    David's  spoon. 


Pig   104     Wire  loop  curved  like  a  s] a. 


EXEl  I  Tlo\    OF  THE  OPEB  \TloN. 

!  sir, i.  The  Corneal  Section.  -The  eye  is  cocainized.  The  operator,  standing 
behind  the  patient,  inserts  the  teeth  of  the  fixing-forceps  firmly  into  the  episcleral  tissue, 
and  makes  tin-  corn  ial  incision  with  a  narrow  Graefe  knife  1 1 <  1<  1  between  the  thumli  and 


EXTRACTION  OF  THE  LENS.  581 

the  index  and  middle  fingers  of  the  other  hand.  We  suppose  we  have  to  extract,  by  a 
superior  section,  a  hard,  mature,  senile  cataract,  theanterior  chamber  being  of  normal 
depth.  The  knife  pierces  the  cornea  |  puncture)  in  its  transparent  margin  (limbus) 
slightly  above  the  horizontal  meridian,  passes  straight  through  the  anterior  chamber,  and 
emerges  (counter-jniiicfiirri  on  the  other  side  at  a  point  corresponding  to  the  puncture. 
The  section  is  continued  by  advancing  the  knife  its  whole  length,  and  at  the  same  I 
cutting  upward  without  changing  its  direction,  parallel  and  close  to  the  iris,  until  it 
emerges  at  the  upper  end  of  the  vertical  meridian,  when'  a  small  conjunctival  flap  is 
formed. 

Second  Step. — The  Opening  of  the  Capsule. — The  cystotome  is  introduced,  with 
its  point  backward,  gently  into  the  anterior  chamber  as  far  as  the  pupil ;  then  it-  tip  is 
pushed  under  the  tipper  part  of  the  iris,  turned  backward,  and  drawn  across  the  capsule 
of  the  lens,  so  a-  to  incise  it  1  or  2  mm.  below  the  equator,  concentrically  with  the 
corneal  margin.  This  maneuver  requires  some  judgment  in  order  to  be  sure  that  the 
capsule  is  opened  without  displacing  the  lens  or  rupturing  its  suspensory  ligament, 
which  would  favor  escape  of  vitreous  during  the  operation  and  prolapse  of  iris  later. 

Third  Step. — -Expulsion  of  the  Lens. — The  speculum  is  removed  ;  the  operator  takes 
the  wire  loop  in  one  hand,  and  Daviel's  spoon  in  the  other.  The  patient  look-  steadily 
down;  the  convex  surface  of  the  spoon  is  applied  to  the  lower  portion  of  the  cornea  and 
pressed  gently  and  steadily  toward  the  centre  of  the  eyeball,  which  causes  the  wound  to 
gape  widely  and  the  lens  to  slip  out  gradually.  When  the  greatest  diameter  of  the  lens 
has  passed  out  of  the  wound  the  lower  part  is  followed  up  with  the  spoon,  so  that  the 
whole  cataract  is  expelled.  If  during  the  expulsion  the  pupil  does  not  dilate  well  and 
the  upper  part  of  the  iris  is  pushed  out  bulgingly,  the  operator  enlarges  the  pupil  by 
pressing  the  bulging  part  of  the  iris  backward  with  the  wire  loop. 

Fourth  Step. — Cleansing-  of  the  "Wound. — During  the  operation  and  cleansing  of 
the  wound  it  is  desirable  to  instil  a  few  drops  of  an  antiseptic  solution,  which  will  keep 
the  eye  wet  and  wash  small  particles  away.  Remnants  of  lens  should  be  driven  out  by 
pressing  with  the  finger  the  edge  of  the  lower  lid  upward  over  the  cornea.  Neither  the 
upper  nor  the  lower  lid  should  touch  the  open  wound.  Pieces  of  cataract  lying  between 
the  lips  of  the  wound  must  be  removed  with  a  well-sterilized  spatula.  Also  small  par- 
ticles of  lens  lying  still  in  the  anterior  chamber  can  be  stroked  out  with  the  spatula. 

If  the  iris  does  not  return  into  its  normal  position  spontaneously  or  by  gently  pressing 
a  fw  times  the  lower  lid  with  the  finger  on  the  lower  margin  of  tin'  cornea,  the  tip  of 
a  blunt  probe  has  to  be  introduced  from  the  side  into  the  anterior  chamber  and  passed 
onward  along  the  iris-angle  beyond  the  vertical  meridian,  in  order  to  disengage  the  iris 
from  the  sinus  of  the  anterior  chamber,  where  it  is  crowded,  and  stroke  it  toward  the 
center  of  the  pupil.  If  this  maneuver  should  not  succeed  or  the  iris  should  show  a 
tendency  to  become  displaced  again,  it  is  best  to  excise  a  small  portion  of  it.  and  with 
a  probe  carefully  push  the  corners  of  the  defect  out  of  the  wound  back  into  the  cham- 
ber.    Care  should  also  be  taken  to  stroke  the  conjunctival  flap  out  of  the  wound. 

Fifth  Step. — Dressing- of  the  Wound. — When  the  patient  is  put  to  bed  the  wound 
is  inspected  once  more,  and,  if  everything  is  satisfactory,  both  eyes  are  bandaged.  A 
piece  of  sterilized  gauze  is  put  wet  on  each  eye  ;  upon  it  is  placed  a  thin  pad  of  absor- 
bent cotton,  the  whole  held  in  position  by  a  roller  bandage  or  strips  of  isinglass  plaster. 

The  patient  should  lie  quietly  on  his  back  as  long  as  he  feels  comfortable;  otherwise 
he  may  lie  on  the  side  of  the  non-operated  eye.  It  is  advisable  to  give  an  anodyne  to 
the  majority  of  patients  soon  after  the  operation 

Modification  of  the  Operative  Procedure. — Tho  corneal  section  is  placed 
more  or  less  in  the  opaque  border  of  the  anterior  chamber.  This  favors  prolapse 
of  iris  and  vitreous,  as  well  as  inflammations  of  the  ciliary  body. 

The  section  is  placed  within  tJu  transparent  cornea.  This,  by  closing  less 
accurately,  tends  to  adhesions  of  the  iris  to  the  scar,  especially  at  the  corners 
of  the  wound,  and  is  more  liable  to  primary  and  secondary  infection. 

The  section  is  made  downward.  This  section  is  less  protected  by  the 
lids,  and  optically  at  a  disadvantage  if  an   iridectomy  has  to  be  made. 

The  opening  of  tin'  capsule  is  made  with  a  cystotome  or  a  hook,  exten- 
sively innl  in  different  directions.  Tn  this  way  the  capsule  is  torn,  not  incised. 
It  has  the  advantage  that  in  a  pertain  number  of  cases  the  shreds  of  the  cap- 
sule are  drawn  to  the  periphery  and  leave  a  sufficiently  clear  pupil,  hwi  the 
laceration  and  promiscuous  opening  often  cause  posterior  synechite,  and  not 
rarely  more  or  less  obstruction  of  the  pupil   I>v  inflammatory  products  which 


OPERATIONS  OX  IBIS  AND  CRYSTALLINE  BODY. 

it  is  difficultand  risky  to  deal  with.  The  opening  of  the  capsule  by  a  periph- 
eric incision  permits  as  easy  and  complete  an  expulsion  of  the  lens  as  the 
central  opening,  and  tends  much  less  to  iritis  and  capsular  deposits.  If  later 
we  wish  to  give  the  patient  permanently  the  greatest  possible  sight  his  case 
admits  of,  we  can  do  it  by  a  simple  discission  of  the  wrinkled  but  not 
thickened  capsule. 

A  'piece  of  iris  is  excised  cither  before  (  preliminary  iridectomy,  Mooren)  or 
during  the  operation  for  cataract  (combined  extraction,  von  Graefe).  This  is 
indicated  in  all  the  ease- — about  10  per  cent. — in  which  the  natural  pupil 
does  not  admit  of  an  easy  exit  of  the  lens  or  in  which  the  protruded  iris 
cannot  be  reduced  or  is  likely  to  form  a  subsequent  prolapse.  That  combined 
extraction  is  a  safer  operation  than  simple  extraction  is  an  assertion  not  con- 
tinned  by  the  writer's  practice  (in  more  than  1000  carefully  recorded  cases  of 
each  method).  Simple  extraction  has  the  disadvantage  that  it  is  followed  by 
prolapse  of  the  iris  in  5  to  10  per  cent,  of  the  cases.  This  can  be  remedied 
without  much  trouble  and  danger  by  excision  of  the  prolapse  within  24  hours 
after  its  occurrence.  In  all  other  respects  simple  extraction  is  superior  to 
combined   extraction. 

The  expulsion  of  the  lens  can  also  be  accomplished  as  follows  : 

Cataracts  may  be  extracted  with  the  capsule.  A.  and  IT.  Pagenstecher 
have  tried  this  old  operation  as  a  general  method,  but  had  to  limit  it  to 
hypermature  cataracts  where  the  capsule  is  thickened  and  the  zonula  Zinnii 
frail  or  ruptured.     For  such  cases  it  is  the  best  method. 

In  soft  and  traumatic  cataracts,  including  those  produced  by  operative 
interference — e.  g.  discission — in  excessive  myopia,  zonular  cataract,  etc.,  the 
so-called  linear  extraction  js  appropriate. 

With  a  lance-shaped  knife  the  cornea  is  cut  to  the  extent  of  5  or  6  mm.  near  its 
border,  and  the  capsule  opened  by  piercing  it  with  the  lance,  or  it  may  be  lacerated 
with  a  cystotome.  The  soft  lens-substance  is  let  out  by  backward  pressure  with  the  tip 
of  the  lance.  If  this  is  not  sufficient,  the  posterior  lip  of  the  wound  is  pressed  hack  by 
a  wire  loop,  ami  as  much  of  the  cataract  is  coaxed  out  as  will  follow  a  moderate  press- 
ure. The  reaction  is  mostly  insignificant,  but  a  subsequent  capsulotomy  is  needed  in 
most  cases. 

In  tremulous  and  dislocated  cataracts,  or  when  vitreous  escapes  befort  the 
lens,  the  fixing-forceps  and  speculum  should  be  removed  immediately  after 
the  opening  of  the  capsule  and  the  lens  expelled  by  pressing  with  the  <<lc/cof 
tin  lower  lid  t<m-<ir<l  tin  center  of  the  globe,  while  the  upper  lid  is  pressed  gently 
on  the  sclerotic  above,  near  the  section.  In  this  way  the  lens  is  moved  into 
the  wound,  pin--  the  gap,  and  by  a  little  additional  pressure  mostly  comes 
out  without,  or  with   but    little,   loss  of  vitreous. 

It',  in  exceptional  cases,  these  external  manipulations  do  not  succeed,  the 
lens  has  to  be  drawn  oul  by  a  traction-instrument — a  spoon,  a  curved  wire 
loop  (Fig.  104),  or  a  -harp  hook- — introduced  behind  the  lens,  beyond  the 
posterior  pole.  The  introduction  of  traction-instruments  should  be  avoided 
as  much  as  possible. 

For  the  cleansing  of  the  pupil  from  remnant--  of  cataract  a  Daviel's  spoon 
has  been  used  :  the  remnants  also  have  been  washed  out  with  a  syringe  by 
injecting  a  very  mild  antiseptic  lotion  {irrigation  of  thi  anterior  chamber). 
These  procedures  do  not  often  succeed,  nor  arc  they  free  from  danger.  In 
expelling  them  by  external  manipulation  care  should,  however,  be  taken  lest 
by  an  unusual  degree  of  pressure  vitreous  protrude. 

Mistakes  and  Accidents  during-  the  Operation. — Insufficiency  of  the 
corn*.  <it  section  leads  to  stripping  off  of  the  cortex  and  bruising  of  the  wound, 


EXTRACTION  OJ    THE  LENS.  583 

with  deleterious  consequences.  Its  presence  is  recognized  if  the  lens  presents 
in  the  wound,  bu1  does  not  advance.  No  forcible  pressure  should  be  used, 
but  the  section  should  lie  enlarged  by  a  strong  pair  of  strabismus-scissors 
(those  of  Stevens  answer  well). 

It'  the  knife  on  its  passage  through  tin  anterior  chamb*  r  engages  in  ///<■ 
iris,  <>r  it'  the  counter-puncture  is  mil  <if  the  right  place,  the  knife  should  he 
drawn  back  and  its  direction  corrected. 

If  the  iris  falls  <>r>  r  //"  knif(  when  the  knife,  after  the  counter-puncture,  i- 
moved  upward,  in  many  cases  the  iris  can  he  re-dressed  by  turning  the  edge 
of  the  knife  slightly  forward  ;  hut  if  this  fails  to  push  the  iris  back,  it  i- 
best  to  continue  and  to  complete  the  section.  The  exsection  of  a  small  piece 
of  iris  does  not  much  interfere  with  a  good  recovery. 

Disturbances  of  the  Healing-  Process. — Profuse  intraocular  hemorrhage 
during  or  after  the  operation  i^  followed  by  the  ruin  of  the  eye,  do  what  we 
may. 

Prolapse  of  iris  is  treated  in  the  manner  already  described  (page  07<i'. 

Iritis  is  treated  as  usual — leeches,  atropin,  anodyne-,  etc. 

Qyclitis  with  capsulitis,  which  mostly  manifests  itself  in  the  second  week 
by  pain,  marked,  deep-seated  circumcorneal  injection,  with  a  round,  clear 
pupil  and  good  sight,  is  commonly  tedious  and  requires  patient  treatment  for 
from  three  to  six  weeks.  Then  the  sclera  gets  white,  the  vitreous  clears  up, 
the  capsule  is  more  or  less  opaque,  hut  the  vision  is  commonly  not  greatly 
damaged,  aud  can  he  improved  by  a  subsequent  discission. 

Irido-cyclitis,  especially  after  combined  extraction,  is  more  deleterious. 
It  last-  weeks,  and  sometimes  month-,  damage-  sight  greatly,  had-  to 
closure  of  the  pupil,  and  dense  pseudo-membranes  behind  the  iris.  ^  e 
should  not  tire  in  treating  such  cases,  for  not  infrequently,  even  if  sight  is 
reduced  to  perception  of  light,  a  cystectomy  will   restore  useful  vision. 

Irido-cyclitis  ruins,  in  r<ir<  cases,  tin  other  eye  by  sympathetic  <>j>liflm/- 
iii  i". 

Suppuration  may  occur  in  the  cornea,  the  iris,  and  the  vitreous.  In  almost 
all  cases  it  destroys  the  eye  by  extension  to  the  deeper  tunic — panophthal- 
mitis. 

In  some  cases  a  corneal  suppuration  is  limited  to  the  lips  of  the  wound 
and  the  adjacent  parts.  The  result  is  partial  preservation  of  the  cornea, 
indrawn  scar,  and  closure  of  the  pupil.  If  the  eyeball  is  not  soft  and  the 
light-perception  good,  an  iridectomy  may  restore  a  moderate  degree  of 
vision. 

Whether  a  beginning  suppuration  of  the  Hap  will  he  limited  or  pn 
to  total  destruction  of  the  cornea  seems  to  depend  more  on  the  nature  of 
the  individual  case  than  on  the  medication  employed.  The  author  ha-  ii"t 
found  that  galvano-cautery  or  any  other  mean-  ha-  a  controlling,  or  even 
favorable,  influence  on  the  morbid  process.  <  )f  the  many  mode-  of  treatment 
recommended  and  praised,  the  best  seems  to  be  to  open  the  wound  and  estab- 
lish drainage  of  the  anterior  chamber  by  reopening  the  wound  with  ;i  spatula 
once  every  day  or  oftener.  Eyes  with  ring  abscess  and  panophthalmitis  are 
beyond  rescue.  Our  endeavpr  should  lie  to  relieve  the  atrocious  pain  and 
establish  a  safe  and  non-irritable  stump  suitable  for  wearing  an  artificial 
eye.  This  is  besi  accomplished  by  poulticing  ami  incisions  giving  tree 
vent  to  the  pus. 

The  result  of  cataract  extraction  i-  restoration  of  useful  sight  in  about 
95  per  cent,  of  the  uncomplicated  cases,  perception  of  light  in  ::  per  cent., 
total  blindness  in  2  per  cent. 


584        OPERATIONS  ON  TBIS  AND   CRYSTALLINE  BODY. 

III.  Ripening  Operations  for  Immature  Cataract. — A  cataract 
may  be  mature  —  i.  <.  opaque  in  all  its  parts— and  yet  not  in  the  best  condi- 
tion for  extraction.  This  is  the  case  when  the  lens  is  swollen  by  imbibition, 
which,  through  the  shallowness  of  the  anterior  chamber,  renders  it  difficult 
to  pass  the  knife  through  the  aqueous  humor  without  injuring  the  iris, 
and  to  make  the  counter-puncture  at  the  righl  place.  Usually  in  from  three 
to  six  months  the  imbibed  liquid  will  be  absorbed,  the  lens  will  be  smaller 
and  compact,  and  the  anterior  chamber  of  normal  depth.  This  is  the  time 
for   the  extraction. 

<  >n  the  other  hand,  cataracts  may  be  immature  and  yet  can  be  extracted 
easily  and  cleanly.  Tin-  is  the  case  when  the  nucleus  is  opaque  and  the 
transparent  cortex  pervaded  by  gray  lines  situated  in  the  layers  next  to 
the  capsule;  or  when  the  cortex  is  transparent,  but  the  nucleus  amber- 
colored,  and  the  patient  has  reached  the  age  of  sixty  years.  Frequently 
enough  in  cataracts  not  coming  under  the  above  categories  the  natural  ripen- 
ing i-  so  -low  as  to  cause  the  greatest  discomfort  and  render  the  patients 
unfit  for  work.  Under  these  circumstances  artificial  ripening  has  been 
resorted  to  in  different   ways : 

1.  Opening  of  the  capsule  with  a   needle,  as  in  discission  of  soft  cataract 
later  on).     This  is   the  oldest   and    perhaps  most  efficient  method,  yet  it 

has  the  disadvantage  of  ripening  the  anterior  cortex  only,  so  that  after  the 
extract  ion  we  are  surprised  by  finding  a  considerable  quantity  of  lens-matter 
left  behind.  This  may  not  be  the  case  if.  ;i<  Schweigger  recommends,  the 
discission   goes  deeper  into  the  lens-substance. 

2.  [ridectomy  and  trituration  of  the  lens  by  rubbing  a  blunt  instrument 
over  the  cornea  (Forster). 

'■'>.  Paracentesis  of  the  cornea  and  trituration  of  the  lens  with  a  blunt 
probe  (  Born  t.  spatula  (Sasso  and  Piscaldi ),  or  trowel  ( 15.  Bettman)  introduced 
into   the   anterior  chamber. 

4.  Paracentesis  of  the  cornea  and  trituration  of  the  lens  through  the 
cornea  (T.  \l.  Pooley,  -I.  A.  White). 

The  writer  has  used  some  of  these  methods,  with  little  satisfaction.  He 
advises  his  patients  to  wait  till  Nature  ripens  their  cataracts — which  she 
always  does  harmlessly — and  if  they  cannot  wait,  he  in  most  cases  would 
rather  remove  an  unripe  cataract  (provided  the  anterior  chamber  is  not 
shallow),  and  deal  with  the  remnants  later,  than  subject  the  patients  to  pre- 
liminary ripening  procedure-,  which  are  unreliable  and  require  operations 
I'M-  secondary  cataract  not  less  frequently  than  where  immature  cataract- 
are  removed. 

I  V.   Discission  of  the  lens  is  indicated — 1.    In  all  cataract- of  young 

people    lip   to    fifteen    years  of   age. 

'2.  In  -oft  cataracts  of  adult-  n-  long  as  there  is  no  hard  nucleus.  In 
these  the  di-cission  ha-  frequently  to  be  followed  by  extraction  on  account  of 
the  advent  of  orlaucoma. 


G.TIEMANN   it  CO. " J 

Pig   105.    Knife-needle. 


3.  In  transparent  lenses  in  younger  people  suffering  from  excessive 
myopia,  1  u'  I>.  mid  over. 

Instruments. — Fixing-forceps,  a  discission-needle,  or  -mall  knife-needle 
(Fig.  105). 


OPERATIONS  ON  THE  CAPSULE.  585 

The  execution  of  discission  varies  under  differenl  conditions. 

For  division  of  soft,  zonular,  and  partial  cataracts  the  operator  chooses  a  short 
knife-needle,  thrusts  it  through  the  cornea  midway  between  center  and  circumference, 

and  through  the  capsule,  2  mm.  beyond  its  center;  draws  it  back  to  make  a  horizontal 
incision  of  4  mm.  through  the  capsule;  then  he  rotates  the  instrument  90°,  transfixes 

the  capsule  2  mm.  above  the  horizontal  incision  and  cuts  down  into  the  horizontal  in- 
cision; tiow  he  turns  the  needle  180°,  transfixes  the  capsule  2  mm.  below  the  horizontal 
incision,  and  cuts  upward  into  the  latter.  In  this  way  the  capsule  is  opened  by  a 
crucial  incision  of  4  mm.  in  either  direction.  The  cuts  should  be  superficial,  lest  the 
lens  by  too  rapid  imbibition  swell  too  much  and  cause  glaucoma.  Yet  a  small  particle 
of  lens-substance  may  be  pushed  with  the  needle  into  the  anterior  chamber,  for  small 
and  superficial  openings  of  the  capsule  may  close  again  and  have  no  effect.  In  most 
cases  the  discission  has  to  be  repeated  several  times,  and  the  last  time  the  posterior 
capsule  should  be  divided,  otherwise  it  will  by  wrinkling  and  dotting  obstruct  the  pupil 
subsequently. 

For  the  removal  of  the  transparent  lens  in  eases  of  excessive  myopia  the 
same  precautious  and  repeated  operations  have  been  made,  but  Dr.  Fukala,  the 
chief  advocate  of  the  "operative  treatment  of  myopia,"  now  recommends 
breaking  up  the  lens  in  the  first  operation  by  extensive  discission,  soon  to  be 
followed  by  extraction.  The  writer  has  no  persona]  experience  in  removing 
the  transparent  lens  in  myopia.  The  operation  litis  been  practised  of  late  by 
a  number  of  eminent  European  oculists,  and,  on  the  whole,  favorably  com- 
mented upon.  It  is  like  operating  on  zonular  cataract,  and  said  to  have  no 
influence  on  the  fundus  changes.  Hemorrhage  in  the  vitreous  and  detach- 
ment of  the  retina  have  been  noticed  after  the  operation.  In  a  large  number 
of  cases  the  visual  tests  after  the  operation  have  discovered  ti  remarkable 
increase  of  the  sharpness  of  vision  (see  also  page  224). 

Ij.  Operations  on  the  Capsule,  the  so-called  Secondary  Cata- 
ract.— For  secondary  cataract  many  operative  procedures  have  been  recom- 
mended. 

1.  Discission  is  indicated  for  all  obstructions  of  the  pupil  that  can  be  cut 
with  a  small  knife  or  a  needle.  It  is  rarely  that  the  capsule,  when  partially  or 
totally  left  in  the  eye,  remains  permanently  clear;  it  wrinkles,  dots,  and 
thickens,  diminishing  the  vision  more  and  more.  Discission  should  be  done 
if  the  vision  is  less  than  |$.  The  best  time  to  do  it  is  From  six  to  twelve 
weeks  after  the  extraction,  when  all  irritation  has  passed  and  the  capsule 
has  not  yet  become  thick  and  tough.  It  can  be  done,  however,  at  tiny  later 
period.     For  many  years  the  writer  has  operated  in  the  following  way  : 

The  eye  is  cocainized,  tbe  pupil  dilated.  An  assistant  throws  the  focal  point  of  an 
intense  pencil  of  light  lArgand  gas-burner,  incandescent  gas,  or  electric  light;  large 
hand  lens)  on  the  capsule,  leaving  half  of  the  cornea,  through  which  the  operator  look-, 
linilluminated.  The  operator  has  previously  examined  the  eye  with  focal  light  and  the 
ophthalmoscope  to  ascertain  how  much  diminution  of  sight  is  attributable  to  the  cap- 
sule. If  he  gets  a  clear  image  of  the  fundus,  cystotomy  is  out  of  the  question  ;  further, 
he  has  to  find  out  where  the  capsule  is  least  tough  in  order  to  determine  where  and  in 
which  direction  it  should  be  split.  The  plan  of  the  operation  is  the  same  as  in  discission 
of  sot't  cataract  (see  above). 

A  straight  knife-needle  with  a  sharp  point,  a  sharp  cutting  edge  and  a  rounded  back 
is  used.  The  blade  and  -haft  should  be  so  proportioned  that  the  shaft  just  fills  the 
wound  made  by  the  blade.  Sickle  shaped  needles  do  not  readily  .-tab  the  delicate, 
elastic,  and  readily  escaping  pieces  of  capsule  when  the  first  incision  has  been  made. 
Needles  of  so  little  width  as  here  required  cannot  be  made  sharp  if  thej  have  two  cut- 
ting edges  instead  of  one  and  a  back,  a-  on  a  knife.  With  a  well-made  knife-n. 
three  incisions  can  be  made  without  escape  of  aqueous  humor  or  bruising  of  the  ct\>sr<  of 
the  puncture-canal  in  the  cornea. 

The  capsule  must  be  divided  by  two  incisions  (no  tearing), T-shaped;  sometimes 
three  incisions, +,  crucial.  Bands  offering  resistance  must  be  left  alone;  it  suffices  to 
clear  the  space  beside  them.     The  needle  should   not    be  entered   more  deeply  into  the 


586        OPERATIONS  ON  IRIS  AND   CRYSTALLINE  BODY. 

vitreous  than  is  necessary  to  split  the  capsule.  The  incision  should  be  effected  by  the 
simultaneous  movement  of  a  lever  and  a  knife  which  is  gradually  withdrawn,  the  corneal 
puncture  being  the  fulcrum.  The  handle  of  the  knife-needle  is  to  be  held  between  the 
brawn  of  the  thumb  on  one  side  and  that  of  the  index  and  ring  fingers  on  the  other,  so 
that  an  axis  rotation  of  lsu-  can  lie  easily  and  securely  made.  If  by  some  accident  or 
other  the  splitting  of  the  capsule  has  been  insufficient,  no  harm  is  done  by  introducing 
the  needle  again,  from  another  point  of  the  cornea,  in  the  same  sitting  or  later  on. 

The  reaction  of  this  operation  is  mostly  insignificant.  The  writer  1ms  done 
this  operation  seventeen  or  eighteen  hundred  times  ami  never  lost  an  eve  by 
it,  and  rarely  ever  damaged  one.  Suppuration  has  never  followed,  but  glau- 
coma occurred  every  now  and  then,  in  about  1  per  cent,  of  the  eases.  It  has 
always  been  cured  by  a  myotic  <>r  an  iridectomy.  The  results  for  sight  have 
been  mosl  satisfactory,  and  the  sharpness  of  sight,  once  acquired,  was  not  lost 
again  by  a  disease  that  was  in  causal  connection  with  the  operation,  it'  excep- 
tion is  made  of  cases  of  subsequent  glaucoma  which  were  inaccessible  to 
treatment.  The  patients  should  be  warned  not  to  let  themselves  be  deluded 
by  the  absence  of  discomfort  during  the  first  days,  but  avoid  exposure  and 
over-exertion,  and,  should  irritation  occur,  at  once  consult  an  oculist  and 
have  a  myotic  instilled  or  an  iridectomy  made  if  glaucoma  be  present.  The 
cases  arc  very  rare,  however.1 

•1.  Cystectomy,  iridectomy,  iridotomy,  or  irido-cystectomy  should  be  done  if 
the  pupil  is  occupied  by  tough  pseudo-membranes  or  closed  altogether.  The 
operations  are  described  before  (see  pages  oTT-oTD). 

3.  In  cases  of  tough  capsules  a  double-needle  dilaceratiori  may  be  done. 
One  needle  is  introduced  with  one  hand  through  the  nasal  side  of  the  cornea 
and  thrust  through  the  center  of  the  lens,  and  held  there  ;  another  is  intro- 
duced with  the  other  hand  through  the  temporal  side  of  the  cornea,  and 
thrust  through  the  aperture  in  the  capsule  which  the  first  needle  has  made. 
Bv  approaching  the  bandies  to  each  other  the  points  diverge,  ami  tear  a  hole 
into  the  capsule  •without  dragging  on  the  ciliary  processes.  By  this  pro- 
cedure we  often  succeed  in  making  a  permanently  good  opening  in  the 
capsule.      It  is  not  hazardous. 

'Operations  on  the  capsule  for  secondary  cataract  are  dreaded  by  many  experienced 
operators,  who  have  lost  eyes  i  which  had  obtained  useful  vision  through  extraction  of 
primary  cataract  I  by  the  severest  inflammations,  including  suppuration  and  panophthal- 
mitis. The  reason  why  the  writer  thus  far  has  escaped  SUCb  sail  experience  probably  is 
that  he  perform-  tie-  extraction  with  a  view  to  supplement  it  by  a  discission— namely,  in 
such  a  way  as  to  exclude,  as  much  a-  i-  in  his  power,  any  reaction  that  may  lead  to  the 
deposition  of  inflammatory  products  in  the  pupil.  This  object,  he  thinks,  is  obtained, 
more  than  by  anything  else,  by  the  peripheric  incision  of  the  capsule,  which  is  rarely 
followed  by  iritic  processes.  His  statistics  of  many  hundred  cases  show  the  average 
acuteness  of  sight  to  he  fy$  before  and  -.\\  after  the  secondary  operation.  The  latter  is 
done  in  about  70  per  cent,  of  the'  cases,  and  consists  nearly  always  in  a  discission.  In 
less  than  2  \«-r  cent,  ha-  he  bad  occasion  to  make  another  operation  for  secondary 
cataract. 

The  after-treatment  of  cataract  operations  has  been  mentioned  above  in 
different  place-,  the  dressing  on  page  578,  the  operative  treatment  of  prolapse  of  the 
iris  on  page576.  To  prevenl  accidental  injury,  in  particular  iris-prolapse,  various  kinds 
of  masks  are  in  use.  Some  masks  imply  danger  by  themselves,  all  are  more  or  less 
uncomfortable,  and  many  patient-  of  the  author  have  preferred  to  have  their  hands  tied. 

It  i-  advisable  to  inspect  the  eye  the  day  after  the  operation  and  remove  an  iris  prolap-e. 

if  there  should  lie  any,  at  once.    The  bandage  may  he  removed  from  the  non-operated 
m  the  third  or  fourth  day,  from  tin-  operated  eye  several   days  later.     The  patient 
may  be  kept  in  bed  for  five  or  -ix  daj  -.  old  people  less,  for  tear  of  hypostatic  pneumonia. 
Attacks  of  mania  are  combatted  by  hypodermic  injections  of  byoscin,  gr.  ],'-,,-,  pro  dosi. 


OPERATIONS   UPON   THE   EYE-MUSCLES. 


By  S.  C.  A.YRES,  M.  I)., 

OF   CINCINNATI. 


Operations  upon  the  ocular  muscles  may  be  necessary  for  the  relief  of 
concomitant  and  paralytic  strabismus,  as  well  as  for  want  of  balance  in  oppos- 
ing muscles  where  squint  does  not  exist. 

The  surgical  correction  of  strabismus  includes  tenotomy  of  one  or  more 
of  the  ocular  muscles,  or  advancement  combined  with  tenotomy.  Partial  and 
complete  tenotomies  are  also  performed  to  correct  various  types  of  hetero- 
phoria,  and  advancement  may  be  employed  for  the  same  purpose.  Finally, 
advancement  preceded  by  tenotomy  of  the  opposing  muscle  is  utilized  to 
relieve  the  faulty  results  of  strabismus  operations,  or  in  certain  case-  to 
counteract  the  deviation  produced  by  paralytic  squint. 

I.  Complete  Tenotomy. — (a)  Tenotomy  of  the  Internus. — The  oper- 
ation for  convergent  strabismus  which  has  been  very  generally  adopted  i-  the 
one  devised  by  v.  Graefe.  It  is  the  easiest  of  all  the  operations,  and  has 
only  one  disadvantage,  if  it  may  properly  be  so  called — namely,  the  necessity 
of  a  suture  in  the  conjunctiva.     It  is  performed  in  the  following  way  : 

After  the  conjunctiva  is  cocainized  the  lids  are  separated  by  a  spring  speculum,  and 
an  assistant  seizes  the  conjunctiva  close  to  the  outer  side  of  the  cornea  and  rotates  the 
eye  directly  outward  in  the  axis  of  the  commissure,  in  order  to  prevent  the  natural  tend- 
ency of  the  patient  to  turn  the  eye  upward.  The  operator  grasps  the  conjunctiva  with 
a  pair  of  forceps  directly  over  the  tendinous  insertion  of  the  muscle,  raises  it.  and 
makes  an  opening,  either  in  a  vertical  or  horizontal  direction,  large  enough  to  admit  the 
easy  introduction  of  the  hook.  Next,  the  subconjunctival  tissue  is  incised,  so  as  to 
expose  the  tendon  of  the  muscle,  and  the  hook  is  passed  beneath  the  tendon,  care  being 
exercised  to  secure  the  entire  tendon.  The  muscle  is  severed  close  to  its  insertion  in  the 
sclera  with  two  or  three  cuts  of  the  scissors. 

An  examination  should  now  lie  made  with  the  hook,  above  and  below,  to  determine 
whether  the  tendon  has  been  entirely  severed,  and  also  to  ascertain  whether  any  offshoots 
remain  which  may  limit  the  motion  of  the  eye  outward.  If  the  patient  i<  not  anesthe- 
tized, this  may  be  readily  determined  by  directing  him  to  forcibly  rotate  the  eve  out- 
ward. The  patient  should  nexl  in-  directed  to  --fix  "  an  object  near  by — the  point  of  a 
pencil  or  the  tip  of  the  finger.  If  convergence  still  remains,  the  effect  of  the  operation 
may  be  increased  by  incising  the  capsule  of  Tenon.  This  should  be  done  with  care. 
and,  after  snipping  the  capsule  above  and  below  the  severed  tendon,  adduction  and 
abduction  should  !»■  tested.  If  the  effect  i>  satisfactory,  the  conjunctival  wound  should 
be  closed  with  one  or  two  sutures,  both  eyes  bandaged,  and  the  patient  required  to  remain 
within  doors  until  the  following  day,  when  the  bandage  may  In-  removed. 

If  too  much  effect  has  been  produced,  a  suture  should  at  once  be  inserted  in  the  cut 
end  of  the  muscle  from  within  outward  and  brought  oul  through  the  conjunctiva  close 
1«»  the  cornea.  It  should  he  securely  tied,  and  then  a  bandage  applied,  as  above  di- 
rected, until  the  following  day.  when  the  eye  should  he  opened  and  allowed  to  take  part 
in  the  visual  act.  The  primary  suture  may  he  removed  on  the  second  day  after  tin* 
operation,  but  when  a  suture  i<  introduced  to  counteract  excessive  i  Sect  it  should 
remain  for  two  or  three  days. 

(b)  The  subconjunctival  operation,  commonly  known  :i~  Critchett's 
operation,  is  done  in  the  following  way  : 

587 


588  OPERATIONS   UPON  THE  EYE-MUSCLES. 

The  eye  having  been  cocainized,  the  lids  are  separated  by  a  spring  speculum  (it  is 
supposed  the  internal  rectus  is  to  be  operated  upon),  and  an  assistant  firmly  seizes  with 
forceps  the  conjunctiva  and  subconjunctival  tissue  near  the  outer  edge  of  the  cornea  to 
prevent  rotation  of  the  eye  on  its  axis.  The  operator  nexl  raises  the  conjunctiva  with  a 
fine-toothed  forceps  over  the  lower  border  of  the  rectus  muscle,  and  makes  an  opening 
sufficiently  large  to  admit  easy  insertion  of  the  scissors  and  hook.  It  is  better  to  have 
this  opening  too  large  than  too  small.  After  the  incision  of  the  conjunctiva  the  sub- 
conjunctival tissue  is  divided  by  successive  short  snips  with  the  scissors,  and  undermined 
in  the  direction  of  the  caruncle,  until  an  opening  is  made  in  the  capsule  sufficiently 
large  to  enable  the  operator  easily  to  introduce  the  hook.  The  hook,  held  in  the  right 
hand,  is  inserted  on  the  flat,  its  point  in  contacl  with  the  sclera,  and  i-  passed  under  the 
muscle  and  drawn  toward  the  insertion  of  its  tendon.  Then  the  point  is  elevated  until 
it  raises  the  conjunctiva  in  a  tent-like  manner.  The  hook  is  now  grasped  by  the  left 
hand  of  the  operator,  the  assistant  removes  the  forceps,  and  the  tendon  is  severed  by  a 
-  of  shorl  snips  until  the  lessening  of  resistance  and  the  elevation  of  the  hook 
under  the  conjunctiva  indicate  complete  division  of  the  tendon.  Where  the  tendinous 
insertion  is  broad  it  may  no1  be  entirely  taken  up  on  the  hook,  and  another  attempt  to 
secure  it  should  be  made.  After  the  section  lias  been  performed  the  bonk  should  be 
swept  through  the  opening  in  order  to  catch  any  strands  which  may  have  escaped 
division.  If  a  decided  effect  is  desired,  the  opening  in  the  capsule,  above  and  below, 
may  be  enlarged. 

"The  conjunctival  wound  does  not  need  a  suture  to  close  it.  and  only  a  compress 
bandage  for  a  day  is  necessary.  It  is  more  difficult  to  perform  this  operation  than  the 
one  previously  described,  because  the  tendon  cannot  be  seen,  but  onl\  felt.  Sometimes 
with  an  unruly  patient  the  cutting  is  not  smooth  ;  occasionally  the  tendon  slips  oil'  the 
hook.  Straight  scissors  are  better  in  this  operation  than  curved,  although  the  operator 
may  use  the  kind  he  prefers. 

Snellen's  Method. — Snellen  makes  a  vertical  incision  in  the  conjunctiva 
directly  over  the  middle  of  the  tendon  of  the  muscle.  After  the  opening  has  been 
sufficiently  enlarged  and  the  tendon  exposed  he  seizes  it  with  a  pair  of  forceps  and 
makes  an  opening  or  buttonhole  in  it,  through  which  lie  passes  the  hook  and  cuts 
the  upper  portion,  and  then  the  lower  portion,  of  the  tendon  in  succession,  close  to  the 
sclerotic.  The  subsequent  dressings  are  the  same  as  after  the  Graefe  operation.  He 
claims  that  this  method  does  not  interfere  with  the  capsule  of  Tenon  or  with  the  indirect 
insertion  of  the  muscle  in  its  connection  with  the  capsule. 

In  order  to  increase  the  effect  of  a  tenotomy,  in  certain  cases  Knapp 
inserts  a  .suture  through  the  superficial  layers  of  the  sclera  at  the  outer  side 
of  the  eve  and  passes  it  through  the  skin  beyond  the  outer  canthus,  where  it 
i-  tied  and  allowed  to  remain  a  few  hours.  II'  insufficient  effect  is  found  to 
exisl  the  day  after  the  operation,  it  can  be  remedied  in  some  cases  by  again 
cocainizing  the  eve  and  opening  the  wound,  and  passing  the  hook  under  the 
tendon  and  separating  it  from  the  sclera. 

There  is  a  marked  difference  in  the  size  and  strength  of  internal  recti 
muscles.  The  hook  can  be  readily  pushed  beneath  most  of  them,  but  occa- 
sionally a  tendon  i-  found  which  is  thick  and  broad,  and  apparently  drawn 
very  tightly  over  the  sclerotic,  and  which  presents  an  unusual  amount  id' 
resistance.  In  such  eases  only  the  point  of  a  hook  can  be  inserted  under- 
neath the  tendon,  which  musl  be  severed  by  successive  short  snips.  In  these 
cases  there  is  danger  of  perforating  the  sclerotic. 

Choice  of  Operation. —  It  i>  probable  that  mosl  <d*  the  tenotomies  of  the 
internal  rectus  are  performed  either  byGraefe's  or  Critchett's  method.  The 
judgmenl  and  experience  of  the  operator  will  be  his  guide  in  choosing  the  one 
be-t  Buited  to  each  individual  case.  The  writer  prefers  the  subconjunctival 
operation. 

Tenotomy  of  an  Externus. — 'Phis  is  accomplished  in  a  manner 
identical  with  that  described  iii  connection  with  the  internus.  The  external 
rectus  is  inserted  farther  from  tin-  cornea  (7  to  s  nun.)  than  the  internus,  its 
insertion  i-  not  so  broad,  and  it  i-  more  lax  than  the  inner  muscle.  The 
effects  of  it-  division  are   not    so  marked  as   those  seen  after  tenotomy  of  the 


GRADUATED   OR   PA  RIVAL    TF.NOTOMY. 


58D 


interims,  and  hence  are  often  disappointing.     Not  infrequently  it  is  accessary 
to  tenotomize  both  externi  simultaneously. 

(e)  Gruening-'s  Method. —  In  absolute  divergenl  strabismus  Dr.  Gruening 
tenotomizes  both  external  recti  at  one  sitting,  as  follows  : 

Where  the  divergence  is  not  more  than  '1  mm.  the  tendons  are  divided  at  their  Inser- 
tion. Whenever  the  deviation  measures  mure  than  2  nun.  the  tendons  are  divided  a1  a 
distance  from  their  insertion,  this  distance  corresponding  to  the  degree  of  squint. 
When  the  deviation  amount-  to  5  mm.  by  the  corneal  reflex,  both  tendons  are  divided 
at  that  distance  from  the  point-  of  insertion.  After  closing  the  conjunctival  wound  a 
silk  suture  is  passed  through  the  conjunctiva  over  both  intend  muscles  in  a  line  with 
the  horizontal  meridian  of  the  cornea,  and  tied  over  a  pledget  of  cotton  on  the  bridge 
of  the  nose.     This  position  is  maintained  twenty-four  hours. 

(/)  Tenotomy  of  the  Superior  and  the  Inferior  Rectus. — In  operating 
on  the  superior  and  the  inferior  rectus  muscles  the  same  precautions  are  required 
as  in  operations  on  the  internal  and  external  muscles.  Jt  is  better  to  employ 
the  open  method  by  cutting  down  upon  and  exposing  the  insertion  of  the 
tendon. 

II.  Graduated  or  Partial  Tenotomy.— Operations  on  the  internal, 
external,  and  vertical  muscles  for  esophoria,  exophoria,  and  hyperphoria  are 
made  by  partial  or  graduated  tenotomies,  as  devised  by  Dr.  Geo.  T.  Stevens. 
The-  tendon  of  the  muscle  is  partially  severed,  and  then  a  test  of  the  effect 
produced  is  made  and  the  operation  continued  until  the  desired  result  is 
obtained.     Dr.  Stevens  operates  as  follows : 

If  the  right  interims  is  to  be  operated  upon,  the  patient  is  directed  to  turn  his  eves 
well  to  the  right.     The  surgeon,  with  a  pair  of  fine  forceps  (Fig.  406,  A,  £),  takes  a 


„ _J 


Fig.  406.-  instruments  used  in  gradu  to-my. 

minute   fold   of  the  conjunctiva  at  the  center  of  insertion   of  the  tendon.      Drawing 

this  little  fold  of  conjunctiva  slightly  away  from  the  eyeball  with  the 

of  the  tenotomy-scissors  (Fig.  406,   '<').  the  operator  snips  the   fold   'ran-.. 

that  an  opening  h  mm.  in  extent  is  made  through  the  membrane.     Now  tl 


590  OJ'EEAT/OXS   VPoy    THE  EYE-MUSCLES. 

the  points  being  closed,  are  pressed  into  the  little  opening  and  slightly  backward,  where 
the  points  are  permitted  to  spring  apart,  after  which  they  arc  again  closed,  this  time 
holding  a  small  fold  of  the  tendon  just  behind  the  insertion.  This  being  put  upon  the 
stretch,  the  scissors  by  little  snips  dissect  the  tendon  from  the  eyeball  between  the 
layers  of  the  capsule  (which  should  remain  intact)  toward  one  border  of  the  insertion. 
Then  the  tendon  is  cut  toward  the  other  border  of  its  insertion.  Alter  this  the  tests  lor 
adduction  and  abduction  are  made,  and  further  operative  interference  regulated  accord- 
ing to  the  results.  In  like  manner,  the  tendon  of  the  external,  superior,  or  interior 
rectus  may  be  partially  divided. 

This  operation  has  received  commendation  and  criticism,  and  it  is  open 

to  both.  It  is  suitable  to  cases  where  a  very  slight  effect  is  desired.  The 
fact  that  it  has  to  be  repeated  several  times  is  an  argument  against  it,  and  in 
favor  of  a  more  pronounced  effect  which  can  be  gained  in  one  or  two  partial 
tenotomies. 

III.  Advancement  or  Readjustment  and  Resection. — In  this 
operation  the  tendon  of  a  rectus  muscle  is  brought  forward  to  a  new  attach- 
ment. 

(a)  Advancement  to  Correct  Faulty  Strabismus  Operations. — Oper- 
ations for  advancement  after  squint  operations  present  difficulties  and  com- 
plications not  found  in  other  cases.  The  conjunctiva  over  the  incision  is 
generally  firmly  cicatrized  to  the  subconjunctival  tissue  and  sclera.  This 
may  be  due  to  the  fact  that  the  original  incision  was  not  closed  by  a  suture 
and  that  the  exposed  scleral  surface  had  granulated.  Again,  the  insertion  of 
the  muscle  is  sometimes  very  thin  and  cord-like,  and  is  attached  to  the  sclera 
by  a  mere  thread.  The  retraction  of  the  muscle  may  have  been  very  great, 
and  one  must  search  carefully  for  its  new  and  abnormal  insertion. 

First,  the  cicatricial  surface  should  be  denuded  by  cutting  away  this  tissue  until  the 
sclera  is  exposed  and  the  muscle  brought  into  view.  A  hook  is  now  passed  beneath  the 
muscle,  which  is  raised  up  until  it  can  be  seized  with  catch-forceps,  when  its  insertion 
is  severed.  It'  tlie  muscle  is  atrophied  and  cord-like,  it  will  be  necessary  to  insert  the 
in  i  dies  very  far  back  in  order  to  secure  the  necessary  purchase,  and  the  difficulties  of 
passing  the  needles  under  these  conditions  are  sometimes  very  considerable,  owing  to 
the  cicatrization  above  mentioned,  [f  the  muscle  is  thin,  a  thread  armed  with  three 
needle-,  as  described  elsewhere  (de  Wecker's  advancement  operation,  see  below),  should 
be  used;  but  where  it  i-  broad  enough  for  the  insertion  of  one  thread  through  its  upper 
and  another  through  its  lower  border,  this  is  the  better  plan  to  adopt,  because  it  spreads 
the  muscle  and  gives  it  a  more  secure  attachment  to  the  sclera.  Both  eyes  should  be 
bandaged  lor  two  or  three  days  after  the  operation.  As  soon  as  the  eye  is  firmly  fixed 
in  its  new  position,  providing  no  inflammation  has  ensued,  both  eyes  should  be  opened 
and  the  patient  allowed  to  walk  as. usual  around  the  ward  or  house. 

(6)  De  Wecker's  Method  of  Advancement. — De  Wecker's  operation 
is  performed  in  the  following  manner: 

A  vertical  incision  is  made  in  the  conjunctiva  close  to  the  cornea,  and  the  subcon- 
junctival tissue  cut  away  until  the  tendon  of  the  muscle  is  exposed.  One  branch  of  a 
de  Wecker's  clamp  is  now  passed  under  the  tendon  of  the  muscle,  and  when  it  is  in  the 
p roper  position  the  other  branch  is  pressed  down,  thus  holding  it  by  the  forceps  (Fig. 
407).  The  tendon  is  now  severed  close  to  the  sclera,  and  an  exploration  is  made  with 
a  small  hook  to  ascertain  whet  her  any  fibers  or  oil's  hoots  of  the  muscle  remain.  A.  thread 
armed  with  three  needles,  one  in  the  middle  and  the  other  two  not  far  from  the  end-  of 
the  suture,  is  prepared  tor  the  second  step  of  the  operation.  The  middle  needle  is 
passed  through  the  center  of  the  tendon  from  it-  under  surface,  and  come-  out  through 
the  conjunctiva.  The  location  of  this  stitch  is  regulated  by  the  effecl  to  be  produced, 
being  inserted  nearer  the  caruncle  when  more  effecl  is  desired.  The  two  needle-  are 
then  passed  deeply  under  the  conjunctiva,  coming  out  in  the  vertical  meridian  of  the 
eve  at  a  distance  of  4  m m.  from  the  cornea,  one  above  and  the  other  below.  The  clamp- 
forceps  are  now  removed,  and,  if  the  muscle  is  to  be  shortened,  thai  portion  of  the 
muscle  within  the  clamp  is  severed.  The  middle  needle  having  been  cut  off  and  the 
others  also  removed,  the  two  suture-  are  tied  as  follows :  The  operator  and  his  assistant 


SCHWEIGGER'S  OPERATION  OJ    RESECTION,    ETC.        591 

each  take  one  of  the  threads  and  simultaneously  tighten  them.  Winn  the  desired  posi- 
tion lias  been  attained  the  knots  are  tied  and  the  ends  of  the  thread  cut  oh'.  An  over- 
correction is  made,  because  alter  removal  of  the  threads  the  tendon  recedes  from  the 
original  position. 

If  after  two  or  three  days  there  is  an  over-correction,  the  threads  are  removed,  and, 


Fig.  407. — De  Wecker's  advancement. 


after  cocainizing  the  eye,  a  delicate  hook  is  introduced  into  the  wound  and  the  attach- 
ments of  the  muscle  loosened  sufficiently  to  overcome  the  defect.  If  this  is  not  neces- 
sary, the  stitches  are  allowed  to  remain  until  the  fifth  or  sixth  day. 

(c)  Noyes's  Operation  for  Advancement. — Dr.  Noyes  describes  his 
operation  as  follows  : 

"Suppose  the  right  rectus  interims  is  to  be  advanced.  The  right  rectus  externus  is 
first  divided;  then  seize  the  insertion  of  the  rectus  interims  with  fixation-forceps,  taking 
a  deep  bite  to  include  all  that  can  be  lifted;  sever  the  insertion  freely,  and  cut  down 
above  and  below  into  the  conjunctiva  to  the  extent  of  10  to  15  mm.;  have  the  forceps 
fast  to  the  tissues  by  shutting  the  spring  catch,  lay  it  aside  and  then  remove  a  vertical 
oval  of  conjunctiva  in  front  of  the  insertion,  leaving  a  strip  G  mm.  wide  next  thecornea. 
Lift  the  muscle  and  pass  a  curved  needle  from  within  outward  at  its  middle  and  as  fur 
back  as  the  proposed  effect  will  demand.  With  the  needle  in  place  cut  off  superfluous 
material  in  front  of  it,  and  then  draw  it  through.  The  other  two  needles  are  introduced 
in  succession  and  the  tissues  in  front  are  cut  off.  This  is  done  to  avoid  the  danger  of 
cutting  off  the  sutures.  We  now  have  three  threads  through  the  muscle-fascia  and  con- 
junctiva. The  needles  at  the  other  ends  of  the  thread  are  next  to  lie  passed  forward 
beneath  the  remaining  conjunctival  strip,  taking  hold  of  the  outer  layer  of  the  sclera, 
so  that  the  points  emerge  at  the  limbus  corneas.  The  middle  thread  is  tightened  first, 
and  then  the  others  in  succession.  The  double-knot  is  not  tied  until  the  thread-  have 
been  successively  tightened,  and  the  eye  is  in  a  proper  position.  If  there  is  much 
crumpling  of  tissue,  it  must  be  cut  away,  leaving  the  parts  smooth.  The  stitches  are 
allowed  to  remain  from  four  to  seven  days.  A.  bandage  is  applied  tor  twenty-tour  or 
forty-eight  hour-.'" 

The  author  does  not  think  it  necessary,  except  in  rare  cases,  to  cut  away 
the  conjunctiva  as  recommended  above.  He  has  found  that  it  usually  smooths 
down  in  a  short  time. 

(fZ)  Schweigger's  Operation  of  Resection  of  a  Rectus  Muscle.^. 
Schweigger  incises  the  conjunctiva  vertically,  as  well  as  the  tissue  of  Tenon's  capsule 
over  the  insertion  of  the  muscle  to  lie  advanced.  A  hook,  curved  on  the  flal  and  with 
an  olive  point,  is  passed  underneath  the  muscle  and  lifts  it,  exposing  to  view  the  entire 
tendon.  A  second  hook  is  passed  under  the  in  u  side  in  the  Opposite  direction.  One  hook 
is  pressed  toward  the  corneal  margin  as  far  as  the  insertion  of  the  tendon  will  permit, 
and  the  other  one  to  that  point  where  it  is  desired  to  insert  the  threads,  thus  exposing 
the  muscle  from  •'>  to  10  nun. 


592 


OPERATIONS   UPON   THE  EYE-MUSCLES. 


Two  doable-armed  catgut  threads  are  now  prepared.  One  needle  is  passed  under 
the  upper  edge  of  the  muscle  and  pierces  the  same  below  the  middle.  The  second  is 
passed  from  the  lower  end  and  pierces  the  muscle  above  its  middle.  Each  thread  is 
then  tied,  thus  including  the  entire  muscle.  The  amount  to  be  tied  off  is  measured  with 
a  millimeter  rule.  That  portion  of  the  muscle  between  the  catgut  threadsand  its  inser- 
tion is  then  resected.  Then  the  two  needles  are  passed  through  the  insertion  or  stump 
of  the  muscle  and  superficially  through  the  sclera.  Both  the  threads  are  now  tied  and 
cut  otl'  and  the  conjunctival  wound  closed  with  silk  sutures.  The  antagonistic  muscle  is 
always  tenotomized  before  the  sutures  in  the  muscle  to  be  advanced  arc  tightened. 

(e)  Prince's  Single-suture  Advancement. — Dr.  A.  E.  Prince  has 
devised  what  he  calls  the  "pulley  operation."  An  anchor  or  pulley  loop  is 
made  in  the  dense  episcleral  tissue  about  1  mm.  from  the  corneal  margin. 
The  sutures  inserted  into  the  niusele  are  passed  through  this  loop,  and,  being 
fixed  and  solid,  it  affords  an  unyielding  point  of  resistance.  This  method 
was  later  modified  by  its  author  to  a  single-suture  operation,  which  is  per- 
formed in  the  following  manner  : 

A  conjunctival  incision  is  made  over  and  parallel  to  the  attachment  of  the  tendon  of 
the  muscle  to  l.e  advanced.  The  tendon  is  secured  by  an  advancement-forceps  (Fig.  408), 
separated  from  the  sclera,  and  advanced,  allowing  the  conjunctiva  to  retract.  Two  slender 
eve-needles  (Tiemann  No.  25)  on  either  end  of  a  No.  3  iron-dyed  silk  suture  are  passed 
from  within  outward,  perforating  the  capsule,  muscle,  and  conjunctiva  at  a  variable 
point  depending  upon  the  amount  of  displacement  to  he  effected,  thus  securing  the 
middle  portion  of  the  muscle  in  a  sling  from  which  it  can  neither  slip  nor  escape.  With 
the  exception  of  cases  requiring  a  small  amount  of  advancement  of  the  muscle,  as  those 
in  which  the  suture  is  used  as  a  control  to  prevent  an  over-correction  following  a  tenot- 
omy, the  portion  of  the  tendon  in  the  grasp  of  the  forceps  is  exsected  about  '2  mm. 
anterior  to  the  sling.  The  sclera  being  now  fixed,  preferably  with  Critchett's  short  fix- 
ation-forceps, an  unyielding  anchorage  in  the  form  of  a  fibrous  pulley  is  secured  in 


Fig.  ins. — Prince's  ndvancemenl  forceps. 


Pig   pi'.'.     Prince's  advancement. 


line  with  the  rectus  by  introducing  either  needle  into  the  dense  episcleral  tissue  2  mm. 
from  the  Bclero-comeal  junction    Fig.  409). 

Both  ends  of  the  suture  are  now  broughl  together,  forming  the  lir-t  portion  of  a  Bur- 
gical  knot,  and  tightened  to  effeel  a  slight  over-correction.  This  suture  is  permitted  to 
remain  four  days,  unless  it  i-  desired  to  diminish  the  effect,  which  may  be  safely  done 
after  forty-eighl  hours  by  removing  the  suture  and  opening  the  wound  with  a  small 
Btrabismus-hook.    Tenotomy  of  the  opposing  muscle  is  made  as  in  other  operations. 

This  operation  is  better  than  the  one  firsl  described  by  Dr.  Prince,  and  gives  very 
-.it isfactory  results. 


CHOICE  OF  AN  OPERATION.  593 

Dr.  E.  E.  Holt  has  devised  a  somewhal  similar  operation.1 

i  /i  Landolt's  Operation  for  Advancement. —  Landolt  is  a  firm  believer 
"in  the  incomparable  superiority  of  the  advancement  of  the  muscle  over  its 
setting  back/5  He  says  :  "  There  is  more  than  one  good  method  which  leads 
to  the  same  end.  The  essential  point  in  all  advancements  consists  in  always 
bringing  the  muscle  and  its  surrounding  part  as  near  the  cornea  as  possible, 
and  firmly  fixing  them  there." 

After  exposing  the  muscle  the  surgeon  inserts  two  threads,  one  through  the  upper 
and  one  through  the  Lower  border  of  the  muscle,  more  or  less  behind  its  attachment  ac- 
cording to  the  effect  desired.     After  division  of  the  tendon  the  threads  are  passed  under 

the  superior  and  inferior  borders  of  the  cornea,  and,  when  necessary,  as  far  as  it-  vertical 
diameter.  The  threads  are  then  knotted,  hringing  the  tendon  forward  toward  the 
corneal  margin.     An  assistant   turn-  the  eyeball  in  the  direction  of  the  muscle  to  be 

advanced.  When  resection  of  the  muscle  is  necessary,  allowance  fortius  is  made  before 
the  muscle  is  cut  off,  and  then  that  portion  of  the  muscle  still  adherent  to  the  tendon  is 
removed. 

Landolt's  argument  for  advancement  is  that  "  it  causes  the  eve  to  enter  its 
muscular  investment,  from  which  the  tenotomy  causes  it  to  escape."  He 
does  the  operation  in  cases  of  strabismus  in  preference  to  tenotomy.  Since 
advancement  is  so  seldom  followed  by  any  reaction,  he  believes  that  it  will 
come  into  more  general   use  for  strabismus. 

The  writer  believes  that  this  method  of  operating  will  be  and  should  be 
more  generally  adopted.  With  the  present  aseptic  precautions,  it  is  no  more 
dangerous  than  a  simple  tenotomy,  although  more  difficult.  The  final  cosmetic 
results  will  be  more  satisfactory.  It  better  preserves  the  function  of  the 
muscle  and  prevents  any  advancement  of  the  eye. 

(g)  Stevens's  Operation  of  Tendon-shortening  or  Advancement. — Dr. 
Stevens's  operation  for  advancement  is  as  follow-  :  The  opening  in  the  conjunctiva  is 
the  same  as  for  tenotomy  (page  589).  Then,  lifting  the  border  of  the  conjunctiva  nearest 
the  cornea  by  the  fine  forceps,  a  little  pocket  is  made  by  the  points  of  the  scissors  or  the 
lance-probe  j  Fig.  406,  D),  extending  under  the  conjunctiva  more  or  less  toward  the 
cornea  in  proportion  to  the  greater  or  less  effect  which  we  propose  to  induce.  The 
forceps  seizes  the  central  portion  of  the  tendon,  and  it  is  dissected  from  the  eveball 
entirely  or  partially  as  the  case  may  he.  The  fine  tendon  crochet  (Fig.  406,  F)  or  the 
fixation-forceps  with  catch  now  seizes  the  tendon  behind  the  section  and  draws  it 
forward  through  the  conjunctival  opening,  when  one  needle  on  a  double-armed 
thread  i-  passed  through  the  central  portion  of  it  from  \  to  1  mm.  behind  the  cut  ex- 
tremity. The  other  needle  is  made  to  penetrate  the  conjunctiva  at  the  extreme  end  of 
the  pocket  and  the  thread  drawn  through.  Another  thread  i-  inserted  in  a  similar 
manner  a  little  to  one  side  of  the  first,  in  order  to  allow  between  the  two  threads  a  little 
bridge  of  tissue.  Now  the  surgeon  draw-  upon  the  end-  of  the  threads,  forcing  the  cut 
end  of  the  tendon  into  the  little  pocket,  and  fa-ten-  the  threads  by  tying  them  across 
the  little  bridge.     The  suture-  are   removed  on   the  third  or  fourth   day. 

Choice  of  an  Operation.— The  choice  of  an  operation  will  depend  much 
on  the  method  one  ha-  practised  or  ha-  seen  practised.  No  our  method  has 
all  the  good  qualities  to  recommend  it.  hut,  as  all  are  intended  to  accomplish 
the  same  purpose,  the  surgeon  can  choose  the  one  best  suited  to  his  own 
ideas.  The  method  of  resecting  the  muscle  ;i-  performed  by  Schweigger, 
Noyes,  mid  other-  produces  excellenl  results.  In  this  way  tin1  muscle  i-  p.  r- 
manently  shortened,  and  the  cut  end  of  the  muscle  attache-  it-elf  to  the 
sclent  at  the  point  where  the  original  insertion  existed.  It  is  not.  however, 
always  necessary  to  resect  the  muscle.  In  Nbyes's  operation  the  thread  is 
passed  underneath  the  conjunctiva  of  the  severed  muscle.  It  is  probable 
that    the    Noyes    operation    is  freer   from    the   possibilities  of  danger  than 

1  Tra  /  Am.  Ophth.  Society,  vol.  iv.  p.  123. 

■ 


594  OPERATIONS   UPON   THE  EYE-MUSCLES. 

Schweigger's,  owing  to  the  deep  insertion  of  the  needle  in  the  sclera  in  the 
latter.  Tin'  former  is  the  one  the  writer  prefers,  but  he  considers  the  two 
threads  in  the  upper  and  lower  edges  of  the  muscle  sufficient,  without  the  use 
of  the  third  or  middle  thread.  In  the  limited  space  allowed  it  has  been  im- 
possible  to  mention  many  of  the  operations  devised  by  different  surgeons.  A 
choice  had  to  be  made  from  the  many,  and  it  has  been  done  without  any 
intended  discourtesy  to  those  omitted. 

I V.  Advancement  of  the  Capsule  ;  de  Wecker's  Method. — This 
operation  is  performed  as  follows: 

A  vertical  incision  as  Long  as  the  corneal  diameter  is  made  through  the  conjunctiva 
over  the  tendon.  The  excision  of  a  balfmoon-shaped  piece  of  conjunctiva  is  only  neces- 
sary in  very  high  degree  oi  deviation.  An  opening  in  the  capsule  is  made,  and  through 
this  the  book  is  inserted  from  above  downward.  The  hook  is  passed  completely  under 
the  tendon  until  its  point  is  free  on  the  opposite  side.  At  the  same  time  the  capsule  is 
incised  above  and  helow.  Next,  two  double-armed  threads  are  employed  in  the  follow- 
ing way:  One  end  of  the  thread  is  passed  through  the  incision  in  the  capsule  from  the 
inner  surface,  so  that  it  pierces  muscle,  capsule,  and  conjunctiva.  The  point  at  which 
the  muscle  is  pierced  is  regulated  by  the  effect  to  be  produced.  The  other  end  of  the 
thread  is  carried  through  the  incision  under  Tenon's  capsule  forward  toward  the  corneal 
margin,  through  the  superficial  layers  of  the  sclera,  until  it  emerges  from  the  conjunctiva 
at  the  vertical  meridian  of  the  eye.  about  5  mm.  from  the  cornea.  There  the  two 
threads  are  tied  simultaneously  by  the  operator  and  his  assistant.  A  surgical  knot  is 
first  made,  and  when  the  eye  is  in  position  the  double  knot  is  completed.  The  con- 
junctiva is  then   closed  by  three  sutures. 

Knapp  modifies  this  operation  by  the  use  of  a  third,  middle  suture  passed 
through  the  equatorial  flap  of  the  conjunctiva,  through  the  tendon  (which  was 
held  up,  drawn  forward,  and  folded  with  a  squint-hook),  underneath  the 
squint-hook,  and  through  the  episcleral  tissue  and  the  flap  of  conjunctiva 
near  the  cornea. 

Advancement  of  the  capsule  is  inferior  to  the  advancement  or  resection 
operations  described  above.  It  leaves,  for  a  while  at  least,  an  ugly  knot  or 
elevation  under  the  conjunctiva,  and  its  final  results  are  not  as  certain  and 
i'vi-v  i'rom   danger  as  other  methods. 

Accidents  and  Complications. — Subconjunctival  hemorrhage  is  more  or 
less  abundant  in  every  case  of  tenotomy  or  advancement,  but  it  is  readily 
absorbed  and  needs  no  treatment  other  than   the  use  of  hoi  fomentations. 

Retrobulbar  hemorrhage  or  hemorrhage  into  Tenon's  capsule  occurs  occa- 
sionally. It  is  not  likely  to  lead  to  serious  results,  but  may  vitiate  the 
immediate  effects  of  the  operation.  A  compress-bandage  should  be  applied 
over  the  eye.  and  on  this  iced  compresses  laid  and  changed  frequently. 
Retrobulbar  hemorrhage  may   be  caused  by   vomiting  during  anesthesia. 

Granulations  occasionally  spring  from  the  incision  in  the  conjunctiva. 
They  are  readily  controlled  by  -nipping  them  off  with  scissors  close  to  the 
sclera  or  touching  them  with  a  crystal  of  copper  sulphate  or  alum.  Dr. 
Noyes  report-  a  case  where  diphtheritic  inflammation  attacked  the  wound 
after  a  strabismus  operation,  and  resulted  in  divergence. 

Ulceration  of  the  margin  of  the  cm-ma  from  the  end  of  the  thread,  which 
was  cut  off  too  Long,  occurred  in  the  experience  of  the  writer.  It  was 
promptly  relieved  by  cutting  oil*  the  thread.  The  breaking  of  a  thread 
during  an  advancement  operation  is  a  very  uncomfortable  accident.  It 
should  be  avoided  by  carefully  testing  the  thread,  which  should  l>e  strong 
enough  to  stand  the  traction. 

Panophthalmitis  and  orbital  inflammation  have  been  known  to  follow 
advancement  operation-,  but  the  occurrence  is  extremely  rare.  Perforation 
qj  the  sclerotic  during  the  operation  for  strabismus  occurs  occasionally,  even 


INSTRUMENTS  AND   DRESSINGS. 


595 


( lases  are   reported   by  Drs. 
>thers.      Panophthalmitis    has 


in  the   hands  of  the  niost   skilful   operators. 
Ha-ket,    Derby,    Knapp,    E.    William.-,    and 
followed  this  accident. 

Instruments  and  dressings  for  an  ordinary  tenotomy  of  one  of  the  recti 
muscles  are — a  spring  speculum,  two  pair-  of  fixation-forceps  (Fig.  41<>i.  two 
strabismus-hooks  (Fig.  Ill),  the  one  -mailer  than  the  other,  two  pairs  of 
scissors,  one  curved  (Fig.  112)  and  one  straight  (Fig.  H3),  a  needle-holder 
(Fig.  414),  and  tw ■   three  needles  threaded  with  fine  black  silk  which 


Fig.  410.— Fixation-forceps. 


Fig.  411.— Strabismus-hooks. 


has  been  waxed,  absorbent  cotton  sponges,  and  dry  absorbent  cotton,  fine 
ganze  bandages,  and  a  compress. 

As  the  cornea  becomes  dry  during  exposure  from  the  influence  of  cocain, 


Fig.  412. — Curved  scissors. 


Fig.  U3.— Strabismus-scissors. 


it  is  well  to  have  a  dropper  and  some  sterilized  water  in  a  glass  dish  close  by, 
so  that  the  cornea  can  be  moistened  in  case  it  is  necessary. 

For  advancement  operation-,  in  addition  to  the  above,  it  is  necessary  to 


FIG.  414.— Xeedle-holder. 

have  long  black  silk  thread  or  catgut  sutures,  armed  with  two  <>r  three 
needles,  as  described  in  the  various  methods  devised  by  different  operators. 
Local  anesthesia  by  cocain  is  much  more  desirable  than  general  anesthesia, 
for  the  reason  that  the  effects  can  be  at  once  tested  and  any  under-  or  over- 
correction remedied  ;  buf  in  children  it  may  be  necessary  to  administer  an 
anesthetic.  It  is  especially  desirable  to  operate  for  advancement  under 
cocain,  for  we  want  the  aid  of  the  patient  to  determine  the  effect  produced. 
Eucain  i-  recommended  by  Silex  in  squint  operations. 


OPERATIONS    UPON    THE    LACHRYMAL  APPARATUS. 


I'.v  SAMUEL  THEOBALD,  M.  D., 

I  i]     BALTIMORE,  MI>. 


Removal  of  the  I,achrymal  Gland. — This  may  be  accomplished  by 
cither  of  two  procedures  : 

The  gland  may  be  exposed  by  an  incision  through  the  integument  of  the  upper  lid 
parallel  with  the  orbital  margin,  drawn  out  by  means  of  a  tenaculum  and,  with  a  knife 
or  scissors,  separated  from  its  attachments.  The  objection  to  this  method  is  that  it 
involves  a  more  or  less  complete  division  of  the  levator  palpebrae  superioris  muscle, 
which  may  result  in  the  production  of  ptosis. 

The  other,  and  probably  better,  plan,  suggested  by  Velpeau,  is  to  divide  the  external 
canthus,  evert  the  upper  lid,  and  cut  down  upon  the  gland  from  the  superior  conjunctival 
cul-de-sac.  This  method  docs  not  endanger  the  integrity  of  the  levator  muscle,  and 
leaves  a  less  conspicuous  scar  than  the  first-described  procedure. 

Bowman's  Operation  for  Fistula  of  the  Lachrymal  Gland. — 

The  purpose  of  this  operation  is  to  convert  an  external,  cutaneous  fistula  into 
one  opening  into  the  conjunctival  sac,  and  hence  causing  little  or  no  annoy- 
ance. 

A  threaded  needle  is  passed  a  short  distance  into  the  fistula,  and  is  then  made  to 
transfix  the  lid,  being  brought  out  upon  its  conjunctival  surface.  A  second  needle, 
upon  the  other  end  of  the  thread,  is  next  passed  through  the  lid  at  a  point  close  to  the 
orifice  of  the  fistula.  The  two  ends  are  then  tied  tightly,  and  the  thread  is  Jeft  to  cut 
it-   way  out.     To  promote  the  closure  of  the  external  fistula  its  v(\isf<  are   freshened. 

Division  of  the  Canaliculus. — En  performing  this  operation  it  is 
important  that  the  edge  of  the  knife  should  not  be  inclined  forward;  other- 
wise a  slight  perceptible  deformity  will  result,  and,  besides,  the  position  of  the 
divided  canaliculus  will  not  be  the  most  favorable  lor  carrying  oil'  the  tears. 
Weber's  beak-pointed  canaliculus-knife  (Fig.  Jloi.  or  the  modification  of  it 
shown  in  Fig.  416,  is  usually  employed. 


Pig.  11  5     Weber's  beak-pointed  canaliculus-knife. 


i  [G    116     Probe  pointed,  Btraighl  canaliculus  knife. 

The  operator  should  -land  behind  the  patient,  letting  the  patient's  head  (covered 
with  a  napkin  n -t  against  hi>  chest,  the  left  hand  being  used  for  the  lefl  eye  and  the 
ri<_dit  hand  for  the  right  eye.  The  lid  being  kept  upon  the  stretch  with  the  thumb  of 
the  opposite  hand,  the  probed  tip  of  the  canaliculus-knife  is  introduced  verticall}  into 
the  punctum  (which,  together  with  the  canaliculus,  should  have  been  dilate. I  previously 
by  the  passage  ol  one  or  two  of  the  smallest-sized  probes),  and  then,  the  direction  of 
the  knife  having  been  changed,  it  is  passed  horizontally  along  the  canaliculus  until  its 
progress  is  arrested  by  the  inner  wall  of  the  lachrymal  sac  (Fig.  417).    This  point  having 


DESTR  U(  'TIO  .  V   O  F  Til  K  L  A<11  in  'M.  1  /.  S.  1  < ',    /•;  7  V  '. 


597 


been  reached,  and  the  edge  of  the  knife  being  directed  upward  or  upward  and  lightly 
backward,  the  lid  being  kept  still  on  the  stretch,  the  canaliculus  is  divided  by  simply 
elevating  the  handle  of  the  knife,  [f  the  operation  is  done  as  a  preliminary  step  to  the 
introduction  of  Lachrymal  probes,  the  canaliculus  should  be  divided  well  up  to  its  junc- 
ture with  the  sue  ;  but  if  done  for  some  other  purpose,  such  as  eversion  of  the  punctum 
or  stricture  of  the  canaliculus,  it  may  not  be  necessary  to  carry  the  division  quite  to  this 
point. 

The  edges  of  the  divided  canaliculus  usually  show  for  several  days  a  disposition  to 
grow  together,  and  to  overcome  this  they  must  be  separated  every  day  or  every  other 
day  by  the  passage  of  a  greased  probe.  A  few  instillations  of  eocain  render  the  opera- 
tion of  division  of  the  canaliculus  almost  painless. 

The  foregoing  description  applies  especially  to  division  of  the  lower  canaliculus; 
but  the  upper  canaliculus,  which,  in  the  writer's  experience,  seldom  needs  to  be  divided, 
may  be  operated  upon  by  essentially  the  same  procedure. 


Passage  of  canaliculus-knife. 


Kxcision  of  the  I,achrymal  Sac. — Owing  to  the  delicate  structure 
of  the  walls  of  the  sac,  this  is  not  an  operation  easy  of  performance. 

A  vertical  incision  of  sufficient  length  is  made  through  the  skin  and  the  internal 
palpebral  ligament  down  to  the  sac,  which  is  then  dissected  out  as  carefully  and  com- 
pletely as  possible  with  a  scalpel  or  a  pair  of  blunt-pointed  scissors.  After  this  the 
cavity  left  by  the  removal  of  the  sac  and  the  upper  part  of  the  nasal  duct  are  scraped 
with  a  sharp  spoon,  and,  the  wound  having  been  cleansed  with  an  antiseptic  solution. 
the  edges  of  the  incision  arc  closed  accurately  with  stitches  and  a  suitable  aseptic 
dressing  applied. 

Destruction  of  the  lachrymal  Sac  by  Caustic  Agents,  etc. — 
Destruction  of  the  lachrymal  sac  by  the  actual  cautery  is  an  operation  of 
classical  origin,  having  been  practised  by  the  Romans  nearly  two  thousand 
years  since.  In  more  recent  times  tiie  obliteration  of  the  sac  has  been  effected 
by  the  use  of  caustic  agents,  such  as  nitrate  of  silver,  chlorid  of  /inc.  nitric 
acid,  Vienna  paste,  caustic  potash,  etc.,  ind  still  more  recently  by  the  thermo- 
cautery and  the  galvano-cautery.  The  merit  claimed  for  this  procedure  (and 
also    for   excision   of  the  sac)  is  that  it   not    only  relieves   the    patient    of    the 

dacryocystitis  and  its  unpleasant  < sequences,  bul  that  in  some  cases  it  cures 

the  epiphora  through  the  inhibitory  influence  which  it  appeal'-  to  evert  upon 
the  activity  of  the  lachrymal  eland. 

The  usual  method  of  performing  this  operation  is  to  make  a  free  incision  into  the 
sac  through  the  external  integumenl  ami  the  palpebral  ligament,  and  through  this  to 
introduce  the  caustic  or  the  tip  of  the  galvano-  or  thermo-cautery,  a  Manfredi's  spec- 
ulum being  employed  to  protect  the  lips  of  the  incision. 


598      OPERATIONS  UPON  THE  LACHRYMAL  APPARATUS. 

Introduction  of  lachrymal  Probes. — Small  probes  arc  sometimes 
passed  through  the  undivided  canaliculus  (to  overcome  occlusion  of  the 
puncta,  etc.),  but  division  of  tin;  canaliculus  always  precedes  the  passage  of 
probes  for  the  cure  of  occlusion  of  the  nasal  duct.  Cocain  lessens,  bul  does 
not  entirely  do  away  with,  the  pain.  It  should  always  be  used,  however,  and 
the  probe  should  be  anointed  with  vaselin  containing  10  :100  of  cocain. 

The  writer  prefers  to  stand  behind  the  patient,  using  the  left  hand  for  the  left  eye 
and  the  right  hand  for  the  righl  eye.  as  in  division  of  the  canaliculus,  since  the  patient's 

head  can  be  more  easily  steadied  in  this  position.    The  probe  is  passed  horizontally 

along  the  canaliculus,  the  lid   being  kept  upon  the  stretch 

with  the  thumb  of  the  Opposite  ha  ml,  until  its  point  conies 

in  contact  with  the  inner  wall  of  the  lachrymal  sat';   it  is 

then    turned    into   a    vertical    position   and    passed    slowly 

through  the  duct   until  the  floor  of  the  nose   is  reached 

(Fig.  418).     No  especial  difficulty  attends  the  introduction 

<>f  the  large  probes  commended  by  the  writer,  provided 

they  are  properly  constructed.     It  is  of  the  first  impor- 


Fig.  418. — Introduction  of  lachrymal  probe. 


Pig.  U.9.— Theobald's  lachrymal  probe. 


tance  that  their  tips  should  not  be  too  square  and  blunt.  The  accompanying  illustration 
(Fig.  Ill)  ,  which  represents  the  actual  size  of  the  largest  probe  of  the  series,  Nos.  15 
and  16,  -hows  the  proper  shape  of  the  ends  as  well  as  thecurve  which  has  been  found 
most  convenient. 


OPERATIONS   ON   THE  ORBIT. 

IJv    V.    BULLER,  M    I'., 

OF    MOXTKKAi.,  CANADA. 


All  operations  on  the  orbital  tissues  should  be  performed  in  accordance 
with  the  strictest  principles  of  antiseptic  surgery.  Even  when  septic  condi- 
tions are  present,  they  will  in  this  way  be  favorably  modified  :  it'  absent,  the 
surgeon  will  himself  be  to  blame  if  they  follow  his  manipulations.  It  will 
not  be   sufficient   to   take   these    precautions   merely   during    the   operation. 

Every  time  the  wound   is  dressed,  and   until  healing  has   been  fully  ac< 1- 

plished,  the  same  vigilance  is  imperative.  The  momentary  use  of  an  unclean 
probe  may  inflict  more  injury  than  the  disease  would  have  done  if  left  to 
itself. 

Abscess  of  the  Orbit.— If  an  abscess  has  formed  in  the  orbit,  there 
should  be  no  unnecessary  delay  in  opening  it.  For  this  purpose  a  straight, 
narrow  bistoury  may  be  used,  the  incision  being  made  at  the  point  of  greatest 
tenderness  and  swelling,  or,  if  there  be  fluctuation,  where  this  is  most  dis- 
tinct, close  to  and  parallel  with  the  margin  of  the  orbit.  There  need  be 
no  hesitation  about  thrusting  the  point  deeply  into  the  orbit,  but  only  the 
external  wound  should  be  wide.  An  opening  in  the  skin  and  oculo-orbital 
fascia  half  or  three-quarters  of  an  inch  in  length  is  desirable  to  relieve  ten- 
sion, unload  engorged  blood-vessels,  evacuate  pus  if  present,  and  facilitate 
keeping  the  wound  open  as  long  as  may   be  necessary. 

This  is  best  done  with  a  tent  of  borated  gauze  or  lint  inserted  after 
thorough  cleansing  with  some  warm  antiseptic  solution,  such  as  a  1  per  cent, 
solution  of  pheno-salyl  or  any  other  that  the  surgeon  may  prefer.  Com- 
presses of  sterilized  gauze  soaked  in  warm  solution  of  sublimate  1  :  5000  or 
boric  acid  3  per  cent.,  frequently  changed,  are  to  be  used  till  the  inflam- 
matory symptoms  subside.  The  wound  itself  and  the  eye  must  be  thoroughly 
cleansed  at  least  two  or  three  times  daily.  In  severe  cases  of  phlegmonous 
inflammation  of  the  orbit  early  and  free  incision  before  the  formation  of 
pus,  both  above  and  below,  conducted  on  the  same  principles,  may  be  the 
means  of  saving  the   patient's   vision  or  even   his  life. 

Enucleation  of  the  eyeball,  eviscerations,  and  Mules's  oper- 
ation are  described  on  pages  571—573. 

Introduction  of  an  Artificial  Bye  (Prothesis  Oeuli). — An  artificial 
i  ih  -hould  be  inserted  as  soon  as  the  tissues  are  firmly  healed  and  are  able  t<> 
bear  the  shell,  which  i-  usually  from  ten  days  to  one  month  after  the  opera- 
tion. 

In  order  to  insert  an  artificial  eye  the  upper  lid  i-  seized  between  the  fin- 
gers of  the  left  hand  and  drawn  gently  down  and  out,  and  the  larger  end  of 
the  -hell  is  inserted  vertically  beneath  it.  then  broughi  t<>  a  horizontal  direc- 
tion, while  ;tt  the  same  time  the  lower  lid  is  pulled  down,  when  the  shell  slips 
into  place.  In  order  to  remove  an  artificial  eye  the  head  el'  a  large  pin  is 
inserted  beneath  its   lower  margin,  the  lower   lid    being  at    the  same   time 


600  OPERATIONS  ON   THE  ORBIT. 

depressed,  while  the  eye  is  tipped  upward  and  forward3  when  the  pressure  of 

the  upper  lid  will  force  it  out.  Very  soon  patients  become  exceedingly 
expert  in  taking  out  and  introducing  artificial  eyes,  and  do  not  require  the 
aid  of  a  pin  in  making  the  manipulation  just  described. 

Until  the  tissues  become  accustomed  to  the  artificial  eye  it  should  not  l>e 
worn  constantly,  and  should  never  be  allowed  to  remain  in  the  socket  at 
night,  [f  the  enamel  of  the  shell  becomes  rough,  a  new  one  should  be  >nl>sti- 
tuted.  [f  the  sockel  or  the  stump  upon,  which  the  eye  rests  becomes  irritable 
or  inflamed,  the  shell  should  he  removed  and  the  tissues  treated  with  anti- 
septic lotions  and  mild  astringents  until  they  recover  their  healthy  condition. 
It  should  he  remembered  that  badly  fitting  artificial  eyes  have  occasioned 
sympathetic  inflammation. 

Operations  for  Prothesis  in  Cases  of  Cicatricial  Orbit.— ruder 
certain  circumstances,  particularly  after  lime-burns  and  trachoma,  contraction 
of  the  conjunctiva]  sic  and  the  formation  of  cicatricial  bands  may  render  it 
impossible  for  the  patient  to  wear  an  artificial  eye.  A  number  of  operative 
procedures  have  been  devised  to  overcome  these  difficulties,  hut  the  results 
have  been  confessedly  disappointing,  [ncisions  made  to  admit  the  shell 
always  close  by  cicatrization,  and.  if  anything,  increase  the  contraction.  A 
few  successes  have  followed  transplantation  of  the  conjunctiva  of  a  rabbit,  the 
skin  of  n  frog,  or  Thiersch's  graft.  Operations  based  upon  the  principles  of 
blepharoplasty  (page  555)  have  also  been  tried. 

Harlan's  Operation.1 — In  :i  case  of  cicatricial  contraction  of  the  cul-de-sac  after 
enucleation  Dr.  Harlan  proceeded  as  follows:  "A  heavy  lead  wire  was  inserted  beneath 

the  cicatricial  bands  and  passed  around  the  bottom  of  the  cavity,  and  the  ends  brought 
together  to  form  a  ring.  Way  was  made  for  the  wire  witli  a  pair  of  tine  sharp-pointed 
sci--.(,r-  curved  on  the  Hat.  and  it  was  inserted  behind  the  lower  band,  brought  out  at 
the  outer  canthus,  reintroduced,  and  passed  in  the  same  way  above.  The  wire  was  worn 
for  about  two  months,  when  it  was  cut  down  upon,  its  track  found  cicatrized,  and  the 
upper  sulcus  satisfactory.  The  lower  sulcus  was  deepened  by  reintroduction  of  a  wire. 
A  thin  leaden  shell,  formed  so  that  its  edges  would  rest  where  the  wire  had  been,  was 
afterward  introduced  and  left  in  position  constantly,  except  when  the  orbit  was  cleansed 
with  boric-acid  solution.  After  the  lead  shell  had  been  worn  for  a  few  weeks,  an  artifi- 
cial eye  could  be  worn  without  difficulty." 

Exenteration  of  the  orbit  is  performed  as  follows : 

The  eyeball,  if  present,  b  to  be  removed  in  the  ordinary  way.  Then  the  outer 
canthus  is  divided  to  the  orbital  margin,  the  lids  drawn  strongly  upward  and  down- 
ward respectively,  and  the  soft  tissues  back  of  them  and  the  periosteum  jusl  within  the 
orbital  circumference  divided  with  a  scalpel.  A  strong  pair  of  curved  scissors  is  now 
used  to  peel  off  the  entire  periosteum  to  the  apex  of  the  cavity,  where  the  whole  mass 
i-  d'taded  by  means  of  a  rounded  raspatorium  guided  by  the  forefinger  of  the  left 
hand.  Bleeding  from  the  ophthalmic  artery,  if  considerable,  may  be  checked  by  press- 
ure with  the  finger,  or  by  the  use  of  Paquelin's  cautery.  When  bleeding  has  ceased,  the 
writer  applies  a  thin  layer  of  chlorid-of-zinc  paste,  spread  on  lint,  to  the  shreds  of  tissue 
left  in  the  spbeno-maxillary  fissure  and  apex  of  orbit,  packs  the  cavity  lightly  with 
iodoform  gauze,  and  applies  a  retention  bandage.  This  dressing  may  lie  allowed  to 
remain   for  several  days 

If  the  malignanl  growth  for  which  exenteration  is  proposed  has  involved 
the  skin  of  the  lid-,  these  may  require  to  be  removed  more  or  less  widely,  as 
well  as  the  orbital  structures.  The  gaping  cavity  thus  produced  may  at  the 
-nine  operation  he  greatly  diminished  by  sliding  flaps  of  -kin  from  the 
neighborhood  in  such  a  way  a-  to  partly  conceal  the  deformity,  or  by 
Thiersch  grafts. 

Removal  of  Tumors  from  the  Orbit. — The  mosl  suitable  method 
of  dealing  with  orbital  cysts  ha-  already  been  mentioned  (see  page  531). 

■  /'  m       Imer.  <>i>litlml.  Soc,  L897,  vol.  \iii.  p.  63. 


REMOVAL    OF  TUMORS  FROM    Till-:  OllUlT.  601 

For  nevoid  or  erectile  tumors  electrolysis  gives  the  best  results  in  young 
Bubjects,  and  may  be  repeated  as  often  as  necessary,  every  two  or  three  weeks. 

The  most  rapid  effecl  is  obtained  by  introducing  two  platinum  needles,  one  lor  each 
pole,  if  the  growth  is  large,  the  needle  should  he  two  or  three  inches  in  length.  The 
skin  is  protected  by  coating  the  distal  half  of  the  needle  with  collodion.  During  the  oper- 
ation the  needle  attached  to  the  positive  pole  is  first  introduced  to  the  desired  depth 
and  held  in  -<ifu.  The  negative  needle  is  made  to  penetrate  the  tissues  in  several  places 
around  this,  in  each  of  which  it  is  held  in  position  for  two  or  three  minutes.  There  is 
some  danger  of  injury  to  the  optic  nerve  if  the  needles  are  passed  deeply  into  the  orbit. 

General  anesthesia  is  required,  and,  as  reaction  may  be  severe,  it  is  best  not  to 
attempt  too  much  during  one  sitting. 

In  adults  these  tumors  may  be  partly,  or,  if  encapsulated,  completely, 
excised,  and  in  some  eases  the  electric  cautery  or  thermo-cautery  may  with 
advantage  supplement    the   knife  and  scissors. 

Osteoid  growths  springing  from  or  involving  the  roof  of  the  orbit  may  he 
removed,  but  the  operation  is  somewhat  difficult  and  decidedly  dangerous. 
A  large  percentage  of  such  eases  have  died  from  consecutive  intercranial 
disease — abscess  or  meningitis.  Many  of  these,  however,  date  from  pre- 
antiseptie  days.  If  the  bony  growth  belongs  to  the  inner  or  inferior  walls, 
the  danger  is  much  less. 

The  growth  must  he  exposed  as  freely  as  possible  by  suitable  incisions  of  the  soft 
parts  covering  it,  including  the  periosteum,  which  must  be  carefully  detached.  Then 
the  base  of  the  growth  is  attacked  with  hammer  and  chisel,  cutting  the  bone  with  tiny 
rapid  strokes  until  the  mass  is  detached. 

The  ivorydike  masses  which  sometimes  project  into  the  orbit  from  adjacent  cavities 
maybe  detached  and  "shelled  out"  by  cutting  completely  through  the  normal  bone 
immediately  around  them:  when  thus  isolated  they  may  he  lifted  out  of  the  cavity  with 
suitable  forceps — a  procedure  which  does  not  require  much  force  in  the  absence  of  firm, 
deep  attachments. 

Tumors  of  the  orbit  which  are  extensively  adherent  to  the  globe  or  infil- 
trate the  surrounding  tissues  cannot  be  removed  without  sacrificing  the  eye- 
ball ;  for  these  the  operation  requires  no  special  description. 

In  all  other  eases  an  attempt  may  be  made  to  spare  the  eyeball.  In  any 
doubtful  case  the  surgeon  should  have  an  understanding  that  he  may  sacrifice 
the  eyeball  if  necessary. 

Tumors  of  the  o/>fi<-  inert  may  he  reached  by  a  vertical  wideincision  of  the  conjunc- 
tiva over  the  inner  side  of  the  globe,  detachment  of  the  internal  rectus  tendon,  which  is 
in  be  secured  and  identified  by  a  black  sidv  thread,  and  held  out  of  the  way  by  an  assistant. 
With  the  closed  blades  of  curved  seiv-ors  the  tissues  are  to  lie  separated  down  to,  along, 
and  around  the  growth  quite  to  the  apex  of  the  orbit.  With  a  strabismus-hook  passed 
around  the  nerve  at  this  point  as  a  guide,  use  the  scissors  to  cut  the  nerve  close  to  the 
foramen.  Then  with  small  vulsellum- forceps  bring  the  growth  forward,  reversing  the 
globe,  ami  detach  close  to  the  sclerotic.  Bleeding  must  he  arrested  by  pressure  with  the 
fingers  or  hot-water  injections,  and  the  parts  irrigated  with  perchlorid  solution  1  :  3000 
before  the  tendon  and  conjunctiva  are  sutured  into  place. 

Tumors  outside  the  muscle-funnel  are  to  he  reached  by  free  incision  parallel  to  the 
orbital  margin  over  the  most  accessible  part  of  the  tumor,  doing  all  the  deep  dissection, 
if  possible,  with  the  closed  scissors-blades  or  handle  of  the  scalpel.     .Many  growths  may 

be  successfully  "dug  oul  "  in   this  way,  with  very  little  loss  of  bl I  or  injury  to  the 

surrounding  parts.  All  bleeding  must  be  arrested  before  the  wound  is  closed  with  fine 
silk  suture-,  and  dressed  antiseptically,  with  suitable  provision  for  drainage. 

Kronlein's  Operation.— Tumors  situated  far  hack  in  the  orbit  may  be  exposed  to 
view  and  removed  without  sacrificing  the  eyeball  by  a  method  devised  by  Kronlein,  in 

the  following  manner:    A  crescentic  incision  is  made  around  the  outer  circumference  ol 

the  orbit.     The  periosteum   is  then  divided  at  this  part  to  a  similar  extent,  and  freely 
detached  from  the  outer  wall  of  the  orbit  as  far  as  maybe  necessary.     A.  temporary 
resection  of  a  wedge-shaped  portion  of  the  orbital  wall  can  then  be  made.     The  baa 
the  wedge  corresponds  to  the  outer  orbital  margin,  it-  apex  to  the  anterior  extremitj  ol 


602  OPERATIONS  ON  THE  ORBIT. 

the  inferior  orbital  fissure.  To  accomplish  this  the  zygomatic  process  of  the  frontal  bone 
is  chiselled  through,  a>  well  as  the  intervening  bunt'  between  this  and  the  fissure,  near 
it-  anterior  extremity.  In  the  same  waj  the  base  of  the  orbital  process  of  the  malar 
bone  is  divided,  and  this  second  incision  through  the  bone  is  continued  backward  to  the 
fissure.  The  loosened  portion  of  bone,  together  with  the  tissues  attached  to  it>  external 
surface,  may  now  be  drawn  toward  the  temple  to  such  an  extent  that  the  orbit  is  freely 
exposed  at  it-  outer  side,  and  a  growth  even  at  the  apex  is  rendered  quite  accessible,  and 
may  be  readily  removed.  Alter  this  has  Keen  accomplished  the  triangular  fiap  of  bone 
is  replaced,  the  skin-wound  united  with  sutures,  and  a  suitable  dressing  applied. 

It  is  -aid  that  recovery  is  complete  in  eight  or  ten  days.  The  operation 
i-  neither  difficull  nor  dangerous,  and  would  seem  to  merit  greater  favor  and 
have  a  wider  range  of  application  than  it  has  yet  received.  It  will  he  found 
useful  in  tli«-  extirpation  of  deeply-seated  orbital  tumors,  as  an  exploratory 
operation  in  some  doubtful  cases  of  exophthalmos,  and  is  an  efficient  means 
of  relief  in  violent  phlegmonous  inflammation  of  the  orbit.  Should  the  ex- 
posed  orbit  he  found  in  such  a  condition  that  complete  exenteration  is  deemed 
advisable,  this  may  he  done  at  the  same  sitting. 

Distention  of  the  frontal  sinus,  it'  recent  and  of  a  purulent  charac- 
ter, may  he  relieved  by  a  free  opening  through  its  lower  external  (orbital) 
Avail  and  subsequent  drainage  through  the  same  aperture;  but  in  chronic  dis- 
tention (mucocele),  the  cavity  or  cavities  having  become  much  wider  than  in 
their  normal  state,  simple  incision  will  not  suffice.  Under  these  circum- 
stances the  surgeon  proceeds  as  follows  : 

The  orbital  wall  must  be  so  freely  removed  that  the  little  finger  can  be  passed  into 
the  cavity  after  its  thorough  evacuation  by  syringing  with  some  warm  antiseptic  solu- 
tion. The  little  finger  of  the  other  hand  or  a  strong  probe  is  to  be  pushed  up  the 
oostril  to  a  point  where  the  finger  in  the  sinus  can  be  felt.  Then  an  aperture  of  con- 
siderable size  is  to  be  made  with  a  sharp  scoop  at  this  point,  and  a  drainage-tube  carried 
through  from  the  orbit  and  worn  until  the  discharge  has  ceased  or  the  cavity  has  suf- 
ficiently contracted  to  justify  it-  removal.  Thorough  cleansing  at  least  twice  daily 
must   be   practised    lor   weeks   or   months   to   achieve   this   end. 

This  operation  has  the  disadvantage  of  almost  certainly  injuring  the 
pulley  attachment  of  the  superior  obliqu< — an  accident  which  may  he  avoided 
by  making  an  opening-  with  chisel  or  trephine  in  the  forehead,  a  little  to  one 
side  of  the  median  line,  and  the  counter-opening  into  the  nose  in  the  manner 
ju-t  described. 

The  opening  in  the  forehead  may  with  advantage  be  sufficiently  enlarged 
to  include  the  entire  anterior  wall  of  the  sinus  ;  hut  the  disadvantage  of  this 
method  is  the  somen  hat  unsightly  resultant  scar. 

Orbital  fistula,  if  found  to  extend  into  the  frontal  -inn-,  will  heal  when 
the  sinus  ha-  been  dealt  with  after  one  or  other  of  the  foregoing  methods  ; 
that  is,  after  the  sinus  ha-  been  effectually  drained  into  the  nose. 

Should  the  fistula  he  found  to  lead  into  the  ethmoidal  cell-,  a  five  opening 
may  be  made  down  to  these  part-  along  the  fistulous  tract,  and  any  accumu- 
lated secretion  or  other  inflai atory  delwis  removed  by  syringing  and  the 

gentle  use  of  -mall  curettes.  A  drainage-tube  should  then  he  inserted,  and 
the  cavity  Kept  clean  by  daily  syringing  until  healing  take-  place.  This 
treatment  maybe  required  for  several  month-.  Gruening  has  effected  cure 
of  a  fistula  leading  to  the  ethmoid  cells  by  forcing,  with  a  strong  probe,  an 
opening  through   the  base   into   the   nasal  cavity,  thus  facilitating  drainage 

through    the    nose. 


APPENDIX. 


THE  METHODS  FOR  DETECTING  COLOR-BLINDNESS, 
WITH  SPECIAL  REFERENCE  TO  THE  EXAMINATION 
OF  RAILROAD  EMPLOYES. 

By  J.  ELLLS  JENNINGS,  M.  D., 

OF   ST.    LOUIS,    MO. 


Many  persons  suppose  that  all  that  is  required  to  test  the  color-sense  of  railroad 
employes  is  to  display  the  Hags  and  lanterns  used  as  signals  and  demand  the  name  of 
the  color  exposed. 

The  experienced  observer  knows,  however,  that  many  color-blind  subjects  can  name 
colors  correctly;  hence,  any  test  to  be  effectual  must  ascertain,  not  whether  the  employe 
can  name  colors  correctly,  but  how  he  sees  them,  and  whether  he  can  safely  be  trusted 
to  distinguish  between  the  various  signals  on  all  occasions.  We  determine  this,  first,  by 
making  him  pick  out  and  place  together  those  colors  which  appear  to  him  to  he  the 
same,  and  second,  by  having  him  recognize  colors  at  a  distance  under  various  degrees  of 
illumination,  thus  simulating,  as  far  as  possible,  the  various  atmospheric  conditions 
under  which  railway  signals  may  present  themselves. 

Holmgren's  Method. — The  set  of  worsteds  consists  of  three  large  test-skeins:  1  I 
light  pure  green ;  [2)  rose  purple);  3  red,  and  of  about  one  hundred  and  fifty -mall 
skeins  of  the  following  colors:  red.  orange,  yellow,  yellow-green,  pure  green,  blue- 
green,  blue,  violet,  purple,  pink,  brown,  gray,  including  several  shades  of  each  color  and 
at  least  five  gradations  of  each  tint  from  the  deepest  to  the  lightest. 

First  Test. — The  worsteds  are  placed  in  a  confused  heap  on  a  large  plane  surface 
in  a  good  light,  and  the  light  pure-green  test-skein  laid  a  little  to  one  side.  The  candi- 
date is  now  requested  to  pick  out  those  skeins  most  resembling  it  in  color  and  place  them 
by  the  side  nt'  tin-  sample.  The  examiner  must  explain  that  there  are  no  two  skeins 
exactly  alike,  and  that  an  endeavor  must  be  made  to  find  something  similar  of  a  lighter 
or  darker  -hade.  The  candidate  is  not  to  compare  narrowly  or  to  rummage  much 
among  the  heap,  but  to  select  with  his  eyes,  and  to  use  his  hands  chiefly  to  change  the 
position  of  the  selected  skeins. 

A  person  with  a  i,<>,-„ia/  color-sense  will  pick  out  the  lighter  and  darker  shades  of 
green  rapidly  and  without  hesitation.  He  may,  perhaps,  include  in  his  choice  a  few 
lt'-i-ii  skeins  inclining  to  yellow  or  blue;  but  tins  is  no  evidence  of  color-blindness,  hut 
rather  of  a  lack  of  practice  with  colors. 

The  person  compU  tely  color-blind,  whether  to  red  or  green,  will  select,  with  or  without 
the  greens,  some  confusion  colors  —grays,  drabs,  stone-colors,  fawns,  pink-,  or  yellows. 

The  person  incompletely  color-blind,  or  with  a  feeble  chromatic  sense,  will  add  to  the 
selection  of  greens  one  or  more  light  fawns  or  grays;  or  he  may  pick  out  a  skein, 
hesitate,  add  it  to  the  greens,  and  then  withdraw  it.  and  so  on.  When  confusion  colors 
have  been  selected  the  examiner  know-  that  the  candidate  is  either  completely  or 
incompletely  color-blind.  In  order  to  determine  it-  nature  and  degree  a  second  test  is 
employed. 

Second  Test. — The  worsteds  are  mixed  again,  and  the  large  n  •  test-skein  is  laid 
to  one  aide.  The  candidate  i-  requested  to  pick  out  all  the  lighter  and  darker  sh 
of  this  color;  if  color-blind  he  will  always  -elect  deeper  colors.  Those  subjects  who 
by  the  first  tesl  wen-  found  to  have  ^.feeble  chromatic  sense  will  make  no  mistakes  in  this 
test.  Those  who  are  incompletely  color-blind  will  match  the  rose  with  deeper  purples. 
The  completely  red-blind  candidate  will    select  blue  or  violet,  either  with  or  without 


604  APPENDIX. 

purple.  The  completely  green-blind  subjects  take  green  or  gray  or  one  alone,  either  with 
or  without  purple.  The  violet-blind  subjects  I  rare)  show  a  strong  tendency  to  select  blue 
in  the  first  test,  and  red  and  orange,  cither  with  or  without  purple,  in  the  second  test. 
A-  tin-  examination  has  decided  the  character  and  degree  of  the  defect,  it  is  not  neces- 
sary to  resort  to  the  third  test;  but  as  the  red  skein  used  corresponds  to  the  danger- 
signals,  it  may  occasionally  be  of  value  in  convincing  the  officials  that  the  candidate  is 
unlit  lor  duty. 

Third  Test. — The  sample  for  this  testis  a  skein  of  bright  red,  to  be  used  in  the 
same  way  as  the  green  and  rose.  The  red-blind  subjects  select,  besides  the  red,  green  and 
brown  shades  darker  than  the  red.  The  green-blind  subjects  select  green  and  brown 
.-hades  lighter  than  the  red.  Only  marked  cases  of  color-blindness  will  show  their  delect 
with  this  test. 

Thomson's  Method. — This  consists  of  twodifferent  sets  of  worsteds, which  are  kept 
apart  in  a  double  box.  The  first  set  consists  of  a  large  green  test-skein  and  twenty  small 
skein-,  each  marked  with  a  bangle  having  a  concealed  number  extending  from  one  to 
twenty.  Among  these  numbers  the  odd  ones  are  different  shades  of  green,  while  the 
even  numbers  are  grays,  light-hrowns,  etc.  The  sn-oml  si  I  consists  of  a  large  rose  test- 
skein  and  twenty  small  skeins,  which  are  numbered  from  twenty-one  to  forty.  Here 
the  odd  numbers  are  different  shades  of  rose,  while  the  ten  even  numbers  consist  of 
blues,  greens,  and  grays. 

In  testing  the  worsteds  are  taken  from  the  green  part  of  the  box  and  placed  upon  a 
table  in  a  confused  mass.  The  candidate  is  requested  to  select  ten  tints  to  match  the 
large  green  skein.  When  this  is  done  and  the  numbers  recorded  on  a  blank,  the  worsted 
is  removed  and  the  examiner  proceeds  with  the  second  set. 

Author's  Method. —  Realizing  that  any  test  which  is  limited  to  a  small  number  of 
match  and  confusion  skeins  curtails  the  choice  and  makes  the  defect  more  difficult  to 
discover,  the  author  has  endeavored  to  combine  the  good  points  of  Holmgren's  and 
Thomson's  methods.  The  set  consists  of  live  large  test-skeins:  light  pure  green,  rose, 
red,  blue,  and  yellow,  and  eighty-four  small  skeins,  each  marked  with  a  bangle  having 
a  concealed  letter  and  number.  The  letter  denotes  the  color,  and  the  number  (1  toll) 
denotes  the  shade.  For  example,  A  1  indicates  the  lightest  shade  of  pure  green ;  K  6, 
the  darkest  shade  of  brown. 

The  examination  is  conducted  in  a  manner  similar  to  the  Holmgren  method,  with 
the  addition  of  the  blue  and  yellow  tests.  A  record  of  one  test  is  made  before  proceed- 
ing to  the  next.  In  matching  the  blue  skein  the  color-blind  person  first  takes  the  dark- 
est shades  of  blue,  and  then  adds  the  rose  skeins,  because  he  recognizes  the  blue  in  the 
mixture  of  red  and  blue.  In  matching  the  yellow  he  adds  all  the  green  skein-  that  have 
yellow  in  them. 

Pseudo-isochromatic  Plates  of  Stilling.— The  remarkable  facility  with  which  the 
color-blind  distinguish  colors  to  which  they  are  blind  is  due  to  an  acute  sensitiveness  to 
differences  in  tint  and  intensity  of  light."  In  the  pseudo-isochromatic  plates  Stilling 
seeks  to  deprive  the  color-hl  ind  of  any  aid  in  matching  colors  by  selecting  those  which 
appear  identical  not  only  in  tint,  hut'  also  in  intensity  of  light.  On  a  colored  surface 
of  convenient  size  he  painted  a  spot  of  the  color  mistaken  for  it;  he  then  toned  or 
modified  this  spot  until  the  color-blind  eye  could  not  distinguish  between  the  spot  and 
the  surface,     stilling  then  constructed  ten  plates,  each  plate  containing  four  squares 

filled  by  -mall,  irregular  colored  -pots,  among  which  other  spots  in  a  confusion  color, 
made  to  conform  to  an  Arabic  figure,  are  placed.     The   test-plate   is  held  in  a  good  lighl 

and  the  candidate  required  to  distinguish  the  tracing-.  An  important  feature  of  this 
tesl   is  thai  there  is  no  inquiry  as  to  color. 

Lantem-test— A n  ordinary  switch  lantern  with  a  four-inch  opening  should  he  so 
arranged  that  pieces  of  colored  glass  can  be  placed  in  front  of  the  light.  The  colors  to 
he  used  are  standard  red.  yellow,  pure  light-green,  standard  green,  blue,  and  purple. 
The  luminosity  of  the  light  can  he  varied  by  having  at  hand  pieces  of  while  (ground), 
ribbed,  and  different  thicknesses  of  London-smoke  glass.  As  red  and  green  appear  to 
the  color-blind  as  one  and  the  same  color,  only  lighter  or  darker  than  the  other,  it  is 
to  deceive  him  by  changing  the  luminosity  of  the  light  without  altering  its  color. 
This  r:,n  he  done  by  diminishing  the  lighl  or  by  placing  pieces  of  ground  or  London- 
smoke  glass  before  the  colored  light.  The  candidate  should  he  Beated  al  a  distance  of 
fifteen  feel  from  the  lantern,  and.  according  to  Dr.  Edridge-Green,  should  be  rejected— 
(1 )  if  he  calh  the  red  green  or  the  green  red  under  any  circumstances;  (2)  if  he  calls 
the  white  light  under  an;  circumstances  red  or  green,  or  via  versd;  (3)  if  he  calls  the 
red  green,  or  while  light  black,  under  any  circumstances. 

Quantitative  Estimation  of  the  Color-sense.— The  lantern  may  also  he  u~-t<\  to 
make  a  quantitative  estimation  of  the  color-sense  by  placing  in  front  of  the  lighl   a 

metallic   slide  with    perforations    ranging   from    one   to   twenty  millimeters   ill   diameter. 


COL  0  B-  I  '/SIGN  REQ  UIBED  IN  RA  HAY  AY  SEE  1 1(  /:.        605 

Having  tested  and  recorded  the  average  size  of  the  opening  required  by  the  normal  eye 
to  distinguish  each  color  at  fifteen  feet,  the  candidate  is  placed  at  this  distance  and  is 

u^ked  to  name  the  colors.  It  he  recognizes  them  through  the  one-millimeter  opening, 
his  color-sense  is  normal  =  $.  If  an  opening  of  twenty  millimeters  is  needed,  his  color- 
sense  =  ^y.  [f  he  fails  to  recognize  the  color  through  the  largest  opening,  he  is  told 
to  approach  the   lighl  slowly,  and  it'  he  sees  it  at  three;  feet,  his  color-sense        ,,',,,.  etc. 

Oliver's  apparatus  is  designed  to  test  the  color-sense  of  employes  upon  the  railway- 
grounds  at  a  distance  of  1000  feet.  It  consists  of  twenty-three  shallow  open  wooden 
boxes,  painted  dead  black,  containing  colored  bunting  placed  upon  a  horizontal  beam 
15  feet  from  the  ground.  Arranged  above  the  middle  of  these  boxes  is  a  large  revolving 
box  with  live  partitions  for  the  test-colors.  The  pure-green  test-color  is  displayed,  and 
the  candidate,  employing  one  eye  at  a  time,  is  asked  to  write  upon  a  piece  of  paper  the 
number  of  the  color  in  the  lower  row  (going  from  left  to  right)  that  to  him  is  the  near- 
est match  to  the  upper  color.  This  experiment  is  repeated  with  the  other  test-colors, 
if  the  apparatus  is  to  be  used  at  night,  transparent  colored  glass  is  substituted  for  the 
colored  bunting. 

Chibret's  Photometer. — An  examination  for  color-blindness  is  not  complete  with- 
out making  a  test  of  the  light-sense  (see  page  l.~>4).  The  most  accurate  instrument  for 
this  purpose  is  Chibret's  photometer. 

The  candidate  faces  the  window  and  looks  with  one  eye  into  a  tube,  where  he  sees 
two  equally  bright  disks.  The  eye-piece  is  now  turned  until  he  can  detect  a  difference 
in  the  illumination  of  the  two  disks,  when  the  light-difference  is  indicated  on  the  scale. 
A  normal  eye  recognizes  the  difference  within  five  degrees.  The  light-minimum  is 
measured  by  making  one  disk  entirely  dark,  and  then  turning  the  eye-piece  until  he 
perceives  the  disk  coming  from  the  darkness.  The  scale  should  not  register  more  than 
one  or  two  degrees  (see  also  page  lo2). 

THE  DISPOSITION  OF  THE  COLOR-BLIND. 

Having  ascertained  that  the  color-sense  of  an  employe  is  defective,  the  surgeon 
must  decide  whether  the  defect  is  of  such  a  nature  as  to  warrant  his  discharge,  or 
whether  he  can  with  safety  be  allowed  to  retain  his  position.  If  the  person  in  question 
is  an  applicant  for  employment,  even  a  slight  defect  of  the  color-sense  should  be  suf- 
ficient ground  for  rejection.  If,  however,  we  have  to  deal  with  an  old  employe,  one 
who,  perhaps,  has  discharged  his  duties  in  a  satisfactory  manner,  justice  demands  that 
his  interests  be  studied  so  far  as  is  consistent  with  safety.  Every  case  of  complete  red- 
or  green-bl'mdne**  should  be  dismissed.  Those  who  are  incompletely  color-blind,  and  in 
the  first  test  merely  confound  gray  with  the  sample  color,  may  be  retained  if  the  visual 
acuity  and  light-sense  are  normal. 


STANDARDS  OF  FORM  AND  COLOR-VISION    REQUIRED 
IN    RAILWAY   SERVICE. 

By  A.  G.  THOMSON,  M.  D., 

OF   PHILADELPHIA. 

Laws  regulating  the  examination  of  railroad  employes  for  form- and  color-vision 
have  been  adopted  in  several  State-,  but  there  is  no  official  standard  established  by 
the  I '  ii  it  I'd  State-  ( Jove  rn  nn  nt  for  such  examinations  as  exists  in  Continental  countries. 
The  State  undertakings  in  this  behalf  have  nol  been  uniformly  successful,  as  witness  the 
experiment  tried  some  years  ago  in  Connecticut  by  which  scientific  expert-  were  to  be 
appointed  by  the  governor  and  paid  by  the  railroads.  This  undertaking  proved  a  failure, 
as  the  railroad  officers  would  nol  submit  t  heir  employes  to  the  scrutiny  of  State  officials, 
who,  by  adopting  their  own  standards,  could  practically  discharge  perhaps  15  per  cent, 
of  the  railroad  employes,  disturb  the  discipline,  and   impair  the  organization  of  the 

road-. 

A-  mo-t  of  the  Large  railroad  lines  run  through  several  State-,  to  save  complications 

which  may  arise  out  of  separate  State  Legislation  it  is  found  more  expedient  for  the  cor 


606  APPENDIX. 

porations  to  make  their  own  rules  and  regulations  for  examination  of  their  employes, 
using  their  own  methods  and  appointing  their  own  examiners. 

It  is  found  impracticable  for  corporations,  owing  to  the  Large  force  of  ophthalmic 
surgeons  it  would  require,  to  study  the  refraction  and  make  the  examination  as  scientific 
as,  from  a  medical  point  of  view,  is  admittedly  desirable.  So  it  is,  therefore,  the 
endeavor  of  the  railroads  to  devise  and  establish  a  genera]  system  of  examination  for 
protection  of  the  public  and  its  property  that  can  be  put  in  force  by  a  division  superin- 
tendent, acting  through  an  intelligent  assistant,  under  the  general  supervision  of  an 
ophthalmic  surgeon.  To  this  supervising  surgeon  all  information  collected  could  be 
transmitted,  and  he  would  thus  he  enabled  to  decide  all  doubtful  cases  and  to  protect  the 
railroad  from  any  danger  arising  from  incapable  employes,  and  at  the  same  time  to  save 
good  and  faithful  men  from  being  discharged  from  the  company's  service  without  suffi- 
cient cause. 

Such  a  system  has  been  perfected  by  1  >r.  William  Thomson,  authorized  by  the  Penn- 
sylvania Railroad  Company  since  1880,  and  has  been  adopted  by  other  roads  from  time 
to  time,  until  it  i<  protecting  an  aggregate  total  mileage  to-day  of  over  one  hundred 
thousand  miles.  This  system  has  heen,  as  here  indicated,  subjected  to  the  test  of  expe- 
rience, and  has  proved  very  satisfactory. 

Visual  Acuity. —  The  standards  of  form-vision  in  Continental   countries  and  also  in 

this  country  vary  from  ==,  in  one  or  both  eves  to  ==.  in  one  and  —  in  the  other,  in  the 

J  XX  "  XX  L 

first  class— that  is,  for  employes  on  the  head  end  of  an  engine,  while  in  Class  II,  repre- 
senting the  yard  and  train  service,  the  range  is  anywhere  from  —  in  one  to  —  in  the  other. 

A  railroad  should  require  for  its  safety  two  standards  for  entrance  into  its  service: 
The  standard  of  <  ilass  1,  representing  engineers,  firemen,  and  towermen,  should  require 
~  in  one  eye,  and  not   less  than  J^"  hi  tne  other — vision  taken  separately  without 

glasses. 

Eyperopia  over  2  1>.  should  ensure  rejection — astigmatism  being  eliminated.  This 
can  be  readily  ascertained  by  placing  a  trial  frame  containing  2  I ».  spherical-lens,  before 
the  patient,  and  if  he  has  with  these  lenses  full  acuity  of  vision,  the  optical  defect  is  demon- 
strated. This  practical  test  saves  many  complications,  as  a  man  may  enter  the  service 
as  a  young  man  with  strong  accommodation,  and  when  he  becomes  a  skilled  engineer, 
at  the  presbyopic  age,  he  will  not  have  vision  sufficient  to  reach  the  standard. 

Periodic  examinations  should  he  made  at  intervals  of  five  years,  or  after  an  injury 
which  may  in  any  way  affect  the  vision,  and  also  after  serious  illness  and  on  promotion. 

The  standard  of  Class  [I,  representing  trainmen,  conductors,  brakemen,  switchmen, 
and  yardmen,  >hould  require    "''^.  in  one  and  not  less  than      ==^  in  the  other  eye,  with 

or  without  glasses,  and  the  same  rules  regarding  re-examination  apply  to  them. 

( fid  employes  not  reaching  the  proper  standard  of  the  class  to  which  they  belong  on 
re-examination  should  be  corrected  and  required  to  use  glasses  if  they  be  permitted  in 
that  class  or  transferred  to  other  duties. 

Color-sense. — The  color-sense  is  requisite  to  enable  any  employe"  to  govern  his 
actions  by  day  or  nighl  bj  colored  signals. 
The  standard  8hould  require  three  points: 
I.  Tesl  with  colored  signal-flags. 
II.  Tesi  l,y  comparison  of  colored  worsteds — Holmgren's,  Thomson's,  William-'-. 
or  <  (liver's. 
III.  Test  with  colored  light. 

I.  Test  with  Colored  F/ikjs. — The  man  subjected  to  this  test  should  recognize  four  flags, 
one  of  each  color,  red,  white,  green,  and  blue,  and,  at  a  distance  of  twentj  feet,  tell  their 
color  and  meaning.     A  colored  flag  should  also  he  given  him  to  match  with  worsteds. 

II.  Test  l>;i  Comparison  of  Colored  Worsteds,  Matching  their  ('<>/<>r.-<  without  Telling  their 
Names. — Here  one  of  the  recognized  tests  should  be  used — Holmgren's  or  some  modifi- 
cation of  this  test.  Holmgren's  tesl  consists  in  testing  the  power  of  the  person  to  match 
various  colors  which  are  conveniently  used  in  the  form  of  colored  varus.  About  one 
hundred  ami  fifty  tints  are  employed  in  confused  mixture,  and  three  test-colors— viz. 
light-green,  rose-purple,  ami  red-   are  placed  in  order  before  the  person  examined,  who 

is  directed  to    -elect    similar    color-    from    the   mass.      By  this   manner  the   examiner  can 

judge  whether  -election-  are  correel  or  not    from  the  prompt  or  hesitating  manner  in 

which  the  -election  is  made. 

Testa  which  arc  modifications  of  this,  as,  for  example,  Thomson's  -tick-test,  are 

much  Bimpler  and  more  expedient   lor  use  on  railroads. 

III.  Testvnth  Colored  Light. — The  ordinary  railway-lanterns  of  different  colors  may 
he  used. 


THE  RONTGEN  RAYS  IN  OPHTHALMIC  SURGERY.       607 

[f  the  employe"  be  found  defective  in  his  color-sense,  he  will  undoubtedly  be  detected 
by  these  tests.  He  is  then  allowed  to  go  before  the  ophthalmic  experi  for  final  exami- 
nation, who  may  use  any  oilier  confirming  test  he  may  choose. 

It  is  to  be  remembered  that  this  is  not  an  official  standard — simply  the  requirements 
to  operate  a  railroad  without  danger  to  the  public  and  destruction  to  property. 


THE  RONTGEN  RAYS  IN  OPHTHALMIC  SURGERY. 

By  WILLIAM  M.  SWEET,   M.  D., 

OF   PHILADELPHIA. 

With  the  development  of  improved  methods  of  generating  and  employing  the 
Bontgen  rays  speedy  and  accurate  means  have  been  furnished  by  which  not  only  the 
presence  of  a  metallic  body  in  the  eye  may  be  determined,  but  also  its  exact  position. 
The  early  employment  of  the  new  form  of  radiant  energy  in  experiments  on  animals' 
eyes  gave  little  promise  of  the  successful  application  of  the  method  in  ophthalmic 
surgery  uutil  Charles  H.  Williams  of  Boston  and  C.  E.  Clark1  of  Columbus,  Ohio,  each 
reported  a  case  of  the  removal  of  a  piece  of  metal  from  the  living  eye  which  had  been 
previously  located  by  the  rays.  Shortly  afterward  Max  J.  Stern,  at  the  Philadelphia 
Polyclinic,  located  metallic  bodies  in  the  vitreous  in  four  cases,  and  demonstrated  the 
possibility  of  obtaining  shadows  on  the  photographic  plate  of  foreign  bodies  situated 
in  any  part  of  the  eyeball  or  orbit. 

Practical  Application  of  Rays. — While  numerous  methods  have  been  suggested 
and  employed  for  determining  the  exact  position  of  the  body  in  the  eye,  the  writer  has 


l  I..  120.    Principle  of  method  of  localization. 

found  the  use  of  two  metal  indicators,  one  pointing  to  the  center  of  the  cornea  and  the 
other  situated  to  the  temporal  side  at  a  known  distance  from  the  first,  to  be  simple  in 
application  and  accurate  in  results.    Two  radiographs  are  made  to  give  differenl  rela- 

1  Traits.  Amer.  Ophth.  Soc}  vol.  vi i.  part  iii. 


608 


APPENDIX. 


tions  of  the  shadows  of  the  indicators  and  the  body  in  the  eyeball  or  orbit — one  with 
the  tube  horizontal  or  nearly  so  with  the  plane  of  the  indicators,  and  the  other  with  the 
tubeal  any  distance  below  this  plane. 

The  principles  of  this  method  may  he  understood  from  the  drawing  (Fig.  420),  in 


Fig.  421.-  [ndieating  apparatus  and  plate-holder. 


which  a  candle-flame  is  used  to  represent  the  x-ray  tube.     Rays  of  light  coming^  from 
the  candle  when  s 
and  an  object  in  a 


.Mil'        lo      USCU    \,KJ    lllllC^Clll     Lll^     J±-li\J      l;L*wt-.  llftjo    wi       ii_.ii       ^v^xAAiu^      .**,... 

the  candle  when  at  A,  in  casting  shadows  upon  a  flat  surface  of  two  ball-pointed  rods 
a  sphere  representing  the  eye,  give  the  view  as  shown  on  the  surface  ( '. 


Fig.  122    -Radiograph  made  v.  'Hi  the  tube  horizontal  with  the  plane  of  Indicators. 

When  tin-  Bource  of  lighl  is  carried  I"  low  the  horizontal  plane  of  the  two  rods  to  //,  the 
shadows  of  tie-  indicators  take  tie  position  shown  on  the  surface  />.  while  the  relative 
position  of  the  body  also  changes.     Knowing  the  distance  of  one  of  the  hall-  from  the 

center  of  t  lie  COm<  :i  ami  the  distance  between  the  ha  IN.  the  position  of  the  metal  in  the 


THE   E  0  N  7  > }  EN  B .  I  )  rS  IX  OPI1TH A  LM ic  St  i:<  1 E  /.' ) ' 


609 


eye  may  be  readily  determined,  since  the  shadow  of  the  body  preserves  at  all  tin 
fixed  relation  with  respect  to  the  shadows  of  the  indicating  balls  in  whatever  position 

the  candle  is   placed. 

In  practice  it  is  essential  that  the  axis  of  the  eyeball  shall  be  parallel  with  the  two 
indicators  and  with  the  photographic  plate;  that  one  of  the  indicators  points  to  the 
center  of  the  cornea  and  be  at  a  known  distance  therefrom  ;  and  that  the  two  indicating 
halls  he  in  a  perpendicular  line  with  the  plate  and  at  a  known  distance  from  each  other. 
Simplicity  has  been  secured  by  combining  the  plate-holder  and  indicators  into  a  special 
apparatus  which  is  hound  to  the  side  of  the  head,  as  shown  in  Fi:_r.  421. 

The  determination  of  the  position  of  a  foreign  body  in  the  eye  by  the  method  de- 
scribed may  lie  understood  from  the  two  radiographs  which  are  reproduced  in  I-'i'_r~.  422. 
423.  These  were  made  of  a  man  who  was  shot  in  the  face  by  a  rabbit-hunter,  one  of  the 
shot  penetrating  at  a  point  about  3  mm.  below  the  superior  border  of  the  orbit  of  the 


Fig.  423.— Radiograph  made  with  tube  below  horizontal  plane  "f  indicators. 


left  side.     No  view  of  the  fundus  of  the  left  eye  was  possible,  owing  to  the  denseness 
of  the  vitreous,  although  a  slight  red  reflex  was  present  in  the  upper  portion  of  the  eye. 

In  determining  the  position  of  the  body  in  the  eye  two  circles,  24  mm.  in  diameter, 
are  drawn  upon  paper,  one  to  represent  a  horizontal  and  the  other  a  vertical  section  of 
the  average  adult  eyeball.  Upon  these  circles  are  noted  the  positions  of  the  balls  of 
the  indicators  when  the  exposures  were  made. 

Measurements  are  made  upon  each  of  the  radiographs  of  the  distance  that  the 
shadow  of  the  foreign  body  is  above  or  below  the  shadows  of  the  indicators,  and  these 
distances  are  entered  above  or  below  the  spots  representing  the  two  indicating  balls  on 
the  circle  showing  the  vertical  section  of  the  eye.  Lines  drawn  through  the  points  of 
measurement  from  the  two  radiographs  ('''and  D  and  A' and  /•')  indicate  the  plane  of 
shadow  of  the  foreign  body  at  each  exposure.  Where  the  two  line-  cross,  therefore, 
must  be  the  location  of  the  body  as  measured  above  or  below  the  horizontal  plane  of 
the  eyeball  and  to  the  temporal  or  nasal  side. 

The  location  of  the  foreign  body  back  of  the  center  of  the  cornea  is  determined  by 
measuring  the  distance  thai  the  shadow  of  the  body  is  posterior  to  the  shadows  of  the 
two  indicating  balls  on  the  radiograph  made  with  the  tube  horizontal  to  the  plane  of 
the  indicators,  marking  off  the  measurement  perpendicular  to  each  of  the  spots  repre- 
senting the  indicator-  on  the  horizontal  section  of  the  eye,  and  drawing  a  Hue  through 
these  points.  Since  this  represents  the  plane  of  shadow  of  the  foreign  body  when  the 
radiograph  was  made,  the  metal  must  be  situated  at  some  point  on  this  line.  The 
location  of  the  body  as  respects  the  vertical  section  of  the  eyeball  having  been  deter- 
mined, where  a  line  drawn  perpendicular  to  this  position  intersects  the  plane  of 
shadow  on  the  horizontal  section  is  the  situation  of   the  body  back  of   the  anterior 

portion   of   the  eyeball.      When    the  distance  of   the   platinum    plate   of    the   tube   from 
39 


610 


APPENDIX. 


the  center  indicating  ball  is  known,  the  plane  of  shadow  of  the  body  on  the  bori- 
zontal  section  of  the  eye  is  determined  by  drawing  a  line  directly  from  a  point 
representing  the  tube  to  the  spot  of  measurement  of  the  shadow  of  the  body  back 
of   the    external    indicator.      In    order  to   render   the    various   measurements    clear, 

outline  drawings  of  the  two  radiographs,  reduced  one- 
third  in  size,  are  shown  in  Figs.  426  and  42t>,  the  letter- 
ing corresponding  to  that  employed  on  the  diagrammatic 
circles. 

When  the  photographic  plate  is  in  place  at  the 
side  of  the  head,  it  is  necessary  in  the  majority  of  cases 
to  arrange  the  point  of  fixation  so  that  the  cornea  is 
rotated  slightly  inward,  in  order  that  the  visual  axis 
shall  he  parallel  with  the  plane  of  the  photographic  plate. 
This  rotation  of  the  eyeball  in  no  way  affects  the  method 
of  locating  bodies  within  the  globe,  but  when  the  body 
ha-  penetrated  into  the  orbit  outside  of  the  eyeball,  the 
convergence  necessary  to  ensure  parallelism  of  the  visual 
axis  and  the  plate  leads  to  error  in  the  determination  of 
the  position  of  the  metal.  To  eliminate  this  factor  of 
error  necessitates  a  knowledge  of  the  angle  of  the  orbit 
with  the  plate,  or,  what  is  equivalent,  the  amount  of  de- 
viation of  the  eyeball  from  the  primary  position,  and  the 
employment  of  this  angle  in  plotting  the  diagrammatic 
circle-  representing  the  eyeball.  Another  error  arises  from 
the  false  projection  of  the  shadow  of  the  body  in  the  orbit 
in  relation  to  the  shadows  of  the  indicators,  owing  to 
greater  divergence  of  the  rays  as  the  distance  between  the 
center  indicator  and  the  foreign  body  increases.  This 
false  projection  may  lie  allowed  for  by  noting  the  dis- 
tance of  the  platinum  plate  of  the  tube  from  the  center 
indicator,  and  employing  this  measurement  in  determin- 
ing the  plane  of  shadow  of  the  body  on  the  horizontal 

section    of  the   eye. 

In  making  the  exposures  the  plate  is  to  the  side  of  the 
bead  corresponding  to  the  injured  eye,  and  the  tube  is  placed  about  12  inches  to  the 
opposite  side  and  slightly  forward.  The  patient  should  lie  upon  his  back,  as  this  posi- 
tion ensures  greater  steadiness  of  the  head  and  body  than  when  sitting  upright  with 
some  form  of  head-rest.  An  exposure  of  four  minutes  is  ample  to  secure  clear  shadows 
of  bodies  in  the  eyeball  or  orbit,  ami  with  efficient  apparatus  good  radiographs  may  be 
.secured  in  one-half  this  time.     As  the  best  results  are  achieved  when  the  tube  is  run 


Pig,  124.— Diagrammatic  circles 
representing  the  eyeball :  upper 
circle,  horizontal  section;  lower 
circle,  vertical  section  (reduced 
one-third  in  size). 


Fin.  425.— Outline  drawing  of  radiograph 
made  with  tube  horizontal   uiih   plane  of 
third  in  size). 


Pig.  126.  Outline  drawing  of  radiograph 
made  with  tube  below  horizontal  plane  or  indi- 
cators (reduced  one-third  in  size). 


at  a  high  vacuum,  a  tube  should  he  selected  which  may  be  so  operated  that  the  resist- 
ance offered   to  the  passage  of  the  CUrrenl    does   not    reach   a   point  to  interfere  with  the 

eration  of  the  rays.  The  cathodal  terminal  should  be  ground  and  polished,  so  that 
i  he  raya  are  focussed  to  a  small  point  upon  the  platinum,  whicb  ensures  sharper  outlines 
of  the  foreign  bodythan  when  the  focus-poini  i-  large. 

Accuracy  of  the  Method.-  -It  ha-  been  conclusively  shown  in  actual  work  that  the 
x-rays  may  lie  relied  upon  to  determine  in  nearly  every  instance  the  presence  or  absence 
of  a  foreign  body  in  the  eye.  The  difficulties  of  shadowing  the  body  on  the  plate 
increase  with  the  Bmallness  of  the  object,  especially  if  it  is  Bituated  to  the  nasal  side  of 


OPHTHALMIC  OPERATIONS  ON  ANIMALS'    EYES.        611 

the  eye  and  therefore  some  distance  from  the  sensitive  surface.  ft  i-  evident  that  cases 
may  occasionally  be  s<  en  where  the  body  is  so  small  as  to  fail  to  cast  a  shadow  of  suffi- 
cient distinctness  to  be  recognized  in  comparison  with  the  shadows  of  the  orbital  bones, 
although  eh i | is  of  metal  which  arc  too  minute  to  be  shown  by  the  rays  seldom  strike  the 
eye  with  sufficient  force  to  overcome  the  resistance  of  the  ocular  structures  and  pene- 
trate deeply  into  the  globe.  In  cases  of  doubt  as  to  the  presence  of  a  metal  body  in  the 
eye,  several  exposures  should  be  made  with  the  tube  in  various  positions,  in  order  to 
cause  the  body,  it'  present,  to  be  shadowed  through  the  thinnest  portion  of  the  orbital 
bones,  and  thereby  exhibit  sufficient  contrast  to  assist  in  revealing  its  presence. 

Dangers. — The  introduction  of  more  powerful  apparatus  for  the  generation  of  tin- 
rays  has  reduced  to  a  minimum  the  dangers  of  severe  injury  of  I  be  superficial  structures 
of  the  body  by  decreasing  the  time  of  exposure.  Persons  of  fair  complexion  arc  par- 
ticularly susceptible  to  the  action  of  the  rays,  although  a  slight  redness  of  the  skin  is  all 
that  may  be  expected  in  any  ease  in  the  short  period  required  in  making  the  negatives. 
It  is  a  safe  plan,  however,  to  limit  the  exposures  at  onesitting  to  four,  which  at  the  most 
would  subject  the  patient  to  the  action  of  the  rays  tor  a  period  of  sixteen  minutes.  In 
this  way  it  is  possible  to  note  the  effeel  on  the  skin,  and.  if  additional  radiographs  are 
desired, postpone  the  second  sitting  for  several  day-  in  case  marked  redness  follows  the 
first  exposures. 

Influence  on  Vision  of  Blind  Eyes.— The  experiments  made  by  Hansell,1  by  Wil- 
kinson of  the  California  School  for  the  Blind,  ami  by  Hilgartner  ami  Northrup  con- 
clusively show  that  the  x-rays  have  no  power  whatever  of  exciting  vision  or  even  light 
perception  in  an  eye,  diseased  or  normal,  and  are  without  beneficial  effect  in  the  treat- 
ment of  diseases  leading  to  blindness.  These  investigation-  were  made  upon  a  number 
of  patients  who  were  blind  from  dense  opacities  of  the  cornea,  congenital  cataract,  or 
complete  optic  atrophy. 


THE    PRACTICE     OF     OPHTHALMIC    OPERATIONS    ON 

ANIMALS'    EYES. 

By  CLARENCE  A.  VEASEY,  A.  M.,  M.  D., 

OF   PHILADELPHIA. 

Introduction. — The  frequent  practice  of  ophthalmic  operations  upon  animal-'  eyes 
is  of  the  irreatest  importance  to  the  beginner  in  operative  ophthalmology,  as  it  enables 
him  to  become  acquainted  witli  the  use  of  the  various  instrument-,  to  recognize  the  dif- 
ference in  thedensityof  the  tissues  which  have  to  be  cut,  to  become  thoroughly  familiar 
with  the  technic  of  each  operation,  and  to  lose  a  certain  amount  of  the  timidity  which 
is  almost  invariably  present  when  beginning  operative  work  upon  the  human  eve. 

Instruments. — A  set  of  instruments  should  be  obtained  and  used  for  this  purpose 
alone.  The  following  are  all  which  are  required  for  practising  most  of  the  operations 
on  the  eyeball  and  muscles:  An  eye-speculum,  a  pair  of  fixation-forceps,  an  angular 
keratome,  a  v.  Graefe  cataract-knife,  a  pair  of  iris-forceps,  a  pair  of  iris-scissors,  a  cys- 
totome  and  Daviel's  scoop,  a  cataract-needle,  a  strabismus-hook,  a  pair  of  strabismus- 
scissors,  a  canaliculus-knife,  a  -mall  scalpel,  and  a  few  curved  needles. 

Choice  of  Eyes.— Pigs' eyes  are  the  mo-t  useful  for  practising  the  various  opera- 
tions. They  more  nearly  resemble  human  e\  es  in  -i/e  and  density  of  tissue  than  do  the 
eyes  of  other  animals  that  are  readily  obtainable,  and  they  can  he  easily  fastened  in 
the  various  masks.  Sheep-'  eyes  are  too  large  tor  the  latter  purpose,  and  bullocks'  • 
while  useful  for  demonstrations  before  a  large  class,  possess  tissues  which  are  to,,  dense 
and  are  themselves  too  large  for  the  instruments  which  are  commonly  employed  in 
operation-  on   the  human   eye  to   make  them   of  practical    value. 

For  operations  upon  the  muscles,  the  orbits,  and  the  lids  it  is  necessary  to  have  a 
lead  with  the  eyes  in  their  natural  positions.  For  this  purpose  the  head  of  a  y 
pig,  about  six  weeks  old,  i-  perhaps  the  easiest  obtained  ami  answers  the  purpose  very 
well.  The  butcher  musl  1m-  cautioned,  however,  to  allow  the  head  to  remain  in  scalding 
water  for  the  shortest  possible  time  preparatory  to  removing  the  bristles,  or  the  eyes  will 
be  too  shrunken  to  answer  the  purpose.  Even  with  these  precautions  the  corneas  will 
be  a  trifle  hazy,  but  if  the  eyeballs  retain  their  firmness,  this  defect  will  not  intei 
with  the  subsequent  practice  of  the  operations. 

1  Amer.  Journ.  of  Med.  Sciences,  Nov.,  1S97. 


612 


Apri:xi)ix. 


If  possible,  all  the  operations  should  also  be  practised  upon  t lie  head  of  a  cadaver; 
luit.  unfortunately,  it  is  difficult  to  obtain  material  of  this  character  outside  ol  the  dis- 
secting-rooms of  medical  schools,  and  even  when  it  is  at  hand  the  eyes  are  often  so 
shrunken  and  collapsed,  and  have  undergone  such  great  changes,  that  it  is  fully  as  satis- 
factory, if  not  more  so,  to  practise  on  the  animal'-  eyes.  To  obtain  correct  ideas,  how- 
ever, of  the  topography  of  the  parts  practice  on  a  cadaver  as  fresh  and  well  preserved 
as  possible  i-  essential. 

After  practising  for  a  time  upon  eyes  placed  in  a  mask  and  upon  eyes  in  their 
natural  positions  in  a  pig's  head,  it  is  advisable  to  obtain  some  experience  in  operating 
Upon  the  eyes  of  live  animals.  Dogs.  cats,  or  rabbits  may  be  used,  the  latter  being  per- 
haps tin'  least  expensive  and  most  easily  handled.  The  animals  should  be  anesthetized 
with  chloroform  before  operating,  and  at  the  conclusion  of  the  operation  the  anesthesia 
should  be  pushed  sufficiently  far  to  produce  death. 

Time  of  Removal  of  Eyes  from  the  Animal. — As  eves  always  undergo  various 
changes  shortly  after  death  which  render  them  less  valuable  tor  operative  work,  they 
should  be  removed  from  the  animal  as  soon  as  it  is  killed.  It  is  especially  important 
that  they  be  removed  before  the  animal  is  scalded  preparatory  to  scraping  off  the  bris- 
tles, otherwise  the  corneas  will  become  so  opaque  and  shrunken  as  to  render  them  useless. 
Method  of  Preserving  Eyes  for  Operating  Purposes.  —  Fresh  eyes  are  by  far  the 
besl  and  most  satisfactory  for  operative  work.  They  impart  to  the  hand  a  more  natural 
sense  of  resistance  of  the  tissue-,  and  the  corneas  arc  much  clearer  than  they  can  possi- 
bly be  after  preservation  in  any  liquid.  If  it  is  impossible,  however,  to  obtain  them 
fresh  when  desired,  they  can  be  preserved  for  operating  purposes  lor  about  one  week  by 
placing  them  in  a  yL  of  a  1  per  cent,  solution  of  formaldehyd.  A  stronger  solution, 
though  excellent  as  a  preservative,  hardens  them  too  much  for  operative  work.     Should 

it  be  desired  to  preserve  them  even  longer, 
they  may  be  transferred  to  a  solution  of 
thymol  (1:5000),  in  which  they  will  keep 
for  several  weeks  lAndogsky).  No  matter 
whether  fresh  or  preserved  eyes  are  em- 
ployed, tin1  corneas  will  be  found  to  be  more 
or  less  dry,  so  that  before  beginning  any 
operation  they  should  be  moistened  with 
water. 

The  Operating  Mask.--It  is  custom- 
ary when  practising  operations  upon  animals' 
eves  to  place  the  latter  in  masks  especially 
constructed  for  the  purpose.  The  best  of 
these  is  (he  Viennese  mask  seen  in  Fig.  A'll . 
This  represents  a  human  face  with  most 
of  its  relations  preserved,  and  in  the  orbital 
cavities  are  placed  removable  sockets  in 
which  the  animal's  eves  can  be  firmly  held. 
These  sockets  permit  the  eves  to  be  moved  ill 
all  directions,  and  by  turning  a  central  screw 
on  which  the  eye  rests  the  latter  can  be  tight- 
ened or  loosened,  so  that  the  intraocular  ten- 
sion may  be  decreased  or  diminished  at  will. 
The  face  is  so  attached  to  its  base  that  it  can 
be  placed  at  dilfereiit  angles,  and  is  made  of 
hard    rubber    to    prevent    absorption    of    the 

various  ocular  fluids.     Other  masks  known  as 

"  phantom  face-  "  and  made  of  papi&r  machl 
maj    be  also  used  for  the  -ame  purpose. 

The  Home-made  Mask.  — It  thestudent 
does   not    possess  the   Viennese  mask   or  a 

phantom  face,  a  fairly  satisfactory  substi- 
tute may  be  constructed  at  home  from  a 
small    box    and   a  piece   of  cork.      The   latter 

should  lie  sufficiently  thick  to  enable  the 
hand  to  move  freely  without  striking  the 
lid    of    the    box,    and    is   glued    to   the    latter 

as   shown   in    Fig.  428.     An  eve  i-  readily 

tout  pins,  and  the  lid  can  be  placed  a1  any 


i  to.  i ;,.    Vienna 


fastened  to  this  bj    mean-  of  four   tacks  or 

angle  desired. 

Should  no   mask  be  at  hand,  an  eye  can  be  wrap) 


d  in  a  towel  and  held  in  the  hand 


OPHTHALMIC  OPERATIONS  OX  ANIMALS'    EYES. 


613 


of  an  assistant,  which  rests  firmly  on  a  table  while  the  different  operations  on  the  eyeball 
are  being  practised  (Fig.  429).  The  greatest  objection  to  this  method  is  the  impossibility 
of  holding  an  eye  firmly  without  making  considerable  pressure,  which  spoils,  to  a  certain 


Fig.  428.— Home-made  mask. 


extent,  most  operative  procedures.  The  method  is  of  great  value,  however,  in  prac- 
tising puncture  and  counter-puncture  and  the  different  varieties  of  corneal  sections,  and 
in  these  the  assistant  may  be  dispensed  with,  the  eye  being  held  in  one  hand  while  the 
knife  is  manipulated  with  the  other. 

Preparation  of  the  Eye  for  the  Mask. — When  the  eyes  are  removed  from  the  pigs 


Pig.  129.— Eye  in  towel. 

they  have  attached  to  them,  as  a  rule,  the  stumps  of  the  muscles,  some  conjunctiva,  and 
more  or  less  of  the  orbital  fat.  Enough  of  this  should  be  trimmed  off  .to  enable  the 
eye  to  fit  easily  into  the  socket  of  the  mask,  but  at  the  same  time  care  must  be  exercised 
not  to  remove  too  much  or  the  ey<>  cannot  be  held  sufficiently  tight  for  the  satisfactory 
performance  of  an  operation.  A  little  practice  will  soon  enable  the  student  to  know 
just  how  much  tissue  to  remove,  so  that  the  strongest  possible  grasp  may  lie  maintained 
during  the  whole  operation. 


614 


APPENDIX. 


The  shape  of  the  pig's  cornea  differs  somewhat  from  that  of  the  human  cornea,  and 
in  placing  pigs1  eyes  in  the  mask-socket  the  round  end  should  be  turned  upward.  In 
this  manner  the  shortest  diameter  of  the  eye  is  horizontal,  and  the  iris  is  less  apt  to  fall 
in  front  of  the  knife  in  making  corneal  sections  than  when  placed  in  any  other  position. 

Bi  fore  attempting  to  fit  an  eye  into  the  mask-socket  the  latter  should  be  removed 
from  the  mask  and  the  cavity  made  as  large  as  possible  by  means  of  the  screw  on  which 
the  eye  is  to  rest.  After  this  an  eye  is  placed  in  position,  and  a  small  circular  metal 
band  containing  several  teeth  is  pushed  over  it  to  hold  it  in  place. 


Pig.  130.— Position  of  the  kcratome  in  iridectomy. 


Fig.  431.— Cataract-knife  making  section. 


Pig.  132.— Delft 


f  the  lens. 


Fk;.  i:s.— Anterior  sclerotomy. 


General  Directions. — Before  beginning  to  practise  any  operation  the  instruments 
required  for  thai  operation  should  be  selected  and  placed  within  easy  reaching-distance 
in  the  order  in  which  they  arc  to  be  used,  [f  some  one  is  assisting,  the  operator  should 
not  remove  his  eyes  from  the  field  of  operation  more  than  is  absolutely  required,  the 
assistanl  placing  in  his  hand-  each  instrument  as  it  is  needed  and  removing  the  ones 
that  have  just  been  employed.  The  operator  should  also  be  careful  to  assume  only  such 
positions  in  relation  to  the  animal'-  eye  or  to  the  mask,  as  could  be  easily  attained  if 
operating  on  the  human  eve.  mid  should  studiously  avoid  any  but  the  proper  manner 
of  holding  the  instruments.  In  other  words,  as  much  attention  should  be  paid  to  detail 
as  if  the  operation  were  being  performed  on  a  human  eye.  Thus  only  proper  habits  will 
be  formed,  tor  the  habit-  formed  in  this  work  will  adhere  to  the  student  in  his  later 
work  upon  human  eyes,  and.  if  they  be  incorrect,  will  be  difficult  to  overcome. 

Operations  which  can  be  Practised. — In  general,  most  of  the  operations  which 
are  performed  on  the  human  eye-  may  be  practised  on  animals'  eyes  employed  as  pre- 
viously described.     Figs.  430   133  '  are  sufficiently  illustrative  of  some  of  the  main 

operations. 

1  Taken  from  the  author'-  work,  Ophthalmic  Operations  as  Practised  on  Animals   Eyes. 


THE  MOST  IMPORTANT  MICRO-ORGANISMS  HAVING  ETI- 
OLOGICAL RELATIONSHIP  TO  OCULAR  DISEASES. 


By   G.  E.  de  SCHWEINITZ,  A.  M.  M.  D., 

OF    PHILADELPHIA,    PA. 


The  normal  conjunctiva  always  contains  bacteria,  no  less  than  ten  or  twelve  varie- 
ties having  been  isolated.  If  these  organisms  have  pathogenic  characteristics  they  arc 
very  slight  (Randolph) ;  indeed,  it  is  probable  that  only  two  or  three  varieties  should 
be  classified  as  at  all  pathogenic  (Weeks).  Non-pathogenic  conjunctival  bacteria, 
however,  may  become  harmful  if  the  tissues  in  which  they  exist  are  bruised  or  irritated 
(Randolph). 

Pathogenic  bacteria,  especially  those  related  to  suppuration,  are  frequently  found 
along  the  ciliary  margins  and  in  the  secretion  of  the  lachry mo-nasal  passages. 

The  etiological  relationship  of  micro-organisms  to  various  ocular  affections  has  been 
fully  described,  especially  in  the  articles  on  Diseases  of  the  Conjunctiva,  Diseases  of 
the  Cornea,  and  Sympathetic  Ophthalmitis.  For  the  convenience  of  the  student  a  brief 
description  of  these  organisms,  together  with  the  stains  by  which  they  may  be  recog- 
nized, is  here  inserted. 

Koch-Weeks'  Bacillus. — According  to  Weeks,  this  bacillus  resembles  that  of 
mouse-septicemia  in  form,  and  measures  1  to  'lu  in  length  and  about  0.25  ft  in  thickness. 
It  is  often  associated  with  a  clubbed  bacillus  [pseudo-diphtheritic  or  xerosis  bacillus). 
It  stains  readily  with  ordinary  anilin  dyes,  and  may  easily  be  demonstrated  in  the  secre- 
tion of  affected  eyes.     (See  Plate  2,  Fig.  III.) 

As  reagents  Weeks  uses  methylene  blue,  basic  fuchsin,  or  gentian  violet. 

This  bacillus  has  been  found  by  Weeks,  Morax,  Beach,  and  others  to  be  the  etio- 
logical factor  in  acute  contagious  conjunctivitis,  as  it  is  ftilly  described  on  page  276. 

Pneumococcus  I  Diplococcus pneumonia  I  Weichselbaum );  Micrococcus  Pasteuri  Stern- 
berg); Micrococcus  lanceolatus  (Talamon) ;  FrankeVs  pneumococcus). — This  organism  ap- 
pears in  the  form  of  oval  cocci  each  about  1  u  in  its  longest  diameter.  The  cocci  are 
often  arranged  in  pairs  (hence  the  name  diplococci),  and  sometimes  in  chains  of  three 
to  ten  elements.  The  free  ends  of  the  cocci  maybe  pointed  (hence  the  name  diplococcus 
lanceolatus),  and  they  are  often  surrounded  by  a  capsule  (hence  the  term  capsulated 
diplococcus).  (See  Plate  2,  Fig.  IV.)  The  organism  stains  with  the  ordinary  anilin 
dyes,  and  also  by  Grain's  method. 

Pneumococci  were  first  described  as  a  cause  of  acute  conjunctivitis  by  Morax  and 
Parinaud,  who  supposed  the  disease  was  peculiar  to  early  childhood.  The  later  inves- 
tigations of  Gasperini,  Harold  Gifford,  and  others  show  that  the  affection  is  distinctly 
contagious,  may  attack  adults,  may  be  transferred  from  one  eve  to  another,  and  may 
originate  acute  inflammation  of  the  conjunctiva,  clinically  very  difficult  to  differentiate 
from  the  Koch-Weeks'  bacillus  conjunctivitis  (see  also  pages  275,  276). 

According  to  the  researches  of  Dhthoff  and  Axenfeld,  which  have  been  abundantly 
confirmed,  pneumococci  are  the  most  important  etiological  factors  in  true  serpiginous 
ulceration  of  the  cornea  (see  page  •'!!  1 '.  They  are  also  one  of  the  causes  of  panoph- 
thalmitis. 

Gonococcus  [Gonococcus  of  NeUser ;  Micrococcus  gonorrheal;  Merismopedia  gonor- 
rhea (.—This  organism  is  found  in  gonorrheal  pus,  in  the  form  of  a  micrococcus  about 

0.7  u  in  its  long  and  0.5  u  in  its  short  diameter.  It  often  occur-  in  a  diplocOCCUS-  and 
sometimes  in  ;i  tetrococcus-form,  the  individual  cocci  being  ovoid  in  shape,  with  their 
opposing  surfaces  flattened  or  slightly  concave.  The  organism  appears  in  characteristic 
groups  within  the  leukocytes.  (See  Plate  2,  Fig.  II.;  also  Figs.  187  and  188).  Gono- 
cocci  -tain  readily  with  watery  solutions  of  the  basic  anilin  dy<  -  .  '/.  methylene  blue, 
fuchsin,  etc. — bul  are  decolorized  by  Gram's  method. 

They  are  the  etiological  factor   in   gonorrheal  conjunctivitis  and  in  seven 
conjunctivitis  neonatorum  (see  pages   278,  281). 

lil  1,1 


614  6  APPENDIX. 

Klebs-Lbffler  Bacillus  {Bacillus  diphtheria ;  Loffler's  bacillus). — This  organism 
occurs  in  diphtheritic  products  as  a  slender  bacillus,  with  round,  occasionally  distinctly 
clubbed  ends,  about  3  u  in  Length.  The  bacilli  may  be  irregularly  scattered,  may  appear 
in  clusters,  or  may  assume  a  parallel  grouping;  often  two  bacilli  arc  joined  end  to  end 

Fig.  L90).  The  organism  stains  readily  with  the  ordinary  anilin  dyes,  by  <  > rain's 
method,  and,  best  of  all.  with  Loffler's  methylene  blue.  It  is  the  cause  of  diphtheritic 
conjunctivitis  (see  page  284). 

The  pseudo-diphtheritic  bacillus  morphologically  closely  resembles  the  virulent 
bacillus  diphtheria',  hut  is  not  fatal  to  animals.  It  is  found  in  several  varieties  of  con- 
junctivitis— e.  g.  follicular  conjunctivitis. 

Xerosis  Bacillus. — This  organism  was  first  found  in  xerosis  of  the  conjunctiva,  and 
morphologically,  as  well  as  in  cultures,  closely  resembles  the  diphtheritic  bacillus,  but 
is  non-virulent  to  animals  i  see  also  page  2%).  It  is  said  to  be  present  in  the  normal 
conjunctiva,  and  is  found  in  a  variety  of  conjunctival  diseases,  either  alone,  or,  as  in 
Koch-Week-'  bacillus  conjunctivitis,  associated  with  the  specific  organism.1 

Tubercle  Bacillus  i />'"'•///'/.-.•  tuberculosis;  Koch's  lulu  )■<■/<■  bacillus). — This  organism 
occurs  in  tuberculous  tissue  or  sputa,  in  the  form  of  a  slender  rod  with  rounded  or 
slightly  curved  ends  '.',  to  5  /,  in  length  and  0.3  fi  in  breadth.  Sometimes,  when  stained, 
tlie  bacilli  present  a  "  headed  "  appearance.  In  the  tissue  they  are  irregularly  scattered 
or  arc  arranged  in  small  masses.  They  may  he  single,  or  an  angle  may  he  formed  by 
an  end-to-end  attachment  of  two  of  them  (see  Fig.  201).  Tubercle  bacilli  do  not  stain 
readily  with  ordinary  watery  solution  of  basic  anilin  dyes;  anilin-water  solution  of 
gentian  violet  or  fuchsin  must  he  used.  One  of  the  best  preparations  is  the  Ziehl- 
Neelsen  carbol-fuchsin.  Once  stained, the  bacilli  retain  the  dye  tenaciously.  They  are 
the  cause  of  tuberculous  lesions  in  the  ocular  coats  (see  page  302). 

Leprosy  Bacillus  {Bacillus  lepra  I. — This  organism  occurs  in  the  leprous  tubercles, 
in  the  form  of  a  bacillus  which  closelj  resembles  the  tubercle  bacillus,  hut  is  slightly 
more  slender  (Fig.  200).  The  bacilli  stain  readily  with  the  ordinary  anilin  dyes  and  by 
Gram's  method. 

Staphylococcus  Pyogenes  Aureus  {Micrococcus pyogenes  aureus). — This  organism  is 
one  of  the  bacteria  of  suppuration,  and  occurs  as  a  spherical  coccus  from  0.5  to  0.!)  ^  in 
diameter,  and  grows  in  clusters  and  masses,  hut  is  also  met  with  singly  and  in  pairs 
(see  Fig.  192).      It  stains  readily  with  all  the  anilin  dyes,  and  also  by  Gram's  method. 

Staphylococci  are  related  to  numerous  inflammatory  conditions  of  the  cornea  and 
conjunctiva,  being  found,  for  example,  on  the  ciliary  margins  in  blepharitis,  in  phlyc- 
tenular conjunctivitis,  in  simple  conjunctivitis,  and  in  association  with  specific  organisms 
— for  instance,  with  Loffler's  bacillus  in  diphtheria  of  the  conjunctiva,  and  with  gono- 
cocci  in  gonorrhea!  conjunctivitis.  They  are  freely  present  in  suppurative  conditions 
of  the  lachrymo-nasal  passages,  are  one  of  the  varieties  of  micro-organisms  found  in 
mixed  infections  in  corneal  ulcers  which  are  not  typically  serpiginous,  and  have  been 
claimed  by  Deutschmanil  to  he  the  cause  of  sympathetic,  or,  as  he  called  it,  migratory 
ophthalmitis  (see  page  349).  In  addition  to  staphylococcus  pyogenes  aureus  may  also 
he  found  the  varieties  which  are  known  as  S.  pyogenes  albus  and  X  pyogenes  citreus, 
which  differ  from  the  preceding  organism  in  the  color  of  their  growth,  as  is  designated 
in  the  name.     They  are  also  said  to  he  le>s  pathogenic  than  the  first  one. 

Streptococcus  Pyogenes. — This  organism  occurs  a-  a  coccus  slightly  larger  than 
the  preceding  varieties,  being  aboul  1  u  in  diameter.  It  forms  chains  (see  Fig.  197) 
which  sometimes  are  composed  of  numerous  members.     It  may  he  demonstrati  d  by  the 

USUal  -tains. 

Streptococci  are  found  in  various  suppurative  processes  which  occur  in  the  eye, 
either  alone  or  in  association  with  specific  micro-organisms,  and  they  are  the  cause  of 
certain  varieties  of  corneal  ulcer-.  They  are  especially  frequent  in  the  purulent  secre- 
tion which  comes  from  the  lachrymal  sac,  being  the  cause  of  the  conjunctivitis  which 
i-  associated  with  this  condition.  This  form  of  conjunct  ivit  i-  may  also  he  complicated, 
according  to  Parinaud,  with  hypopyon  and  irido-cyclitis  (see  also  page  294). 

Tie  re  is  one  variety  of  membranous  conjunctivitis  due  to  streptococci  which  occurs 

'The  terms  "  pseudo-diphtheritic  bacillus"  and  "xerosis  bacillus"  have  been  much  con- 
fused, because  tin-  pseudo-diphtheritic  bacilli  ■>(  Hoffmann, which  are  found  in  the  nose  and  throat, 
an-  not  identical  with  the  pseudo-diphtheritic  bacilli  <>i  iln  conjunctiva,  which,  bj  -"me  authorities, 
are  made  t"  include  the  xerosis  bacilli,  the  bacilli  septati  (Gelpke),  the  chalazion-bacilli 
(Deyl  ,  etc. 

The  investigations  of  I ».  II.  Bergey  indicate  that  t  here  i-  a  large  group  of  micro-organisms, 
at  the  head  of  which  i-  the  virulent  Loffler-bacillue,  which  may  occur  in  several  distinct  varia- 
tions, and  at  the  other  extreme  is  the  tero  •  bacillus.  Between  these  extremes  are  many  varia- 
tion- in  type,  as  shown  by  modifications  in  biological  and  morphological  characters,  for  example, 
the  pseudo-diphtheritic  or  Hoffmann's  bacilli. 


MICRO-ORGANISMS.  614  c 

in  children  in  connection  with  the  exanthemata,  but  which,  according  to  Morax,  may 
appear  independently  of  febrile  complications.  The  disease  is  often  mistaken  for  diph- 
theritic conjunctivitis,  and  is  sometimes  called  " streptococcus  diphtheria  <>/'  the  conjunc- 
tiva." .Microscopic  examination  will  decide  the  diagnosis.  The  prognosis  i>  exceed- 
ingly unfavorable. 

In  this  connection  a  brief  mention  of  a  remarkable  form  of  conjunctivitis,  known 
as  Parinaud's  conjunctivitis  or  infectious  conjunctivitis  of  animal  origin,  may  he  made. 
Its  main  characteristic-,  as  summarized  by  Clifford,  who  has  studied  it  in  this  country, 
are  3udden  onset,  thickening  of  the  lids,  mucopurulent  discharge,  the  formation  within 
a  week  or  two  of  large  polypoid  ami  pedicnlated  granulations  on  the  conjunctiva,  be- 
tween which  occur  numerous  smaller  yellowish  one-,  ami  inflammation  of  one  or  both 
of  the  groups  of  lymph-glands  on  the  same  side,  the  pie-auricular  and  retromaxillarv 
groups  being  most  frequently  involved.  The  affection  is  practically  always  one-sided. 
Bacteriological  investigations  have  generally  been  lacking  in  results,  hut  streptococci 
have  been  found  in  the  pus  in  the  eye  and  in  the  inflamed  lachrymal  glands.  The 
treatment  suited  to  trachoma  would  seem  to  be  indicated. 

Trachoma  COCCUS. — This  organism  has  been  described  by  Sattler  and  Michel,  and 
may  be  cultivated  from  the  trachoma  follicle.  It  forms  a  small  diplococcus  (Fig.  l'Joj. 
Its  specificity  has  not  been  demonstrated  (see  page  292). 

Diplo-bacillus  (diplo-bacillus  of  Morax  and  Axenfeld). — This  organism  was  first  de- 
scribed by  Morax  in   1896  as  a  frequent  cause  of  -ubacute  or  chronic  conjunctivitis 


s 


Fig.  133a.— The  diplo-bacillus  of  Morax  and  Axenfeld  (from  a  preparation  by  Dr.  Harold  Gifford). 

According  to  Harold  Gifford,  who  has  investigated  it  in  this  country,  "the  germ  com- 
monly occurs  in  the  form  of  a  diplo-bacillus,  each  member  of  which  measures  2  to  3  /i 
in  length  and  1  to  0.5  «  in  breadth.  Chains  of  these  diplo-bacilli  are  not  infrequent, 
and,  in  cultures,  form  sometimes  as  long  as  three  or  four  of  the  single  bacilli  with  no 
apparent  sign  of  division."  It  stains  readily  with  most  of  the  ordinary  dye-,  but  is  de- 
colorized by  Gram's  method. 

The  conjunctival  affection  which  this  diplo-bacillus  causes  in  general  is  insidious  in 
character.  It  runs  a  course  of  from  six  weeks  to  six  months,  during  which  the  main 
symptoms  are  slight  redness  and  hypersecretion  of  the  conjunctiva  with  moderate  sub- 
jective symptoms.  Often  the  only  sign  of  its  presence  is  a  persisting  agglutination  of 
the  lids  in  the  early  morning.  The  secretion  of  stubborn  subacute  conjunctivitis  should 
always  be  examined  for  this  bacillus.  The  best  local  application  for  relief  of  diplo-bacillus 
conjunctivitis  i-  a  \  per  cent,  solution  of  chlorid  of  zinc,  According  to  Gifford,  diplo- 
bacilli  may  also  originate  a  condition  closely  resembling  subacute  trachoma,  and  some- 
times they  are  the  active  organisms  in  corneal  ulcers. 

The  relation  of  micro-organisms  to  infective  or  sloughing  ulcers  of  the  cornea 

has  he. -n  briefly  referred  to  several  times  in  the   preceding  paragraphs,  and  the  si 

important  bacteria  described.  Uhthoff  and  Axenfeld  thus  summarize  our  knowledge 
on  this  subjeel  : 

(1)  Typically  serpiginous  ulcer  of  the  cornea  with  hypopyon  is  practically  always 
caused  by  the  pneumococcus,  which  may  frequently  be  found  in  these  ulcer-  in  almost 
pure  culture-. 


614  d  APPENDIX. 

-  '  leers  not  typically  serpiginous  are  caused  by  infection  with  staphylococci  and 
streptococci  and  by  mixed  infection.  Occasionally,  pneumoeocci  originate  ulcers  which 
are  not   characteristically  creeping. 

(3)  About  one  per  cent,  or  sloughing  varieties  of  keratitis  is  due  to  a  schizomycetal 
infection — aspergillus  fumigatus. 

The  following  organisms  have  also  been  found  at  times  in  association  with  keratitis: 
Pfeiffer's  capsulated  bacillus,  Bacillus  pyogenes  fetidus,  Bacterium  coli,  Bacillus  pyocyaneus, 
Ozena  bacillus,  and  a  number  of  other  varieties  which  have  not  again  been  discovered  or 
which  could  not  he  identified. 

It  is  interesting  to  observe  that  in  general  suppurative  inflammation  of  the  entire 
eyeball  (panophthalmitis),  although  the  ordinary  bacteria  of  suppuration  may  be 
present,  not   infrequently   there  are   found  special   forms  of  bacilli. 

It  would  be  manifestly  out  of  place  to  describe  in  detail  bacteriological  examina- 
tions (which  are  essential  in  all  carefully-studied  inflammatory  affections  of  the  con- 
junctiva and  cornea)  in  this  place;  but  for  the  convenience  of  the  reader  the  formula' 
of  a  few  of  the  stains  to  which  reference  has  been  made  are  appended.  These  formula? 
(with  one  exception)  have  been  taken  from  Hewlett's  admirable  Manual  of  Bacteriology, 
which  has  been  frequently  consulted  in  the  preparation  of  this  section. 

Ltiffler's  alkaline  methylene  blue. 

Concentrated  solution  of  methylene  blue,  30  c.c. ; 

Solution  of  caustic  potash,  0.01  per  cent.,  100  c.c. 

This  will  stain  cover-glass  specimens  in  from  three  to  ten  minutes. 

Anilin  gentian-violet. 

Saturated  alkaline  solution  of  gentian  violet,  30  c.c. ; 

Anilin-water,  100  c.c. 

This  preparation  will  stain  cover-glass  specimens  in  two  or  three  minutes. 

Carbol-fuchsin  (Ziehl-Neelsen  solution). 

Fuchsin,  1  part; 

.  Absolute  alcohol,  10  parts; 

Five  per  cent,  aqueous  solution  of  carbolic  acid,  100  parts. 
It  should  be  diluted  with  2  to  6  parts  of  water  for  cover-glass  specimens. 

In  Gram's  method  the  cover-glass  specimens  are  stained  for  five  or  ten  minutes  in 
anilin  gentian-violet  solution,  and  then  immersed  for  one  or  two  minutes  in  a  solution 
of  iodin  1  part,  potassium  iodid  2  parts,  distilled  water  300  parts.  When  the  specimens 
are  removed  from  the  iodin  solution  and  drained,  they  are  immersed  in  methylated 
spirit.     After  decolorizing,  the  specimen  may  be  washed  in  water,  dried,  ami  mounted. 

E.  A.  de  Schweinit/'s  method  for  staining  tubercle-bacilli  with  Sudani  iii.  (red-fal 
dye)  is  a  selective  one.  A  saturated  alcoholic  solution  is  used.  This  preparation,  made 
in  the  ordinary  way,  is  stained  for  five  minutes  in  this  solution  and  washed  with  70  per 
ceut.  alcohol. 


THE   EAR. 


THE   EAR. 


THE  ANATOMY  OF  THE  EAR,  INCLUDING  EMBRY- 
OLOGY AND  HISTOLOGY. 

By  BURTON  ALEXANDER  RANDALL,   M.  A.,  M.  D.,  Ph.  D., 


OK    PHILADELPHIA. 


Embryology. — The  human  organ  of  hearing  first  appears  in  early 
embryonic  life  on  each  side  of  the  head  posteriorly  as  a  pit-like  involution 
of  the  epiblast  (Fig.  434),  which  closes  in  to  form  a  spherical  "otic  vesicle" 
(Fig.  435).  Bud-like  hollow  processes  grow  out  from  this — inward,  to  form 
the  endolymphatic  duct  and  sac  ;  forward,  as  the  spirally-coiled  cochleal  tube 
(Fig.  436) ;  outward,  upward,  and  backward,  in  curving  course  to  meet  and 
coalesce  with  similar  outgrowths  and  form  the  three  semicircular  canals,  each 
with  a  Mask-like  dilatation  where  one  of  its  ends  springs  from  the  vesicle. 
This  has  meanwhile  lost  its  spherical  form,  dividing  into  a  more  spherical 
anterior  "saccule,"  connected  with  the  cochleal  tube  by  a  narrowed  "  canalis 
reuniens"  and  an  ovoid  "utricle"  communicating  with  the  semicircular 
canals  by  five  openings — one  non-sacculated  termination  being  common  to  the 
vertical  and  the   posterior  canal.      The  tissue  which  effects  this  cleavage 


SrniiHlani 

*utic  Vesicle       Hinder  lirain  vft^ndolymphatic 

'  t'.Wn\E*tertial 
Semicirc. 

Canal 
ic  Vesicle  ~^4^i£\S~>^\' ■Jjfff\\ 

-■-'■«  Canal 


Fig.  434.— Sagittal  section  of  embryo,        Fig.  435.— Horizontal  section  Fig.  436.— Horizontal  section 

showing   involution    of   epiblast   to    of  head  through   the  develop-  through  developing  labyrinth, 

form  the  otic  vesicle.  ing    eye  ami   full-formed  otic  medulla,     ami     mouth;    fifth 

vesicle ;  third  week  in  human.  week. 

extends  up  into  the  endolymphatic  duct  (Fig.   137),  so   that    the  two  sacs, 
although   in   contact,  communicate  only   by  this  now   Y-shaped   tube. 

Within  the  <>tic  sac.  which  has  now  come  t<>  deserve  the  name  <>f  mem- 
branous labyrinth,  there  has  been  marked  differentiation  of  the  cells ;  while 

617 


618 


THE  ANATOMY  OF  THE  EAR,   ETC. 


externally  a  fibrous  envelope  has  been  formed  from  the  mesoblast,  splitting 
into  a  perichondrium  sheathing  the  cartilaginous  tissues  which  have  been 
encasing  the  structure,  separated  by  spaces  <>t*  growing  complexity  from  the 
delicate  basement-membrane  which  supports  all  parts  of  the  labyrinth. 
Supported  by  this,  the  simple  rounded  neural  cells,  generally  in  single  layer. 
flatten  into  pavement-cells  throughout  most  of  the  extent  of  the  semicircular 
canal.-,  the  utricle,  the  saccule,  ami  part  of  the  cochlea!  tube j  hut  at  each 
point  where  the  developing  acoustic  nerve  sends  fibers  the  cells  assume  a 
columnar  form,  surmounted  by  short,  .-tiff  cilia,  the  " hair-cells,"  above  which 
floats  a  layer  of  gelatinous  material  of  doubtful  function,  but  invariable  and 


Fig.  137.  Labyrinth  nearly  developed,  showing  division  of  vestibular  sacs,  their  hair-cell  ana-. 
and  the  similar  structures  in  the  ampulla  of  the  external  semicircular  canal  ami  flrsl  turn  "t  the  cochlea] 
tube  i  half-schematic). 

early  presence.  Each  of  the  flask-shaped  ampulla'  of  the  semicircular  canals 
presents  such  an  ana.  the"acoustic  crest,"  upon  it-  concave  side;  larger 
areas  are  presenl  in  the  saccule  and  in  the  utricle,  as  shown  in  Fig.  437,  the 

gelatinous  "  blanket  "  of  each  of  the  latter  loaded  with  small  crystal-  of  lime 
— the  otoliths.      In  the  eochleal  tube  the   correspond i ug   structure,  called  after 

it-  discoverer  "Corti's  organ,"  is  extremely  complex  and  merit-  more  ex- 
tended description. 

Within  the  open  spiral  of  the  eochleal  tube  there  forms  a  cartilaginous, 

early-ossifying  conical  axis,  "the  i liolus,"  permeated  with  openings  for  the 

fibers  of  the  cochlea!  branch  <>l   the  nerve,  which  fill-  the  end  of  the  internal 


EMllRYOLOGY. 


619 


auditory  meatus  at  the  base  of  the  cochlea  and  sends  its  separated  fibers 
through  a  spiral  series  of  openings  into  the  windings  of  the  structure  (Fig. 
438).  From  this  conical  axis  a  delicate  ossifying  shelf  is  pushed  out, 
ensheathing  the  diverging  nerve-fibers  to  their  entrance  into  the  cochlea!  tube, 
and  by  a  fibrous  extension  underlying  the  inferior  (mesial)  surface  of  this 
tube.  These  structures,  winding  spirally  like  the  other  portions  of  the 
cochlea,  vary  greatly  in  their  relative  size  from  the  base  to  the  apex  :  lor  the 
"  basilar  membrane,"  with  its  stiff  radiate  libers,  is  narrowest  below,  where 
all  the  other  structures  are  at  their  largest,  and  broadens  progressive^ 
upward  at  the  expense  of  the  bony  "  spiral  lamina"  A.s  its  tense  radiate 
fibers  are  probably  comparable  to  the  strings  of  a  harp  or  piano,  respond- 


Liudilo/y  Can/ft 

Fig.  438.— Section  of  the  human  cochlea  showing  the  two  and  a  half  windings  of  its  scalae. 


ing  to  notes  higher  and  higher  in  proportion  to  their  shortness,  this  is  a 
fundamental  fact  in  the  anatomy  and  physiology  of  the  organ,  as  proven  by 
a  growing  amount  of  pathological  investigation  (see  pp.  644  and  773). 

The  cochlea!  tube,  originally  cylindrical,  has  now  been  compressed  to  a 
triangular  section,  one  side  of  it,  as  stated,  being  flattened  by  the  basilar 
membrane.  Below  and  above  this,  the  cavities  formed  between  the  layer-  of 
surrounding  mcsoblast  constitute  parallel  channels  winding  spirally  upward 
and  known  as  "tympanic;  and  vestibular  seala;"  beyond  these  the  ossifying 
cartilage  forms  a  firm  protecting  spiral,  which  gives  the  ultimate1  snail— lull 
form  from  which  the  cochlea  is  named.  Similar  spaces  about  the  saccule, 
utricle,  and  semicircular  canals  hold  away  the  bony  walls  which  ultimately 
surround  them,  except  at  some  one  point,  generally  the  convexity,  as  in  the 
cochlea  and  the  semicircular  canals.  At  the  attached  point,  where  the  vascu- 
lar supply  is  best,  the  neural  epithelium  is  modified  to  form  secreting  cells 
of  the  endolymph,  those  in  the  cochlea!  tube  being  a  gland-area  of  cylindri- 
cal cells  on  the  outer  wall — the  "stria  vascularis"  (Fig.  139).  The  upper 
wall  of  the  tube  becomes  exceedingly  delicate  ("  Reissner's  membrane"),  the 
neural  cells  flattening  to  a  delicate  pavement,  separated  by  thin  fibrous  tissue 
from  the  endothelial  pavement  without.  The  lower  wall  shows  the  greatest 
modification  both  of  the  cells  and  of  the  supporting  mesoblastic  tissues.  A 
fibrous  cresl  form-  by  thickening  of  the  periosteum  of  the  osseous  lamina, 
ending  outward  in  projecting  teeth,  to  which  is  attached  the  gelatinous  mem- 
brane (m.  tectoria  of  Corti)  before  mentioned  as  presenl  above  all  hair-cells. 
Of  these  four  or  five  row-  are  present,  supported  inward  and  outward  by 
spheroidal  cells,  large,  vacuolated,  and  piled  upward.  \\  ithin,  two  more 
modified  row- of  pillar-cells  (Corti's  rod-)  form  a  tunnel   beneath  their  arch. 


620 


THE  ANATOMY  OF  THE  EAR,  ETC. 


Each  set  has  broadened  feet  and  heads,  the  outer  set  nearly  twice  as  numer- 
ous as  the  inner,  and  connected  outward  with  a  network  of  phalanx-shaped 
elements — "reticular  membrane" — through  the  meshes  of  which  the  outer 
hair-cells9  protrude.  These  latter  are  double  cells — the  lower  fusiform  and 
firmly  attached  below  to  the  basilar  membrane  by  a  slightly  broadened  foot, 
while  the  upper  process  adheres  to  the  side  of  the  peg-shaped  hair-cell,  and 
probably  is  attached  to  the  reticular  membrane.  The  acoustic  nerve-fibers 
pass  out  between  the  plates  of  the  osseous  spiral  lamina  after  emerging  from 
the  "  spiral  ganglion,"  which  occupies  a  canal  in  the  modiolus  at  the  root  of 
the  lamina.  Losing  their  sheaths,  the  axis-fibers  are  sent  through  a  row  of 
openings  below  the  Corti  teeth  to  split  into  ultimate  fibrils,  which  pass,  some 


Fio.  i:>'.i.— Scheme  <>1  section  of  cochlea  in  perspective,  from  human  specimens. 


up   to  the   inner  hair-cells,  some  across  the  tunnel  to  the  outer   hair-cellsf 
while  some  wind  upward  along  the  spiral  tunnel. 

Osteology. — Embryological  study  has  made  clear  the  greater  importance, 
formatively  as  well  as  functionally,  of  the  membranous  labyrinth.  Yet  the 
bony  labyrinth  was  much  earlier  known  and  described,  and  was  deemed  the 
structure  giving  shape  to  its  softer  contents  (Fig.  440).  Its  beauty,  when 
carved  out  of  its  setting  in  the  dense  petrous  bone,  as  is  easy  in  infancy,  or 
of  it-  cast  in  metal  when  liberated  by  corroding  away  the  bone,  has  attracted 
to  it  study  which  it  docs  not  otherwise  deserve.  It  communicates  with  the 
middle  car  by  two  fenestra.  The  lower  "round  window,"  closed  by  the 
delicate  in-drawn  membrana  tympani  secondaria,  connects  with  the  lower 
cochlea]    BCala,    hence    called    tympanic;     while    the    upper    "oval    window/' 

oormally  occupied  by  the  foot-plate  of  the  stapes,  communicates  with  the 

Vestibule,    which    contain-    the    utricle   and    saccule,    separated  fro m    the   oval 
window  by  a    -pace  of  nearly  2  nun. — the   "  cisterna    perilymphat ica."      This 

space  ie  directly  continuous  with  the  upper  "vestibular  scala  "  of  the  cochlea. 

Depressed    cribriform    areas    on    the    mesial    wall  of  the    vestibule    admit    the 


OSTEOLOGY. 


021 


nerve-fibers  to  the  sacs  of  the  membranous  vestibule,  the  saccule  occupying 
the  hemispherical  and  the  utricle  the  hemielliptical  fossa  (Fig.  441). 


Lamina 
Spirali 


Sapi  rior  '  'anal 


<  'ochlea 


Fig.  440.— Bony  and  membranous  labyrinth  (schematic). 

Inward  the  ossifying  cartilage  grows  around  the  acoustic  and  facial  nerves, 
forming  the  internal  auditory  meatus,  shallow  in  infancy,  but  becoming  a 
deep  narrow  canal  later. 


;triae 


C0cble 


Pig.  441.— Diagram  of  the  origin  of  the  acoustic  nerve  and  Its  distribution  t rgai  ol  bearing 

Mills). 

The  firsl  inner  branchial  (nrrow  of  the  embryo  early  narrows  ai  it-  outer 
portion  leaving  little  lateral   extension  to  represenl   the   future    Eustachian 


622 


THE  ANATOMY  OF  THE  EAR,   ETC. 


EiMltaius 


Fig.  442.— Horizontal  section  through  coch- 
lea, tympanum,  and  external  <-ir  of  rat  i  half- 
schematic  i. 


tube,  which  does  not  begin  its  development  until  the  labyrinth  is  almost  full 
formed;  then  it  extends  outward  as  a  narrow  cleft,  gradually  separating  the 
labyrinth  from  the  tissues  without,  in  which  the  ossicles  are  developing,  largely 
from  Meckel's  cartilage  (Fig.  142).  Near  the  closed  outer  extremity  of  the 
cleft,  seven  little  cartilaginous  nodules  grow  to  form  the  auricle;  while  in 
their  midst  an  invagination  of  the  surface  forms  the  external  auditory  meatus, 
which  presses  inward  until  only  the  handle  of  the  malleus  and' the  thin 
membrana  propria  of  the  drumhead  intervene  between  the  cutaneous  lining 
of  the  meatus  and  the  mucous  membrarie  of  the  tympanum.     The  old  theory 

is  baseless  that  the  drumhead  grows  as  a 
septum  across  the  canal,  and  might  fail  to 
do  so.  leaving  a  colobomatous  opening. 
When  a  fistulous  opening  persists,  it  is 
almost  always  from  imperfect  closure  of 
the  branchial  cleft,  and  shows  above  the 
tragus,  at  the  root  of  the  helix,  as  a  tiny 
fistula  (see  Fig.  483). 

Besides  the  ossifying  centers  of  the 
labyrinth  three  principal  adjacent  foci 
form — one  in  the  petro-mastoid  cartilage 
to  imbed  the  inner  ear  and  inwardly 
hound  the  tympanic  portion.  A  second, 
called  the  "annulus"  in  the  infantile 
form,  is  a  ring  incomplete  above  (Fig. 
II-'.!.  Inn  develops  into  an  extensive  scroll  later,  forming  all  but  the  upper 
posterior  wall  of  the  auditory  meatus.  A  third  center  in  the  membranes 
above  the  ear  forms  the  squama,  the  zygomatic  process,  the  outer  half  of  the 
tympanic  roof,  and  the  scutum — the  plate  which  roofs  in  the  external  meatus 
and  forms  the  outer  wall  of  the  attic  and  antrum  portions  of  the  tympanum. 
Another  (post-natal)  center  form-  the  styloid  process.  The  temporal  bone 
at  birth  i-  readily  separated  into  annulus,  squamous,  and  petro-mastoid  por- 
tions,  the  lasl  of  which  is  -till  spongy,  and  can  be  cracked  away  from  the 
enclosed  labyrinth  as  a  nut-shell  from  its  kernel.  Later  the  sutures  unite 
almosl  completely,  and  the  bony  labyrinth  blends  imperceptibly  with  its 
strong,  hard  envelope,  and  we  obtain  the  temporal  hone  as  usually  described 
in  the  anatomical  treatises,  with  which  the  reader  is  supposed  to  he  familiar. 
Tin'  further  note-  on  the  adult  temporal  hone  will  therefore  he  topographical 
and    surgical. 

The  Adult  Temporal  Hum  (Plate!*). — The  outer  aspect  of  the  hone  looks 
much  more  downward  than  is  generally  realized,  although  presenting  as  many 
minor  variations  in  this  as  in  all  other  particulars.  <  me  importanl  "  orienta- 
tion point  "  i-  the  upper  edge  of  the  zygoma,  which  is  almost  invariably 
horizontal.  Less  definite  for  determining  its  true  position  in  the  vertical 
plane  i-  the  auditory  canal,  the  axis  of  which  (so  far  as  the  line  can  be 
determined  for  so  curved  and  tortuous  a  tube)  points  on  an  average  10'  belo\n 
and  lo  hack  of  the  horizontal  transverse  axis  of  the  head.  Its  deviation 
in  each  direction  varies  from  (>  to  20  in  individual  cases.  Sharing  the 
general  proportions  of  the  cranium,  the  temporal  bone  varies  hugely  in  size, 
massivene&s,  and  configuration,  it-  structure  rarefying  with  advanced  life  to 
a  delicacy  like  that  of  childhood,  while  it-  mastoid  process  corresponds  to  the 
muscular  development  to  which  it-  growth  is  a  response.  The  pneumatic 
cells  within  hardly  appear  before  adolescence,  and  probably  enlarge  and 
coalesce  progressively   throughout    life;   and   nature-  economy  of   material 


Plate  9. 


P^^filfAudiloru  ft*' 


jSuprameatal  spine  ^ 

^emomsof^uamo^t.-^"^ 
Jjigasinc.J'oiSa--^- 

Occipital  Groooe-^H^A^^  ^ 

WastoidPrecess-J^S    \  V5,  j-umpanic  Scroll 

Woic?  Process-       &£«**—"  arUuMewitifyheno.du,,** 


Outer  Clspect 

Caroiid  Cctnal  exit  anteriorly 
—  '*  arte  e  posteriorly 


Impress  (//Semilunar  Ganglion  _— 


'rr^Jqueduclof  Cochlea 

— Jugular  Tossa 

Jftglo  -Jf/astoid Foramen 


Groove  for  Great  Petrosal JTerve 
Joining  Social  in  Ma  tat  Tallepi 

Gwooefot  fiaverioiTkliosaliS'rms^ 

Poof  of  Tympanum 
Z.miannte  cfpupr'—' 


Joid  Protest 
igastric  Tossa. 
Occipital  Groove 


iwer 


Inner  Clspeet 


,  Superior  Petrosal /Sinus 
imoidoulcut 


PetiojSyua 


SramoidtSJcuS  of  I  «Ura7  $inu\\ 


Internal  JladtUryCanal 
forJJcoustic-rPar.alirenres 

Jjaueducloftfestilule' 


■JlfaitoiJ^ocamcn 


Medial  a'fecloj 
Jflustoid  Process 


ft(v/o,  J  Process  - 

The  adull  temporal  bone  from  without,  within,  below,  aud 


OSTEOLOGY. 


623 


gives  to  the  large  process  the  more  pneumatic  structure.  Diploe  is  present, 
as  in  all  the  cranial  bones,  bul  i-  in  inverse  proportion  to  the  air-spaces.  The 
type  of  the  cranium  and  the  external  configuration  of  the  temporal  afford 
no  criterion  as  to  the  topography  of  the  bone,  except  thai  we  may  generally 

expect  to  find  a  large  mastoid,  thin-walled  and  large-celled.  The  mastoid 
may  be  said  to  extend  up  to  the  curving  temporal  ridge  which  extend-  hack- 
ward  and  upward  from  the  root  of  the  zygoma,  and  has  been  used  as  an 
index  of  the  level  of  the  middle  cerebral  fossa  within,  as  in  Macewen's 
chosen  "  post-meatal  triangle  :  "  bul  this  cannot  be  relied  upon  as  a  landmark. 
Up  and  hack  from  the  canal  a  small  spine  with  a  depression  hack  of  it  can 
be  almost  invariably  recognized  as  marking  the  hack  margin  of  the  meatus. 
This  is  a  most  important  surgical  landmark,  as  the  point  of  election  for 
opening  the  mastoid  is  close  behind  it.  The  Moor  of  the  middle  fossa  at  the 
nearest  point  averages  6  mm.  above  it  and  is  probably  never  lower  than  this 
spine:  I  have  found  it  as  low  but  5  times  in   1000. 

This  fossa,  which  constitutes  most  of  the  superior  aspect  of  the  bone,  is 
of  uneven  surface,  marked  with  the  gyri  of  the  cerebrum,  and  shows  the 


G/enoia'}, 
J?ivinietn  Jltfurg/'n 
fympanit  fting 


Eustachian  Jul* 

Ca  ro  (i  J  Canal — •~£~)£>t. 

J°£  trcu  S  Pi/ram  id 


'SegiKningKasfc/jPrCCez 
Openinfifor  /Sty/oulJ'iocess 
^:'y/o  ■  Jiyastota  Foramen 


Fig.  443. — Temporal  bone  of  infant ;  lower-outer  surface  showing  squamous,  tympanic,  and  petro- 

mastoid  segments. 


petro-squamous  suture  in  childhood  and  sometime-  into  adult  life.  It  is 
covered  with  thin,  strong  dura  mater,  which  sends  fibrous  prolongations  into 
the  suture,  and  is  most  firmly  attached  along  the  back  i^lisc  of  the  pyramid, 
where  it  passes  into  the  tentorium  and  is  split  to  form  the  superior  petrosal 
sinus  (see  Plate  10,  Fig.  1  ).  Another  sinus  follows  the  petro-squamous 
suture,  after  which  it  is  named,  and  emerge-  at  the  root  of  the  zygoma,  large 
in  fetal  life,  hut  generally  tiny  after  birth,  and  shrinking  to  a  fibrous  thread. 
although  occasionally  persisting  of  good  size  through  life,  and  burrowing  more 
or  less  under  bridges  of  the  inner  surface  of  the  bone.  A  groove  more  mesial  in 
the  floor  accommodate-  the  great  petrosal  nerve  a-  it  passes  from  the  spheno- 
palatine ganglion  backward  to  the  facial  canal  to  blend  with  the  facial  nerve  at 
the  geniculate  ganglion — structures  which  are  often  devoid  of  bony  covering 
(at  the  hiatus  FaMopii)  in  infancy,  and  at  time-  in  adult  life.  Below  the 
tentorium  is  the  posterior  or  cerebellar  fossa,  bounded  forward  by  the  pos- 
terior aspect  of  the  petrous  pyramid.  Here  the  internal  auditory  meatus,  "! 
very  varying  width  and  depth,  is  in  close  relation  with  the  apparent  origin  ol 
the  facial  and  acoustic  nerve  in  the  pun-;  and.  hidden  close  by  iii  the  layers 
of  the  dura,  the  endolymphatic  sac  communicates  through  a  long  cleft — the 
vestibular  aqueduct — with  the  interior  of  the  membranous  labyrinth.     Far- 


G24 


THE  ANATOMY  OF  THE   EAR,  ETC. 


ther  outward  and  backward  the  lateral  sinus,  Leaving  its  course  in  the  edge 
of  the  tentorium,  sweeps  downward  and  in  to  find  exit  into  the  bulb  of  the 
jugular,  forming  the  sigmoid  sulcus  upon  the  base  of  the  pyramid,  and  a  still 
more  marked  turn  as  it  passes  through  the  foramen  lacerum  (Plate  10,  Fig.  2). 
No  point  in  human  anatomy  is  subject  to  greater  variation  as  to  size  and  position 
than  this  sinus  and  the  jugular  bull)  continuous  with  it.  Formed  at  the  torcular 
by  the  confluence  of  the  longitudinal  sinuses,  the  lateral  sinus,  generally 
quite  unequal  in  size  on  the  two  sides,  passes  out  and  forward  (transverse 
sinus)  to  receive  the  superior  petrosal  as  it  curves  down  at  the  posterior  end 
of  the  crest  of  the  pyramid,  to  give  off  the  mastoid  emissary  as  it  turns 
inward,  and  to  receive  the  inferior  petrosal  as  it  passes  forward  at  the  foramen 
lacerum.  As  most  of  the  blood-current  of  the  superior  longitudinal  mums 
usually  flows  to  the  right,  this  is  oftener  the  larger  and  grooves  more  broadly 
and  deeply  the  temporal  bone  at  the  sigmoid  sulcus,  extending  farther  for- 
ward and  outward  with  it >  stronger  curves.  This  cannot  be  counted  upon, 
however,  as  rendering  the  left  temporal  any  safer  for  easily  avoiding  the 
-inns  in  surgically  opening  the  mastoid.  The  space  between  the  sigmoid 
sulcus  and  the  antrum  is  smaller,  actually  as  well  as  relatively,  in  adult  life, 
but  rarely  exceeds  5  mm.,  while  some  10  mm.  usually  intervene  between  it 
and  the  posterior  wall  of  the  external  canal.  A  large  curved  or  bulbous 
sinus  always  approaches  close  to  the  canal  and  to  the  mastoid  cortex,  and 
little  or  no  hone  may  protect  it  in  one  or  both  of  these  directions.  The  fossa 
in  which  the  bull)  of  the  jugular  is  lodged  is  also  of  infinite  variation.  Its 
depth  occasionally  carries  it  actually  into  communication  with  the  internal 
auditory  meatus  :  it  generally  closely  approaches  the  lower  back  part  of  the 
tympanic  cavity  (  Fig.  1  Hi),  with  the  intervening  bony  septum  at  times  dehis- 
cent, and  it  so  trenches,  in  rare  instances,  upon  the  labyrinth  that  its  walls  are 
marked  by  the  semicircular  canals.  The  mastoid  emissary  vein  curves  in 
variable  fashion  out  and  back  from  the  lower  curve  of  the  sigmoid  and 
passes  by  single  or  multiple  channels  through  the  bone,  to  emerge  at  or  near 
the  occipitotemporal  suture.  It  varies  from  a  tiny  vessel  hardly  more 
than   a  nutrient    of  the  bone  to  a  large  sinus  carrying  all   the  blood  of  the 

sigmoid  sinus  to  the  external  jugu- 
lar. The  inferior  petrosal  sinus, 
like  the  superior,  pa~>e<  back  from 

the  cavernous  and  t  ransverse  sinu- 
ses, gathering  the  flow  of  the  eil'cr- 
ents  of  the  pyramid  and  adjacent 
parts.  It  follows  the  line  of  the 
petro-occipital  suture,  and  is  prob- 
ably of  greal  importance  in  some 
cases  as  the  channel  of  infections 
from  the  diseased   tympanum. 

The  lower  aspeel  of  the  tem- 
poral bone  is  marked  by  the  ca- 
nals of  the  carotid  artery  and  the 
fossa  for  the  head  of  the  jugular, 
beginning  in  close  proximity,  but 
curving  strongly  in  opposite  direc- 
tions. The  firsl  bend  of  the  car- 
otid presses  its  convexity  into  close 
relation  to  the  forward  pari  of  the  tympanum,  and  the  wall,  sometimes  dehi- 
scent, is  always  penetrated  by  vascular  twigs.     The  outer  wall  of  the  canal  is 


s :  i     Temporal  of  child,  Bhowlng  growing  mas 

told  process  and  fenestrated  develoj ml  of  the  tym 

panic  .'-"•roil  ;  Buturee  almost  oblit<  rat<  °i 


PLATE    m. 


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the  i:xti;rxal  eah.  625 

in  like  proximity  id  the  Eustachian  tube,  and  dehiscence  is  here  more  fre- 
quent— a  tact  to  be  home  in  mind  in  bougieing  this  passage.  External  to 
this  is  the  glenoid  cavity,  its  posterior  boundary  formed  by  the  tympanic 
scroll — its  juvenile  foramen  often  persistent  (Fig.  444) — constituting  the 
anterior  wall  of  the  auditory  canal.  The  open  Glaserian  fissure  at  its  inner 
extremity  marks  the  sntnral  line  and  gives  place  to  the  gracilis  process  of 
the  malleus,  vessels,  and  the  chorda  tympani.  The  fossa  of  the  digastric 
grooves  deeply  the  under  surface  of  the  mastoid,  paralleled  mesially  hv  that 
for  the  occipital  nerve  and  vessels.  While  the  tip  of  the  mastoid  process  is 
wholly  external  to  these,  it  must  not  he  forgotten  that  thin-walled  pneumatic 
cells  commonly  occupy  the  mesial  boundary  and  may  be  the  source  of  pus 
burrowing  in   the  digastric   fossa. 

The  styloid  process,  partially  ensheathed  by  a  lamina  of  the  tympanic 
scroll,  extends  down,  in,  and  forward  toward  the  lesser  horn  of  the  hyoid.  It 
represents  the  cartilaginous  and  fibrous  axis  of  the  second  branchial  arch, 
undergoing  no  ossification  during  the  early  years  of  life,  but  sometimes 
developing  almost  to  the  form  of  the  stylo-hyoid  of  the  dog.  It  may  thus 
become  10  cm.  in  length,  with  articulations,  real  or  suggested,  in  its  length. 
It  may  occasionally  be  recognized  clinically  in  the  lateral  wall  of  the  pharynx. 
Between  it  and  the  mastoid  lies  the  foramen  of  exit  of  the  facial  nerve.  The 
deep  notch  between  the  apex  of  the  pyramid  and  the  lower  anterior  margin 
of  the  squama  is  occupied  by  the  tip  of  the  great  wring  of  the  sphenoid,  with 
its  spinous  foramen,  from  which  the  middle  meningeal  artery  courses  over  the 
inner  surface  of  the  squama. 

The  External  Ear. — The  auricle,  pinna,  or  helix  is  formed  by  the 
outward  growth  of  the  cartilage,  carrying  the  skin-covering  in  close  contact 
with  it.  Its  form,  subject  to  many  minor  variations,  is  fairly  constant,  and, 
except  at  the  lobule,  closely  moulded  upon  the  cartilaginous  framework.  Its 
apparent  attachment  to  the  head  posteriorly  is  some  20  mm.  back  of  the 
supra-meatal  spine,  and  fairly  corresponds  to  the  region  of  the  mastoid  where 
the  lateral  sinus  is  most  near  the  surface  (see  Plate  10).  The  rest  of  the 
mastoid  surface  is  hairless,  and  seems  to  cling  closely  to  the  surface  which  it 
reveals  beneath  ;  but  its  marked  swelling  in  diseased  conditions  proves  the 
presence  of  much  areolar  tissue  and  a  chain  of  lymphatic  glands  connected 
with  those  below  and  in  front  of  the  ear.  These  are  frequently  involved  in 
ear-disease,  acute  or  chronic,  and  may  need  evacuation  or  extirpation — steps 
complicated  by  the  passage  of  the  facial  nerve  through  the  superficial  group 
forward  and  by  the  adhesions  of  the  deeper  set  to  the  sheath  of  the  jugular 
and  carotid.  The  layers  of  the  cervical  fascia  concern  the  aural  surgeon 
greatly  in  his  work,  and  explain  why  rupture  of  mastoid  empyema  into  the 
digastric  fossa  lifts  the  sterno-mastoid  and  all  the  neck-tissues,  and  how  it 

may  burrow  to  the  posterior  pharynx-wall,  down  to  the  clavicl '  even  into 

the  mediastinum  or  pericardium.  Parotid  al>~ce~s  is  also  -aid  to  endanger 
the  ear  by  bursting  through  the  fiss ures  of  Santorini  of  the  cartilaginous 
canal — a  path  about  as  easily  forced  were  the  cartilage  devoid  of  such  gaps. 

The  external  muscles  of  the  ear  are  rudimentary  ami  unimportant,  al- 
though many  have  ability  to  call  the  attollens  into  play.  The  other-  are 
occasionally  seen  in  spasmodic  action,  twitching  generally  without  the  con- 
sciousness of  the    person. 

The  auditory  canal,  as  has  been  stated,  varies  greatly  in  it-  direction 
and  size,  with  the  result  that  the  structure-  clinically  visible  at  its  bottom  are 
inconstant.  The  lower  anterior  segment  of  the  drumhead  cannot  always  i 
brought   to  view  ;   while   up  and  back  the  incus-shank,  -tapes,  and  stapedius- 

40 


626 


THE  AX  ATOMY  OF   THE   EAR,    ETC. 


tendon,  and  down  and  back  the  niche  of  the  round  window  with  its  prominent 
anterior  lip  may  often  be  looked  for  in  vain.  The  length  of  the  upper  hack 
wall  usually  concerns  the  surgeon,  since  it  marks  the  depth  of  the  structures 
which  he  may  have  to  attack,  while  it  also  gives,  as  above  noted,  a  clue  to 
the  depth  of  the  facial  and  horizontal  semicircular  canals  which  he  must 
avoid  (Fig.  145,  PL  KM.  This  length  to  the  spina  suprameatum  is  from 
1 "_'  to  17  mm.,  and  the  soft  tissues  of  the  canal  lengthen  it  to  about  25  mm. 
The  front  wall  i>  longer,  since  the  oblique  plane  of  the  annulus  places  the 
lower  anterior  parts  of  the  drumhead  some  5  mm.  farther  in  ;  while  the  tragus 
protrudes  a  little  outward,  making  it  some  35  mm.  long.  The  impression  is 
common — based  upon  the  position  of  the  drumhead  as  part  of  the  under  sur- 
laee  of  the  prepared  head  of  the  infant — that  the  infantile  canal  is  much 
shorter  than  the  adult,  and  the  drumhead  more  superficial.  This  has  hardly 
any  truth,  although  accepted  and  taughl  by  many  authorities;  for  the  length 
of  the  undeveloped  bony  meatus  is  fully  represented  by  its  fibrous  precursor 
(Plate  K>).  Only  in  so  far  as  the  cartilaginous  canal  is  smaller  may  we  look 
for  a  few  mm.  Less  depth  of  the  drumhead.  The  caliber  is  smaller  in  infancy, 
and  the  rather  collapsed  tube  follows  the  upward  curve  of  the  squama,  re- 
quiring a  downward  and  outward  traction  to  straighten  it.  The  adult  meatus 
is  very  tortuous,  as  a  rule,  although  occasionally  broad  and  straight.  Its 
lumen  i-  usually  oval  :  vertically  at  the  exit,  but  inclining  obliquely  forward 
a-  it  passes  in,  until  the  axis  may  be  less  than  45'  from  the  horizontal.  With 
this  there  is  curvature  in  the  vertical  plane  and  sometimes  in  the  horizontal, 
so  that  the  inner  portion  has  often  a  downward  trend,  although  the  axis  of  the 
oUter  part  pointed  10°  to  20°  upward.  There  is  commonly  some  widening  of 
the  inner,  anterior  part,  constituting  a  sulcus  close  to  the  drumhead — a  diffi- 
cult place  from  which  to  remove  wax  and  foreign  bodies,  as  many  have  found. 
The  diameter  of  the  canal  is  very  various,  as  is  the  type  of  its  oval,  the  nar- 
rowest   "isthmus"    being    generally    the   most    compressed    portion,    with   a 

minor  diameter  sometimes  as 
small  as  5  mm.  In  the  unmacer- 
ated  canal  the  strong  curves  of 
the  soft  parts  ( Plate  10)  still 
farther  complicate  the  tortuosity, 
although  these  can  be  largely 
eliminated  by  good  traction, 
usually  up  and  back  and  out. 
Yet  the  gain  i-  great  in  getting 
access  surgically  to  the  depths 
of  the  canal,  if  we  lay  forward 
t  In'  soft  parts  and  work  in  the 
shorter,  broader  tube  of  the 
naked  bony  meatus.  In  clinical  cases,  where  free  access  is  needed  or  the 
widesl  exit   tbr  a  foreign  body,  the  jaw  must  be  dropped  so  a-  not   to  press 

upon  the  front  wall  of  the  canal.  That  it  compresses  the  outer  parts  is 
demonstrable  at  a  glance  or  by  moving  the  jaw  with  the  finger  thrust  into  the 
meatus;  but  it  is  generally  forgotten  that  the  bony  wall  often  presents  in 
adult  life  ili<'  foramen  of  lacking  ossification  near  the  drumhead,  which  is  a 
constanl  feature  in  the  early  years  of  life,  and  that  pressure  of  the  jaw-condyle 
may  be  exercised  here  also. 

The  Middle  Bar. — The  Tubo-tympanic  Cavity. — The  drum-cavity, 

like  the  labyrinth,  although  varying  much  in  it-  dimensions  in   individual 

.  i-  practically  of  full  size  at  birth,  and    undergoes   little  or  no  change  in 


.3^£«#"*fc* 


Fig.  ii".. 


-Inner  wall  of  tympanum  and  tube 


THE  MIDDLE  EAR. 


627 


the  development  of  the  temporal  hone  as  a  whole.  It-  full  significance  ana- 
tomically and  pathologically  is  partly  lost  by  those  who  do  nol  follow  Leidy 
in  recognizing  its  threefold  division — in  considering  the  antrum  as  much  a 
part  of  it  as  is  the  attic  or  atrium.  Much  good  surgical  comprehension  and 
practice  has  crystallized  aboul  the  name  attic  for  the  epitympanic  -pare,  and 
further  clarification  will  be  general  when  the  antrum  is  no  longer  considered 
as  one  of  the  mastoid  cells.  The  loose  vagueness  of  ideas  and  terminology 
which  calls  the  tympanic  membrane  ••the  drum"  is  only  less  manifest  when 
we  ignore  this  and  the  relation  of  the  scutum  (pars  ossea  of  the  drumhead, 
Wall))  to  the  upper  and  posterior  tympanic  cavities. 

Embryology  shows  us  that  the  Eustachian  tube,  tympanum,  and  mastoid 
cells  are  one  complex  and  slowly  developing  structure  ;  and,  while  the  last 
are  possibly  merely  adventitious  adnexa,  we  may  yet  learn  to  better  appre- 
ciate their  unity.  Absent,  however,  at  birth,  when  the  orpin  is  otherwise  so 
complete,  we  may  now  regard  them  as  unimportant.  The  tubo-tympanic 
cavity  is  a  portion  of  the  upper  air-passages  as  much  as  are  the  accessory 
cavities  of  the  nose — lined  with  an  extension  of  the  same  nasal  mucous  mem- 
brane with  all  its  pathological  attributes.  Much  of  this  mucous  membrane  is 
at  the  same  time  virtually  a  periosteum,  which  magnifies  its  importance  phys- 
iologically and  increases  greatly  the  importance  of  its  lesions. 

The  tympanum  or  drum-cavity  is  in  man  situated  in  the  midst  of  the 
temporal  bone,  some  20-35  mm.  from  the  opening  of  the  external  canal.  Its 
lower  portion,  the  drum-cavity  proper,  or  atrium,  is  bounded  outward  and 
down  by  the  annulus  and  tympanic  membrane,  and  has  somewhat  the  shape 
of  the  body  of  a  vertebra — a  short  cylinder  with  concave  ends  :  the  inward 
traction  of  the  center  of  the  drumhead  and  the  protrusion  of  the  promontory 
opposite  bring  these  walls  within  about  2.5  mm.  of  each  other.  This  dimension 
might  well  be  called  the  height,  as  it  is  more  vertical  than  the  longer  line 


fyrrioiel '  iSiltUS 


ParotidJIi-ter^ 
Juqh7<11  /tssrt 


-tf/]*s(e<ti  Process 


Pig.  146.— Outer  wall  of  drum-cavity  and  relations  of  carotid,  jugular,  lateral  sinus,  and  racial  nerve  t.> 

tin-  tympanum. 


from  floor  to  roof,  which  is  conventionally  so  called,  the  extreme  obliquity  of 
the  annulus  being  forgotten.  From  front  to  back  it  measures  some  12  mm., 
of  which  !)  mm.  is  bounded  by  the  drumhead.  Roof  the  atrium  has  none,  for 
the   attic    is   continuous  with    it   above,  defined   externally   1>\    the  tympanic 


628 


THE  ANATOMY  OF  THE  EAR,  ETC. 


margin  of  the  squama,  but  less  definitely  elsewhere.  Including  the  5  nun. 
of  the  attic,  there  i-  a  distance  of  about  K>  nun.  from  floor  to  roof,  but  only 
two-thirds  of  this  belong  to  the  atrium.  The  attic  space  above  is  broadest 
at  the  top,  and  overhangs  markedly  the  inner  end  of  the  canal,  with  the 
scutum,  which  separates  them,  but  a  thin  wedge  of  bone.  It  merges  almost 
imperceptibly  into  the  antrum  out  and  bach,  an  hour-glass  contraction  (aditus) 
being  made  by  the  protrusion  of  the  facial  and  horizontal  semicircular  canals. 
A.s  viewed  by  the  clinician,  the  drum-cavity  seems  bounded  by  the  annulus, 
and  through  the  transparent  drumhead  <>r  any  perforation  various  inner  struct- 
ure- are  seen.  Anteriorly,  the  opening  of  the  Eustachian  tube  makes  a  deep 
depression,  as  its  lumen  i.-  nearly  in  line  with  the  axis  of  the  external  meatus 
(they  meet  at  150c  on  an  average).  Down  and  back  the  dark  niche  of  the  round 
window  (see  Fig.  44o)  is  bounded  in  front  by  the  prominent  lip  of  the  prom- 
ontory (/),  marking  the  large  beginning  of  the  fir<t  turn  of  the  cochlea.     Up 

and  back  more  or  less  of  the  shank  or 
j  a  j         /  descending  process  of  the  incus  can 

be  seen  (  /",  Fig.  447),  commonly 
parallel  to  the  malleus  handle,  with 
a  horizontal  line  stretching  back 
from  it — the  stapedius  tendon  (/<). 
Of  the  stapes  little  or  nothing  can 
be  normally  seen  in  the  depths  of 
the  pelvis  oralis.  The  curved  line 
of  lYoeltsch's  posterior  pocket  seems 
to  broaden  the  handle  of  the  malleus 
as  it  spreads  upward,  until  at  the 
incus-shank  it  meets  the  whitish 
line  of  the  chorda  ti/mpaiii,  which 
edges  the  backward  sweep  of  the 
rest  of  it.  This  helps  to  shadow  the  stapes,  the  head  and  anterior  crus  of 
which  are  hidden  by  the  incus,  and  come  to  light  only  when  its  shank  is  dis- 
placed or  lost.  In  the  floor  posteriorly  small  depressions  between  trabecular 
of' bone  give  irregularity  to  what  has  been  called  the  recessus  hypotympanicus, 
important  as  being  often  almost  or  quite  trenched  upon  by  the  head  of  the 
jugular.  Above  the  short  process  (a)and  the  anterior (e) and  posterior  fold-. 
which  can  generally  be  discerned  even  in  the  normal  drumhead,  is  the  flaccid. 
an  m Ura a r — sometimes  defined  into  anterior (c),  middle (d), and  posteriori)  por- 
tions by  visible  "  suspensory  folds" — occupying  the  gap  between  the  extremities 

of  the  annulus,   where  the  tympanic  margin  of  the  Squama  complete-  the  ring. 

This  "  Rivinian  segment  "  is  usually  strongly  notched,  but  varies,  and  gives 
varying  size  to  the  "Shrapnell's  membrane," as  it  is  called  after  the  English- 
man who  first  pointed  out  it-  flaccid  character.  '•  Rivinian  "  it  is  also 
termed,  as  the  Bite  of  the  tiny  pinhole  which  Rivinus,  following  Riolanus, 
pointed  out  asa  frequent  "  foramen  "  here,  and  which  Bochdalek  and  other- 
have  claimed  to  be  congenital.  Embryology  offers  no  explanation  of  its 
occurrence,  and  anatomists  and  clinicians  generally  unite  in  denying  it-  usual 
presence.  Unknown  in  fetal  or  infantile  specimens,  it  grows  more  common 
through  childhood,  averaging  10  percent.;  and  in  adult  life  it  may  be  clin- 
ically recognized  as  a  -ear  or  patent  opening  in  25  per  cent,  of  cases — fre- 
quently symmetrically.  It  is  almost  certainly  the  remains  of  a  pathological 
perforation  in  spite  of  any  negative  history. 

This  upper  region,  like  many  other  parts  of  the  tympanum,  varies  much 
in  it-  visibility  ;  as  the  conformation   and  direction  of  the  canal    may  render 


F 1 1 ; .  147.— Drumhead  showing  lighl  triangle,  malleus 

handle,  and  folds  about  the  short  process 


////;  MIDDLE  EAR. 


629 


illumination  and  observation  difficult  or  easy.  Especially  is  this  the  ease  in 
the  region  of  the  stapes,  which  is  hidden  more  or  less  completely  when  the 
canal  is  horizontal,  Imt  shows  bettor  the  more  upward  is  its  inclination. 
Non-transparency  or  variability  of  the  drumhead  structures  has  influence  in 
concealing  these  important  parts;  but  the  surgeon  who  desires  access  to  them 
should  note  carefully  the  axis  of  the  canal  in  relation  to  the  horizontal  plane 
of  the  head,  as  given  by  the  eyebrows,  eyes,  etc.,  since  it  is  a  criterion  for 
what  he  may  expect  as  to  their  apparent   location. 

The  drumhead  or  tympanic  membrane  is  the  thinned  remains  of  the  tissues 
which  separated  the  ingrowing  external  meatus  from  the  outgrowing  tubo- 
tvmpanic  space.  Long  before  birth  it  has  become  a  delicate  memhraiut 
propria  of  strong,  slightly  elastic  libers,  the  denser,  outer  layer  radiating 
from  the  malleus  handle,  while  the  inner  layer  is  circular.  Both  set-  merge 
peripherally  into  the  fibrous  tissue  of  the  tendinous  annulus  which  form-  the 
thick  margin  inserted  into  the  sulcus  of  the  bony  tympanic  annulus.  To  the 
circular  fibers,  which  are  most  numerous  near  the  annulus  and  least  numerous 
in  the  intermediate  portion,  is  largely  due  the  characteristic  funnel-shape  of 
the  drumhead,  which  increases  when  the  structure  is  cut  loose  from  its  attach- 
ments. They  also  explain  the  maintenance  of  depressed  conditions  of  the 
drumhead  after  the  cause  has  been  removed.  This  fibrous  basis  is  clothed 
externally  by  the  thin  skin  of  the  external  canal  and  internally  by  the 
mucous  membrane  of  the  tympanum.  This  basis  is  present  only  throughout 
the  extent  of  the  membrana  tensa  filling  the  tympanic  annulus.  Above,  in 
the  Rivinian  notch,  the  flaccid  membrane  of  Shrapnel  1  is  almost  devoid  of 
fibrous  tissue  interposed  between  skin  and  mucosa.  The  normal  membrane 
is  capable  of  sustaining  a  pressure  upon  either  of  its  surfaces  of  15  pounds 
to  the  square  inch,  but  will  generally  rupture  under  greater  stress. 


Fig.  i  is     Metal  casl  "f  the  externa]  ear, 
showing  the  curves  of  the  canal. 


FIG.   Il'.t.-  Cast  '>f  the  canal  in 
profile. 


The  handle  of  the  malleus,  partly  sheathed  in  cartilage,  is  inserted 
between  the  layers  of  the  membrana  propria, although  protruding  much  upon 
the  mesial  surface.  Folds  of  the  mucous  membrane,  with  more  or  less  ol 
fibrous  basis,  run  backward  and  forward  from  the  manubrium,  in  relation  in 
part  with  the  chorda  tympani,  but  forming  with  the  drumhead  inverted 
pocket-,  anterior  and  posterior.  Much  variability  marks  these,  like  many 
other  tympanic  structures,  but  generally  they  are  well  defined  and  can  be 
seen  through  the  transparent  membrane.  The  annulus  is  \  ery  obliquely  set — 
it-  plane  (not  a  true  plane,  as  it  is  slightly  spiral)  facing  downward,  outward 
(.".7   ).  and  forward  (37   ).    The  plane-  of  the  two  drumheads  extended  down- 


630  THE  ANATOMY  OF  THE  EAR,    ETC. 

ward  and  forward  would  meet  at  128  .  As  the  external  canal  is  nearly  trans- 
verse, averaging  10°  upward  and  1<>  forward  as  it  passes  inward,  but  with 
it-  innermost  portion  sometimes  curving  downward  below  the  horizontal,  it 
meets  the  drum  membrane  at  a  very  acute  angle.  Tins  is  l>est  measured  upon 
casts  of  the  canal,  which  show  the  upper  hack  wall  to  pass  without  demarca- 
tion into  the  drumhead  (Figs.  448,  449),  while  downward  and  forward  the 
angle  maybe  as  small  as  30  or  less.  This  depends  in  part  upon  the  in- 
drawn funnel-shape  of  the  drumhead,  which  does  not  lie  in  the  plane  of  the 
annulus,  but  bulges  slightly  outside  of  mis  plane  peripherally.  It  is  centrally 
drawn  1  mm.  or  more  within  it  by  the  traction  of  the  tensor  tympani. 

Ossicles. — The  two  larger  ossicles  (see  Fig.  457)  develop  from  the  axis 
of  the  first  branchial  arch  |  Meckel's  cartilage),  and  are  gradually  insulated  by 
the  development  of  the  tympanic  cavity  around  them.  The  gracilis  process  of 
the  malleus,  "  long"  in  infancy,  hut  often  absorbed  or  fused  to  the  (ilaserian 
fissure  in  adult  lite,  is  in  the  seventh  week  the  largest  part  of  the  chain.  The 
malleus  handle,  or  manubrium,  has  been  seen  to  develop  in  closest  relation 
with  the  drumhead,  which  partly  ensheathes  it  ;  and  with  the  major  blood- 
supply  along-  it-  posterior  border  there  must  be  very  serious  destruction  to 
impair  its  nutrition.  The  head  is  suspended  and  vascularized  from  the  roof, 
so  that  it  is  less  prone  to  caries  than  the  neck,  in  contact  with  which  septic 
collections  are  apt  to  he  held  by  Prussak's  pouch;  so  the  ossicle  may  be  cut 
in  two.  The  incus  articulates  with  the  saddle-shaped  surface  by  a  sort  of 
clutch-joint,  engaging  snugly  when  the  handle  moves  inward,  but  loosely  at 
other  times.  Neither  this  nor  the  incudo-stapedial  joint  has  a  definite  struct- 
ure :  equally  careful  students  find  it  a  synchondrosis,  a  true  synovial  joint  with 
interposed  meniscus  or  an  intermediate  form.  There  isa  firm  capsular  ligament 
with  a  strong  reinforcing  band  mesially,  which  constitutes  the  major  support  of 
the  incus.  When  this  is  destroyed,  the  delicate  attachment  to  the  stapes,  if  not 
already  severed  by  the  erosion  of  the  incus-shank,  the  most  vulnerable  part 
of  the  chain,  and  the  stronger  semi-articulation  of  the  tip  of  the  horizontal 
process  to  the  mouth  of  the  antrum,  rarely  retain  the  incus  in  place.  The 
stapes  is  the  virtual  key  to  the  value  of  the  chain,  and  in  the  absence  of  the 
rest  can  fulfil  most  of  the  needs  of  hearing.  Its  annular  ligament  may  be 
considered  a  synchondrosis  with  the  edge  of  the  oval  window,  and  its  foot- 
plate can  be  torn  away  without  necessarily  tearing  the  membranous  closure 
of  this  fenestra.  Membranous  bands  unite  the  crura  with  each  other  and  the 
-ides  of  the  niche  in  most  variable  manner ;  but  these  may  be  the  most 
important  factor-  in  the  greal  majority  of  impairments  of  hearing,  and  their 
minute  and  extended  study  is  greatly  needed. 

The  Eustachian  tube,  some  35  nun.  in  length  in  the  adult,  is  a  trumpet- 
shaped  canal  extending  from  the  pharynx  to  the  tympanum.  It  is  usually 
collapsed,  and  presents  on  transverse  section  a  narrow  vertical  fissure  ca- 
pable of  no  great  lateral  distention.  The  distal  third  of  it-  length  is  sup- 
plied with  bony  wall-  by  the  temporal  bone;  but  the  longer  mesial  por- 
tion ha-  only  cartilaginous  support  furnished  by  the  "hook  cartilage" 
above    (Fig.     150),    which     in    the    median     half    extends    down    on    it-    pos- 

terior  wall  ami  constitutes  the  basis  of  the  prominent  posterior  lip  of  the 
pharyngeal  month  (Fig.  151).  The  tympanic  end  also  broadens  from  the 
narrow  isthmus  at  the  junction  of  the  bony  and  cartilaginous  portion,  to 
merge  imperceptibly  into  the  anterior  part  of  the  tympanum.  The  tube  is 
lined  with  columnar  ciliated  epithelium  and  its  submucosa  is  full  of  race- 
mose glands.  The  basemenl  membrane  is  in  close  relation  with  the  cartilage 
throughout  it-  extent  ;   but   where  cartilage  is  lacking,  is  in  like  relation  to  the 


THE  MIDDLE  EAR. 


631 


membranous  wall.  Two  important  muscles  act  upon  the  tube,  the  so-called 
tensor,  and  the  levator  vdi  palati.  The  latter  lies  beneath  the  tube,  and  acts 
upon  it  only  by  reason  of  the  upward  pressure  of  its  shortening  belly,  per- 
mitting rather  than  causing  the  walls 
to  separate.  The  tensor  is  more  com- 
plex in  its  structure  and  relation.  It 
arises  in  part  from  the  hook  of  the  car- 
tilage, which  it  tend-  to  open  l>y  its 
contraction  ;  other  fibers  arise  from 
the  membranous  anterior  wall  of  the 
tube  and  tend  to  draw  it  away  from 
contact  with  the  opposite  wall.  Still 
other  fibers  arise  from  the  basal  carti- 


t/XHta/oi  tola, 


y  /.:6  c 


Oilioueftlers* 

M 


.dT^uoo/Phc^tyault 


G/axAL 
c/Jfntw 


w0 


Levator  Pa  fa  if 


Fig.  450. — Vertical  section  of  Eustachian  tube  in  the 
middle  third,  showing  the  tubo  palatal  muscles. 


Fig.  451. 


-Pharyngeal  tube-moutli  as  seen  by 
posterior  rhinoscopy. 


lage  above  ;  but  any  compressive  action  upon  the  hook  is  probably  slight,  and  I 
have  found  a  bursa  interposed  in  some  cases  to  facilitate  play.  Passing  down- 
ward and  forward,  the  tensor  fibers  converge  to  the  hamulus  of  the  sphenoid, 
where  the  tendon  turns  inward  and  spreads  in  the  velum.  Weber-Liel  has 
shown  that  some  of  the  fibers  of  the  tensor  are  inserted  upon  the  hamulus, 
and  could  act,  therefore,  only  as  a  dilator  of  the  tube.  Some  of  the  fibers  which 
arise  from  the  hook  of  the  cartilage  seem  to  merge  with  the  fibers  of  the 
tensor  tympani  which  extend  in  the  opposite  direction  ;  and  certainly  they 
have  common  enervation  and  consonant  action.  The  latter  muscle  occupies 
with  its  belly  the  canal,  partial  or  complete,  which  lies  along  the  root'  of  the 
bony  Eustachian  tithe,  and  extends  backward  and  out  to  the  inner  wall  of 
the  tympanum,  where  the  little  tube-like  trochlea  (Fig.  445)  permits  its  ten- 
don to  turn  directly  outward  and,  crossing  the  drum-cavity,  to  insert  itself 
upon  a  tiny  tubercle  on  the  handle  of  the  malleus  nearly  directly  in  from  the 
shorl  process.  Disadvantageous  as  is  it-  leverage,  it  has  abundant  power  to 
keep  tension  on  the  drumhead  through  the  manubrium.  The  stapedius,  the 
other  iutratvmpanic  muscle,  is  still  more  snugly  lodged  in  a  bony  cas< — the 
pyramid  (see  Fig.  145)  :it  the  hack  part  of  the  drum-cavity,  between  the 
facial  canal  and  the  round  window  niche.  Below,  this  is  open  to  receive 
nerve-supply  from  the  facial — above,  its  cavity  curves  forward  to  give  exit  to 
it-  thread  of  a  tendon  close  to  the  head  of  the  stape-.  to  which  it  i-  attached. 
It-  action  i:-  supposed  to  he  rather  antagonistic  t<»  the  tensor  tympani  and  to 
limit    the    pressing   of  the    -tape-    into   the   oval    window. 

Plications  of  the  mucous  ineinhrane  serve  with  their  fibrous  basis  t"  BUS- 


632 


77//;  ANATOMY  OF  THE  FAB,    ETC 


pend  the  malleus  and  incus  from  the  roof  of  the  tympanum,  to  form  an 
external  ligament  fastening  each  to  the  upper  tympanic  margin  and  to  accom- 
pany each  of  the  tensor  tendons  and  the  gracilis  process  respectively.  Them- 
selves variable,  these  hands  are  reinforced  by  others  less  constant,  which  serve 
to  subdivide  the  attic  space  more  or  less  completely  into  several  or,  at  times, 
many  cavities.     One  fairly  constant  "  pouch "  lies  between  the  neck  of  the 


JUateraL  malleo-incucUilfold 


TrussaJisJjouch 


ower  -malleo-ineudalskace 


"     fold 
jf/oor  cells 

TcJxdeell 

Carotid  artery 
fiistac/iiajt  tube 
ffiary/tceal urau\^^    M 


/{osenmu/terj Jossa.  Juaular  bulb  I  lacial  Nert/e 

Fig.  452. — Metal  cast  of  the  middle-car  spaces,  lateral  side  (Siebenmann). 

malleus  and  the  flaccid  membrane,  having  the  short  process  for  its  floor,  as 
described  by  Prussak.  Politzer  has  found  this  often  subdivided,  while 
Kretschmann  thinks  the  usual  condition  is  for  the  pouch  to  extend  back- 
ward along  the  body  of  the  incus.  Much  in  the  pathology  of  inflammation 
in  the  attic  depends  upon  the  individual  variations  of  these  parts  and  the 
retention  of  secretions  within  the  spaces  thus  isolated  (Fig.  452). 

In  the  antrum  comparable  septal  hands  are  often  present;  and  its  lining 
mucous  membrane,  which  extends  into  the  communicating  pneumatic  cells  of 


in,,  i  ,-.:.    Metal  casl  of  very  diploetic  mastoid,  with 
pni  umatic  cells  only  close  about  the  antrum 


Pig   i  .i     Castoi  wholly  pneumatic  mastoid. 


the  mastoid,  often  narrows  greatly  the  entrances  of  these.  Although  sufficient 
tor  good  drainage  in  health,  these  openings  are  apt  to  become  stenosed  by 
inflammatory  swelling,  and  by  retaining  the  secretions  give  rise  to  mastoid 
empyema.  There  is  usually  :i  radiate  or  racemose  arrangemenl  of  the  pneu- 
matic  cells  aboul  the  antrum,  due  to  the  fad  thai  they  are  outgrowths  <>f  the 


THE  MIDDLE  EAR.  633 

tubo -tympanic  space.    At  birth  there  is  merely  diploetic  structure  of  the  tiny 

mastoid  and  adjacent  pyramid  ;  and  in  the  developed  bone  this  may  never  be 
wholly  displaced  i  Fig.  453),  although  probably  steadily  decreasing  as  the  pneu- 
matic cavities  enlarge.  Little  of  it  remains  in  the  greal  majority  of  adult 
bones  which  I  have  examined  (  Fig.  454);  and  study  of  :i  thousand  indicates 
that  hardly  2  per  cent,  could  be  classed  as  diploetic,  and  only  some  10  per 
cent,  as  combining  a  notable  amount  of  diploe  with  the  pneumatic  spaces. 
No  mastoid  is  absolutely  pneumatic,  although  some  senile  bones  show  a  single 
thin-walled  cell  occupying  the  greater  part  of  the  process;  but  no  demarca- 
tion can  be  drawn  as  to  how  far  the  air-cavities  may  be  expected  to  extend. 
In  some  specimens  they  invade  the  occipital  hone  backward  ;  they  may  occupy 
the  zygomatic  process  and  hollow  out  the  pyramid  to  its  very  tip  anteriorly 
— usually  they  pass  close  to  the  sigmoid  sinus.  Some  generally  connect  with 
the  beginning  of  the  Eustachian  tube,  lying  in  its  floor  in  close  relation  to  the 
carotid.  Bordering  on  the  digastric  fossa,  they  arc  thin-walled  and  large  on 
the  mesial  as  well  as  on  the  distal  side.  The  paramastoid  or  paracondyloid 
outgrowth  sometimes  seen  upon  the  occipital,  as  well  as  even  the  condyle 
itself,  may  be  occupied  by  these  pneumatic  extensions  of  the  tympanum. 
Their  function,  if  any,  is  doubtful  ;  and  they  probably  show  merely  Nature's 
economy  of  material  and  only  rarefy  these  structures  within  as  they  grow 
externally  larger.  Too  utterly  variable  for  the  condition  on  the  one  side  to 
form  much  of  a  criterion  for  the  other,  they  have  no  very  great  surgical 
importance.  Hyperostotic  inflammation  can  solidify  the  bone  with  equal 
promptness  whether  it  be  pneumatic  or  diploetic — caries  is  apt  to  be  equally 
destructive  and  extensive  in  each  ;  possibly  pyemic  extension  is  less  ready 
from  the  pneumatic  mastoid  than  when  considerable  diploe  is  present.  When 
aural  surgery  regarded  the  antrum  as  merely  one  of  the  mastoid  cells,  the 
others  seemed  of  little  inferior  importance;  but  more  precise  views  of  the 
anatomy  and  pathology  are  now  dissipating  this  view.  The  surgeon,  in 
undertaking  to  open  a  mastoid  empyema,  acts  upon  the  indications  as  to  the 
location  of  the  pus,  whether  in  the  antrum  alone,  in  the  mastoid-tip,  or 
throughout  the  process,  and  considers  the  cell-spaces  met  only  as  holding 
out  of  his  way  the  more  important  dural  structures  which  be  desires  to  avoid 
in  opening  his  track — usually  to  the  antrum.  His  concern  is  principally  that 
no  anomalous  forwardness  bring  the  sinus  into  his  field  nor  undue  lowness  of 
the  middle  fossa  expose  the  dura  to  unintended  attack.  He  must  know 
that  while  10  mm.  is  the  average  width  of  his  held,  the  lateral  sinus  may 
wholly  occupy  it;  that  above  the  sj>iu<i  there  may  he  none  of  the  fi  mm.  of 
-pace  usually  to  be  expected  ;  and  that  every  bone,  whether  left  or  right,  in 
brachycephalic  or  dolichocephalic,  must  be  treated  as  though  presenting 
the  most  dangerous  relation  possible,  until  exploration  has  proved  the  con- 
trary. Boring  instruments  must  give  place,  therefore,  to  gouge  ami  spoon  ; 
and  the  mastoid  surface  must  be  bared  and  well  scrutinized,  and  not  blindly 
attacked  even  at  the  well-chosen  point.  For  the  antrum  this  is  usually  about 
5-10  mm.  horizontally  hack  of  the  -upraiiieatal  .-pine,  and  the  cavitj  should 
We  reached  at  a  depth  of  10-15  nun.  by  a  channel  parallel  to  the  meatus,  hut 
directed  slightly  more  upward.  Probably  the  facial  and  semicircular  canals 
on  the  farther  side  of  the  antrum  are  never  less  than  15  mm.  from  the 
mastoid  surface  ;  hut  they  are  rarely  more  than  25  nun. — a  depth  which  may 
he  taken  as  the  maximum  permissible  penetration. 

Much  important  anatomical  detail  has  been  here  omitted,  such  as  the  origin 
and  course  of  the  fibers  of  the  acoustic  nerve  ami  their  distribution.  1  hose 
wishing  more  than  is  Bhown  in  Fig.  Ill  are  referred  to  the  exhaustive  works. 


THE   PHYSIOLOGY   OF  THE   EAR. 

By  FRANK   ALLPORT,  M.  D.,  and  R.  O.    BEARD,  M.  D., 

OF   CHICAGO,    ILL.  OF   MINNEAPOLIS,    MINN. 


The  physiology  of  the  oar  is  one  of  those  functional  problems  the  solu- 
tion of  which  depends  upon  the  application  of  physical  principles  to  the 
operations  of  the  living  tissue-cell.  It  involves,  essentially,  the  translation 
of  physical  phenomena  into  tonus  of  physiological  activity.  Nevertheless,  a 
clear  distinction  must  be  made  between  the  physical  laws  under  which  auditory 
stimuli  are  conditioned  and  the  physiological  laws  under  which  auditory  im- 
pressions are  developed  and  interpreted. 

The  production  and  propagation  of  sound-waves  are  governed 
by  these  physical  laws.  Matter,  in  direct  ratio  to  its  elasticity  and  inversely 
to  its  density,  is  susceptible  of  vibratory  motion.  Those  forms,  phases,  or 
degrees  of  vibratory  motion  to  which  the  organs  of  hearing  are  responsive 
are  termed  sound-waves.  The  limitations  of  this  term  are  dependent  upon 
the  capacity  of  the  auditory  apparatus,  and  vary,  therefore,  with  the  degree 
of  auditory  development    in  the  particular  species  or  individual. 

Waves  of  sound  may  be  defined,  under  these  limitations,  as  the  to-and-fro 
or  oscillatory  movement-  of  particles  of  matter,  each  particle  similarly  affect- 
ing it<  immediate  neighbors,  so  that  alternating  condensations  and  rarefactions 
of  these  particles  of  the  sound-transmitting  medium  are  produced.  These 
vibratory  movements  occur  in  a  direction  cither  longitudinal  or  transversal  to 
the  axis  of  the  propagation  of  the  sound,  according  to  the  nature  and  arrange- 
ment of  the  conducting  agent. 

Particles  of  matter  which  an'  at  similar  points  of  condensation  or  rarefac- 
tion are  siid  to  be  in  the  same  "  phase."  The  distance  between  such  particles 
in  similar  phase  is  termed  the  wave-length.  This  distance — and  therefore 
the  wave-length — varies  with  the  velocity  of  the  wave-movement  and  with 
the  rate  of  the  sound-vibrations — i.e.  the  degree  of  velocity  per  second, 
divided  by  the  number  of  vibrations  per  second,  gives  the  measure  of  a  par- 
ticular wave-length.  The  velocity  of  sound-waves  is  determined  by  the 
relative  elasticity  and  density  of  the  transmitting  medium. 

A  wide  variance  is  discovered  in  the  sound-propagating  qualities  <>f  dif- 
ferenl  media,  such  as  air,  water,  solids,  etc.  ;  but  the  superiority  of  a  medium 
as  a  conductor  of  sound-wave-  doe-  not  altogether  overcome  the  difficulty  of 

their  transference  from  one  medium  to  another,  a-  from  air  to  water. 

The  impact  of  sound-waves  upon  substances  of  suitable  form  and  position 
will  cause  a  reflection  of  sound  ;  that  is,  a  reprojection  of  sound  waves  of 
similar  character  to  a  distant  focus.  Echo  is  an  illustration  of  sound-reflec- 
tion  from  :i  reflector  30  distanl  that   the  primary  waxes  die  away  before  the 

secondary  or  return  waves  reach  the  curat  the  focal  point. 

Sound-waves,  passing  through  a  substance  of  biconvex  form  and  of 
greater  density  than   the  air,  may  be   refracted,  a-  light  i.-  in    passing  through 


PR0Ol<  Tlo.X  AM>   rROIWdAlTOX  OF  SOUND-WAVES.     635 

a  lens,  to  a  focus  in  front  of  the  refractive  body.  The  expansion  or  diffusion 
dt'  sound-waves  is  limited  in  their  conveyance  through  tubular  passages,  and 
thus  sound  may  be  said  to  be  susceptible  of  collection. 

Sound-waves  arc  possessed  of  certain  physical  properties  which  arc  the 
subjects  of  recognition  by  the  organs  of  hearing.  The  accurate  analysis  of 
these  qualities  is  dependent  upon  the  degree  to  which  the  specialization  of 
auditory  function  has  been  carried. 

Sound-waves  are  measured  (1)  by  their  amplitude  ;  that  i-,  l>\-  the  energy 
of  the  movement  of  the  vibrating  particles — by  the  degree  of  their  excursion 
upon  either  side  of  a  position  of  rest.  This  property  marks  the  force  of  the 
stimulus  to  which  the  auditory  nerve- terminals  are  subjected,  and.  together 
with  the  degree  of  responsive  irritability  possessed  by  these  terminals,  deter- 
mines the  loudness  or  intensity  of  a  sound. 

Sound-waves  are  measured  (2)  by  that  property  which  is  termed  pitch — a 
feature  determined  by  the  number  of  vibrations  per  second  which  the  particles 
of  the  sound-transmitting  medium  undergo.  The  range  of  variability  in 
this  vibration-rate  possible  of  appreciation  by  the  human  ear  is  a  very  wide 
one,  although  its  limits  vary  widely  with  the  degree  of  auditory  development. 
The  appreciable  extremes  of  vibration  are  placed  between  24  per  second  and 
40,000  per  second,'  but  the  more  usual  limits  of  discernment  are  between  .'>."> 
and  16,000. 

Sound-waves  are  characterized  (3)  by  the  presence  or  absence  of  rhythm 
in  the  recurrence  of  their  vibrations.  If  the  vibrations  have  a  regular 
periodicity,  they  are  said  to  give  musical  sounds;  if  they  are  of  irregular 
rhythm,  they  constitute  noises. 

Waves  of  sound,  and  particularly  of  musical  sound,  are  distinguished 
(4)  by  their  quality  or  timbre,  a  property  which  rests  upon  the  fact  that  they 
are  usually  of  a  compound  character — i.  e.  they  are  associated  or  consist  not 
of  single,  but  of  several,  waves.  This  association  is  usually  of  a  funda- 
mental or  dominant  tone,  characteristic  of  the  vibrations  of  the  conducting 
medium  as  a  whole,  with  partial  or  over-tones  produced  by  the  coincident 
vibrations  at  a  more  rapid  rate,  and  therefore  of  a  higher  pitch,  of  different 
portions  of  the  conducting  medium. 

When  the  vibration-rates  of  associated  tones,  whether  fundamental  or 
partial,  are  in  the  same  arithmetical  relation  as  small  whole  numbers  are  to 
each  other  (e.g.  as  4  to  5,  or  as  6  to  8) — that  is,  when  their  relationship  of 
rate  cannot  be  expressed  in  integral  multiples — the  resultant  note  is  termed 
a  harmonic. 

When  the  vibration-periods  of  coactive  or  associated  sound-waves  are 
not  coincident,  or  in  this  relationship  of  small  whole  numbers  to  each  other — 
whether  they  give  rise  to  fundamental  or  to  over-tones — a  phenomenon 
termed  beat  ensues.  The  beat  is  due  to  an  increased  intensity  of  sound 
whenever  the  waves  are  in  the  same  phase — that  is,  when  they  arc  alike  in 
the  phase  of  condensation  or  alike  in  the  phase  of  rarefaction — and  to  an 
interference  with  or  diminution  of  the  sound  when  the  wave-  .ire  in  opposite 
phase- — that    is,   the   one   in    rarefaction   and   the   other   in   condensation. 

The  number  of  these  beats  depends  upon  the  difference  in  the  vibration- 
rate  of  the  associated  waves.  When  this  difference  is  not  great  and  the  beat- 
are  therefore  i'cw,  they  are  readily  appreciated  by  the  ear  and  do  not  produce 
unpleasant  effects  upon  it.  As  the  difference  of  vibration-rate  increases  and 
the  beats  become  more  numerous,  they  introduce  a  discordanl  element,  and 
at  length  (when  about   .",:;  per  second)  they  produce  a  sort  of  vertigo  of  the 

1  Blake  and  others  cite  the  appreciation  of  tones  i<>  80,000  or  more. 


636 


THE  PHYSIOLOGY  OF  THE  EAR. 


auditory  sensations  which  we  translate  as  dissonance.  Further  increasing  in 
number,  the  beats  become  gradually  fused  and  the  roughness  of  sound  lessens, 
until  they  reach  the  extreme  time-limit  of  distinct  sensations  ( 132  per  second) 
and  are  lost.  So  that  sound-waves  whose  vibration-periods  are  widely  differ- 
ent, and  which  give  rise  to  a  very  large  number  of  beats  very  frequently 
repeated,  afford   do  appreciation  of  beats  whatever  to  the  human  ear. 

Of  especial  Wearing  upon  the  physiology  of  hearing  are  the  physical 
principle-  of  sound-selection.  Certain  substances  have  a  capacity  for  sym- 
pathetic vibration.  They  are  inherently  endowed  with  a  definite  vibration- 
period,  and  whenever  sound-wave-  of  this  particular  pitch  approach  them, 
they  are  excited  to  vibrations  in  harmony  with  the  stimulating  waves,  and 
thus  serve  to  swell  the  volume  of  the  primary  sound.  To  vibrations  of 
period  variant  from  their  own  they  are  dumb.  So  marked  is  this  tendency 
to  sympathetic  vibrations  in  certain  media  that  they  are  termed  resonators, 
and  the  quality  which  they   possess  is  called  resonance. 

Sympathetic  vibration  is  so  acute  a  quality  in  some  agents — as,  for 
instance,  in  the  strings  of  a  piano-forte — that  a  complex  musical  note  sounded 
in  their  near  neighborhood  will  be  resolved  into  its  component  tones  by  their 
selective  power,  each  string  responding  to  its  own   intrinsic  tone.     In  this 

quality  lies  the  foundati* f  the  analysis  of  sound,  unquestionably  one  of 

the   physico-physiological  functions  of  highly  specialized   organs  of  hearing. 

These  function-  of  the  auditory  apparatus  will  be  best  understood  if  the 
close  relationship  between  physical  principles  and  physiological  conditions, 
which   this  term   implies,  is  borne  in   mind. 

The  Sound-collecting  Apparatus. — The  external  ear.  consisting  of 
the  pinna  and  the  meatus,  has  the  primary  duty  of  collecting,  reflecting,  and 


*"  Serve 


t'uslaMihn  7iiic 
laid  open 


5/lort  Irocess      Floor  of  Tympa^t^" 

Fig   IV).    Frontal  section  of  the  organ  of  hearing  (modified  from  Politzer). 

perhaps,  to  a  degree,  resonating  the  waves  of  sound.  The  auricle  with  its 
conch-like  form  and  it-  labyrinthine  depressions  is  essentially  a  sound- 
gatherer.     In  this  function  il  is  assisted  in  some  animals,  although  rarely  in 

man.  by  a  -roup  of  inn-cle- — the  attollens  auricula?,  moving  the  ear  upward  ; 

the  attrahens  auricula?,  drawing  it  forward  and  upward;  and  the  retrahena 
auricula',  pulling  it  backward.  Slighter  alterations  in  the  form  of  the  auricle 
may  be  effected  by  a  second  -roup — viz.  the  tragicus,  the  antitragicus,  the 


THE  SOUND-CONDUCTING   APPABA  TUS.  637 

helices  major  and  minor,  the  transversus,  and  the  obliquus  auricula?.  By  the 
tragus  and  by  means  of  the  curvature  of  the  meatus  the  drumhead  is  pro- 
tected from  the  too  severe  impact  of  powerful  vibrations  <>r  currents  of  air, 

and  the  canal  from  the  too  easy  entrance  of  insects  and  foreign  bodies.  The 
presence  of  hairs  and  of  the  cerumen  in  the  meatus  also  guards  the  ear  from 
these   invaders. 

The  position  of  the  tragus  and  the  form  of  the  curvature  of  the  canal 
also  suggest  that  from  the  center  of  tlhc  conch  sound-waves  may  he  reflected 
to  the  inner  face  of  the  tragus,  from  that  surface  to  the  roof  of  the  meatus, 
and  thence  to  the  tympanic  membrane.  The  tubular  passage  of  the  meatus 
indicates   its  sound-collecting:  and,  possibly,   its  sound-resonating  qualities. 

The  Sound-conducting  Apparatus. — The  middle  ear,  including  the 
tympanic  membrane,  the  chain  of  ossicles,  the  intratympanic  muscles,  and  the 
fenestra?  ovalis  and  rotunda,  together  with  the  perilymph  enclosed  by  the 
bony  labyrinth  of  the  internal  ear,  is  pre-eminently  the  organ  of  sound- 
conduction.  To  this  function  the  appendages  of  the  middle  ear,  the  Eusta- 
chian  tube,  the  antrum,  and  the  mastoid  cells  indirectly  minister.  In  the 
process  of  conduction  the  sound-waves  which  break  upon  the  tympanic 
membrane  are  transmuted,  through  its  agency,  into  a  mechanical  movement, 
a  molecular  vibration,  which  involves  both  the  chain  of  ossicles  and  the 
perilymph,  and  is  retransmitted,  through  the  medium  of  the  latter,  into 
sound-vibrations  in  the  internal  ear. 

The  tympanic  membrane,  a  small,  thin,  membranous  sheet,  tautlv 
stretched  across  the  junction  of  the  external  with  the  middle  ear,  with  its 
slight  irregular  convexity,  with  its  ra- 
dial and  circular  fibers  centering  at  the 
umbo  and  giving  it  a  certain  fixity  of 
form,  with  its  tensity  increased  by  mus- 
cular action,  is  admirably  adapted  to 
its  purpose.  The  longitudinal  vibra- 
tions of  the  sound-waves  which  reach 
it  through  the  column  of  air  in  the 
external  meatus  excite  in  it,  as  they 
do  in  other  bodies  similarly  stretched 
and  whose  cross-section  is  of  similarly 

small    dimension,  vibrations  of  a  trans-  Fig.  456— Vertical  section  of  the  middle  ear, 

rori„l  f^rm  Tlin<  tlu.  Jrnmliood  xt\  drumhead,  and  external  canal,  showing  the 
\er*ai    IOim.       LUUS   tne   arumneaa    VI-      ossicles  and  tendons  of  tensor  and  stapedius. 

brates  inward  and  outward  between  the 

cavities  it  divides.  Through  the  attachment  of  the  handle  of  the  malleus 
to  its  umbo  it  i-  not  only  put  into  direct  relations  with  the  chain  of  ossicles, 
but  i-  controlled  by  the  tensor  tympani  muscle.  This  muscle,  the  tendon  of 
which  is  attached  to  the  upper  third  of  the  handle  of  the  malleus,  and  trav- 
erses a  portion  of  the  middle  meatus,  executing  around  a  bony  eminence 
near  the  Eustachian  canal  a  turn  almost  at  righl  angles  to  the  body  of  the 
muscle,  takes  it>  fixed  point  in  a  groove  running  above  the  lumen  of  that 
canal.  The  contraction  of  this  muscle,  controlled  by  efferent  branches  of 
the  fifth  nerve,  serves,  in  all  probability,  a  double  purpose.  It  draws  the 
malleus  inward,  and  thus  increases  the  tensity  of  the  tympanic  membrane, 
rendering  it  more  acutely  responsive  to  sound-waves  oi'  high  pitch.  It  also 
increases  the  contact  between  the  handle  of  the  malleus  ami  the  drumhead 
at  the  umbo,  the  former  serving,  in  consequence,  as  a  ''damper"  by  which 
tin-  fundamental  tone  of  the  tympanic  membran< — which  in  bodies  of  such 
structural    form    would    tend    to    be    over-prominent — may    be    diminished. 


(338 


THE  PHYSIOLOGY  OF  THE  EAR. 


This  suggests  the  fact  that  the  vibrations  of  this  membrane  are  of  a  com- 
posite character.  It  is  susceptible  of  simultaneous  response  to  sound-waves 
having  a  very  wide  range  of  variance  l>otli  as  to  pitch  and  quality. 

The  Ossicular  Chain. — These  delicate  vibrations  of  the  drumhead  are 
brought   to  bear  upon  the  chain  of  ossicles  (Fig.  457)  through  the  handle 


Fig.  457.— Ossicles  from  within,  showing  attachment  of  malleus  handle  to  drumhead,  the  insertion 
of  the  tensor  tendon  below  the  chorda,  the  axis  of  rotation  through  the  gracilis  process  and  the  poste- 
rior ligament  of  the  incus,  and  the  tooth  of  its  articulation  with  the  malleus  head, 

of  the  malleus.  The  ossicles — which,  taken  as  a  whole  and  physiologically, 
must  be  regarded  as  a  continuous  chain — are  too  minute,  in  all  their  dimen- 
sions alike,  to  encourage  the  theory  that  they  area  medium  of  sound-conduction 
by  molecular  vibration.  The  shortest  of  wave-lengths  is  long  as  compared 
with  their  greatest  measurements.  Moreover,  the  mutual  arrangement  of  the 
malleus,  the  incus,  and  the  stapes,  and  their  relations  to  the  drumhead  at  one 
extremity  of  the  chain  and  to  the  oval  window  at  the  other,  are  such  as  to  indi- 
cate their  performance  of  an  exclusion  upon  the  principle  of  a  lever  of  the  second 
class.  A  line  drawn  from  the  tip  of  the  horizontal  process  of  the  incus  through 
the  incudo-stapedial  joint  of  the  same  bone  to  the  end  of  the  handle  of  the  mal- 
leus represents  this  lever  (  Fig.  158).  The  handle  of  the  malleus  is  the  point 
of  applied  power,  begotten  by  the  vibrations  of  the  tympanic  membrane ;  the 
cud  of  the  shorl  process  of  the  incus  is  the  fulcrum,  and  the  incudo-stapedial 
joint  is  the  point  of  the  effect,  which  i-  transmitted  through  the  attached 
stapes  and  causes  it-  impact  upon  the  oval  window.  The  unity  of  this  lever 
i-  secured  by  the  interlocking  of  the  tooth  of  the  incus  with  the  groove  of  the 
malleus.  At  the  same  time,  the  ossicular  chain  is  safeguarded  from  undue 
rigidity  by  the  Im.-e  capsular  ligament  attaching  the  head  of  the  malleus  to 
it-  articulation   with  the  incus. 

I  bus  in  the  event  of  excessive  pressure  developed  within  the  middle  car, 
pushing  out  the  drumhead  and  carrying  the  malleus  with  it,  the  ossicles  no 
longer  acl  ;i-  :i  whole,  -inc.-  ih,.  reversal  of  the  lever  would  bend  to  tear  the 
stapes  away  from  the  fenestra  ovalis.  [nstead,  a  separation  occurs  between 
the  articular  surfaces  of  the  malleus  and  the  incus,  the  head  of  the  former 
gliding  oui  of  it-  sockel  and  the  tooth  of  the  latter  tending  to  unlock.  Should 
this  outward  movement  of  the  drumhead  be  so  extreme  ;is  to  carry  a  pari  of 
the  head  of  the  malleus  back  upon  the  incus  again,  the  point  of  most  forcible 


THE  APPENDAGES  OF  THE  MIDDLE  EAR.  639 

contact  would  again  be  at  the  tooth,  which  would  then  serve  as  a  fulcrum, 
converting  the  ossicles  into  a  lever  of  the  first  class  and  carrying  the  stapes 
hack  again  upon  the  fenestra. 

In  the  ordinary  action  of  this  physiological  lexer  the  movemenl  of  the 
short  arm  is  materially  less  than  that  of  the  lone.-  arm,  while  the  energy  of 
the  movement  is  multiplied  two  and  a  half  times  between  the  point  of  its 
application  and  the  point  of  its  discharge.  As  Helmholtz  states  it:  "The 
mechanical  problem  which  the  apparatus  within  the  drum  of  the  ear  had  to 
solve  was  to  transform  a  motion  of  greal  amplitude  and  little  force,  such  as 
impinges  on  the  drumhead,  into  a  motion  of  small  amplitude  and  greal  force, 
such  as  had  to  he  communicated  to  the  fluid  of  the  labyrinth."  Thus  a  -harp 
and  relatively  forcible  blow  is  struck  by  the  stapes  upon  the  oval  window. 
The  effect  of  this  blow  may  he  accentuated  or  diminished  by  the  action  of 
the  stapedius  muscle.  1  nis  muscle  from  its  origin  in  the  pyramid  in  the 
back  wall  of  the  tympanic  cavity  passes  to  its  insertion  upon  the  capitulum 
of  the  stapes.  It  is  efferently  controlled  by  fibers  of  the  seventh  nerve. 
Under  ordinary  circumstances  its  contraction  draws  the  foot  of  the  stapes  out- 
ward toward  the  drumhead,  while  the  heel  is  thus  brought  more  sharply  into 
contact  with  the  fenestra.  A  more  forcible  contraction,  which  may  he  excited 
reflexly  by  too  powerful  vibrations  of  the  tympanic  membrane,  would  tend  to 
draw  the  whole  foot-plate  away  from  the  oval  window,  and  would  thus 
diminish  the  pressure  upon  the  contents  of  the  labyrinth. 

Sound-vibrations  may  reach  the  middle  ear  through  the  bones  of  the 
skull  instead  of  by  the  ordinary  path  of  the  meatus,  or  they  may  be  trans- 
ferred from  one  side  of  the  head  to  the  other ;  but  in  either  ease  it  appears  to 
be  true  that  the  tympanic  membrane  receives  these  sound-waves  and  transmits 
their  effects  through  its  own  transversal  vibrations  to  the  chain  of  ossicles. 

It  is  possible  that  to  some  small  degree — and  especially  in  the  event  of 
fixity  of  the  ossicles — the  air  contained  in  the  tympanic  cavity  may  he  thrown 
into  vibrations,  and  that  these  may  affect  the  perilymph  through  the  oval  or 
round  window. 

The  Appendages  of  the  Middle  Ear. — A  thin  mucoid  fluid  is  secreted  by 
glands  imbedded  in  the  submucous  liningof  the  tympanic  cavity,  or  more  prob- 
ably formed  by  the  deliquescence  of  its  effete  cells.  The  ciliated  epithelium, 
which  constitutes  the  mucous  membrane  of  the  cavity,  excepting  upon  the  sur- 
face of  the  ossicles  and  the  tympanic  surface  of  the  drumhead,  and  is  found  also 
in  the  Eustachian  tube,  with  which  the  tympanic  cavity  is  continuous,  serves 
to  carry  the  excess  of  fluid  toward  and  through   the  tube  into  the  pharynx. 

The  Eustachian  tube  has  an  irregular  lumen,  and  in  its  lower  portion  its 
walls  are  in  somewhat  loose  contact,  and  appear  to  be,  as  a  usual  thing,  closed. 
The  tube  opens  for  the  discharge  of  the  mucous  secretion  of  the  middle  ear 
into  the  pharynx;  it  is  opened  also  during  the  act  of  deglutition,  when  air 
finds  its  way  into  the  middle  ear.  Its  most  important  and,  perhaps  it-  sole, 
functions  are  thus  to  drain  the  tympanic  cavity  and  to  preserve  an  equilibrium 
of  pressure  between  the  gaseous  contents  of  the  cavity  and  the  atmosphere. 
Should  the  contained  gases  become  absorbed  and  the  tuhe  l>c  impermeable,  a 
vacuum  results  which  may  cause  retraction  of  the  drumhead  and  disease  oi 
the  intratympanic  tissues.  The  opening  of  the  tube  during  acts  of  degluti- 
tion is  sufficient,  as  a  rule,  to  maintain  this  equilibrium  of  intratympanic  and 
extratympanic  pressure. 

The  antrum  and  the  mastoid  cells  are,  physiologically,  extensions  of  the 
tympanic  cavity,  although  their  communications  with  that  cavity  arc  not 
always  patent.     Their  functions  are  still  a  matter  of  conjecture.     They  proba- 


640  THE  PHYSIOLOGY  OF  THE  EAR. 

bly  serve  as  pneumatic  spaces  within  which  a  supply  of  air  may  be  retained 
as  an  additional  means  of  maintaining  the  air-pressure  within  the  tympanum. 
They  have  been  supposed  also  to  serve  as  diffusion-chambers  for  excessive 
sound-vibrations,  which  may  be  communicated  to  the  air  in  the  tympanic 
cavity,  and  which  might  otherwise  fall  with  undue  energy  upon  the  windows 
of  the  labyrinth.  There  is  little  evidence,  however,  in  support  of  this  view, 
since  sound-waves,  within  ordinarily  wide  limits,  and  whether  conveyed 
through  the  external  meatus  or  through  the  bones  of  the  head,  are  transmitted 
to  the  tympanic  membrane,  and.  centering  at  the  umbo,  are  forwarded  through 
the  movements  of  the  ossicular  chain  rather  than  through  the  air  of  the  cavity. 

The  Bony  Labyrinth  and  the  Perilymph. —  By  means  of  the  fenestra 
ovalis  and  the  fenestra  rotunda,  the  windows  of  the  bony  labyrinth,  increase 
and  decrease  of  pressure  in  the  perilymph  are  provided  for.  'flic  influence  of 
the  sound-vibrations  of  the  drumhead,  through  what  may  be  called  the  sound- 
movement  of  the  ossicles,  is  conveyed  to  the  perilymph  by  the  impact  of  the 
-tapes  upon  the  membrane  which  curtains  the  oval  window  and  divides  the 
tympanic  cavity  from  the  vestibule.  The  shock  which  is  thus  transmitted  to  the 
fluid  of  the  bony  labyrinth  follows  the  course  of  its  cavity,  and  is  finally  ex- 
pended upon  the  membrane  of  the  round  window,  which  curtains  the  cochlear 
canal  from  the  middle  ear.  Thus  in  the  round  window  a  safety-valve  is 
afforded  for  any  excess  of  pressure. 

What  has  been  said  of  the  chain  of  ossicles  with  reference  to  (heir  insus- 
ceptibility to  molecular  vibrations  is  equally  true  of  the  perilymph,  enclosed 
as  it  is  in  a  bony  cavity  of  minute  dimensions,  of  labyrinthine  form,  and 
with  resistant  walls.  The  impact  of  the  stapes  upon  the  oval  window  pro- 
duces, not  waves  of  sound  travelling-  through  the  particles  of  this  fluid,  but 
a  wave-movement  which  involves  the  perilymph  as  a  whole.  So  difficult  is 
the  transference  of  sound-vibrations  from  one  kind  of  medium  to  another, 
that  the  vibratory  movement  of  the  perilymph  more  readily  develops  sound- 
waves in  the  walls  of  the  membranous  labyrinth  than  would  a  series  of 
molecular  vibrations  passing  through  the  particles  of  this  fluid.  Such  a 
movement  has,  in  fact,  an  advantage  over  sound-vibrations  of  the  molecular 
form  as  a  means  of  communicating  to  the  sensitive  structures  of  the  internal 
ear  the  influence  of  the  sound-waves  which  break   upon  the  drumhead. 

The  Sound-recording  Apparatus. — The  utricle,  the  semicircular  ca- 
nals, the  saccule,  and  the  cochlear  canal  make  up  the  membranous  labyrinth, 
enclosing  the  endolymph  and  surrounded  by  the  perilymph  within  its  bony  sac. 
These  organs  are  concerned  not  merely  with  the  receipt  of  auditory  impressions 
in  general,  but  with  the  analysis  and  synthesis  of  sound.  The  impressions 
which  they  record  are  destined  for  the  development  of  auditory  sensations, 
which,  in  their  turn,  give  rise  to  auditory  perceptions  and  judgments  relating 
to  intensity,  rhythm,  pitch,  quality,  distance,  location,  etc.  The  part  which 
each  portion  of  the  membranous  labyrinth  plays  in  the  attainment  of  these 
physiological  ends  is  not  yet  sufficiently  well  worked  out  to  justify  much  in 
the  way  of  precise  statement.  Certain  propositions  may  be  established,  how- 
ever, with  some  measure  of  confidence,  and  these  form  the  basis  for  certain 
safe  conclusions. 

The  principles  of  sound-conduction  indicate  that  the  walls  of  the  mem- 
branous labyrinth,  with  their  fibrous  structure,  are  a  better  medium  for  the 
development  and  transmission  of  Bound-waves,  as  the  result  of  the  impact 

of  the    perilymph    upon    them,  than    the   endolymph    contained    within    these 

membrai -  wall-  can  possibly  be.     The  endolymph  is  a  viscid  fluid  whose 

density   would    prove   an   obstacle    to    acute   vibratory    motion.      In    variable 


rm;  soi'Xh-iiKcoitDiXG  APPARA  res. 


641 


quantity  it  bathes  the  specialized  auditory  epithelium  of  the  crista?,  the 
macula?,  and  the  cochlear  spiral  (Fig.  158).  From  its  contact  with  a  highly 
vascular  membrane,  the  stria  vascularis,  from  it-  identity  with  1 1 1  *  *  cerebral 
fluid  and  the  continuity  * » t*  its  channels  with  those  of  the  brain,  from  its 
homology  with  nutrient  fluids  in  other  Localities,  it  may  fairly  be  considered 
as  an  agenl  of  nutrition  to  these  epithelial  cells,  rather  than  as  a  medium 
through  which  sound-waves  are  conveyed  to  them.  A  difficulty,  too,  and  a 
quite  unnecessary  one,  is  invoked  in  the  idea  of  the  transmission  of  vibra- 
tions through  the  walls  of  the  membranous  labyrinth  to  a  medium  of  so 
markedly   different   a  character  and   vibratory   quality   as   the  endolymph. 

It  would  -eein  that  the  auditory  epithelium  resting  upon  the  inner  surface 
of  these  membranous  walls  must  be  more  readily  affected  by  sound-vibrations 


Fig  458.— Section  of  guinea-pig's  cochlea,  with  its  scala  media  (JO  winding  from  base  t<>  apes  b<  tw<  •  n 
ihe  vestibular  ( V)  and  tympanic    T)  seals     I 

directly  transmitted  to  it  from  beneath  than  by  vibratory  movements  in  the 
endolymph  above  (Fig.  459). 

The  peculiar  form  of  the  bony  labyrinth,  as  related  to  the  points  at 
which  the  sweep  of  the  perilymph  begins  and  end- — viz.  at  the  two  fenestra 
— indicate-  that  the  force  of  the  movement  of  the  perilymph  is  probably 
conveyed  aero--  the  membranous  labyrinth,  and  hear-  strongly  upon  the 
ampullae,  the  utricle  and  saccule,  and"  the  walls  of  the  cochlear  canal. 

The  functions  of  the    internal  ear  are  of  a    more  varied    character  than    i 
-iiLr'je-ted  hv  the  general  term  auditory  impressions.     There  arc  reasons,  still 

41 


.ill- 


THE   rilYsiOLOaV  OF  THE  EAR. 


under  debate,  but  perhaps  sufficiently  conclusive,  for  regarding  the  semi- 
circular canals,  or  t Ik-  terminals  of  the  vestibular  nerve  in  their  crista',  as 
well  as  in  the  macula;  of  tlic  utricle  and  saccule,  as  the  source  of  afferent 
impressions  which  assist  in  the  preservation  of  both  static  and  dynamic 
equilibrium.1  Whether  these  impressions  arise  from  the  movements  of  the 
endolymph  within  the  semi-circular  canals,  and  are  therefore  dependent  upon 
position,  or  whether  they  are  the  effect  of  vibrations  transmitted  through  the 
walls  of  the  ampulhe  to  the  vestibular  terminals,  is  a  question  still  sub  judice ; 
but  there   remains   little  doubt  that  these  terminals  are,  in  one  way  or  the 


FlG.  459.— Transverse  section  of  a  lower  turn  of  the  eoehlea,  showing  the  structure  and  relations  of   the 

cochlear  {■anal,  SM  (Piersol). 

other,  concerned  in  the  development  of  equilibriar  impressions.  The  presence 
of  the  so-called  otoliths  or  otoconia  in  the  walls  of  the  labyrinth  has  given 
rise  to  the  suggestion  that  they  are  concerned  in  the  causation  of  these 
impressions.  Recent  experiments  tend,  however,  to  prove  that  the  vestibular 
portion  of  the  labyrinth  is  not,  in  an  exclusive  sense,  an  organ  of  equilibra- 
tion. It  is  simply  an  afferent  field  from  which  the  centers  of  co-ordination 
receive  a  certain  measure  of  instruction.-'  In  the  event  of  its  injury  or 
removal,  leading  to  temporary  symptoms  of  vertigo,  compensatory  phenomena 
have  been  developed,  which,  in  their  readiness  of  appearance  and  their 
measure  of  substitutive  function,  are  in  direct  ratio  to  the  degree  of  cerebral 
development.3  ( >ne  distinct  phase  of  the  equilibriar  functions  of  the  internal 
ear  is  observed  in   it-  afferent  regulation  of  compensatory  movements  in  the 

eyeball.1      lint    while    the   evidence    hold-   g 1    that  the   auditory  epithelium 

and  the  nerve-terminals  of  the  crista?  and  the  macula-  are  the  recipient-  of 
other  than  purely  auditory  impressions,  it  is  not  necessary  to  dissociate  the 
equilibriar  from   the  auditory   functions  of  the  vestibule,  or  to  consider  it 

'  Howell:   American  Text  Book  of  Physiology. 

Pano  and  Marini :  Sperimentale,  Parte  •"»  and  <>,  1893. 
■■  Ewald  :   Pfluger's  Arehiv,  lx.  p.  192.  '  *  rum  Brown  :   Lancet,  May  28,  IS95. 


Tin;  soiNi)-iii;<  ohdixc  appaha  TUS. 


643 


exempt  from  auditory  duties.  The  fact  that  thi>  organ  is  of  some  physio- 
logical service  in  co-ordinating  the  movements  of  the  body  does  not  even 
argue  a  separative  function  for  this  purpose.  The  sense  of  equilibrium  is 
not  wholly  independent  of  the  sense  of  hearing.  Loud  or  peculiarly  harsh 
noises,  and  those  extreme  disturbances  of  rhythm  which  are  incident  to  the 
occurrence  of  numerous  heat-  in  musical  sounds,  often  beget  sensations  of  a 
vertiginous  character.  Extremely  deaf  persons  have  ;i  characteristic  uncer- 
tainty of  gait,  which  in  deaf-mutes  often  amount-  to  actual  insecurity; 
Forty  per  cent,  of  the  unfortunates  of  this  class  who  have  been  examined 
have  been  found  faulty  in  co-ordination.1  An  absence  of  nystagmus  is  fre- 
quently observed  in  such  persons  (('rum-Brow  n).  While  these  facts  do  not 
conclusively  prove  the  interdependence  of  equilibriar  and  auditory  function-, 
they  suggest  a  very  close  relationship  between  them. 

Furthermore,  the  absence  of  the  cochlea  or  its  very  rudimentary  form 
in  certain  animals  who  possess  the  sense  of  hearing  to  a  marked  degree,  com- 
pels the  recognition  of  the  vestibular  portion  of  the  internal  ear  a<  a  receiver 
of  auditory  stimuli  of  at  least  certain  kinds.  Conversely,  the  form  and  the 
arrangementof  the  cochlea  (Fig.  460)  indicate  unmistakably  that  it  is  an  organ 
of  sound-analysis  and  perhaps  of  sound-synthesis,  but  do  not  offer  equally 
good  evidence  of  its  capacity  to  develop  those  auditory  impressions  which 
create  sensations  and  judgments  relating  to  intensity,  rhythm,  dissonance,  etc. 

It  is  altogether  probable  that  the  auditory  epithelium  and  the  nerve- 
terminals  of  the  macula?,  and  perhaps  of  the  crista?,  are  the  media  by  which 
are  appreciated  those  qualities  which  pertain  to  so-called  noises,  and  which 
establish  the  differentiation  between  rhythmic  and  arhythmic  sounds  (Howell). 
It  is,  in  fact,  these  primary  auditory  functions  with  which  those  animals  are 
conspicuously  endowed  who  have  only  the  vestibular  portions  of  the  internal 
ear,  while  we  have  little  or  no  evidence  that  they  are  possessed  of  the  facul- 
ties of  sound-analysis  and  synthesis. 

These  most  highly  specialized  of  auditory  functions  by  which  the  varia- 
tions in  pitch  and  quality  of  sound-waves  are  recognized,  by  which  composite 
notes  are  resolved  into  their  component  tones,  and  by  which  individual  tones 


Fig.  460.— Corti'a  organ,  showing  the  Inner  (A)  and  outer  (*)  hair-cells,  the  supporting  pillars  (/,  g),  and 

basilar  membrane  (6)  I  Piersol  i. 

are  fused     into  complex   sensations,  are     unquestionably    po d   by   the 

cochlea. 

In  the  basilar  membrane  (  Fig.  460),  upon  which  tl rgan  of  <  'orti  rests, 

is  found  the  only  structure  in  the  highly  developed  ear  which   satisfactorily 

accounts  for  the  faculty  of  tone-election.     Although  in  man  it   is  of  -mall 

1  Brack  :   Arehivf.  d.  get.  Physiol.,  vol.  lix.  p.  16 


644  THE  PHYSIOLOGY  OF  THE  EAR. 

dimensions  as  a  whole,  its  radial  tensity,  together  with  its  longitudinal  laxity, 
tlH>  sufficiently  wide  range  of  difference  in  the  radial  Lengths  of  its  fibers,  and 
the  Dumber  of  these  radial  fibers,  estimated  at  24,000,  are  qualities  which 
suggest  it-  vibratory  function  and  endow  it  with  ample  possibilities  of  selec- 
tive vibration.  By  selective  or  sympathetic  vibration  is  meant  the  possession 
by  its  individual  fibers  of  intrinsic  pitch,  in  consequence  of  which  each  will 
vibrate  only  in  harmony  with  a  sound-wave  whose  vibration-period  is  iden- 
tical with  it-  own. 

To  the  rods  and  cell-  of  the  organ  of  Corti  these  vibrations  are  certainly 
transmitted;  in  them  they  are  intensified  perhaps,  and  by  them  are  conveyed 
a-  impressions  of  sound  to  the  terminals  of  the  auditory  nerve.  Physiology 
has  not  vet  gone  so  far  as  to  differentiate  the  several  functions  of  the  rods, 
'.)  loii  in  number,  of  the  inner  and  outer  hair-cells,  numbering-  15,500  ( Howell), 
of  the  twin-cells  of  Deiters,  or  of  the  cells  of  Hensen  and  of  Claudius, 
which  all  enter  into  the  delicate  structure  of  this  organ.  They  are  doubtless 
the  media  of  communication  between  the  basilar  membrane  and  the  terminals 
of  the  auditory  nerve,  but  they  are  probably  far  more  than  this.  Their 
structure  and  mutual  arrangement  suggest  a  mechanism  for  the  execution 
of  vibrations  of  rapid  period  or  high  pitch,  and  for  the  differentiation  of 
varying  vibration-rates.  They  may  serve  not  only  as  a  means  of  analyzing 
composite  sound-waves,  but  as  a  means  of  synthesizing  complex  auditory 
impressions. 

In  the  tectorial  membrane  exists,  seemingly,  a  physiological  "damper" 
by  which  excessive  vibration-  or  too  dominant  tone-  are  diminished.  While 
it  i-  difficult  to  demonstrate  it-  possession  of  this  function,  its  form,  situation. 
and  relations  to  the  organ  of  Corti  and  to  the  overarching  membrane  of 
Reissner  justify  the  conclusion.  Excessive  wave-movements  within  the  vestib- 
ular scala  would  necessarily  bear  upon  the  stretched  membrane  of  Reissner, 
and  would  subject  the  endolymph  beneath  it  to  a  pressure  which,  operating 
upon  the  upper  surface  of  the  tectorial  membrane,  would  depress  ita  free 
extremity  toward  or  upon   the   delicate   hair-cells   which   it  surmounts. 

That  such  highly  elaborated  Functions  as  these  attributed  to  the  organ  of 
Corti  exist  in  the  human  ear  is  predicated  on  the  remarkable  development  of 
many  individuals  in  the  faculties  of  sound-analysis  and  synthesis — faculties 
which,  while  resting  lastly  upon  the  possession  of  specialized  nerve-centers 
which  develop  sensations  and  beget  auditory  perceptions  and  judgments, 
must  needs  require  some  mechanism  upon  which  the  sound-waves  may  be 
registered  and  in   which   these   varying  auditory   impressions  arise. 

The  Mechanisms  of  Auditory  Sensation,  Perception,  and 
Judgment. — The  specialized  auditory  epithelia  of  the  cochlea,  the  maculae, 
and  the  cristas  are  the  media  of  communication  between  the  recording  appa- 
ratus of  the  ear  ami  the  terminations  of  the  auditory  nerve. 

There  i-  neither  satisfactory  evidence  nor  physiological  analogy  in  sup- 
port of  the  theory  that  auditory  impressions  are  developed  elsewhere  than 
in  these  nerve-terminal-  or  conveyed  to  the  nerve-centers  by  other  than 
auditory  nerve-paths.  The  apparenl  reaction  to  high  note-  or  to  loud  low 
tones  which    has  been    observed  in  animal-  which    have    been    deprived  of  the 

membranous  labyrinth  is  doubtless  a  matter  of  general  sensation  rather  than 
audition  i  Bernstein ). 

In  view  of  the  varied    character   and  location  of  the  auditory  epithelium, 

anil  the  finely  specialized  quality  of  these  nerve-terminals,  it  cannot  be 
doubted  that  they,  in  common  with  other  Bpecial-sense  nerve-ending-,  have 
a   selective  action  upon  auditory  stimuli.     They  must  have  something  to  do 


THE  MECHANISMS  OF  AUDITORY  SENSATION,    ETC.      645 

with  determining  the  nature  of  the  impression  which  a  given  stimulus 
excites.  Conversely,  their  responses  must  be  conditioned,  as  are  those  of 
other  nerve-terminals,  by  the  character  and  the  mode  of  application  of  th  ■ 

stimulus. 

Nut  only  with  the  recognition  of  the  qualities  of  intensity,  periodicity, 
and  pitch,  hut  with  the  fixation  of  the  limits  of  this  recognition,  they  must 
be  partially  concerned.  That  such  limits  of  function  exist  has  been  clearly 
shown.  Fatigue-phenomena,  incident  to  excessive  intensity,  too  rapid  repe- 
titions, and  extremes  of  vibration  in  sound  are  shared  by  the  auditory  ter- 
minals. Wundt '  has  successfully  disputed  the  doctrine  of  the  specific  nerve- 
energy  of  the  conducting  fibers  of  the  auditory  nerve;  hut  to  carry  this 
contention  down  to  a  denial  of  the  specific  functions  of  the  terminals  would 
be  a  physiological  reduetio  ad  absurdum,  since  it  would  deny  all  utility  to  the 
highly  differentiated  structural  forms  of  these  receiving  cells. 

The  degree  of  irritability  manifested  by  the  auditory  terminal-  varies 
physiologically  with  hereditary  conditions,  age,  training,  and  functional 
fatigue.  An  illustration  of  this  variation  with  age  is  -ecu  in  the  marked 
contraction  of  the  compass  of  the  human  hearing  incident  to  advanced  years.2 

The  specific  functions  of  the  nerve-centers  of  the  bulb,  of  the  basal 
ganglia,  and  of  the  cortex,  which  are  in  anatomical  relations  with  the  fibers 
of  the  cochlear  and  vestibular  branches  of  the  auditory  nerve,  arc  not,  as 
yet,  well  understood.  The  fact  that  a  portion  of  the  vestibular  division  is 
traceable  to  the  cerebellum  re-emphasizes  the  probability  of  an  equilibriar 
function  in  the  vestibule.  The  deep  centers  of  the  bulb  and  of  the  lateral 
nucleus,  to  which  the  cochlear  and  vestibular  nerve-  are  primarily  traced,  are 
possibly  of  purely  trophic  function. 

The  decussation  of  the  auditory  fibers  in  large  part,  by  which  the  trape- 
zoid bodies  are  formed,  is  suggestive  of  a  fusion  of  the  binaural  auditory 
impressions  in  the  nerve-centers  of  the  two  sides — an  event  which  Schafer, 
however,  denies. 

In  the  posterior  quadrigeminal  body  and  the  internal  geniculate  body  we 
find  evidence  of  the  existence  of  auditory  centers  to  which  the  major  portion 
of  the  auditory  fibers  pass  from  the  olivary  body  through  the  fillet.  These 
arc.  clearly,  the  seats  of  auditory  sensation.  In  this  localization  there  is  a 
striking  homology  to  the  visual  sensory  centers  of  the  anterior  quadrigeminal 
body.3  The  posterior  nucleus  of  the  thalamus  is  possibly  involved  also  in  the 
registration  of  sensations  of  hearing.1 

Of  the  manner  in  which  auditory  sensations  are  developed  in  response  to 
a  varied  range  of  auditory  impressions  but  little  can  be  said  at  present.  It 
is  unlikely  that  each  vibration-wave  which  produces  an  impression  upon  the 
nerve-terminals  is  represented  by  a  separate  and  distinct  sensation.  In  all 
probability,  certain  fusions  of  sound-wave  impressions  are  received  by  the 
nerve-endings,  having  Inch  synthesized  perhaps  in  the  cochlea,  and  these  arc 
translated  into  composite  primary  sensations  analogous  to  the  primary  visual 
impulses,  and  then  "in  <.t'  these  integers  of  sensation,  a-  it  were,  other  and 
more  complex  sensory  groups  are  developed.  These  center-  are  susceptible 
of  an  increase  of  irritability  dependent  upon  stimulation.  By  the  receipt 
of  an  impression,  or  perhaps  of  a  series  of  similar  impressions,  the  auditory 
center-  an-  awakened   to  the  appreciation  of    a    succeeding  and  dissimilar 

1  Phil      -     lien,  vol.  viii. 

2  Zwaardemaker :    Wchivi    of  Otology,  July,  1894.     Partly  ascribable,  probably,  to  cl 
in  the  conducting  apparatus. 

3  Starr:  Atlas  of  Nerve-cdl*.  '  I 


646  THE  P ID s TOLOGY  OF  THE  EA  R. 

impression.  With  the  binaural  conduction  of  .sound  there  appears  to  be  an 
alternating  centric  increase  of  sensation   upon  the  two  sides.' 

There  is  not  only  a  close  homology,  but  a  functional  relationship, between 
the  auditory  and  the  visual  centers  of  the  quadrigemina.  Acoustic  stimula- 
tion of  the  posterior  body  lend-  to  a  quite  apparent  increase  of  irritability  in 
the  cells  of  the  anterior  body,  and  to  such  a  degree  that  more  distinct  visual 
sensations,  especially  in  the  color-field,  are  induced.2 

1'he  functions  of  sound-perception,  of  auditory  judgment,  and  of  auditory 
memory  are  localized  in  the  cerebral  cortex.  In  a  portion  of  the  first  and 
second  temporal  convolutions  lying  ventral  to  the  Sylvian  fissure,  and  in 
direct  communication  with  the  auditory  sensation-centers  of  the  basal  ganglia3 
by  fiber-tracts  which  pass  in  both  directions,1  lie  the  centers  which  constitute 
the  auditory  brain. 

These  conical  functions  have  to  do  with  the  analysis  and  synthesis  of 
sound,  with  the  recognition  of  rhythm,  with  the  determination  of  distance, 
and  sound-location,  and  with  the  recollection  and  re-creation  of  sounds 
previously  registered.  The  remarkable  development  of  the  faculties  of 
sound-analysis  and  synthesis  in  certain  individuals  predicate-  a  high  order 
of  specialization  in  this  seal  of  the  musical  mind.  The  judgments  of  sound- 
distance  and  location  are  largely  instructed  by  a  comparison  of  the  sensations 
begotten  of  impressions  made,  simultaneously  or  alternatingly,  upon  the  two 
sides.  In  the  estimate  of  distance  the  intensity  of  a  sound  is  a  governing 
and  an  often  misleading  guide.  Thus  a  low.  feeble  sound  produced  in  the 
near  neighborhood  will  often  convey  the  impression  of  distance,  and  via 
versd.  In  making  up  the  judgment  of  distance  it  is  not  so  much  the  total 
intensity  as  the  intensity  of  the  component  elements  of  a  sound  which  gives 
the  mosl   correct   conclusions  (Bloch). 

The  location  of  a  sound  is  almost  wholly  dependent  upon  binaural  hear- 
ing. Bloch  has  shown  that  it  is  more  readily  determined  in  the  horizontal 
and  frontal  planes  than  in  the  sagittal  plane.  A  comparison  by  the  nerve- 
centers  of  the  several  characteristics  of  intensity,  continuance,  pitch,  and  qual- 
ity in  the  sounds  received  by  the  organs  of  hearing  upon  the  two  sides  is  the 
major  factor  in  the  case.  The  degree  of  sound-collection  achieved  by  the 
two  auricles  i-^  a  minor  influence  in  informing  the  judgment  of  the  locality 
of  a  sound. 

The  function  of  sound-memory  is  but  imperfectly  developed  in  the  major- 
ity of  persons,  while  in  a  very  few  individuals  it  reaches  a  high  degree  of  per- 
fection. The  existence  of  a  memory-center  for  auditory  perceptions,  apart 
from  the  temporal  (.'enters  of  sound-perception  and  judgment,  is  undemon- 
strated. 

Aiiv  tendency  to  dogmatic  statement  in  regard  to  the  specific  functions 
of  auditory  centers  is  arrested  by  the  promise  of  new  light  which  is  suggested 
by  the  recent  investigations  of  Kolliker,  v.  Lenhosselt,  and  Held  into  the 
origins  of  the  auditory  nerve-fibers,  and  by  the  late  demonstration  by  Ramon 
y  Cajal  of  a  new  auditory  nucleus  in  front  of  the  convexity  of  the  upper 
olivary  body. 

1  Blocb  :  Archives  of  Otol.,  xxiv.  2. 

Epstein:  Zeil8chr.f.  Biol.,  xxxiii.  N.  I'..  B.  XV.  Starr:   Op.  cit. 

*  <     v.  Monakow:  Arehivf.  Paychiatrie,  Bd.  xxvii. 


ETIOLOGY  AND   PATHOLOGY. 

By  C.  R.  HOLMES,  M.  J)., 


OF     CINCINNATI.   OHIO. 


ETIOLOGY. 


Age. — Infancy  and  childhood,  the  latter  of  which  we  shall  consider  as 
ending  at  fifteen  years,  furnish  relatively  a  much  larger  percentage  of  ear- 
affections  than  youth  and  adult  life,  hi  childhood  there  is  greater  tendency 
to  purulent  inflammation,  while  later  the  chronic  catarrhal  form  predomi- 
nates. The  percentage  of  ear-affections  in  childhood,  as  given  by  different 
authors,  varies  considerably  :  Bezold  found  it  to  he  '2-\  per  cent.,  while  Hesse 
puts  it  at  4-'>  per  cent.  Difference  in  locality,  climate,  altitude,  etc.  must 
naturally  produce  diverse  results  in  affections  so  readily  influenced  by 
external  Surroundings. 

Heredity  plays  an  important  part  in  ear-affections:  especially  i-  one 
impressed  with  this  when  examining  the  reports  of  our  deaf-mute  institute-, 
where  25  per  cent,  or  more  are  so  attributed.  From  extensive  observations, 
however,  I  am  satisfied  that  quite  a  number  of  these  cases  are  not  congenital, 
but  acquire  deafness  during  the  first  and  second  years  of  life  as  a  result  of 
adenoids,  which  cause  inflammation  and  hyperplasia,  with  extension  to  the 
middle  and   internal   ear. 

Predisposition. —The  transmission  from  parent  to  child  of  a  predisposi- 
tion to  catarrhal  or  purulent  inflammations  of  the  mucous  membranes  in 
general,  and  of  those  lining  the  cavities  of  the  middle  ear.  nose,  and  pharynx 
in  particular,  while  first  recognized  and  most  ably  described  by  v.  Troltsch,  has 
not  as  yet  received  the  attention  due  its  importance;  for  by  an  curly  recog- 
nition of  this  the  physician  may  by  prophylactics,  such  as  early  treatment, 
removal  of  adenoids  and  hypertrophied  tonsils,  favorable  climatic  influences, 
etc.,  limit  or  entirely  prevent  the  development  of  ear-affections. 

Anatomical  development  is  an  important  factor  in  predisposition  to 
ear-affections  :  deep  niches  in  which  are  set  the  round  and  oval  windows, 
unusual  development  of  the  promontory,  extra  thickness  of  the  tegmen 
tympani,  and  general  reduction  in  the  size  of  the  attic  aecessarily  favor 
adhesions  and  deafness  after  inflammation. 

Sex. — Up  to  the  twelfth  year  the  percentage  of  aural  diseases  i-  about 
equally  divided  between  the  sexes,  but  in  youth  and  adult  life  men  are  more 
frequently  affected  than  women,  which  may  readily  be  accounted  for  by  intem- 
perance, excessive  use  of  tobacco,  and  greater  amount  of  exposure  to  wel  and 
cold. 

Biirkner  found,  from  statistics  of  nearly  100,000  ear-patients  "l'  various 
observers,  that  in  24.44  per  cent,  the  disease  involved  the  external  ear,  in 
68.52  per  cent.,  the  middle  ear  and  tympanic  membrane,  in  7.04  per  cent.. 
the  internal  ear. 

Seasons. — Winter  and  spring,  the  seasons  when  pneumonia  i-  most 
prevalent,  furnish  about  66  per  cent,  of  acute  middle-ear  affections.     W  bile 


648  ETIOLOGY  AND  PATHOLOGY. 

bacteriology  lias  proven  that  "catching  cold"  is  not  so  frequent  a  cause  as 
formerly  supposed,  yet  the  fact  still  remains  that  it  predisposes  through  vaso- 
motor disturbances,  paralyzing  the  action  of  the  ciliated  epithelium,  etc,  and 
causing  secretions  favorable  to  the  development  of  bacteria.  Violent  and 
rapidly  developing  middle-car  inflammations  are  frequently  due  to  imprudent 
exposure  when  overheated,  to  drafts,  standing  with  thin-soled  -hoes  on  damp 
and  cold  earth  or  stones,  etc.  Chronic  catarrh  involving  the  ear  is  perhaps 
always  associated  with  a  similar  condition  of  the  naso-pharynx. 

Injuries. — Injuries  are  either  followed  directly  by  ear-affections  or  pre- 
dispose  to  them.  Those  of  the  external  ear  are  least  dangerous,  rarely  lead- 
ing to  permanent  detect.  Bruises  of  the  auricle,  as  from  a  blow,  may  cause 
hematoma  and  resulting  deformity  ;  injuries  supplemented  by  infection 
directly  to  the  external  meatus  lead  to  localized  or  diffused  inflammation, 
which  may  extend  to  the  membrana  lympani  and  middle  car,  with  extensive 
destruction.  Rupture  of  the  tympanic  membrane  may  result  from  direct 
injury,  such  as  clumsy  efforts  at  the  removal  of  foreign  bodies  from  the 
meatus;  also  from  violent  explosions,  or  a  blow  upon  the  ear  with  the  open 
hand,  causing  sudden  condensation  of  the  air  in  the  external   meatus. 

Injuries  involving  the  base  of  the  skull  generally  extend  to  the  inner 
and  middle  ear,  with  rupture  of  the  tympanic  membrane — although  the 
latter  may  not  rupture,  and  may  prevent  the  escape  of  blood  and  cerebro- 
spinal fluid.  The  line  of  fracture  runs  usually  either  transversely  or  parallel 
to  the  long  axis  of  the  petrous  portion.  In  a  specimen  in  my  collection, 
taken  from  a  man  fifty  year-  of  age  who  fell  from  a  high  scaffold,  there 
are  extensive  fractures  at  the  base,  involving  both  temporal  bones,  with 
hemorrhage  into  both  tympanic  cavities.  The  right  temporal  bone  has 
a  fracture  extending  from  the  orifice  of  the  internal  carotid  between  the 
foramen  spinosum  and  hiatus  Fallopii,  passing  outward  through  the  Eusta- 
chian tube  and  anterior  portion  of  the  tympanic  cavity.  Another  irreg- 
ular fracture  runs  at  right  angles  to  the  first,  passing  through  the  apex 
of  the  petrous  bone  and  through  the  canal  of  the  internal  carotid,  immedi- 
ately internal  to  the  internal  auditory  meatus,  down  to,  but  not  opening,  the 
jugular  bulb;  and  yet  both  tympanic  membranes  are  intact  <in<l  normal. 
Where  death  does  not  result  from  the  primary  injury,  inflammation  and  sup- 
puration have  frequently  followed,  which  I  believe  to  be  largely  due  to 
subsequent  infection  in  examining  or  treating  the  part-  with  non-aseptic 
instruments. 

Occupations  involving  much  noise,  such  as  those  of  boiler-makers,  cop- 
persmiths, machinists,  locomotive  engineers  ami  firemen,  etc.,  often  cause 
deafness.  Aeronauts  and  divers  at  times  suffer  from  tinnitus,  dizziness,  and 
deafness  due  to  hemorrhages  into  the  labyrinth,  tympanum,  or  meatus. 

GENERAL  DISEASES  AND  AFFECTIONS  OF   SPECIAL  ORGANS,  AND 
THEIR   INFLUENCE  UPON    HEARING. 

Nervous  System. —  Hemorrhagic  pachymeningitis  may  cause  sudden 
loss  of  hearing  through  extensive  hemorrhage  into  the  internal  ear;  or 
repeated  -mull  hemorrhages  may  take  place,  with  resulting  nerve-degenera- 
tion ami  progressive  loss  of  hearing,  until  total  deafness  results,  associated 
with  various  noises,  hallucinations  and  dizziness.     According  to   Moos,  the 

disturbai f  hearing  in  multiple  cerebral  sclerosis  in  all  probability  remits 

from  sclerotic  degeneration  of  the  nucleus  and   trunk  of  the  eighth   nerve. 

Cerebral    tumors  may   indirectly  cause    disturbance  of   hearing.     The 


VASCTLAR  SYSTEM.  649 

interesting  experiments  of  Gell6,  Berthold,  ami  Baratoux  demonstrated  that 
cutting  of  the  trunk  of  the  trigeminus  led  to  inflammatory  symptoms,  hyper- 
emia, and  exudation  of  pus  in  the  middle  ear.  Kirschner  also  demonstrated 
that  irritation  of  the  fifth  caused  increased  secretion  of  mucus  in  the  middle 
ear.  Gradenigo  has  proven  that  with  increased  intracranial  pressure  we 
may  have  changes  of  the  acusticus  similar  to  those  observed  in  choked  disk. 
Ladame  and  Bernhardt  found  that  disturbance  of  hearing  as  a  result  of 
tumors  of  the  pons  occurs  in  about  27  per  cent.,  and,  as  a  rule,  on  one  side 
only,  'rumor-  of  the  cerebellum  may  cause  disturbance  of  hearing  on  the 
side  affected,  opposite,  or  both  -ides.  Ladame  found  disturbance  of  hearing 
in  9  per  cent.  Incases  where  tumors  of  the  corpora  quadrigemina  existed 
Bernhardt  found  the  ears  involved  4  times  in  11  cases,  or  36.36  per  cent.  ; 
in  2  total  deafness,  in  1  subjective  noises,  and  in  1  ease  noises  and  partial 
deafness.  In  tumors  of  the  base  the  disturbance  is  seldom  limited  to  any 
individual  nerve,  because  of  the  close  proximity  of  the  origin  of  all  the 
cranial  nerves;  the  eighth  is  involved  in  about  one-third  of  the  cases,  while 
the  optic  nerve  is  more  frequently  affected  than  any  of  the  others.  Tumors 
involving  the  eighth  nerve  are  sarcoma,  neuroma,  glioma,  gummata,  tuber- 
cular nodules,  psammoma,  and  fibroma  (see  p.  769). 

General  Symptoms. —  It  i-  difficult  to  make  a  diagnosis  of  brain-tumors 
from  aural  symptoms  alone,  especially  if  we  find  disease  existing  in  the  mid- 
dle or  internal  ear;  but  subjective  noises,  dizziness,  unsteady  gait,  partial  or 
total   deafness  affecting  one  or  both  sides  or  crossed,  are  important   aids. 

Tischkow  has  demonstrated  that  in  progressive  paralysis  there  is  a  forma- 
tion of  new  blood-vessels  in  the  cartilage  of  the  ear,  growing  into  it  from 
the  perichondrium  :  it  is  from  these  easily  ruptured  vessels  that  the  hemor- 
rhages take  place  in  hematoma. 

Epilepsy  and  hysteria  have  each  some  influence  upon  the  ear,  hut  as  yet 
the  results  and  conclusions  are  too  much  at  variance  to  follow  up  the  finely- 
spun  theories  in  the  brief  space  of  this  article. 

Respiratory  Organs,  and  their  Relation  to  Ear-affections. — The  respir- 
atory organs  are  by  far  the  most  important  causative  factors  in  inflammations 
of  the  ear.  Biirkner  found  'I'l. <!  per  cent,  of  acute  middle-ear  catarrh  and  26 
per  cent,  of  the  chronic  variety  ascribed  to  cold  in  the  head.  Nasal  and 
pharyngeal  catarrh  is  responsible,  according  to  various  authors,  for  from  33 
percent,  to  (JO  per  cent,  of  ear-affect  ions.  My  belief,  based  upon  a  careful 
investigation  of  this  point,  is  that  the  higher  percentages  are  more  nearly 
eorrect.  We  are  daily  more  forcibly  impressed  with  the  great  importance 
of  the  above-named  disease  a-  a  cause  of  ear-affections.  Pertussis,  hay-fever, 
measles,  etc.  have  their  influence  on  account  of  the  extension  of  catarrhal 
inflammation  to  the  middle  ear.  Hemorrhages  into  the  ear  can  occur  as  a 
result  of  whooping-cough. 

Vascular  System. — Atheromatous  changes  no;  infrequently  cause  sub- 
jective noises  in  the  ear-,  which  are  constant  and  increased  by  circulatory 
disturbances.  Where  there  i-  no  other  middle-ear  affection,  hearing  is,  as 
a    rule,    normal    in    this  class  of  cases. 

Many  aural  inflammations  are  ascribed  to  dentition  with  as  much  proba- 
bility as  the  concurrent  intestinal  involvement  ;  and  others  are  doubtless 
influenced   by  dental   irritation. 

Nephritis,  whether  interstitial  or  parenchymatous,  frequently  lead-  to 
disturbances  of  hearing.  Douraergue  found  it  in  35  per  cent.  I'll''  symp- 
toms vary  from  subjective  noises  to  partial  and  total  deafness,  either  one  or 
I),, tli  sides  becoming    affected,  the  causes  being  hemorrhages,   inflammatory 


650  ETIOLOGY  AND   PATHOLOGY. 

changes  of  the  mucous  membrane,  or  pressure  from  edema,  while  the  purely 
nervous  manifestations  can  be  caused  by  the  uremic  poisons.  The  subjective 
symptoms  and  the  hearing  often  improve  temporarily  after  the  elimination 
of  poisonous  products  and  the  reduction  of  arterial  tension  and  edema  by 
medication. 

Sexual  Organs. — Disturbance  of  menstruation,  especially  its  cessation, 
influences  the  ears.  Levy  reports  a  typical  case  of  complete  deafness  on 
both  sides  after  cessation  of  the  menses,  without  any  other  symptoms.  Upon 
return  of  menstruation,  three  months  Utter,  hearing  was  completely  restored. 

Hemorrhage  from  the  ear  (vicarious  menstruation)  can  also  occur  with 
or  without  perforation  of  the  membrana  tympani  and  without  existing 
inflammatory  symptoms.  In  the  imperforate* I  cases  the  hemorrhage  comes 
from  the  surface  of*  the  membrana  tympani  and  external  meatus  (probably 
out  of  ceruminous  glands)  (Gradenigo). 

General  Conditions. — Rachitic  children  are  frequently  affected  with  ear- 
disease,  which  is  probably  due  to  malnutrition  and  catarrhal  predisposition. 
Eitelberg  examined  both  ears  of  250  children  belonging  to  this  class,  and  of 
the  500  tympanic  membranes  only  -"i!)  were  normal.' 

Gouty  deposits  are,  according  to  Garrod,  more  frequently  found  in  the 
ear  than  in  any  other  organ.  These  deposits  vary  in  size  from  a  pinhead  to 
half  a  pea,  of  pear-like  appearance,  generally  located  in  the  folds  of  the 
auricle,  hard  or  soft,  and  contain  a  milky  or  creamy  fluid.  Victims  of  this 
di-eas(>  generally  sutler  lancinating  pains  in  the  ear  before  and  during  a  gouty 
attack.  Gout  predisposes  to  the  formation  of  exostoses  of  the  external 
meatus,  and  these  are  found  more  frequently  among  the  English  than  any 
other  nationality. 

Eczema,  hemorrhage,  purulent  inflammation,  and  rapid  necrosis  of  the 
temporal  hone-  are  encountered  as  a  result  of  diabetes:  the  rapid  destruction 
is  accounted  for  by  the  lowered  resisting  power  of  the  tissues,  combined  with 
extensive  arterial  sclerosis.  This  explains  why  in  these  cases  violent  mas- 
toiditis can  rapidly  develop  from  a  simple  naso-pharyngeal  catarrh. 
The  arterial  changes  favor  excessive  hemorrhages — a  fact  to  be  remembered 
when  operating.  The  diploeoceus  of  pneumonia  is  often  found  in  the 
acute  purulent  secretion  of  these  cases,  and  is  generally  associated  with 
the  streptococcus  pyogenes  and  staphylococcus  pyogenes  albus.  Haber- 
mann  demonstrated  the  staphylococcus  pyogenes  aureus  in  the  walls  of 
the  blood-vessels;  the  resulting  toxin  may  lead  to  necrosis  of  the  vessel- 
wall  and  hemorrhage. 

Caries  of  the  teeth  not  infrequently  causes  otalgia,  either  constant  or 
intermittent.  The  pain  may  radiate  to  the  ear,  shoulder,  and  from  there  to 
the  fingers  of  the  affected  side  (Urbantschitsch). 

Acute  and  Chronic  Infectious  Diseases. — Bacteriological  studies  of 
the  eiliet  of  acute  and  chronic  infectious  diseases  upon  the  ear  have  dur- 
ing recent  years  been  pursued  with  much  energy  by  many  aide  investigators. 
The  principal  bacteria  which  so  far  have  been  studied  as  causative  factor-  of 
inflammation  of  the  ear  an  — 

a.  The  diploeoceus  of  pneumonia  ; 

b.  Staphylococcus  pyogenes  albus  and  aureus  ; 

c.  Streptococcus  pyogenes  ; 

d.  Bacillus  pyocyaneus. 

Each  may  be  found  alone  or  two  or  more  varieties  (mixed  forms)  may  be 

1  Four  hundred  boys,  generally  healthy  and  athletic,  in  ;i  Philadelphia  Bchool,  showed 
hard  I  v  two  dozen  normal  drumheads.     Ed. 


DIPHTHERIA    AND  SCARLET  I' i: VEIL  651 

found  at  the  same  time,  making  it  Impossible  to  state  which  is  the  primary 
causative  agent. 

Pathogenic  Germs. — The  various  streptococci  arc  divided  into  two 
main  groups — streptococcus  brevis  and  longus:  the  firs!  is  uon-pathogenetic 
(saprophyte);  the  second  is  virulent,  and  may  be  found  in  the  differenl 
inflammatory  processes.  Furuncles  of  th  •  external  meatus  can  be  caused  by 
any  of  the  staphylococci,  although  the  staphylococcus  aureus  is  the  most 
frequent  cause,  gaining  an  entrance  by  the  hair-shafts.  The  middle  ear  may, 
according  to  the  cause  and  character  of  the  inflammation,  harbor  any  of  the 
above-named  varieties.  In  inflammation  of  the  internal  ear  we  find  prin- 
cipally the  streptococcus. 

Avenues  of  Infection. — There  are  several  paths  by  which  the  micro- 
organisms may  enter  the  ear: 

1.  Through  the  Eustachian  tube; 

2.  Through  the  external  meatus  and  perforated  membrana  tympani  ; 

3.  Through  the  dura!  process  in  the  petro-squamous  fissure  ; 

4.  Through  the  lymph-  and  blood-vessels. 

While  the  Eustachian  tube  is  the  most  frequent  avenue  for  the  bacteria 
to  enter,  nature  has  provided  an  important  barrier  against  invasion  from  the 
nose  and  pharynx  in  the  ciliated  epithelium,  ir/mse  motion  is  from  the  tympanic 
cavity  toward  the  pharynx ;  it  is  when  this  epithelium  is  rendered  defective 
by  pathological  changes  that  the  exciting  cause  may  enter.  The  main  defence 
against  bacterial  invasion  is  a  perfectly  healthy  organism.  Infection  of  the 
internal  ear  occurs  most  frequently  through  the  lymphatics,  especially  those 
of  the   periosteum. 

The  character  of  the  inflammation,  whether  catarrhal  or  purulent,  active 
or  passive,  depends  largely  upon  the  virulence  and  number  of  the  invading 
bacteria  and  the  resisting  power  of  the  invaded  mucous  membrane.  If 
the  bacteria  enter  in  small  numbers  and  slowly,  they  may  cause  only  an  irri- 
tation with  lymph-exudation,  division  of  the  lymph-nuclei,  but  not  of  the 
protoplasm  (Moos),  formation  of  giant-cells,  blood-vessels,  connective  and 
even  osseous  tissue.  If,  however,  they  enter  suddenly  in  large  numbers, 
then  the  resulting  disturbance  of  nutrition  causes  a  rapid  breaking  down  of 
the  parts  ;  reaction  may  begin  and  new  tissue  develop,  resulting  in  hyper- 
plasia and  partial   or  total  obliteration  of  the  original  anatomical   relation-. 

Whether  the  disease  shall  promptly  run  its  course  or  change  into  the 
chronic  form  depends  upon  the  continued  activity  of  the  germs  present  or 
upon  the  gradual  dying  out  of  the  first  culture,  and  implantation  of  new 
varieties  upon  the  now  affected  membrane.  The  general  health  is  often 
impaired  by  previous  disease  and  permits  only  slow  restoration.  We  also 
find,  especially  in  measles  and  diphtheria,  that  there  are  extensive  changes 
in  the  endothelium  of  the  blood-vessels — fatty  degeneration  and  thrombosis, 
with  necrosis  of  the  vessel-walls,  resulting  hemorrhages,  and  extensive  or 
total  loss  of  hearing.  .Minute  capillary  hemorrhages  may  also  result,  causing 
the  death  of  a  limited  area  only  of  the  uerve-tissues,  with  temporary  or  per- 
manent partial  deafness. 

Diphtheria  and  Scarlet  Fever. —  Biirkner  found  acute  otitis  media  puru- 
lenta  resulting  in  1.5  per  cent,  of  all  cases  of  primary  diphtheria  oi  the 
pharynx,  and  nerve  deafness  in  7  per  cent.  The  ear  is,  however,  more  fre- 
quently involved  in  diphtheria  than  would  appear  from  statistics,  because  in 
fatal  cases  of  diphtheria  (average  duration  six  days)  death  results  before  the 
ear-affection  has  become  fully  developed.  The  authorities  nearly  all  ;> 
that    purulent  otitis   media   results  in   about   5  per  cent,  of  all  scarlet-fever 


652  KTIOL OG  Y  A  ND  I\ I  THOL OG  ) '. 

cases.  Bezold  found  in  185  cases  of  purulent  otitis  media  from  scarlet  fever 
30  times  total  destruction  of  the  tympanic  membrane,  with  loss  of  one  or 
more  ossicles,  and  59  times  destruction  oi'  at  least  two-thirds  of  the  mem- 
brane. 

The  author  found,  in  an  examination  of  500  children  at  the  Institute  for 
Deaf-mutes  in  Jacksonville,  111.,  that  their  deafness  was  ascribed  to  scarlet 
fever  in  7.2  per  cent,  and  to  diphtheria  in  0.8  per  cent. 

The  rapidity  with  which  destruction  may  result  to  the  ear  from  diphtheria 
is  almost  incomprehensible.  Where  death  has  occurred  sixty  to  seventy-two 
hours  after  the  beginning  of  the  disease  the  microscopic  examination  of  the 
middle  and  internal  ear  has  revealed  numerous  micrococci,  not  alone  in  the 
blood-vessels,  but  also  in  the  deeper  layer-  of  the  mucous  membrane  and  in 
the  lacunae  of  the  adjoining  hone,  often  leading  to  extensive  or  circumscribed 
necrosis. 

In  measles  we  Hud  that  while  the  ears  arc  frequently  involved,  there  is 
much  less  tendency  to  extensive  destruction  than  in  diphtheria  or  scarlet 
fever,  the  disease  rarely  going  beyond  an  acute  catarrh.  Solomonson  found 
deaf-mutism  caused  by  measles  in  5.6  per  cent.,  Hartmann,  3.6  per  cent. 
Tobeitz  found  otitis  media  in  21.!)  per  cent,  in  convalescent  children.  Of  22 
children  dying  from  measles,  the  ears  of  17  Mere  examined  post-mortem, 
and  in  everyone  the  mucous  membrane  of  the  middle  ear  was  found  to  be 
diseased,  although  in  only  i  <>j  them  had  there  ban  any  clinical  manifestation 
of  ear-complication. 

Typhoid  fever  is  at  time-  accompanied  by  aural  inflammation  varying 
from  a  slight  catarrhal  to  a  violent  purulent  form.  This  is,  however, 
often  overshadowed  by  the  severity  of  other  symptoms,  and  not  noticed 
until  convalescence  has  begun.  The  severe  deafness  at  times  present  may  he 
due  to  weakness  of  the  nerve-centers,  and  in  a  lew  eases  to  changes  in  the 
labyrinth:  mastoiditis  may  also  occur;  while  with  parotid  suppuration 
discharge  of  pus  into  the  external  meatus  is  not  an  infrequent  occurrence. 
Cerebral  Origin. — Disturbance  of  hearing  of  cerebral  origin  i-  frequent, 
and  includes  a  wide  range  of  manifestations,  which  may  he  caused  by  morbid 
processes  of'  the  brain  or  it-  membranes,  but  most  frequently  l>v  involvement 
of  the  internal  ear.  By  far  the  largesl  number  are  found  as  sequelae  to 
cerebro-spinal  meningitis:  according  to  Knapp  and  Moos,  the  deafness 
develops  in   mosl   cases  in   the  first   or  second  week. 

flic  percentage  of  cases  where  the  ears  are  involved  in  cerebro-spinal 
meningitis  varies  greatly  in  different  epidemics.  Competenl  observers  have 
reported  on  epidemics  where  disturbance  of  hearing  seld,om  occurred,  while  in 
othersnearly  all  who  recovered  were  deaf.  In  Ziemssen's  Handbuch  I>r.  Roth 
reported  that  from  the  districl  of  Oberfrank,  with  55,000  inhabitants,  there 
were  during  a  period  of  two  years  58  cases  sent  to  the  Bamberg  Deaf  and 
Dumb  [nstitute  a-  a  result  of  cerebro-spinal  meningitis,  and  Moos  reports 
that   in   hi-  own   practice  59.3  per  cent,  became  deaf-mute-. 

In  the  Jacksonville  Institute  for  Deaf-mute-  I  found  cerebro-spinal 
meningitis  given   a-  the  cause  of  deafness  in    1  I   per  cent,  of  the  cases. 

Lar-en  reports  the  following  carefully  examined  case:  "A  girl  aged  seven 
years  became  hard  of  hearing  on  the  tenth  day  of  an  attack  of  cerebro- 
spinal meningitis,  totally  deaf  on  the  sixteenth  day,  and  died  on  the  thirty- 
lir-t  day.  Section  showed  the  tympanic  membrane  normal  ;  line  and  intense 
injection  in  the  entire  middle  ear,  with  muco-purulenl  i tent-.  In  the  inter- 
nal auditory  canal  the  nerves  were  imbedded  in  pus.  The  membranous 
labyrinth   could    not   he  recognized;  the  aemicircular  canal- were  idled  with 


Tcm:i;<i  losls.  653 

a  soft  reddish  tissue  (connective  tissue  -with  fatty  degenerated  round  cells  and 
blood-corpuscles)  ;  the  same  condition  was  found  in  the  vestibule  and  in  the 

cochlea;  and  in  the  vestibule  of  the  left  car  also  a  small  quantity  of  pus; 
extensive  purulent  meningitis  of  the  convexity  and  base;  the  medulla  was 
also  surrounded  by  purulent  exudations.  The  microscopical  examination  of 
the  acoustic,  the  facial,  cochlear,  and  vestibular  nerve-  revealed  no  patho- 
logical changes.  The  otitis  was  evidently  caused  by  direct  infection  from 
the  meningitis." 

Micrococci. — The  diplococcus  of  pneumonia  is  frequently  found  in 
middle-ear  secretion.-,  often  in  pure  culture-,  even  in  cases  where  there  is 
no  evidence  of  involvement  of  the  lungs. 

Since  the  appearance  of  influenza  otologists  have  had  abundanl  oppor- 
tunity to  study  its  influence  upon  the  sound-conducting  apparatus,  and  the 
resulting  inflammations  of  the  ears  have  been  classified  into  tour  varieties 
(Moos): 

1.  Swelling  and  hyperemia  of  the  lining  of  the  middle  ear,  with  little  or 
no  interference  with   hearing. 

2.  Pain,  fever,  diffuse  redness  of  the  tympanic  membrane,  and  exudation 
into  the  middle  ear,  at  first   sero-mucoid,  later  muco-purulent. 

3.  "The  hemorrhagic"  (myringitis  hemorrhagica  bullosa),  the  most 
typical  of  the  four  varieties;  bullae  varying  from  bright  red  to  a  dull  venous 
color  are  usually  situated  on  the  tympanic  membrane,  but  at  times  found  in 
the  osseous  portion  of  the  canal ;  there  are  much  pain,  fever,  and  deafness. 

4.  The  form  characterized  by  violent  purulent  inflammation  of  all  parts 
of  the  middle  ear,  generally  involving  the  mastoid,  with  fever,  pain,  and 
great  prostration. 

The  author  has  had  occasion  to  study  all  of  these  forms,  and,  while  the 
first  two  varieties  have  nothing  very  distinctive  by  which  to  differentiate 
them  from  similar  affections  due  to  other  eau>es,  those  of  the  third  and 
fourth  classes  are  characteristic  when  taken  in  connection  with  the  general 
symptoms.  The  hemorrhages  which  are  so  frequent  in  this  affection,  \\<>\ 
alone  in  the  ear,  but  in  other  parts  of  the  body,  are  perhaps  to  be  attributed 
to  necrosis  of  the  vessel-walls  by  the  toxin  of  the  influenza  bacillus,  which 
seems  to  have  been  positively  identified  by  Pfeiffer,  Kitasato,  ('anon,  and 
others.  This  bacterium  i-  not  easy  of  isolation,  and  appears  always  to  be 
found  in  connection  with  one  or  more  pathogenic  germ-,  or,  as  Ribbert  states 
it,  "the  exciting  germ  of  influenza  is  everywhere  the  quartermaster  for  the 
various  pathogenic  organisms." 

Mumps  is  probably  due  to  a  bacterium  which  A.  Ollivier  claim-  to  have 
isolated.  In  recent  vears  quite  a  number  of  cases  have  been  reported  with 
severe  involvement  of  the  ear-.  Complete  deafness  of  both  ears  has  been 
reported,  even   where  the  parotitis  was  limited  to  one  side. 

Tuberculosis. — Suppuration  of  the  middle  ear  i-  a  frequent  affection  in 
the  later  stages  of  lung-tuberculosis.  The  ear-affection  usually  develops 
painlessly:  the  first  symptom  noticed  is  more  or  less  marked  deafness,  fol- 
lowed by  a  slight  discharge  of  a  watery  consistency  :  tin'  disease  in  the 
severe  form  may,  however,  be  accompanied  by  the  usual  symptoms  of"  acute 
otitis.  In  case  the  chronic  form  becomes  painful,  we  have  to  deal  with  a 
mixed  infection  of  tubercle  bacilli  and  streptococcus,  with  resulting  increase 
of  offensive  purulent  secretion,  often  leading  to  total  destruction  of  the 
ossicles  and  necrosis  of  the  mucous  membrane,  the  bony  wall-  becoming 
denuded,  especially  the  promontory.  There  is  nearly  always  extensive  break- 
ing down  of  osseous  tissue,  which  may  cause   facial  paralysis  and  even  ero- 


654  ETIOLOG  Y  .  1  ND   PA  THOLOQ  V. 

sion  of  the  carotid.  (Seven  deaths  have  been  reported  from  carotid  hemor- 
rhage. I 

Microscopically,  we  may  find  it  a  very  difficult  task   to  demonstrate  the 

tubercular  nature  of  the  affection  by  examination  of  the  secretions  from  the 
ear  alone,  the  tubercle  bacilli  often  being  absent,  while  the  sputum  contains 
them  in  great  abundance.  In  many  cases  this  is  due  to  the  development  of 
the  streptococci  upon  the  soil  first  occupied  by  the  tubercle  bacilli,  the  new- 
arrivals  flourishing,  while  the  others  become  few  or  are  not  at  all  present  in 
the  discharge.  But  we  musl  also  remember  that  a  non-tubercular  suppura- 
tion of  the  middle  ear  may  occur  in  a  patient  suffering  from  phthisis  pul- 
monalis. 

Syphilis. — Strange  as  it  may  seem,  considering  the  prevalence  of  acquired 
syphilis,  there  are  no  reliable  data  as  to  the  frequency  of  this  factor  being  a 
causative  agent  in  ear-aifections.  That  it  is  one  of  importance  is  well  under- 
stood ;  but  so  long  as  the  statistics  of  authorities  vary  from  20  percent,  to  less 
than  1  per  cent.,  we  must  consider  them  of  little  value.  The  following  changes 
have  been  observed :  Condylomata  of  the  external  meatus;  while  inflamma- 
tion of  the  middle  ear  often  results  from  syphilitic  infection  of  the  nose  and 
pharynx.  In  the  internal  ear  we  may  find  hyperemia,  small-cell  infiltration, 
connective-tissue  formation,  chalk  deposits,  ossifying  periostitis,  stapes  anky- 
losis, and  primary  suppurative  inflammation  of  the  labyrinth.  In  inherited 
syphilis  the  disease  chiefly  attack-  the  labyrinth,  developing  most  frequently 
between  the  ages  of  eighl  and  twenty  years.  Hutchinson  teeth  and  other 
stigmata  are  generally   present. 

Toxicants. — The  abuse  of  certain  drugs  has  a  marked  influence  upon  the 
ears,  quinin,  salicylic  acid,  and  tobacco  being  the  most  important.  Every 
one  is  familiar  with  the  effect  of  large  doses  of  quinin.  The  tinnitus  and 
deafness  have  in  some  cases  proven  permanent.  The  subjective  noises  are 
caused  by  labyrinthine  hyperemia  in  the  first  instance,  but  may  later  be  due 
to  ischemia.  The  action  of  salicylic  acid  is  similar,  but  less  marked  than 
quinin.  The  direct  action  of  tobacco  upon  the  nerve  of  hearing  has.  so 
far.  not  been  clearly  established,  but  is  perhaps  similar  to  the  action  upon 
the  optic  nerve.  Its  deleterious  effect  upon  the  mucous  membrane,  causing 
dryness,  brings  about  or  greatly  aggravates  existing  catarrhal  troubles,  involv- 
ing the  Eustachian  tube  and  middle  ear.  causing  tinnitus  and  the  usual  laby- 
rinthine complications  in  advanced  cases. 

PATHOLOGY. 

Auricle. — Transitory  hyperemia  of  the  auricle  occurs  not  infrequently 
in  patients  suffering  from  chronic  tympanic  catarrh  or  from  a  healed  purulent 
middle-ear  inflammation  associated  with  naso-pharyngeal  catarrh,  and  is  refer- 
able to  the  sympai hel ic  nerve. 

Intertrigo  is  an  excoriation  of  the  skin  behind  the  ears,  accompanied  by 
secretion  of  serum  and  formation  of  crusts.  It  is  often  caused  by  keeping 
the  ears  pressed  firmly  againsl  the  head  by  infant  cap-,  and  is  favored  by  a 
lack   of  cleanliness  and  a   tender  -kin   in   a   strumous  subject. 

/■.'■:<  ni'i. — The  various  classifications  of  eczema  mark,  after  all,  only  dif- 
ferent stages  of  the  same  disease,  ami  here  we  n 1  only  recognize  the  affec- 
tion as  acute  and  chronic.  Every  exciting  cause  giving  rise  to  hyperemia 
is  capable  of  producing  eczema  by  favoring  development  of  bacteria.  Gout, 
rheumatism,  etc.  predispose  to  this  disease,  in  adults  generally  limited  to  the 
externa]   meatus. 


THE  EXTERNAL   MEATUS.  655 

Herpes  auricularis  is  a  rare  affection,  distinguished  by  the  format] >f 

vesicles,  generally  1« ►«  ti t*«  1  upon  the  anterior  surface,  and  caused  by  irritation 
of  the  trophic  nerve-  supplying  the  affected  area. 

Phlegmonous  inflammation  may  result  from  infected  wound-  or  infectious 
diseases,  as  typhoid  (suppuration  of  the  parotid  i.  erysipelas,  measles,  scarlet 
fever,  and  diphtheria,  and  may  develop  primarily  or  by  extension  from  the 
throat  and  middle  ear. 

Diphtheria  may  involve  the  aural  region  through  the  infection  of  open 
surfaces.  In  two  patient-,  male.-,  eighteen  and  thirty  years  of  age,  upon 
whom  the  author  had  performed  the  radical  mastoid  operation,  there  was 
diphtheritic  infection  of  the  wound.-  ;  in  the  younger,  preceded  by  tonsillar 
and  pharyngeal  involvement  ;  in  the  other  the  wound  only  was  affected  : 
both  cases,  however,  experienced  but  slight  constitutional  disturbances. 
Cultures  and  microscopic  examination-  gave  the  typical  Klebs-Lofler  bacilli. 

Perichondritis  of  the  auricle  is  not  often  encountered.  The  cause  is  fre- 
quently obscure,  sometimes  resulting  from  injury  or  metastatic  infection,  as 
from  furuncles  or  otitis  externa  diffusa.  A  swelling  similar  toothematoma 
develops,  and  a  synovial-like  fluid,  which  later  becomes  purulent,  separates 
the  perichondrium  from  the  cartilage.  Deformity  usually  results  through 
chondromalacia.  Othematoma,  or  blood-tumor  of  the  auricle,  is  formed  by 
an  exudation  of  blood  between  the  perichondrium  and  cartilage,  but  may 
occur  between  the  perichondrium  and  skin.  The  affection  i-  either  traumatic 
or  idiopathic,  the  former  resulting  from  direct  injury,  causing  rupture  of  the 
blood-vessels.  The  idiopathic  variety  is  generally  encountered  in  the  insane, 
in  whom  the  intracranial  lesion,  with  degeneration  and  softening  of  the 
vessel-walls  and  formation  of  calcareous  deposits,  favors  spontaneous  rupture 
under  increased  blood-pressure  during  maniacal  excitement  or  from  slight 
-elf-inflicted  bruises  when  violent.  The  theory  of  intracranial  disease  ;i-  a 
cause  of  the  idiopathic  variety  has  found  strong  support  in  the  experiments 
of  Brown-Sequard,  who  caused  hemorrhage  in  the  ears  of  animals  in  from 
twelve  to  twenty-four  hours  after  section  of  the  restiform  bodies.  The 
lobule  is  rarely  affected,  but  may  suffer.  It  is  more  frequently  the  seat  of 
abscess  from  infection  after  piercing  for  ear-rings. 

Keloids  ^fibromata)  occur  now  and  then  as  a  result  of  wearing  heavy  ear- 
rings of  impure  metal  ;  the  growth-  may  vary  in  size  from  a  pea  to  a 
chicken's  c^  (Knapp),   and   are  more  common    in   the   negro. 

Atheromatous  cysts  are  also  found  upon  the  auricle,  generally  upon  the 
posterior  surface  (sec;  Fig.  4<>1  (.  The  serous  variety  also  develops,  although 
less  frequently. 

There  are  a  number  of  affections  which  so  rarely  involve  the  external 
ear  that  it  would  be  out  of  place  to  describe  them  at  length  in  this  article, 
and  I  shall  merely  name  them  —  to  wit  :  syphilis,  lupu-.  hypertrophy  of  a  part 
or  all  of  the  auricle,  necrosis  chalk  deposits,  ossification,  and  injuries. 

The  External  Meatus. — Hyperemia  is  often  found  in  connection  with 
inflammation  of  the  auricle  or  middle  ear,  and  may  be  quickly  evoked  by 
the  speculum  ;  and  hemorrhage  of  the  external  meatus  may  result  from  inju- 
ries, careless  removal  of  inspissated  cerumen,  or  foreign  bodies. 

Funmcles  are  circumscribed  glandular  inflammation-  ;  hence  they  are  most 
frequently  situated  in  the  cartilaginous  portion  of  the  meatus,  but  may  also 
be  found  in  the  osseous  canal.  The  central  ma—  break-  down,  forming  :i 
necrotic  slough  surrounded  by  pus;  left  to  itself,  it  usually  evacuates  spon- 
taneously. It  i-  now  generally  accepted  that  the  cause  is  in  most,  if  not  all, 
cases  due  toa  bacterial  infection,  the  staphylococcus  aureus  being  found  much 


656 


ETIOLOGY  AND   PA  T1IOLOGY. 


more   frequently  than  any  of  the  other  bacteria.      The  point   of  entrance   i- 

along  the  hair-shafts  and  by  the  mouths  of  the  sebaceous  or  sweat  glands. 

"...     i  ., 

AJbrasion   of  the    skin   by   linker-nails,  ear-curettes, 

hair-pins,    etc.    is   a    frequent    cause    of    infection. 

Transmission    by  failure    to    disinfect  the  syringe- 

uozzle  was  observed   in   the  Cincinnati  Hospital  in 

1892.     A   typical  case  of  furuncular  inflammation 

of  the  external  meatus  was  admitted,  and  within  a 
short  time  eight  eases  developed  among  ear-patients 
in  different  parts  of  the  house,  who  up  to  this  time 
had  not  suffered  from  the  affection.  In  searching 
for  a  cause  I  found  that  the  same  syringe  had  been 
used  lor  all  of  these  cases  without  disinfecting  the 
nozzle  ;  after  correcting  this  no  more  eases  of  furun- 
cles developed  in  the  service. 

Reflex  tropho-neurosis  is  also  cited  as  a  cause. 
The  inflammation  may  in  severe  cases  extend  deeply, 
giving  rise  to  perichondritis  of  the  canal  and  auricle  : 
even  in  the  less  severe  cases  we  at  times  find  exten- 
sion to  the  tympanic  membrane  and  middle  ear.  The 
author  recently  observed  a  case  where  two  furuncles 
of  the  cartilaginous  portion,  accompanied  by  only 
slight  -welling'  and  pain,  caused  marked  deafness, 
tinnitus,  and  the  loss  of  a  calcareous  plaque  in  the 
fig.  46i.— Sebaceous  cysi  of     anterior  half  of  the  tympanic  membrane,  with  result- 

thirtiH'ii   years' duration   in    a  P  ttti"        i         ,    j  i  •  n 

man    of    twenty-eight,    from      ing  perforation.      \\  hen  located  on  the  posterior  wall 

Sowth  ha^n  removed     and   near  the  orifice  of  the  external  canal,  they  may 

had  to  great  edematous  swelling  behind  the  auricle, 

even  causing  the  latter  to  stand  out  at  right  angles — closely  resembling,  and 

being  mistaken  for,  acute  mastoiditis. 

Otitis  externa  diffusa  is  a  general   inflammation  of  the  external  ear  which 

may  result  from  the  causes  given  under  "  Furuncles."     The  whole  lining  of 

the  canal  becomes  a  deep  red,  swollen,  and  covered  with  more  or  less  sero- 

purulent  secretion.     In  severe  cases  there  is  swelling  and  inflammation  of  the 

auricle,  even  extending  over  the  mastoid  ami  parotid,  with  enlargement  of  the 


^    -Pel- 


'■><•?  :Vz£r?~  ■ 


Pig  462.    Section  of  cholesteatoma  mass  from  canal. 


gland-  about  the  ear.      The  middle  car  ie  seldom   involved,  yet  perforation  of 

the  tympanic  membrane  and  purulent  otiti>  media  and  mastoid  complications 

may  resull  ;  bul  the  inflammation  in  the  external  meatus  is  not  infrequently 

indary  to  involveraenl  of  the  tympanic  cavity,  attic,  and  mastoid  cells. 


THE  EXTERNAL   MEATUS. 


657 


From  the  latter  there  may  l>e  a  direct  opening  through  the  posterior  wall  of 
the  canal,  with  protrusion  of  granulations  and  discharge  of  pus. 

Cholesteatoma  (or  pearl  tumor)  of  the  external  canal  is  rare.  The  growth 
results  from  prolonged  inflammation  of  the  epithelium,  causing  excessive 
proliferation  of  the  rete  oiucosum  and  exfoliation  of  the  epidermal  layer, 
forming  laminated  mother-of-pearl  colored  masses,  in  which  are  found 
numerous  cholesterin  crystals.  Fig.  4<i2  clearly  shows  the  laminated 
structure  of  the  growth.  The  ear  from  which  this  specimen  was  taken 
showed  extensive  changes  secondary  to  an  arrested  otitis  media  purulenta. 
The  external  meatus  was  almost  filled  with  the  epithelial  mass,  imbedded  in 
which  were  three  firm  globular  pearl  tumors  from  :'>  to  <i  mm.  in  diameter. 
Removal  of  these  left  three  corresponding  depressions  in  the  floor  of  the 
meatus,  equal  in  depth  to  about  one-half  the  diameter  of  the  round  masses, 
and  lined  with  a  pearly  membrane. 

Neoplasm. —  Exostoses,  and  hyperostoses,  or  bony 
growths  of  the  external  canal,  are  most  frequently 
situated  on  the  posterior  wall,  at  the  junction  of  the 
cartilaginous  and  bony  canals  (Figs,  463,  494).  In 
structure  they  are  generally  of  ivory  hardness,  but 
may  be  cancellous.  They  are  ascribed  to  the  irrita- 
tion of  discharge  in  some  cases,  and  in  the  British 
upper  classes,  among  whom  they  are  not  uncommon, 
to  gout  or  inordinate  bathing. 

Lupus,  syphilis,  cysts,  angioma,  osteosarcoma, 
and  epithelioma  have  been  reported. 

Otomycosis. — A  number  of  vegetable  parasites 
develop  in  the  external  meatus,  especially  the  as- 
pergillus  niger,  flavus,  and  fumigatus.  Microscop- 
ically, they  appear  in  the  deeper  part  of  the  meatus 

d,i       ,  •  l  i  •   i    i  l      i  canal  and  trephining  <>f  mas- 

on the  tympanic  membrane  as  brownish-black,     toid  (Randall). 

grayish-white,  or  yellowish   punctated  masses.     The 

germs  cannot  develop  in  the  normal  ear,  but  maceration  of  the  epithelium 
from  any  inflammatory  cause  favors  their  growth.  Examination  of  a  fragment 
placed  under  the  microscope  reveals  ir- 
regularly interlaced  threads  or  hyphae 
(mycelium  (a),  Fig.  464),  covered  more 
or  less  densely  by  globular  masses  of 
fallen  spores  (6) ;  here  and  there  a  flower- 
like  mass  is  found,  supported  upon  hyphae 
— i.  e.  the  sporangium  or  fruit-capsule 
(c),  consisting  of  the  central  receptaculum 
('/).  upon  which  are  seated  the  long  radi- 
ating cells  (sterigmata),  (e);  bearing  the 
round  conidia  or  spores. 

Cervminous*  masses  consisl  of  secre- 
tion from  the  ceruminal  and  fat-glands, 
exfoliated  epithelium,  hair-,  and  dust  : 
their  formation  primarily  depend-  upon 
hypersecretion,  due  to  an  excitation  of 
the  glands  secondary  to  middle-ear  con- 
gestion of  inflammation.  It  is  also 
claimed  that  subnormal  secretion,  com- 
parable to  the  dry  pharyngitis  often   present,  is  responsible  for  the  unnatural 

12 


Pig.    163.— Hyperostosis    of 


Pig,    164      \m-  i  "Uus  nigrii 
Hum  fiber;  b,  i\  rangium  : 

taculum  :  ',  Bterigmata, 


658 


ETIOLOGY  AXD  PATHOLOGY. 


consistence  and  faulty  exit.  When  large  they  may  lead  to  pathological 
changes  by  pressure,  erosion  of  the  external  meatus,  atrophy,  ulceration,  and 
even  perforation  of  the  tympanic  membrane. 

The  Tympanic  Membrane. — Vascular  engorgement,  especially  along 
the  hammer-handle  and  Shrapnell's  membrane,  results  readily  from  undue 
pressure  of  a  speculum  while  making  an  examination  or  after  syringing  and 
forcible  inflation. 

Primary  inflammation  is  rare.  In  mild  eases  the  dermal  or  mucous 
layers  only  are  affected,  according  as  the  inflammation  originates  from  the 
meatus  or  tympanic  cavity  ;  while  in  the  severer  forms  the  fibrous  layer  is 
also  affected  with  round-cell  infiltration  and  softening,  favoring  perforation. 
<  'limine  inflammations  lead  to  hypertrophic  changes  in  the  eutieular  and  mucous 
layers,  with  increased  growth  of  the  rete  Malpighii  and  exfoliation  of  the 
epithelial  layers.  Granulations  may  also  form.  Practically,  the  same 
changes  occur  in  the  mucous  layers,  hut  here  the  granulations  become  larger, 
even  polypoid.  The  changes  in  the  membrana  propria  or  middle  layer  are 
of  an  atrophic  character:  the  infiltration  and  softening,  aided  by  pressure  of 
the  pent-up  exudation,  soon  lead  to  perforation,  the  size  of  which  depends 
much  upon  the  virulence  of  the  bacterial  infection.  The  seat  of  perforation  is 
most  frequently  in  the  anterior  lower  quadrant.  When  the  attic  and  mastoid 
cells  are  involved  the  opening  is  often  in  the  upper  and  posterior  portion. 
The  healing  of  perforations  is  participated  in  only  by  the  epidermic  and 
mucous  layers,  hence  the  secondary  membranes  are  always  flaccid,  unless,  as 
frequently  occurs,  infiltration  and  formation  of  calcareous  plates  have  re- 
sulted. When  the  openings  are  very  large  or  repeated  ruptures  have  taken 
place,  the  perforations  become  permanent,  especially  if  the  patient  is  past 
thirty. 

Atrophic  changes  of  a  part  or  all  of  the  drumhead  an1  found  in  chronic 
middle-ear  catarrh.  The  membrane  is  thin  and  drawn  in  sometimes  in  scar- 
like areas,  strongly  suggesting  past  perforation. 

Chalky  deposits  arc  generally  located  in  the  middle  portion  of  the  anterior 
or  posterior  half  of  the  tympanic  membrane;  they  are  most  often  halfmoon- 
or  horseshoe-shaped,  and  rarely  reach  to  the  hammer-handle  or  tympanic 
ring.     The  deposits  may   be  found    only    in   the   membrana    propria,   but  in 


Fig.  165.  Drumheads  -ln>v\  ring  perforation  in  the  flaccid  membrane  (cand  e) :  on  the  right,  uncover 
Ingthe  malleus-head,  and  with  chalk  crescents  (d)  posteriorly  and  In  the  edge  oi  theiower  perforation 
(i     H0I1 


3evere  cases  :ill  layers  are  involved.  The  pathological  changes  found  in  the 
tympanic  membrane  are  of  themselves  of  little  value  as  an  index  of  hearing 
(Fig.  165  i.  as  witness  the  righl  and  hit  drumheads  of  a  man  twenty-four 
years  of  age  who  Buffered  for  many  years  from  chronic  purulent  otitis  media. 


TYMPANIC  CA  VITY.  659 

Hearing  distance,  watch,  right  car,  whispered  voice,  at  20  feet,  £|  ; 

Hearing  distance,  watch,  left  ear,  -4;50  ;  only  low  voice  spoken  into  the 
external  canal. 
Tympanic  Cavity. — From  a  pathological  point  of  view  we  find  the  raosl 
important  factor  in  middle-ear  inflammation  to  be  its  mucous  membrane.  It 
is  in  this  that  the  inflammation  must  begin,  and  because  of  it-  peculiarly 
intimate  relation  with  its  underlying  periosteum  do  we  so  frequently  find  that 
the  pathological  changes  extend  to  the  bone,  resulting  in  hyperostosis  or 
necrosis.  There  is  greal  tendency  to  thickening  of  the  mucous  membrane, 
favored  by  the  many  irregularities — slit-like  passages  and  depressions  due  to 
the  chain  of  ossicles,  ligaments,  and  numerous  bony  projections  within  this 
small  .-pace.  Various  classifications  have  been  attempted  ;  the  most  practical 
is  a  clinical  basis,  where  we  divide  the  inflammations  into — 

a.  Sero-nincons  middle-ear  catarrh. 

b.  Proliferous  inflammation  of  the  middle  ear. 

c.  Muco-purulent  inflammation  of  the  middle  ear. 
(I.  Acnte  purulent  inflammation  of  the  middle  ear. 
e.   Chronic  purulent  inflammation  of  the  middle  ear. 

(a)  Sero-mucous  Middle-ear  Catarrh. — Synonyms. — Acnte  middle- 
ear  catarrh;  Secreting  form  of  middle-ear  catarrh;  Otitis  media  serosa; 
Catarrh  of  the  cavura   tympani  and   Eustachian  tube. 

This  form  most  frequently  results  as  an  extension  from  the  nose  and 
pharynx  through  the  Eustachian  tube.  There  is  congestion  of  the  mucous 
membrane  and  exudation  of  serum,  which  may  be  mixed  with  mucus,  the 
latter  resulting  from  the  beaker-cells  of  the 
epithelium,  as  mucous  glands  are  rare  or  entirely 
absent  in  the  middle  ear.  A  few  pyogenic  or- 
ganisms may  also  be  found,  having  entered 
through  the  tube,  and  may  in  most  cases  be 
regarded  as  the  exciting  cause.     The  exudation 

may  fill  a    part    or    all  of  the    Cavity.      The    pic-  Fig.  466.— Serous  fluid  within  the 

•     r.  r .,  i   •        l  "  •      T7 •        tt'o      tympanum     showing    through    the 

ture  frequently  presented  is  shown  in  ±  lg.  4()b.    unchanged  drumhead. 

The  drumhead  seldom  ruptures  in  this  affection. 

Resorption,  aided  by  paracentesis  or  spontaneously,  with  complete  restoration 

of  the  parts,  is  the  usual   result  if  properly  treated  and  the  exciting  cause 

corrected.      The  affection,  having  once  developed,  is   liable  to  recurrence  and 

may  pass  into  the  chronic  form. 

i A)  Proliferous  Inflammation  of  the  Middle  Bar. — Synonyms. — Otitis 
media  catarrhalis  chronica ;  Otitis  media  sclerotica  ;  Otitis  media  catarrhalis 
sicca. 

This  form,  as  stated  above,  may  also  develop  from  the  acute  variety,  but 
very  often  it  begins  without  any  active  inflammatory  symptoms.  'I  here  is  a 
general  or  circumscribed  involvement  of  the  mucous  membrane,  the  former 
most  often  after  the  exudative  variety  ;  localized  forms  frequently  involve 
the  oval  and  round  window-  or  their  immediate  surroundings.  The  mucous 
membrane  becomes  swollen  by  round-cell  infiltration  and  proliferation  of  all 
its  structures,  which  is  later  followed  by  connective-tissue  formation,  sclerosis, 
atrophy,  or  calcareous  changes.  The  ossicles  may  be  completely  imbedded 
and  the  niches  filled  with  the  swollen  membrane  ;  even  the  space  between  the 
stapes-crura  and  the  niche-wall  may  be  obliterated.  The  opposing  surfaces 
of  the  membrane  press  upon  each  other,  the  inflamed  epithelium  becomes 
eroded  by  pressure,  and  adhesions  form  which  may  completely  fill  the  round- 
window  "niche.     Adhesive  fibrous  bands  may  form  between  any  or  all  ot   the 


.;<■,!> 


ETIOLOGY  AND   PATHOLOGY. 


^Ossicles  and  their  surrounding  walls.  Even  calcareous  changes  take  place  in 
the  mucous  membrane,  generally  limited  to  the  promontory. 

Ankylosis  of  the  foot-plate  of  the  stapes  with  the  oval  window  is  unfor- 
tunately a  condition  frequently  encountered  in  this  form  of  middle-ear 
inflammation,  caused  by  calcification  and  ossification  of  the  ligamentous  ring 
of  the  foot-plate  or  by  the  formation  of  bony  masses  involving  the  foot- 
plate, niche,  oval   window,  or   in   the  vestibule  (Politzer). 

In  most  cases  progressing  toward  stirrup-ankylosis  there  is  intense 
hyperemia  of  the  wall  of  the  promontory  (Schwartze) ;  and  Hartmann  found 
in  this  class  of  cases  purulent  naso-pharyngeal  catarrh,  with  intense  hyper- 
emia and  swelling  of  the  mucous  membranes  of  these  parts. 

(c)  Muco-purulent  Inflammation  of  the  Middle  Ear. — Synonyms. — 
Acute  catarrhal   inflammation   of  the  middle  ear;  Otitis   media  acuta. 

The  differentiation  between  this  form  and  otitis  media  serosa  is  best 
shown   in  the  following  table  : 


Otitis   Media   Serosa. 

Tympanic  membrana  remains  trans- 
parent, and  with  only  very  slight  or  no 
injection. 

Mucous  membrane  of  middle  oar  only 

moderately  inflamed,  with   very  slight,  if 
any,   proliferation. 

The  exudate  is  a  clear  serous  fluid  or 
transparent  mucus. 


Absence  of.  or  only  slight,  inflammatory 

symptoms. 

Absorption,  as  a  rule,  slow. 


Of  it  is  Mel  in  Acuta. 

Intense  injection;  inflammatory  exu- 
dation, with  partial  or  complete  opacity  of 
the  tympanic  membrane. 

Intense  congestion  and  swelling  of  the 
mucous  membrane,  due  to  interstitial  exu- 
dation and  proliferation  ;  epithelium  opaque 
and  swollen. 

Opaque  mucus,  mixed  with  great  quan- 
tities of  pus-cells,  or  purulent  fluid  tinged 
with  blood  from  the  torn  capillaries,  due 
to  the  sudden  swelling  and  great  engorge- 
ment. 

Much  reaction,  with  resulting  symp- 
toms. 

Absorption  rapid  when  patulency  of 
tube  is  restored. 


(d)  Acute  Purulent  Inflammation  of  the  Middle  Ear. — Synonyms. — 
Acute  suppuration  of  the  middle  ear;  Otitis  media  acuta  suppurativa  sen 
perforativa. 

The  pathological  changes  are  very  similar  to  otitis  media  acuta,  described 
above,  hut  much  more  intense,  the  purulent  exudation  much  more  copious, 
with  breaking  down  of  the  mucous  membrane  in  circumscribed  areas  and 
early  perforation  of  the  tympanic  membrane.  The  inflammatory  changes  are 
not  limited  to  the  lower  tympanum,  but  the  attic,  antrum,  and  even  the 
mastoid  cells,  are  affected.  The  internal  ear  is  generally  not  involved  ;  but  the 
five  anastomosis  between  the  vessels  of  the  noddle  and  inner  ear  may  lead  to 
great  hyperemia  in  the  labyrinth  and  serous  effusion,  seldom  to  purulent 
inflammation  (Politzer).  On  account  of  the  intimate  relation  between  the 
mucous  membrane  and  the  periosteum  we  frequently  see  subperiosteal 
abscesses  and  bone-necrosis.  This  condition  may  run  its  course  and  end  in 
resolution,  with  scarcely  any  visible  changes  of  the  tympanic  membrane  and 
middle  ear,  ami  with  or  without  marked  changes  of  hearing  power;  or  the 
disease  may  continue  ami   pa--  into  the  chronic  stage. 

('  )  Chronic  Purulent  Inflammation  of  the  Middle  Ear. — Synonyms. 
— -Otitis  media  suppurativa  Ben   perforativa  chronica;  chronic  otorrhea. 

for  convenience  of  study  we  may  divide  the  pathological  changes  occur- 
ring in  this  disease  into  live  heading-  : 

1.   We  encounter  formation  of  connective-tissue  band-,  membranes,  and 


CHRONIC  PURULENT  INFLAMMATION  OF  MIDDLE  EAR.    661 

masses  filling  the  round  window,  partially  imbedding  the  ossicles,  and  in  rare 
cases  even  filling  all  of  the  tympanic  cavity. 

2.  Cystoid  spaces  are  nearly  always  found  in  the  enormously  hypertrophied 

mucous  membranes   see  a,  Fig.  467).    The  formati f  numerous  bands  and 

membranes  within  the  mid. lie  ear  results  in  the  formation  of  spaces  between 


Fig.  467.— Section  of  aural  polypus  from  the  promontory,  showing  cystic  spaces  (/). 

them,  either  entirely  closed  off  or  as  irregular  canals  which  become  lined  with 
cubical  or  cylindrical  epithelium  (be).  These  spaces  are  often  filled  with 
mucus  and  degenerated  epithelial  masses  (df). 

3.  Aural  Polypi. — These  tumors  originate  from  the  mucous  membraneor 
periosteum  of  the  middle  ear,  or  in  rare  instances  from  the  dermoid  layer  of 
the  tympanic  membrane.  Practically,  we  need  only  recognize  two  varieties: 
(a)  The  round-celled  polypus  (ftynonyms,  Mucous  polypus,  Cellular  polypus, 
Granulation  tumor)  :  and  (/>)  Fibroma. 

The  former  variety  is  by  far  the  more  frequent,  and  consists  of  a  hyaline, 
homogeneous,  myxomatous  stroma,  sustained  by  a  delicate  fibrous  structure 
enclo.-ino-  numerous  round-cells.  They  are  very  vascular,  the  vessel-walls 
being  of  the  embryonal  type.  The  epithelial  covering  may  occur  in  single  or 
multiple  layer.-  of  columnar  or  squamous  cell-,  ami  varies  according  to  the 
location  from  which  the  growth  has  it-  origin  (see  Fig.   I'm  . 

The  fibroma,  a-  it-  name  indicates,  contains  a  denser  fibrous  framework 
and  i-  less  rich  in  blood-vessels.  Its  surface  is  covered  with  several  layers 
of  pavement  epithelium,  which  penetrate  into  the  stroma  with  finger-like 
projections. 

4.  Cholesteatoma. —  There  is  >till  no  unanimity  among  authors  a-  to  the 
origin  of  cholesteatoma,  but  the  besl  theory  i-  that  advanced  by  Haberman, 
Politzer,  ami  Bezold,  that  it  i-  due  to  an  extension  of  the  epithelium  from 
the  external  canal  or  outer  surface  of  the  tympanic  membrane  through  an 
opening  in  the  latter  into  the  tympanic  cavity,  attic,  and  mastoid  cell-. 

In  cholesteatoma  of  the  mi. Idle  ear  we  find  the  rete  Malpighii  in  most 
intimate  anatomical    relation  with    the  periosteal   layer    see    Fig.    168),   the 

1*1 l-vessels  in  the   former    being  in  direct    connection  with  those  of  thi 

latter.     Continued  irritation  from  existing  otitis  causes  rapid  proliferation  ol 
epidermic  cells,  resull inur  in  the  "  throwing  off"  <T  pearl-colored   layer-  from 


662 


ETIOLOGY  AND  PATHOLOGY. 


the  stratum  corneum,  which  explains  the  laminated  structure  of  the  chole- 
steatomatous  mass. 

Complete  epidermization  of  the  middle  ear  (including  the  mastoid  cells) 
can,  according  to  Schwartze  and  Politzer,  occur  without  leading  to  the  for- 
mation of  cholesteatoma  if  the  inflammatory  process  is  arrested  early.  This 
is  also  proven   in  those  cases  where  the  radical   mastoid  operation  has  been 

performed   on     patients    suffering 


3  one 


If; 


-■Strata,,,  Co/-, 


from  extensive  cholesteatoma- 
formation  in  the  middle  ear. 
Here  we  aim  to  "paper"  the 
whole  of  the  bony  cavity  with  an 
epithelial  lining,  taking  its  origin 
from  the  transplanted  Haps  formed 
from  the  external  meatus:  not- 
withstanding these  conditions  we 
are  now  enabled  to  (aire  most  of 
this  class  of  cases.  I  have 
operated  upon  several  cases  from 
three  to  five  years  ago,  which 
can  now  be  classified  as  cured, 
since  there  is  no  sign  of  any 
return   up  to  date. 

The    epithelial    invasion    may 
also  take  place  through  a  fistulous 
opening  of  the  mastoid  cortex  or  posterior  bony  meatus  (Politzer). 

The  size  of  the  cholesteatomata  may  vary  from  a  pinhead  to  a  pigeon's 
egg.  When  large  they  cause  absorption  of  the  bony  walls  in  any  direction. 
In  two  of  my  cases  the  cortical  plate  of  the  mastoid  had  been  entirely  absorbed, 
so  that  when  making  the  incision  the  knife  cut  directly  through  the  skin  and 
into  the  cholesteatomatous  mass. 

o.  Iloin-iiiro/rcmciif. — Because  of  the  intimate  relation  of  the  mucous 
membrane  of  the  middle  car  and  its  periosteum  we  frequently  encounter 
superficial  or  deep  bone-involvement  in  purulent  inflammations.  The 
hammer  and  anvil  (rarely  the  stirrup)  arc  often  eroded  or  even  totally 
destroyed  (Fig.  4(j<»). 

Suppurative  Middle-ear  Inflammation  with  Tuberculosis. — Mid- 
dle ear  suppuration  is  frequently  associated  with  lung-tuberculosis,  and  is 
characterized    by  the  formation  of  one   large  or    several    small   perforations 

in  the  tympanic  membrane,  with  ex- 


# 


Pig.  168.    Section  through  osseous  wall  of  antrum, 
showing  periosteum,  rete  Malpighii,  and  stratum  cor- 

m  um  (and  cholesteatoma, diagramatio  (after Kuhn—Z. 
f.  O.  xxi.i. 


f         % 

i 

i 


tensive    tissue-changes,    without   the 

usual  pain  and  inflammatory  symp- 
toms. But  we  must  bear  in  mind 
that  we  may  find  non-tubercular 
purulent  otitis  media  in  a  patient 
suffering  from  tuberculosis  in  other 
parts  of  the  body.  Neither  musl  we 
conclude  that  the  aural  affection  is 
non-tubercular  when  we  fail  to  find 
the  tubercle  bacilli  in  the  secretion  : 
their  presence  or  absence  in  the  ear 
may  depend  Upon  the  period  of  the 
infection  and  upon  the  Dumber  and  activity  of  the  streptococci  (Moos).      The 

mucous  membrane  tii-t  becomes  infiltrated'  by  cellular  proliferation,  followed 


i'i'.                      Ins  of  ossicles   from  a   boy  of 
twelve    Dotti  •!  lim  -  Indicate  Loss  of  i ■  bj  caries. 


LABYRINTH.  663 

by  ulceration,  tubercle  formation,  and  caseous  degeneration.  This  may  <x  t « 1 1<  I 
deeper,  involving  the  bone,  which  becomes  denuded  or  carious ;  the  ossicles 
arc  also  generally  involved,  even  the  foot-plate  of  the  stirrup  may  be  eroded 
and  the  disease  extend  to  the   internal  ear  and  cranial  cavity. 

Eustachian  Tube. — The  mucous  membrane  of  the  Eustachian  tube  is 
subject  to  the  same  changes  thai  we  find  in  the  naso-pharynx,  and  disease 
may  extend  to  the  middle  ear  by  continuity  of  tissue  or  by  the  entrance  of 
infected  secretion  through  its  lumen  during  violent  acts  of  coughing  and 
sneezing,  by  Valsalva's  method,  or  by  the  use  of  unclean  catheters  and 
bougies. 

To  guard  against  infection  the  movement  of  the  ciliated  epithelium  is 
directed  from  the  tympanic  cavity  toward  the  pharynx  ;  while  the  isthmus,  <>r 
narrowest  portion  of  the  tul>e  at  the  junction  of  the  bony  and  cartilaginous 
portions,  forms  another  harrier.  If  the  disease  lias  once  passed  beyond 
these,  and  especially  the  chronic  catarrh,  then  we  cannot  hope  for  a  cure  in 
the  middle  ear  until  the  inflammation  of  the  nose  and  pharynx  has  been 
relieved  (see  pp.  727  and  747). 

Where  the  inflammation  becomes  chronic,  there  is  thickening  of  the 
mucous  membrane,  with  increased  prominence  of  the  normally  existing  folds 
in  the  tube,  which,  with  increased  secretion  from  the  glands,  causes  occlusion 
of  the  lumen,  preventing  free  ventilation  of  the  middle  ear.  This  condition 
may  continue  for  years,  but  sooner  or  later  the  atrophic  changes  begin,  with 
partial  destruction  of  the  glands,  and  reduction  or  obliteration  of  the  folds  ;  the 
mucous  membrane  becomes  thin  and  the  tube  patulous.  Occlusion  of  the 
tube  is  observed  as  a  result  of  ulceration  from  syphilis,  diphtheria,  and 
tuberculosis. 

The  Mastoid. — The  intimate  communication  between  the  tympanic 
cavity  and  mastoid  cells,  and  direct  continuation  of  the  mucous  membrane 
from  one  to  the  other,  explain  why  in  severe  inflammation  pathological 
changes  are  found  both  in  the  antrum  and  adjoining  cavities.  There  is  great 
tendency  to  periosteal  involvement  and  necrosis  of  the  bone  (see  Fig.  ~>04), 
with  formation  of  abscesses — subperiosteal  or  extradural  as  well  as  truly 
empyemic :  especially  is  this  likely  to  occur  if  through  swelling  of  the 
mucous  membrane  the  passage  is  closed  between  the  antrum  and  the  rest  of 
the  tympanic  cavity. 

Where  the  inflammation  is  chronic  we  may  have  hyperplasia  of  the 
osseous  tissue,  which  graduallv  obliterates  all  of  the  pneumatic  spaces,  result- 
ing in  sclerosis  or  even  in  eburnation  of  the  bone.  At  the  same  time,  peri- 
osteal irritation  may  lead  to  hyperostosis  of  the  exterior  of  the  mastoid 
(see  ]).  7")1 ). 

labyrinth.  —  In  general  anemia  we  observe  disturbance  of  the  internal 
ear.  The  symptoms  are  at  times  especially  marked  where  there  has  been 
great  and  sudden  loss  of  blood.  Diminution  of  the  caliber  of  the  labyrin- 
thine vessels,  due  to  endarteritis,  is  also  a  factor.  Hyperemia  may  resuli 
from  a  number  of  causes,  such  as  general  congestion,  inflammation  of  the 
middle  ear,   meningitis,  and   the   various  infection-  diseases. 

Hemorrhage  into  the  labyrinth  may  result  from  injury,  infectious  disease, 
meningitis,  pernicious  anemia,  and  abuse  of  various  drugs.     The  hemorrhages 
may  be  small  and  quickly  absorbed,  with   restoration  of  function,  or  more 
extensive,  with  partial  or  total   loss  of  hearing.     The  apoplectic  forms  "I 
.Meniere'-  disease  are  regarded  a-  due  to  hemorrhage  or  acute  exudation. 

Secondary  inflammation  of  the  internal  ear  i-  frequent  and  may  result 
from  — 


664  ETIOLOGY  AND   PATHOLOGY. 

a.  Inflammation  of  the  middle  car,  the  avenue  of  infection  being  gener- 
ally through  the  windows,  external  semicircular  canal,  lymph-  and  blood- 
vessels. 

I).  Meningitis,  often  resulting  in  total  deafness  and,  if  in  early  childhood, 
deaf-mutism.  In  this  disease  we  often  find  thrombosis  of  the  smaller  vessels 
and  erosion  of  their  walls,  due  to  bacterial  toxin,  while  the  acoustic  nerve 
is  often  infiltrated  with  small  hemorrhages  and  bacterial  colonies.  If  the 
patient  survives  the  meningeal  attack,  the  inflammation  in  the  labyrinth  may 
run  a  chronic  course,  granulation-tissue  forms,  which  again  changes  to  con- 
nective tissue  associated  with  development  of  new  bone,  partially  obliterating 
the  spaces  within  the  labyrinth  (see  Fig.  old,  p.  7(J8). 

Acquired  Syphilis. — Considering  the  frequency  of  this  disease,  we  must 
regard  labyrinth  complication  as  rare,  and  in  cases  where  it  does  occur  we 
nearly  always  find  that  the  patient  has  previously  suffered  from  catarrhal 
or  purulent  otitis,  which  caused  congestion  of  the  internal  ear,  acting  as  a 
predisposing  factor. 

The  syphilitic  inflammation  of  the  labyrinth  may  develop  in  one  or  both 
cars  at  almost  any  period  after  the  infection,  hut  most  frequently  during  the 
first  two  years.  The  chief  pathological  changes  found  consist  of  endarteritis, 
with  partial  or  total  obliteration  of  the  vessel  lumen.  The  inflammation  may 
lead  to  necrosis  or  the  formation  of  new  osseous  deposits,  causing  synostosis 
of  the  stapedio-vestibular  articulation  :  strangulation  of  the  auditory  nerve 
by  periostitis  and  bony  deposits  in  the  internal  auditory  canal  are  also 
encountered. 

Hereditary  syphilis  generally  attacks  the  internal  ear  between  the  eighth 
and  twentieth  years,  and  is  found  from  three  to  five  times  more  frequently 
in  the  female  than  in  the  male.  It  is  generally  associated  with  interstitial 
keratitis,  but  the  latter  often  exists  without  affection  of  the  labyrinth. 
Hutchinson  found  deafness  only  15  times  in  102  patients  suffering  from 
syphilitic  keratitis.  The  pathological  changes  found  in  the  internal  ear  as  a 
result  of  inherited  syphilis  are  very  similar  to  those  resulting  from  the 
acquired  infection. 

Internal  Auditory  Canal. —  Inflammation  of  the  acoustic  nerve  is 
encountered  as  a  result  of  extension  from  the  labyrinth  to  the  brain,  or  the 
process  maybe  reversed.  In  11  cases  of  mixed  forms  of  meningitis  exam- 
ined by  Gradenigo  he  found  that  the  inflammation  involved  the  nerve  in  the 
internal  meatus  13  times,  the  one  exception  being  in  a  case  where  the  men- 
ingitis had  existed  only  a  few  hours. 


EXAMINATION  OF  PATIENTS;  SYMPTOMATOLOGY 
AND  DIAGNOSIS;  INSTRUMENTS  NEEDED,  AND 
METHODS  OF  THEIR  EMPLOYMENT. 


By   JOHN   E.  SHEPPARD,  M.D., 

OF     BROOKLYN,    N.  Y. 


Toe  clinician  must  always  hear  in  mind  the  embryological  and  physio- 
logical division  of  the  organ  of  hearing  into  a  sound-conducting  and  a  sound- 
perceiving  apparatus,  as  contrasted  with  the  anatomical  division  into  three 
parts,  the  external,  middle,  and  internal  ear — the  sound-conducting  apparatus 
consisting  of  the  external  and  middle  ear ;  the  sound-perceiving  apparatus 
including,  of  course,  the  internal  ear,  the  auditory  nerve,  and  the  perceptive 
centers  in  the  brain.  While  a  consideration  of  the  function  requires  only 
the  division  into  conducting  and  perceptive  portions,  the  threefold  anatomical 
division  is,  on  the  other  hand,  necessary  for  examination  :  since  for  the 
external  ear,  including  the  periotic  region,  the  auricle,  external  auditory 
canal,  and  membrana  tvmpani,  we  depend  principally  on  inspection  and 
palpation  ;  for  the  middle  ear,  including  the  Eustachian  tube  and  tympanic 
cavity,  we  must  rely  largely  on  pneumatic  measures;  and  for  the  internal 
ear  on  acoustic  methods. 

The  general  plan  which    it    is   proposed  to  follow    in    this  chapter  is  to 
describe  the   methods,  in    the  order   in    which   they  come,   which  I   have  for 
years  followed  as  a  routine  in  my  daily  examination  of  patients.     These  may 
be  divided  according  to  the  following  general  arrangement  : 
1.  Clinical  History,  with  General  Symptomatology  ; 
II.   Functional  Examination  ; 
III.   The  Periotic  Region  ; 
I  V.  ( Otoscopy  ; 

V.    Examination  of  Nose,  Naso-pharynx,  and  Pharynx  ; 
VI.    Examination  of  the  .Middle  Ear. 

By  a  general  adherence  to  this  plan  it  is  believed  that  accuracy  of  diag- 
nosis, the  sine  qud  von  of  proper  treatment,  may  be  most  uniformly  attained. 
A-  an  incentive  to  uniformly  thorough  examination  in  every  case  the  writer 
is  a  firm  believer  in  some  form  of  history  blank,  which  each  aurisl  may 
develop  by  experience  to  suit  his  own  needs.  The  one  shown  at  the  end  of 
this  chapter  is  the  resull  of  the  combined  experience  of  my  colleague.  Dr. 
Adderton,  and  myself,  and  is  the  one  which  we  have  used  for  several  years 
with  eminent  satisfaction.  The  blanks  are  printed  on  moderately  still'  card- 
board, so  that  they  may  be  kept  lor  reference  after  the  manner  of  a  card 
catalogue. 

I.  THE  CLINICAL  HISTORY,  WITH  SYMPTOMATOLOGY. 

A  record  should  first  be  made  of  the  patient's  name,  address,  age.  date 
of  the  first  vbit.  occupation,  whether  previously  treated,  and.  if  so,  to  what 


666  EXAMINATION  OF  PATIENTS,  ETC. 

extent  :  after  which  the  patient's  general  condition  of  health  should  be 
inquired  into.  The  patient  should  then  be  asked  to  state  what  is  the  most 
troublesome,  symptom,  the  principal  cause  of  complaint,  this  statement  to  be 
followed  by  a  careful  inquiry  into  the  duration  of  the  trouble.  My  reason 
Cor  thus  commencing  the  investigation  is  that  in  routine  cases  much  time  will 
be  saved  through  thus  early  getting  information  which  will  result  in  the 
following  questions  being  asked  more  intelligently.  The  so-called  cardinal 
symptoms,  of  one  or  more  of  which  the  patient  will  complain,  and  as  to  the 
general  significance  of  which  a  few  words  are  demanded,  are  the  following: 
(a)  Defect  of  hearing,  (/>)  tinnitus,  (c)  pain  in  or  around  the  ear,  ('/)  dis- 
charge from  the  ear,  (e)  visible  alterations  in  the  external  parts,  (/)  vertigo. 
It  should  be  remembered  that  most  of  these  symptoms  may  arise  from  extra- 
aural  causes;  defect  of  hearing  may  be  due  to  intracranial  lesions;  pain  is 
frequently  felt  in  the  ear  when  the  trouble  is  at  a  distance;  tinnitus  may  be 
due  to  increased  arterial  tension,  anemia,  toxic,  or  other  general  causes  ;  and 
vertigo  has  a  varied  origin.  On  the  other  hand,  serious  constitutional  dis- 
turbance may  arise  from  unobserved  ear-disease — e.  </.  some  obscure  pyemias. 

Defect  of  Hearing. — The  quantitative  and  qualitative  determination 
of  this  will  be  described  later.  As  having  a  certain  symptomatic  value  may 
be  mentioned  the  following  generalizations  :  An  insidious  onset,  without 
definite  cause  and  with  early  occurrence  of  tinnitus,  is  suggestive  of  middle- 
ear  catarrh  (sclerotic  form).  Relatively  rapid  loss  of  hearing  (from  good 
hearing  to  great  deafness  within  a  month),  with  but  few  or  no  accompanying 
symptoms,  suggests  the  possibility  of  labyrinthine  syphilis.  Sudden  deafness 
without  symptoms  point-  to  the  probability  of  cerumen  impaction.  "Hear- 
ing better  in  a  noise"  (paracusis  Willissii)  means,  as  a  rule,  a  special  form  of 
middle-ear  disease;  while  those  with  nerve-deafness — boilermakers  and 
others — usually  hear  worse  in  a  noise.  Autophonia  or  tympanophonia,  that 
condition  in  which  the  patient's  voice  seems  to  him  to  go  out  through  the  ear 
instead  of  the  mouth,  indicates,  as  a  rule,  some  pathological  condition  of  the 
Eustachian  tube,  but  is  occasionally  present  in  other  conditions  of  the  middle 
ear  or  in  impacted  cerumen.  It  is,  on  the  contrary,  so  far  as  my  knowledge 
uoes,  never  met  with  in  internal-ear  troubles. 

Tinnitus  should  next  be  inquired  about.  It  is  variously  described  by 
patient-,  but  two  general  classes  may  be  made  out  :  1.  Pulsating,  due  to 
arterial  congestion  which  i-  probably  in  either  the  external  or  middle  ear  if 
it  i-  -topped  by  pressure  on  the  common  carotid,  and  in  the  internal  ear  if 
-topped  by  pressure  over  the  vertebral  artery  in  the  suboccipital  triangle; 
2.  Non-pulsating,  or  continuous,  with  varying  characteristics:  the  high- 
pitched  sounds,  hissing,  singing,  etc  are  often  due  to  increased  ten-ion  in  the 
middle  ear,  irritating  the  auditory  nerve,  and  often  relieved  by  inflating  the 
tympanum  ;  the  deep  humming  sounds,  worse  after  exertion,  relieved  after 
lying  down  a  little  time,  are  often  due  to  anemia;  the  rushing  sounds  arc 
oiten  due  to  venous  congestion,  are  worse  on  lying  down,  and  may  be  relieved 
by  purgation.  Finally,  it  should  not  be  forgotten  that  the  hearing  by  the 
insane  of  bells,  music,  voice-,  etc.  maybe  caused  by  aural  disease,  a1   times 

remediable.  It  is  of  course  easy  to  locate  in  the  middle  ear  the  little  crack- 
ing due  to  -wallowing,  the  crackling  caused  by  ail-  entering  a  tympanic  cavity 
containing  fluid,  the  loud  pulsating  30unds  accompanying  acute  inflamma- 
tion-of  the  membrane,  the  tympanum,  or  the  mastoid  cells,  or  the  loud,  at 
time-  rhythmic,  noi-e-  due  to  contraction  of  the  palatal  mu-eles,  generally 
with  participation  of  the  ten-oi'  tympani  or  stapedius  muscles  (often  percep- 
tible to  others). 


THE  CLINICAL   HISTORY,    WITH  symptomatology.     ijr.T 

Pain — earache — is  an  important  symptom,  and  should  be  carefully 
investigated.  It  accompanies  acute  inflammatory  affections  of  the  external 
and  middle  ear,  the  exacerbations  common  in  chronic  middle-ear  inflamma- 
tions, with  extension  of  caries  or  development  of  cholesteatoma,  a-   well  as 

mastoiditis  and  mastoid  periostitis.     In  inflammati f  the  external  ear  the 

pain  is  usually  accompanied  by  tenderness  in  fronl  of  or  below  the  auricle, 
and  is  increased  by  motion  of  the  jaw.  If  it  is  the  tympanic  membrane  or 
tympanum  that  is  involved,  the  pain  is  accompanied  by  mure  or  less  deaf- 
ness, and  is  increased  by  sneezing,  coughing,  blowing  the  nose,  or  by  inflation. 
Pain  in  the  course  of  a  chronic  middle-ear  suppuration  usually  indicates  pus- 
retention,  and  is  described  by  the  patient  as  deep-seated.  In  inflammation 
of  the  mastoid  or  it-  covering  periosteum  the  pain  is  more  or  less  radiating 
in  character,  and  is  commonly  attended  by  tenderness  over  all  or  pari  of 
that  process.  Keflex  pain,  neuralgic  in  character,  is  often  felt  in  the  ear.  all 
the  other  cardinal  symptoms  <>t'  ear-disease  being  absent,  and  i-  caused  by 
diseased  teeth,  inflammatory  conditions  about  the  throat  and  tongue,  and  by 
malarial  poison  and   the  rheumatic  diathesis. 

Discharge. — Inquiry  should  be  made  whether  there  i>  discharge,  and. 
if  not,  whether  it  has  previously  existed.  It'  there  ha-  been  discharge 
which  has  ceased,  then  it  i>  only  natural  to  expect  to  rind  the  results  of  such 
suppuration  in  the  shape  of  cicatrices  in  the  membrane,  old  dry  perforations, 
or  more  or  less  binding  down  of  the  structures  in  the  tympanic  cavity  by 
cicatricial  tissue  ;  if  there  is  discharge,  note  the  quantity,  the  time  since  it 
commenced,  the  nature  of  it — that  most  frequently  found  i-  pus — and  if  this 
be  in  considerable  amount,  and  particularly  if  it  contain  mucus,  it  i-  safe  to 
say  the  trouble  is  in  the  middle  ear  and  that  the  membrane  is  perforated  ; 
when  mixed  with  blood  it  usually  indicates  granulations  or  polypi  ;  a  copious 
hemorrhage  late  in  a  chronic  suppurative  case  usually  mean-  erosion  of  a 
blood-vessel,  internal  carotid  or  bulb  of  the  jugular.  A  .-canty  discharge, 
at  first  watery,  then  purulent,  attended  with  itching,  would  indicate  the 
external  canal  as  the  source.  Fetor  of  the  discharge  is  of  relatively  little 
diagnostic  value  unless  very  persistent  under  treatment,  when  it  becomes 
suggestive  of  diseased  bone  or  retention  of  putrefactive  material  in  the 
antrum  or  mastoid  cells.  Duration  of  discharge  and  mode  of  onsel  arc 
significant.  A  recent  sudden  discharge,  preceded  by  pain,  indicate-  acute 
middle-ear  inflammation  ;  but  if  not  preceded  by  pain  in  an  ear  which  has 
not  previously  discharged,  suspicion  of  tubercular  trouble  should  beat  <>!]<•<• 
aroused.     A  history  of  discharge  recurring  at  interval-  of  from  two  week-  to 

two  month-,  lasting  but  a  short   time,  and   usually  preceded  by  pain,  is  g 1 

ground  for  suspecting  attic  trouble  with  perforation  in  Shrapnell's  membrane. 
The  long  standing  of  a  suppuration  indicates  most  often  neglect  :  in  other 
cases  granulations,  polypi,  carious  ossicles,  involvement  of  the  antrum  or  mas- 
toid cells,  and  at  time-  naso-pharyngeal  disease  or  constitutional  dyscrasia. 

Vertigo. — Under  this  heading  may  be  mentioned  not  only  the  disturb- 
ances of  equilibrium,  but.  as  being  closely  allied  thereto,  the  nausea,  vomit- 
ing, and  loss  of  consciousness  which  at  time-  accompany  conditions  and 
manipulation-  of  the  ear.  Since  we  see  these  symptoms  with  pathological 
condition-  of  the  several  parts  of  the  ear.  they  cannot  be  -aid  t"  indicate  any 
particular  disease,  excepting  possibly  in  the  case  of  a  patient  having  a  tend- 
ency to  fall  always  in  the  same  direction.  A-  a  rule,  the  patient  tall-  away 
from  the  affected  ear,  ami  in  such  a  case  it  i-  presumptive  evidence  in  favor 
of  a  lesion  of  the  internal  ear.  probably  Bome  portion  of  the  semicircular 
canals.      An   attack   which   from    the   suddenness   and    -  verity   of    it-   first 


66$ 


EXAMINATION  OF  PATIENTS,    ETC. 


appearance  seems  almost  apoplectiform  in  character,  attended  by  deafness, 
tinnitus,  and  often  vomiting,  suggests,  of  course,  hemorrhage  into  some  por- 
tion of  the  labyrinth.  Less  violent  vertigo  arises  from  increased  tension  of 
the  labyrinthine  fluid  secondary  to  middle-ear  disease — e.g.  pressure  of  a 
granulation  or  a  cholesteatomatous  mass  upon  the  stapes,  or  from  syringing 
too  forcibly  or  with  too  cold  water.  There  are  various  other  sources  of 
vertigo,   however,   besides  the  ear,   which  must  be  excluded. 

Cause. — Having  thus  gone  through  with  the  symptomatology,  the  patient 
should  next  be  interrogated  as  to  the  supposed  cause — whether  there  may 
have  been  an  injury  to  the  ear  or  head;  in  regard  to  bathing,  to  head- 
colds,  throat-affections,  mouth-breathing,  exanthemata,  or  whether  he  has  had 
syphilis,  rheumatism,  or  gout  ;  or  if  he  has  been  taking  large  doses  of  medi- 
cine, such  as  quinia  or  the  salicylates  ;  and  finally,  whether  or  not  the  occu- 
pation may  have  any  bearing  on  the  ease.  Under  this  heading  information 
of  great  value  will  be  frequently  obtained  as  regards  both  diagnosis,  prog- 
nosis, and  treatment.  As  the  next  step,  may  be  summed  up,  as  briefly  as 
possible,  the  course  of  the  trouble,  a  recapitulation,  as  it  were,  of  the  history 
as  gained  up  to  this  time — the  principal  complaint,  its  mode  of  onset,  its 
duration,  and  the  necessary  data  with  regard  to  the  symptoms.  The  final 
step  in  this  part  of  the  examination,  which  in  very  many  cases  may  be 
omitted,  is  an  inquiry  into  the  family  history  with  regard  to  deafness. 
Since  in  some  cases  important  information  is  obtained,  it  seems  well  to  have 
a  -pace  in  the  history  blank  devoted  to  heredity.  Following  this  is  another 
space  for  "  Remarks,"  which  should  be  a  part  of  every  record  blank,  in  which 
should  be  noted  anything  of  interest  peculiar  to  the  case  and  for  which  there 
is  no  place  elsewhere. 


II.  FUNCTIONAL  EXAMINATION. 

Having  thus  finished  the  preliminary  examination,  the  next  thing  to 
investigate  is  the  function  of  the  organ.  How  much  is  the  hearing  impaired? 
Where  is  the  lesion  that  causes  the  deafness? 

i.  Quantitative  Tests. — To  determine  how  much  the  hearing  is  affected 
compare  the  distance  the  ear  under  examination  hears  a  given  sound  with  the 
distance  the  same  sound  is  heard  by  a  normal  ear.  This  is  conveniently 
expressed  in  fraction  form,  as  suggested  by  Prout,  the  denominator  repre- 
senting the  hearing  distance,  in  feet  or  inches, 
of  the  normal  ear;  the  numerator,  that  of  the 
ear  being  investigated.  The  sounds  most  used 
as  tests  are  the  tick  of  a  watch  and  of  Politzer's 
acoumeter,  the  voice,  and  the  vibrations  of  the 
tuning-fork.  The  watch-tick  answers  very  well 
for  observations  by  the  same  individual,  but  does 
not  permit  a  comparison  of  results  with  those  of 
other  observers.  To  meet  this  objection  Politzer 
devised  his  acoumeter  (  Fig.  170),  so  i  hat  all  might 
have  an  instrument  giving  a  sound  of  uniform 
quality  and  intensity.  I  n  testing  the  hearing  with 
either  of  these  they  should  be  gradually  brought 
from  beyond  the  limit  of  hearing  toward  the  ear 
until  heard.  The  ideal  test  for  impaired  hear- 
ing, however,  is  the  human  voice,  and  the  different  degrees  of  deafness  are 
represented  as  hearing  for  whispered  words,  for  ordinary,  loud,  or  shouting 


Fn  tzer      acoumeter, 

with  the  steel  rod  <•  to  be  stnirk  by 
mmer  u  falling  just  the  dis- 
■  rmitted  tjj  the  stop  g,  while 
the  thumb  and  index  finger  grasp  it 
at  by, and  '-an  resl 
the  bone  •■!'  the  hi 


QUALITA  TIVE   TESTS. 


conversation.  For  different  observers  to  obtain  as  nearly  as  possible  a  uni- 
form result  in  the  test  with  whispered  words  the  so-called  "  reserve-air"  method 
should  be  used,  the  reserve  air  consisting  of  what  is  left  in  the  lungs  after  a 
forced  inspiration  followed  immediately  by  a  norma]  expiration.  Since  patients 
become  rapidly  accustomed  to  test-phrases  if  repeated,  this  should  !»<•  avoided — 
e.  g.  by  using  numbers,  of  two  figures,  interspersed  at  time-  with  words  or 
phrases  of  another  character.  To  avoid  error  if  one  ear  is  very  deaf  and  the 
other  but  slightly  so  or  not  at  all,  with  the  latter  stopped  tightly  with  the 
moistened  finger  of  the  patient,  or,  better  still,  of  an  assistant,  and  the  deaf 
ear  toward  the  examiner,  note  the  result;  then  have  in  addition  the  deaf 
ear  tightly  stopped  and  repeat  the  tests.  If,  now,  the  patienl  hears  the  same 
as  with  the  deaf  ear  unstopped,  it  is  evident  that  deafness  is  complete,  and 
that  the  hearing  in  the  first  tot  was  with  the  stopped  ear.  Since  the  mere 
sound  may  be  heard,  the  patient  should  he  made  to  repeal 
[""m      |v(iS         the  words  in  all  the  tests. 

2.  Qualitative  Tests.— Having  with  the  preceding 
tests  found  the  amount  of  deafness,  the  purpose  of  the  fol- 
lowing measures  is  to  locate  the  lesion  either  in  the  sound- 
conducting  or  the  .sound-perceiving  apparatus,  for  which  pur- 
pose we  use  the  Galton  whistle  and  tuning-forks  of  various 
pitch.  The  normal  ear  perceives  vibrations  as  musical  notes 
when  repeated  at  regular  intervals  from  KJ  up  to  32,500  vibra- 
tions to  the  second,  and  these  may  be  called  the  lower  and 
upper  limits  of  audition.  These  limits  vary  in  a  character- 
istic way  with  disease  of  the  conducting  or  perceiving  appa- 
ratus. Again,  there  is  a  fairly  definite  ratio  in  the  normal 
ear  between  the  duration  and  loudness  of  tuning-fork  vibra- 
tions by  air- and  by  bone-conduction,  and  this  ratio  is  altered 
more  or  less  definitely  according  to  the  part  of  the  ear  affected 
by  disease.  The  lower  tone-limit,  or  rather  any  lack  of  hear- 
ing for  the  lower  notes,  may  be  determined  with  sufficient 
accuracy  by  means  of  the  C  large-clamp  tuning-fork  (Fig. 
471),    whose    range    of    vibrations    is    from     2b'    to    <i  I    to 


Fig.471.  -Dench's 
large  tuning-fork 
with  clamps  al  ends, 
giving  64  v.  s.,  and 
without    clamps     26 

V.  s. 


'~~Jl 


Fig.  472.— Galton's  whistle  with  rubber  bulb.    The  pipe  below  the  opening  is 
filled  by  a   plunger  advanced  or  withdrawn   by  a   screw,  each  turn  being 
shown  by  tin-  scale  upon  tin-  enlarged  tube,  ami  it>  tenths  by  thai  on  the 
revolving  collar.     It  gives  an  audible  sound   from  0.5    theoretical] 
LO  or  L2  (4200  or 


the  second.  The  upper  tone-limit  can  he  mosl  accurately  determined  by 
Komi's  rods,  but  these  are  too  time-consuming  for  daily  use,  and  Galton  s 
whistle  (Fig.  472  gives  the  same  result  much  more  quickly  and  with  suffi- 
cient  accuracy. 

To  properly  compare  air- with  bone-conduction  we  need  the  absolute 
duration  of  each  and  the  relative  intensity  of  the  two.  To  obtain  the  former 
a  freshly  -truck  tuning-fork   is  held  in  front  of  the  external  auditory  canal, 


670  EXAMINATION  OF  PATIENTS,  ETC. 

the  time  in  seconds  being  taken  from  the  moment  it  is  struck  until  it  ceases 
to  be  heard  by  the  patient;  duration  of  bone-conduction  is  obtained  in  the 
same  way,  except  that  the  handle  of  the  vibrating  fork  is  rested  firmly  upon 
the  mastoid  process  until  it  is  no  longer  heard.  Relative  intensity  is  obtained 
by  placing  a  freshly  struck  tuning-fork  in  rapid  succession  two  or  three  times 
upon  the  mastoid  and  opposite  the  meatus,  and  having  the  patient  determine 
whether  air-  or  bone-conduction  is  louder.  By  air-conduction  the  sound- 
waves reach  the  perceptive  centers  through  the  sound-conducting  apparatus; 
by  bone-conduction  the  path  is  through  the  cranial  bones.  In  the  normal 
car  the  duration  of  air-conduction  is,  roughly  speaking,  about  double  that  of 
bone-conduction.  In  obstructive  trouble  in  the  conducting  apparatus  the 
duration  of  air-conduction  is  lessened  as  compared  with  that  of  bone-con- 
duction. In  trouble  with  the  perceptive  apparatus  the  duration  of  both  is 
lessened,  that  for  bone-  relatively  more  than  that  for  air-conduction,  especially 
for  the  higher  forks.  Aided  by  these  facts,  the  methods  of  locating  the 
lesion  may  be  briefly  reviewed. 

"Weber's  Test. — Weber  found  that  if  a  vibrating  tuning-fork  was  placed 
upon  the  middle  line,  antero-posteriorly,  of  the  head,  either  on  the  vertex, 
forehead,  or  upper  incisor  teeth,  and  one  ear  stopped,  the  fork  was  heard 
louder  in  that  ear.  Reasoning  from  this,  in  any  given  case,  if  the  hearing 
is  impaired  in  one  ear  only  or  unequally  in  the  two  ears,  and  a  vibrating  fork 
on  the  vertex  is  heard  better  in  the  worse-hearing  ear,  it  follows  that  the 
lesion  in  the  bad  ear  is  an  obstructive  one — i.e.'xn  the  sound-conducting 
apparatus  ;  and,  vice  versd,  if  it  is  heard  worse  in  the  worse-hearing  ear,  then 
the  trouble  is  in  the  perceptive  apparatus. 

RinneVs  Test. — If  the  conducting  apparatus  in  any  given  case  is  normal 
and  a  vibrating  fork  is  pressed  upon  the  mastoid  until  it  ceases  to  be  heard 
by  hone-conduction,  and  is  then  held  opposite  the  meatus,  it  is  again  heard 
by  air-conduction.  Ii'  the  conducting  apparatus  is  affected  to  any  marked 
extent,  the  vibrating  fork,  allowed  to  die  away  on  the  mastoid,  is  not  heard 
when  brought  opposite  the  meatus.  In  the  former  case  (air-conduction 
exceed-  bone-conduction,  A.-C.  >  B.-C,  and  Rhine's  test  is  said  to  be  positive 
(R.  -  ),  and  indicates,  as  a  rule,  no  marked  trouble  with  the  conducting 
apparatus  (middle  ear).  In  the  latter  case  bone-conduction  preponderates 
(B.-C  >■  A-C),  ami  Rhine's  test  is  negative  (R. — ),  indicating  disease  of  the 
conducting   parts  (middle  ear).1      In    many  cases,   undoubtedly,  Weber's  and 

Ui '■'-  teste  give  valuable  information  ;  yet    there  are  many,  the  doubtful  or 

border  line,  cases  in  which  they  cannot  be  relied  on  for  diagnosis. 

Schwabach's  Test. — In  this  method  the  Ilartmann  series  of  live  forks 
is  used:  C  =  128v.s.,C  256  v.  s.,  Cn  =  512  v.  s.,  ( ""  1024  v.s.,C,v  = 
2048  v.-.;  and  of  these  the  absolute  duration  and  the  relative  intensity  of 
both  air- and  bone-conduction  are  noted.  When  compared  with  the  results 
obtained  from  examination  of  a  series  of  normal  ears  this  furnishes  data  which, 
in  my  judgment,  are  mosl  valuable  for  diagnostic  purposes.  The  ( '  '  fork. 
26  to  64  v.  s.,  may  be  added  to  the  -eric-.  A-  Alderton  has  shown,  for 
routine  work  a  sufficiently  accurate  result  in  the  majority  of  eases  may  be 
obtained   by  using  the  low   fork  ('  '  or  C  and  the  ( ""  fork,  these   indicating 

'Tin'  terras  "  I.'.      "  and  "  I!       "  in  themselves  mean  nothing;  in  fact,  I  have  reason  to 

'■  thai  experienced  aurists  have  not  infrequently  to  Btop  and  mentally  translate  them      As 

substitutes,  for  general  adoption,  I  propose  the  following  formulae,  which  I  know  are,  in  practice, 

largely  used:  viz,  for  Rinne"-f-,  A.-C.       B.-C.  (air-conduction  greater  than  bone-conduction  . 

and  for  Rinne1     .  B.-C.        \   ;      I s-conduction  greater  than  air-conduction).    These  formula; 

convey  a  definite  idea,  and  their  \i»-  is  not  attended  with  any  i e  consumption  of  time  or 

space. 


SC1I  WWliACH'S  TVS  7 . 


671 


pretty  clearly  the  location  of*  the  trouble.     A  diagnosis  of  middle-ear  trouble, 
having  eliminated  by  inspection  obstructive  trouble  in  the  external  auditory 

meatus,  may  be  made  alter  going  through  with  some  or  all  of  the  above  teste 
— I.  If  there  is  loss  or  impairment  of  hearing  tor  the  lower  note-  of  the 
scale,  "with  elevation  of  the  lower  tone-limit;  II.  If  air-conduction  only  is 
diminished,  bone-conduction  remaining  unchanged  or  even  increased — the 
normal  ratio  of  B.-C.  <A.-C.  being  thus  changed,  particularly  so  for  the 
lower  notes.  If  the  lesion  is  marked,  B.-C  becomes  louder  and  longer  than 
A.-C. ;  III.  W  with  the  impaired  hearing  the  upper  tone-limit  by  A.-C.  is 
lint  little,  or  not  at  all,  affected.  Diseases  of  the  internal  ear  are  recognized 
in  the  same  manner  by — I.  No  elevation  of  the  lower  tone  limit;  II.  The 
maintenance  through  the  lower  notes  of  the  normal  ratio  between  A.-C.  and 
B.-C,  the  absolute  duration  of  both  being,  however,  reduced,  and  very  mark- 
edly so,  that  for  the  higher  notes  by  B.-C  ;  III.  Lowering  of  the  upper 
tone-limit,  with  frequently  entire  deafness  for  certain  of  the  higher  not.-. 
To  illustrate  the  manner  of  recording  in  compact  form  the  result  of 
tuning-fork  investigations,  I  have  subjoined  a  record  for  normal  hearing,  for 
chronic  middle-car  catarrh,  and  for  disease  of  the  sound-perceiving  apparatus. 
The  relative  intensity  is  shown  in  the  horizontal  space  marked  Rhine — A.-< '. 
being  louder  than  B.-C,  it  will  be  observed,  throughout  the  series  in  normal 
hearing  and  in  nerve-deafness  ;  the  reverse  being  true  for  chronic  catarrh, 
B.-C.  being  louder  than  A.-C,  except  for  the  highest  fork,  in  which  the 
intensity  by  A.-C  and  by  B.-C  are  about  equal.  The  figures  represent 
absolute  duration  in  seconds,  the  upper  line  representing  the  duration  by 
A.-C,  the  lower  one  that  by  B.-C  : 


1. 

A.-C. 

A.-C. 

A.-C. 

A.-C. 

A.-C. 

Rinn£. 
Schwabach. 

2. 

B.-C. 

B.-C. 

B.-C. 

B.-C. 

Equal 

A.-C. 

25 

15 

33 

32 

22 

A.-C. 

6 

6 

10 

11 

1-2 

B.-C. 

13 

7 

13 

13 

14 

B.-C. 

15 

11 

16 

13 

'.' 

C 

C 

C" 

("" 

c,v 

C 

C 

C» 

cm 

C" 

1 

1.  Typical  of  normal  hearing. 


2.  Typical  of  obstructive  trouble  in  the  sound-con* 
ducting  apparatus. 


3.      A.-C. 

A.-C 

A.-C  A.-C 

A.-C 

Rinne\ 

A.-C.     17 

I-", 
7 

19        11 

10 

B.-C. 

- 

3         3 

U 

C 

C 

C" 

c,v 

3.  Typical  of  trouble  In  the  sound-perceiving  appar 

To  those  who  wish  to  gel  along  with  the  smallest  possible  number  of 
diagnostic  instruments  for  ear-work  it  may  be  ^au\  thai  fairly  accurate 
opinions  may  be  formed  with  the  use  of  bu1  three  instruments— viz.  a  Low- 
pitched  tuning-fork  (C  '  >,  26  to  i;  1  v.  s.,  to  determine  the  lower  tone- 
limit,  and  thereby  the  presence  of  trouble  in  the  conducting  apparatus 
Galton  whistle,  to  determine  the  upper  tone-limit,  and  thereby  the  presence 
of  disease  of  the  perceptive  apparatus;  finally,  another  tuning-fork,  oi  512 
or  1024  v.  s.  (with   such  a   -roup  of  instruments,  I    should  say  the  one  ol 


, J 7  2  /.'.V.  1 .1/ /X.  1  TION  OF  PA  TI  EN  TS,    E T(  \ 

1024  v.  s.  would  give  the  most  information),  for  the  determination  of  absolute 
duration  of  A..-C.  and  B.-C.  To  one  determined  to  get  along  with  hut  one 
fork  I  would  recommend  C"  of  512  v.  -.,  but  with  this  alone  accurate  diag- 
aostic  work  is  impossible.  Other  tests  have  been  devised  to  aid  in  locating 
diseases  of  the  ear. 

Gelle's  Test  (Prrssions  Centripetals). — In  the  normal  ear,  if  a  vibrating 
tuning-fork  he  placed  on  the  vertex,  and  then  the  air  in  the  external  auditory 
canallie  compressed,  the  sound  dies  away,  to  return  again  with  removal  of 
the  compression.  This  is  believed  to  prove  mobility  of  the  chain  of  ossicles, 
hut  particularly  of  the  foot-plate  of  the  stapes  in  its  niche,  and  Gelle's  test 
is  positive,  +  ;  otherwise  it  is  negative,  —  ;  i.e.  in  rigidity  of  the  ossicular 
chain  (trouble  in  the  conducting  apparatus). 

Bing's  test  or  experiment  is  essentially  a  modification  of  YVcl>er*s  test. 
A  vibrating  tuning-fork  is  held  on  the  vertex  until  it  ceases  to  be  heard; 
then  either  external  auditory  canal  is  closed  with  the  finger,  and  the  fork  is 
again  heard  for  an  interval  which  is  called  the  period  of  secondary  percep- 
tion. With  a  normal  conducting  apparatus  this  interval  of  secondary  per- 
ception is  well  marked  ;  hence  if  the  interval  is  shortened  a  lesion  of  the 
sound-conducting  apparatus  is  to  he  inferred.  If  the  interval  he  normal  and 
vet  deafness  is  present,  the  seat  of  the  trouble  must  be  in  the  perceptive 
apparatus. 

<  )ther  tests,  a  detailed  description  of  which  is  forbidden  by  lack  of  space, 
are  those  of  Itelber<>-  and  Gradenigo  relative  to  the  "fatigability"  of  the 
perceptive  apparatus;  that  of  "binaural  synergy "  of  Gelle ;  the  "interfer- 
ence otoscope"  of  Lucae  ;  and  the  reaction  of  the  auditory  nerve  to  the 
electric  current. 

III.    THE    PERIOTIC    REGION. 

Having  thus  finished  the  preliminary  history  and  the  functional  examina- 
tion, we  may  now  investigate  the  parts  surrounding  the  auricle,  making  use 
of  inspection  and  palpation  for  this  purpose.  The  supra-auricular  region  is 
at  times  the  seat  of  subperiosteal  abscesses  in  adults  as  well  as  in  children. 
The  preauricular  region  may  be  the  seat  of  mumps,  lymphadenitis,  parotitis, 
or  pus-burrowing.  In  the  infra-auricular  region  lymphatic  inflammation 
with  redness  and  swelling  is  common  in  acute  inflammatory  affections  of  the 
external  ear.  A  hard,  cord-like,  tender  swelling  along  the  anterior  border  of 
the  sterno-mastoid  muscle  should  arouse  suspicion  of  sinus-disease  involving 
the  jugular.  A  more  diffuse,  hard  swelling  in  this  region  is  a  common 
accompanimenl  of  the  Bezold  form  of  mastoid  abscess,  breaking  into  the 
digastric  fossa.  The  postauricular  or  mastoid  region  should  always  receive 
careful  attention,  particularly  in  cases  attended  by  pain  or  suppuration. 
There  may  he  pain,  tenderness,  redness,  swelling,  fluctuation,  sinuses,  or 
cicatrice-.  Pain,  with  or  without  other  evidence  of  underlying  trouble,  is 
one  of  the  most  important  symptoms  of  mastoid  inflammation.  The  point 
of  greatest  tenderness,  whether  <>n  or  behind  the  mastoid  process,  should  hi' 
noted,  remembering  that  tenderness  of  the  mastoid  itself  usually  means 
underlying  inflammation,  while  tenderness  behind  it.  particularly  if  at  the 
seal  of  the  mastoid  foramen,  may  mean  disease  of  the  lateral  sinus.  Swell- 
ing is  cither  circumscribed  and  movable,  when  it  indicates  an  inflamed  gland, 
or  diffused,  a-  in  subperiosteal  abscess,  etc.  Fistula  and  sinuses  must  he 
carefully  investigated.  When  congenital  they  usually  open  anteriorly,  and 
are  often  attended  l»\  other  malformations.  When  acquired  they  arc  mosl 
often  postauricular,  and  may  lead  to  the  remain-  of  a  superficial  (glandular) 


(>TOS<  ()/>)'. 


673 


abscess,  forward  to  the  external  auditory  canal,  to  the  periosteum,  to  the 
underlying  bone,  to  the  interior  of  the  petrous  b i,  to  the  groove  for  tin- 
lateral'  sinus,  or  into  the  cranial  cavity.  The  presence  of  cicatrices  may 
throw  light  on  the  nature  of  previous  troubles. 


IV.  OTOSCOPY. 

Now  that  we  approach  the  examination  of  the  ear  itself,  it  should  be 
remembered  of  the  external  auditory  canal  that  it  is  somewhat  oval  in  sec- 
tion, about  14,  inches  in  length,  its  general  direction  inward,  forward,  and 
upward,  and  that  it  is  somewhat  angled  at  the  junction  of  the  cartilaginous 
with  the  bony  portion.  Hence  to  straighten  the  canal  for  purposes  of  exam- 
ination the  auricle  must  he  pulled  outward,  backward,  and  upward,  except 
in  infants  and  young  children,  in  whom,  owing  to  the  absence  or  shortness 
of  the  bony  portion,  it  should  be  pulled  downward  instead  of  upward  (see 
Plate  10).  "  The  relation  of  the  tympanic  membrane  to  the  inner  end  of  the 
canal  should  also  be  borne  in  mind,  the  plane  of  the  membrane  being  from 
above  and  behind  in  a  direction  downward,  for- 
ward, and  inward,  in  the  very  young  approaching 
more  nearly  the  horizontal  than  in  the  adult  C?  Ed.), 
so  that  the  posterior  superior  quadrant  is  nearest  to 
the  outer  end  of  the  canal,  and  may  easily  he  in- 
jured, particularly  in  children,  by  the  careless  in- 
troduction of  a  small  speculum. 

Illumination. — To  examine  an  ear  it  is  neces- 
sary to  have  some  mean- of  illuminating  it, and,  since 
direct  illumination  is  for  various  reasons  unsat- 
isfactory, we  now  use  altogether  the  reflecting 
mirror,  preferably  so  fixed  with  a  band  as  to  be 
used  as  a  head-mirror,  which  may,  if  desired,  be 
used  as  a  hand-mirror.  It  should  be  provided 
with  a  double  ball-and-socket  joint  (Fig.  473); 
may  vary  in  size  from  '1"  to  4"  in  diameter; 
should  have  a  hole  in  the  center,  through  which 
the  examiner  may  view  the  ear  ;  should  be  concave, 
and,  most  important  of  all  in  making  a  selection, 
should  have  a  focal  length  of  not  less  than  (J  nor 
more  than   10   inches. 

Of    next     importance     to    the     mirror     is  the 
speculum.     This  may  be  made  of  metal  (German 
silver,  aluminum),  hard  rubber,  glass,  or  celluloid  ; 
it  may  be  round  or  oval  in  section,  with  or  without  a  curve  between  the  large 
and  small  ends,  may  be  long  or  short,  and   made  up  in   set-  or  "nests"  "t 
three  or  fourdifferenl  sizes.     The  choice  of  material  may  depend  largely  upon 
personal  preference.     Each  kind  has  its 
advantages  and  disadvantages.    My  own 
preference  is  for  the  hard  rubber,  or,  still 
more,  for  the  pinkish  ( flesh-colored  |  cel- 
luloid, which  I   have  now  used  lor  two 
years  with  great  satisfaction. 

Other  instrument-   needed   tor  the 
routine  examination  of  the  ear  are  such  as  are  used  for  the  removal  of  the 
frequently-found  obstructions  in  the  canal — cerumen,  hairs,  epithelial  flakes, 


FlG.  17;'..— Forehead  mirror. 


dtz 


(374 


EXAMINATION  OF  PATIENTS,  ETC. 


cotton,  etc.  These,  when  small  or  in  the  cartilaginous  portion  may  often 
be  pushed  aside  by  the  speculum,  but,  if  large  or  in  the  bony  canal,  must 
be  removed  by  other  means.  Should  the  canal  be  blocked  by  a  large  ceru- 
minous  or  epithelial  plug,  a  foreign  body,  or  with  pus,  it  is  best  cleansed  by 
the  use  of  a  syringe  and  warm  water.  The  most  satisfactory  form  of  syringe 
for  office  use  is  one  with  either  glass  or  metal  barrel,  of  two  to  four  ounces 
capacity,  and  having  an  angular  tip  of  small  diameter  (Fig.  474).  Other 
instruments  for  this  purpose  are  the  cotton-carrier,  the  probe,  the  blunt  hook, 
the  Gross  ear-scoop  and  hook,  and  Mime  form  of  ear- forceps.  An  ordinary 
steel  cotton-carrier  answers  the  purpose.  In  using  it  wrap  a  small  pledget 
of  cotton  tightly,  leaving  about  ]  inch  of  the  cotton  beyond  the  end  of  the 
carrier  to  protect  the  canal-walls  from  injury.  With  this  much  loose  debris 
can  be  easily  mopped  from  the  canal,  as  well  as  small  quantities  of  pus,  etc. 
A.S  a  rule,  entirely  too  large  a  pledget  of  cotton  i>  used:  much  better  results 
can  be  obtained  from  a  few  small  pledgets  intelligently  used  in  a  well- 
illuminated  canal  than  from  an  unlimited  number  of  the  large  pledgets  that 
are  so  much  in  vogue.  The  probe  and  blunt  hook,  as  combined  in  the  1 1  art  - 
mann   instrument  (Fig.  d7o),  are   very  useful    in   clearing   out   a   canal  and 


FlG.  475.— Hartmann's  combined  probe  and  blunt  book. 

investigating  the  condition  of  its  walls  as  well  as  of  the  tympanic  membrane. 
The  Gross  ear-scoop  and  hook,  found  in  many  of  the  minor  surgical  pocket- 
cases,  is  also  a  decided  aid  in  many  cases,  but  must  be  used  with  great 
caution  and  with  good  illumination  of  the  canal.     A  good  pair  of  ear-forceps 


l'i'..  i,r,.    Bartmann's  ear 


i-  a   necessity — their  number  and   forma   approach  legion  :   that  which  has 
served  me  most   usefully  is  the  Hartmann  dressing-forceps  (Fig.  I7»i). 

It    may  not    be  out  of  place    to  make  one   more  general  remark    aboui  all 


APPEARANCES  OF  THE  CANAL.  675 

ear-instruments  which  permit  of  it — i.e.  they  should  be  bent  at  an  angle  of 
about  135°,  instead  of  being  straight,  because  this  shape  allow-  of  easier  and 
more  skilful  use,  and  avoids  the  objection  which  holds  against  all  straight 
instruments — viz.  that  with  them  the  index  finger  must  of  necessity  intrude 
more  or  less  upon  the  line  of  vision. 

Source  of  Light. —  In  car-work  this  is  a  matter  of  importance.  Sun- 
light, daylight  from  a  northern  window,  the  reflection  from  white  clouds,  :i 
white  wall  or  fence,  cannot  any  of  them,  he  used  at  all  times.  Hence  arti- 
ficial light,  which  may  be  had  constantly  and  of  uniform  intensity,  must  be 
our  standby.  The  oxyhydrogen  flame,  the  incandescent  electric  li-lit.  gas- 
light  plain  or  modified  by  the  Welsbach  burner,  the  kerosene  lamp,  the  old- 
fashioned  tallow-dip,  have  all  of  them  their  uses;  hut  for  routine  work  my 
preference  is  for  the  Welsbach  burner. 

Technic  of  Examination. — The  ear  to  lie  examined  should  lie  turned 
away  from  the  light  and  toward  the  examiner,  the  light  being  about  on  a  level 
with  the  patient's  ear.  The  examiner  should  always  use  the  same  eye,  thus 
training  it  to  do  the  best  possible  work,  and  should  with  the  chosen  eye 
always  make  the  observations  through  the  perforation  in  the  center  of  the 
head-mirror.  The  other  eye  should  always  be  kept  open,  both  to  avoid 
fatigue  and  to  locate  the  direction  of  the  reflected  light  and  to  aid  in  focu- 
sing it  more  quickly  upon  the  ear.  This  being  done,  the  auricle,  the  concha, 
and  so  much  as  possible  of  the  canal  should  be  carefully  observed  before  a 
speculum  is  introduced;  otherwise  affections  of  these  parts  maybe  hidden 
by  the  speculum  and  entirely  overlooked.  Should  pieces  of  epithelium  or 
cerumen  be  in  the  way,  remove  them  carefully;  should  the  canal-wall-  be 
found  swollen,  as  from  furuncle,  introduction  of  the  speculum  may  be  too 
painful  and  have  to  be  postponed  ;  in  such  a  case  the  evident  swelling, 
together  with  the  history,  perhaps  sufficing  for  a  diagnosis. 

Having  the  light  properly  focussed,  and  having  chosen  a  speculum  of 
appropriate  size,  it  is  introduced  as  follows:  Seize  the  upper  outer  part  of 
the  patient's  auricle,  if  the  right  one,  between  the  middle  and  ring  fingers, 
if  the  left  one,  between  the  index  and  middle  fingers,  of  the  left  hand,  and, 
supposing  the  case  to  be  an  adult,  pull  the  auricle  firmly  upward,  outward, 
and  a  little  backward  to  straighten  the  canal  ;  then  with  the  right  hand 
introduce  the  speculum,  with  a  slight  rotary  motion,  inward  past  the  fre- 
quently existing  hairs,  etc.  in  the  outer  portion  of  the  canal,  and  grasp  it 
between  the  left  thumb  and  index  finger,  the  right  hand  being  thus  1'  ft 
free  for  other  manipulation-.  Epithelial  Hake-,  cerumen,  pus,  etc.  obstruct- 
ing the  view  must  be  removed  by  the  appropriate  instruments,  so  that  an 
unimpeded  view  of  the  tympanic  membrane  may  be  obtained.  An  occasional 
difficulty  i:-  an  unduly  prominent  antero-inferior  canal-wall,  but  practice  in 
changing  a  little  the  line  of  vision  and  the  position  of  the  speculum  will 
overcome  this.  In  exceptional  cases  the  presence  of  the  speculum  in  the  cm- 
gives  rise  to  a  troublesome  ear-cough,  and  still  more  rarely  to  a  feeling  of 
faintness  or  positive  fainting,  or  even  to  epileptiform  attacks.  A-  a  rule, 
however,  the  patient  become-  rapidly  accustomed  to  the  presence  of  the 
speculum. 

Appearances  of  the  Canal. — The  epidermis  lining  the  normal  canal 
has  an  opaque  whitish  color.  Under  pathological  condition-  the  wall-  may 
become  h\  peremic,  may  be  the  -eat  of  localized  <<r  diffuse  swellings,  or  may 
show  serous  or  purulent  excretions,  ulcerations,  or  fistulas,  while  the  lumen  of 
the  canal  may  be  more  or  less  filled  with  serous,  mucous,  or  purulent  secre- 
tions, with  collection-  of   cerumen  or  thrown-off  epithelium,   with   for 


676  EXAMINATION  OF  PATIENTS,   ETC. 

bodies,  or  with    tumors  (exostoses,  polypi,   etc.)   which  arise  either  from  its 
walls  or  from   the   tympanic  cavity. 

Appearances  of  the  Tympanic  Membrane. — The  normal  membrane 

is  somewhat  oval  in  shape,  pearly  gray  in 
d  " 5  *  color,  and  translucent,  with  certain  promi- 

i  ;  ;  nent  landmarks — the  short  process  of  the 

;  ■  V i  <?       malleus,   antero-supcriorly,  looking  much 

/^'"        '-7    x  h      like  a  small  pustule  (a,  Fig.  477),  with  the 

v^--,  manubrium  or  handle  of  the  malleus  run- 

-.    v;.^  ning  from  it  downward  and  backward  to 

i    the  center  of  the  membrane,  the  umbo(i); 

k  antero-inferiorly  from  this  is  the  triangle 

I  of  light,   "cone  ol*   light,"  or  light-reflex 

m (m),  due  in  shape  and  position  to  the  con- 

v^  cavo-convex  face  of  the  membrane   and 

fig.  47-.-The  normal  drumhead.  its  general  oblique  position  relative  to  the 

axis  of  the  canal,  whereby  the  rays  of 
light  from  the  observer's  mirror  strike  only  here  upon  a  surface  at  right 
angles  to  the  line  of  vision — the  rule  being  that  any  point  which  appears 
brightly  illuminated  is  on  a  plane  <tf  right  angles  to  the  line  of  sight.  The 
margins  of  the  membrane  are  set  in  the  bony  tympanic  ring,  which  encircles 
it  completely  except  at  its  upper  part,  where  there  is  a  notch,  the  notch 
of  Rivinus.  Filling  in  this  space  above  the  short  process  is  the  flaccid 
membrane  or  ShrapneWs  membrane,  separated  from  the  other  portion  of  the 
membrane,  the  tense  or  vibrating  membrane,  by  the  anterior  and  posterior 
folds  (e.g.),  whiter  than  the  rest  of  the  membrane  and  running  forward  and 
backward  from  just  above  the  short  process. 

Pathologically  the  tympanic  membrane  may  present — 
(a)  Changes  in  Color. — The  luster  may  be  lost,  with  general  dulness  and 
indistinctness  of  the  landmarks,  from  soaking,  loosening,  or  thickening  of 
the  outer  layer  of  the  membrane  (drops,  syringing,  superficial  or  underlying 
inflammation).  Opacity  results  from  thickening  of  any  or  all  the  layers, 
either  of  the  whole  membrane  or  of  circumscribed  yellower  white  patches, 
single  or  multiple,  large  or  small,  due  to  fibrous  or  calcareous  degeneration, 
and  indicating,  as  a  rule,  severe  preceding  inflammation.  A  bright,  coppery 
appearance  is  due  to  a  congested  tympanic  mucosa.  A  dark,  hair-like  line, 
concave  upward  across  the  whole  membrane  or  across  cither  anterior  or  pos- 
terior half,  or  both  (see  Fig.  b!7),  indicates  fluid  in  the  tympanic  cavity.  In 
hyperemia  the  individual  blood-vessels,  not  normally  -ecu,  become  visible 
along  the  malleus-handle  (see  Fig.  8,  Plate  11)  over  Shrapnell's  mem- 
brane, or  radiating  in  a  thick  network  over  the  rest  of  the  membrane,  which, 
in  the  higher  grades  of  inflammation,  becomes  pink  or  even  bright  red,  all 
the  landmarks  being  lost. 

{!>)  Changes  in  Surface. — The  normally  smooth  surface  of  the  mem- 
brane may  become  irregular  through  the  projection  of  ecchymoses,  vesicles, 
interstitial  abscesses,  granulations,  polypi,  or  through  the  wrinkling  due  to 
large  cicatrices,  or  to  atrophy,  or  to  loosening  of  the  superficial  epithelial 
layer,  from  disturbance  of  its  nutrition,  seen  occasionally  in  acute  under- 
lying inflammation. 

(c)  Changes  in  Position. — The  membrane  may  be  retracted  or  bulged, 
either  in  pari  or  in  it-  entirety.  Retraction,  as  a  whole,  is  usually  due  to  in- 
sufficienl  ventilation  <>f  the  tympanic  cavity,  and  is  recognized  by  the  follow- 
ing changes  in  appearance:  the  anterior  half  is  thrown  into  deeper  shadow; 


/.oss    of  SUBSTANCE.  677 

the  short  process  is  unduly  prominent,  as  are  the  anterior  and,  to  a  greater 
extent,  the  posterior  folds;  the  malleus-handle  is  fore-shortened,  the  light- 
reflex  lessened  in  size  and  brilliancy  or  absent,  and  al  times  ih<'  tympanic 
cavity's  inner  Mall  and  other  structures  become  unduly  visibli — -viz.  the 
promontory  posteriorly,  the  round-window  niche  postero-inferiorly,  and  pos- 
tero-superiorly  the  descending  process  of  the  incus,  the  head  and  posterior 
cms  of  the  -tape-,  the  tendon  of  the  stapedius  muscle,  and,  finally,  the  chorda 
tympani  nerve  crossing  the  tympanic  cavity  just  below  the  posterior  fold. 
Circumscribed  retraction  is  due  to  the  indrawing  either  of  atrophic  area.-,  which 
usually  have  ill-defined  margins,  or,  much  more  frequently,  of  thin  cicatrices, 
which  may  be  large  or  small,  single  or  multiple,  adherent  or  non-adherent, 
with  margins,  however,  as  a  rule,  definite  and  cleanly  cut.  These  localized 
depressions  appear  thinner,  more  translucent,  and.  when  not  adherent,  more 
movable  than  the  surrounding  membrane,  and  they  not  infrequently  present 
at  their  deeper  portions  a  larger  or  smaller  light  reflex.  Bulging  of  the 
membrane,  either  localized  or  general,  is  usually  caused  by  fluid  in  the 
tympanic  cavity. 

(d)  Loss  of  Substance. — Perforations  vary  in  -ize  from  a  pinhole  to 
absence  of  almost  the  whole  membrane.  They  may  occur  in  any  part  of 
either  the  vibrating  or  the  flaccid  nt<  ml>r<i nc,  or  be  present  in  both  simultane- 
ously. They  present  as  circular,  elliptical,  oval,  kidney-  or  heart-shaped  open- 
ings, through  which  the  tympanic  mucous  membrane  becomes  visible.  Two, 
three,  or  four  perforations  of  the  same  membrane  are  occasionally  seen,  and 
among  the  great  rarities  may  be  mentioned  the  sieve-like  perforations  which 
at  times  accompany  tubercular  or  diphtheritic  otitis  media.  It  should  be 
noted  whether  the  margins  of  the  perforation  are  red  and  raw,  as  in  recent 
active  perforations,  or  white  and  cicatricial,  as  in  permanent  opening-.  In 
examining  for  suspected  perforation  it  is  of  the  greatest  importance  that  the 
whole  surface  of  the  membrane  should  be  swept  over  with  the  eye,  particu- 
larly near  the  margin-  ;  and  on  no  account  should  ShrapnelPs  membrane  be 
overlooked,  that  part  from  which  we  obtain  evidence  of  the  most  serious  of 
middle-ear  troubles  (see  Plate  11  ). 

The  diagnosis  of  perforation-  is.  as  a  rule,  easy,  but  is  at  times  difficult, 
particularly  so  of  the  very  -mall  and  the  very  large  our- — in  the  former 
because  the  size  permits  the  edge-  to  completely  overlie  one  another,  making 
a  diagnosis  by  unaided  inspection  at  time-  impossible  ;  in  the  latter,  in  which 
— e.  </.  the  whole  vibrating  membrane,  including  the  malleus-handle  and 
short  process,  have  been  destroyed  by  the  suppurative  process,  because  we 
have  not  the  edges  of  the  perforation  sufficiently  in  evidence  to  aid  the  eye  to 
establish  the  two  plane: — that  for  the  perforation  margin-  and  that  for  the 
inner  tympanic-cavity  wall.  In  the  difficult  cases  the  following  aid-  to  diag- 
nosis may  be  mentioned: — 1.  A  perforation  whistle  can  usually  be  obtained 
by  forcing  air.  by  some  of  the  method-,  to  be  described,  from  the  nose,  through 
the  Eustachian  tube,  out  through  the  perforated  membrane.  2.  It'  before 
using  the  air-douche  in  a  given  case  the  external  canal  i-  thoroughly  dried, 
and  after  using  it  fluid  i-  found,  it-  presence  i-  almosl  certain  proof  oi  a 
perforation.  '■'>.  Another  proof  is  furnished  by  the  passage  of  fluid  into  the 
naso-pharynx  when  syringing  an  ear.  1.  A  perforation  is  indicated  by  the 
presence  of  mucus  in  the  water  with  which  an  ear  ha-  been  syringed.  5.  \ 
pulsating  light-reflex  seen  in  the  depth  of  a  canal  menu-  with  the  greatesl 
probability  a  perforated   membrane. 

To  distinguish  perforations  from  cicatrices  and  atrophic  spots,  in  addi- 
tion   to   tin'   above   guides,    then-   arc   two    instruments  which,  as   aids   to 


678 


EXAMINATION  OF  PATIENTS,    ETC. 


diagnosis,  should  be  the  constanl  companions  of  the  aurist.  The  first  of 
these  is  the  bent  profa  and  blunt  hook  (see  Fig.  475),  whose  use  is  to  deter- 
mine the  point  of  insertion,  consistence  and  mobility  of  tumors  or  inflamma- 
tory new  growths  (polypi,  exostoses,  furuncles),  to  determine  the  presence  of 
fistulous  openings  or  of  bone-caries,  as  well  as  by  actual  touch  to  investigate 
the  surface  of  the  membrane  (perforations,  etc.).  The  other  instrument  is 
Sieglefs  pneumatic  speculum,  or  sin-linn  speculum  (Fig.  478). 


Pig.  178.-  Siegle's  speculum,  the  small  end  made  to  fit  air-tif.'lit  into  the  canal,  and  the  large  end 
i  Losed  by  a  glass  sel  In  at  an  angle  and  fitted  with  means  to  condense  and  rarefy  the  air  in  the  auditory 
canal. 

To  t lie  examiner  illuminating  the  canal  through  the  air-tight  speculum 
will  thus  be  disclosed  whether  the  mobility  of  the  malleus  is  impaired  or 
whether  the  membrane  is  relaxed  ;  sunken  cicatricial  pouches  can  he  distin- 
guished from  open  perforations,  adhesions  of  the  membrane  or  of  depressed 
cicatrices,  or  (.t'  the  malleus-handle  to  the  inner  wall  of  the  tympanic  cavity 
can  lie  made  out  ;  and  not  infrequently  collections  of  pus  in  the  attic  or 
antrum  can   he  detected  and  emptied  by  this   apparatus. 

V.   EXAMINATION   OF   NOSE,   NASOPHARYNX,   AND  PHARYNX. 

Since  so  many  of  the  middle-ear  diseases  have  their  origin  in  the 
approaches  to  the  Eustachian  tube,  the  examination  of  the  nose,  naso- 
pharynx, and  pharynx  may  well  lie  made  preliminary  to  an  investigation  of 
the  middle  ear.  For  the  details  of  such  examination  the  reader  i^  referred 
to  the  appropriate  chapters,  special  attention  being  given  to  the  following 
point-:  1.  In  the  examination  of  the  fauces,  to  the  activity  of  the  palatal  mus- 
cles during  phonation,  these  being  also  tubal  muscles  ;  2.  To  the  appearance  of 
the  naso-pharyux,  and  especially  of  the  mouths  of  the  Eustachian  tubes,  by 
posterior  rhinoscopy  :  -"..To  the  patency  of  each  nostril  in  relation  to  respira- 
tion, ventilation,  and    Eustachian  catheterization. 


VI.  EXAMINATION  OF  THE  MIDDLE  EAR. 

A.8  preliminary  to,  and  really  a  part  of,  investigation  of  the  middle  ear 
mii-t  firsl  he  considered  the  differenl  means  of  determining  the  patency  of 
tie  Eustachian  tube.  For  the  accomplishment  of  this,  three  methods  may  he 
used  : 

I.  As  giving  a  valuable  preliminary  idea  of  the  condition  of  the  tubes 
may  l><-  tried  Politzer's  experimenl  of  holding  a  vibrating  tuning-fork  in 
front  of  tin-  patient's  open  nostrils,  when,  during  the  act  of  swallowing,  if 
the  tube-  ;iiv  patulous,  tee  vibrations  are  more  distinctly  heard  by  the  patient. 
The  rationale  is  of  course  plain  :  the  ad  of  swallowing  opens  the  tubes  when 
they  are  normally  patulous,  and  the  -mind  passes  through  them  into  the  tym- 
panic cavity.     Negatively,  if  under  these  <• litions  the   patient    hears  the 


INFLATION  OF  THE  EAR,    WITH  ALSCILTATIOX.         679 

vibrations  on  one  side  only  or  fails  to  hear  them  on  either  side,  it  is  evidence 
in  the  former  cast'  of  tubal  obstruction  <>n  the  side  on  which  the  fork  was  qo! 
heard;  in  the  latter  case  tubal  obstruction  on  both  side-  i-  to  lie  suspected. 

2.  Inflation  of  the  Bar,  with  Auscultation.— Several  methods  of 
inflation  are  in  vogue,  with  all  of  which  auscultation  mas-  he  carried  out, 
with  by  far  the  most  success,  however,  in  the  first  method  to  be  described 
— viz. : 

A.  Inflation  by  nieans  of  the  Eustachian  Catheter. — The  instruments 
necessary  for  this  are — (a)  Eustachian  catheter,  made  of  metal  or  hard  rubber 
(to  the  latter  I  give  the  preference),  o\  to  0  inches  long,  ami  made  in  three 
sizes;  its  last  inch,  the  tip  or  beak,  is  gently  curved  till  the  point  makes 
with  the  shank  an  angle  of  140°  to  150°  ;  the  large  end  is  funnel-shaped  to 
fit  a  corresponding  tip  on  the  air-bag,  bottle,  etc.,  and  lias  on  it  a  ring  point- 
ing in  the  same  direction  as  the  tip  of  the  catheter,  (b)  An  air-bag,  single 
or  double,  (r)  The  auscultation-tube,  which  has  been  miscalled  an  "oto- 
scope," consisting  of  a  piece  of  light  rubber  tubing  24  to  30  inches  long,  having 
at  the  ends  olive-shaped  pieces — one  white,  the  other  black,  so  that  they  may 
be  distinguished  from  one  another,  and  the  same  one  always  used  by  the  ex- 
aminer. With  this  the  sounds  caused  by  the  passage  of  air  through  the 
Eustachian  tube  into  the  tympanic  cavity  are  observed.  Before  describing 
the  introduction  of  the  catheter  the  following;  general  remarks  may  be  in 
place  :  Catheterization  should  be  performed  with  both  patient  and  physician 
in  the  sitting  position  ;  the  patient's  head  should  be  in  such  position  that  the 
floor  of  the  nose  will  be  as  nearly  as  possible  horizontal.  While  a  head-rest  is 
useful,  it  is  by  no  means  necessary  ;  secretion  should  be,  as  far  as  possible, 
removed  (by  blowing,  etc.)  from  the  nose  and  naso-pharynx  ;  a  dash  of 
cocain  may  without  disadvantage  be  applied  to  the  nostrils.  The  patient 
should  keep  the  eyes  open,  should  on  no  account  hold  the  breath,  but  should 
breathe  through  the  nose  ;  it  is  well  to  occupy  the  patient's  hands  by  giving 
them  the  air-bag  to  hold  ;  then  with  the  diagnostic  tube  in  place,  dip  the 
already  disinfected  catheter  into  water  or  oil,  blow  through  it  to  empty  it  and 
to  see  that  the  lumen  is  clear,  and  proceed  to  introduce  the  catheter. 

With  the  fingers  of  the  left  hand  resting  on  the  patient's  forehead  and 
nose,  where  they  should  remain  until  the  end  of  the  procedure,  the  tip  of  the 
nose  being  moderately  elevated  by  the  left  thumb,  the  catheter  is  held  like  a 
pen  between  the  thumb  and  first  two  fingersof  the  right  hand,  and  is  entered, 
in  almost  a  vertical  position,  into  the  nostril  until  the  beak  passes  over  the 
initial  eminence  on  the  floor  of  the  nose.  It  is  then  rapidly  brought  to  a 
horizontal  position,  and  passed  gently  backward  until  the  beak  is  felt  to 
touch  the  posterior  pharyngeal  wall  ;  if  the  catheter  is  brought  too  -lowly  to 
the  horizontal  position,  the  tip,  instead  of  passing  along  the  floor  of  the  nose, 
may  easily  enter  the  middle  meatus.  Another  important  consideration  is  to 
hold  the  catheter  as  lightly  as  possible,  not  firmly  grasped,  when,  with  almost 
inappreciable  force  from  behind,  it  will  in  the  majority  of  cases  find  its  own 
way  through  the  nostril.  Qp  to  this  point — viz.  finding  the  posterior  pha- 
ryngeal wall  with  the  beak  of  the  catheter — the  two  methods  to  be  described 
of  finding  the  mouth  of  the  tube  are  identical.  By  the  firsl  and  certainly 
the  easier  method  the  beak,  as  indicated  by  the  ring  at  the  outer  end  of  the 

catheter,  i-  turned  toward  the  side  to  be  catheterized  into  the  fossa  <>t  Rosen- 
miiller;  it  is  then  drawn  gently  outward  for  from  J  to  '■  of  an  inch,  when 
the  impression  is  given,  and  altera  little  practice  readily  recognized,  of  the 
beak  turning  downward  a-  it  passes  the  prominent  posterior  lip  <»f'  the  tube- 
month,  followed,  as  it   enters  this,   by  a  distincl    feeling  of  turning  upward 


680 


EXAMINATION  OF  PATIENTS,    ETC. 


again.  It  should  now,  the  ring  pointing  toward  the  oujjer  angle  of  the  eye, 
be  firmly  grasped  between  the  thumb  and  index  finger  of  the  left  hand,  the 
otlur  fingers  remaining  in  position  on  the  patient's  nose;  the  operator's  hand, 
the  catheter  and  the  patient's  head  becoming  thus,  as  it  were,  one  body,  so 
that  movements  of  the  latter  do  not  displace  the  catheter.  By  the  second 
method,  instead  of  turning  the  beak  of  the  catheter  toward  the  side  to  be 


■  —Introduction  of  catheter,  first  method. 


Fn;.  4.mi. — Sin  md  moth'  ><I. 


catheterized,  it  is  turned  toward  the  opposite  side,  drawn  forward  until  the 
beak  is  fell  to  impinge  against  the  posterior  edge  of  the  nasal  septum,  and  is 
then  rotated  downward  through  an  are  of  200°,  when  it  will,  as  a  great 
general  rule,  enter  the  mouth  of  the  tube,  and  is  to  be  grasped  as  before. 
Air  is  now  blown  through  the  catheter  and  Eustachian  tube  into  the  tym- 
panic cavity,  and  the  important  information  gained  from  the  auscultation- 
tube  is  to  be  noted. 

Auscultatory  Sounds. — These  are  produced  either  at  the  pharyngeal 
end  of  the  Eustachian  tube,  in  the  tube  itself,  or  in  the  tympanic  cavity. 
With  the  part-  in  a  normal  condition  there  is  heard  with  each  compression  of 
the  air  bag  a  soft,  dry,  blowing  sound,  together  with  a  slight  thud  <>r  impact 
sound  of  the  current  of  air  against  the  tympanic  membrane.  Pathological 
conditions  in  the  tympanic  cavity,  in  the  tube,  or  in  the  naso-pharynx  change 
the  character  of  the  sounds  heard  in  a  more  or  less  characteristic  way — e.g. 
the  crackling  rides  of  fluid  in  the  tympanic  cavity,  the  whistle  with  a  per- 
forated membrane,  the  high-pitched  rather  distant  sounds  due  to  a  narrowed 
Eustachian  tube,  the  coarse  distant  rasping  due  to  mucus  in  the  pharyngeal 
end  of  the  tubes.  These  sounds  are  worthy  of  careful  study,  practice 
enabling  one  to  localize  their  source  and  to  gain  important  knowledge  "I 
the  conditions  present. 

Obstacles  to  Catheterization. — These  are  met  with  in  the  nose  in 
the  form  of  dell,  .•lion-,  ridges,  and  spurs  of  the  nasal  septum;  and  in  the 
naso-pharynx  in  the  form  of  variations  in  the  location  and  prominence  o\ 
the  pharyngeal  extremity  of  the  Eustachian  tube  in  different  cases;  and  on 
the  two  sides  of  the  same  case  in  the  varying  width  of  the  naso-pharynx,  ami 
from  muscular  contraction  due  to  the  presence  of  the  catheter  in  the  naso- 
pharynx. Skill  and  patience  will  usually  succeed  in  getting  the  catheter 
past  the  nasal  obstructions;  if  not,  a  catheter  with  a  larger  curve  to  the 
tip  maybe  passed  through  the  other  nostril.  Delicate  manipulation  with 
differently  curved  catheters  or  with  the  same  catheter  differently  moulded,  ;it 
the  aame  time  insisting  that  the  patienl  Wreathe  through  the  nose,  will  over- 
come   the    obstacles    met   with    In    the    oaso-pharynx.      Timidity  of  a    patient 

when  catheterized  for  the  first  time,  and  the  discomfort  to  all  patients  in 
whom  difficulties  are  encountered,  may  be  greatly  lessened  or  entirely  avoided 
l>\  the  use  of  ;i  -mall  quantity  of  > ain  solution. 


VALUE  OF  CATHETERIZATION  AND   POLITZERIZATION.     081 

Dangers  of  Catheterization. —  Emphysema,  eveE  fatal  in  its  conse- 
quences, has  resulted  from  the  use  of  the  Eustachian  catheter  with  highly 
condensed  air ;  but  with  the  hand  apparatus,  some  form  of  which  is  at  preseni 
almost  universally  u<c<\,  even  slight  emphysema  should  never  result.  The 
experience  of  one  of  my  colleagues  leads  me  to  utter  a  word  of  warning 
against  the  careless  use  of  the  catheter  in  elderly  persons  with  fragile  blood- 
vessels and  an  apoplectic  tendency.  A  rare  hut  not  dangerous  result  of 
catheterization  is  severe  dizziness  or  even  momentary  unconsciousness,  due  to 
sudden  disturbance  of  labyrinthine  pressure.  It  may  he  avoided  by  begin- 
ning the  inflation  very  gently,  when,  if  no  unpleasant  symptoms  follow,  the 
strength  of  the  air-current  may  he  increased.  Another  occasional  result, 
never  in  my  experience  attended  with  serious  consequences,  is  rupture 
of  the  tympanic  membrane,  although  this  accident  is  more  frequent  with 
Pulitzer's  method  of  inflation. 

Substitutes  for  Catheterization. — The  other  methods  of  inflation  in 
common  use  are  those  known  as  Valsalva's  and  Politzer's. 

B.  The  Valsalva  method  consists  of  an  attempt  to  blow  the  nose  with 
the  mouth  tightly  shut  and  the  nose  closed  with  the  finger  and  thumb,  when, 
if  one  or  both  of  the  Eustachian  tubes  are  normally  patulous,  the  air  will  enter 
one  or  both  of  the  tympanic  cavities.  This  method  has  a  certain  diagnostic 
value,  because  it  permits  the  examiner  to  watch  the  tympanic  membrane 
during  the  act  of  inflation  and  to  note  the  effect  of  the  increased  intratym- 
panic  pressure. 

C.  Politzer's  method  requires  an  air-bag,  the  Politzer  bag  ( 8  oz.  capacity ), 
and  a  nose-piece,  preferably  a  conical  hard-rubber  one  large  enough  to  oc- 
clude one  nostril,  which  is  best  connected  with  the  air-bag  by  means  of  from 
8  to  12  inches  of  rubber  tubing.  The  idea  of  the  original  Politzer  method 
and  of  its  many  modifications  is  to  blow  air  into  one  nostril,  the  other 
being  occluded,  at  the  moment  when  the  soft  palate  and  uvula  are  by 
some  maneuver  forced  back  against  the  posterior  pharyngeal  wall,  shutting 
off  the  naso-pharynx  from  the  throat  below  it.  Politzer  accomplished  this 
by  having  the  patient  take  a  small  mouthful  of  water  and  -wallow  it  at  a 
given  signal  (nodding  the  head,  the  word  "now,"  or  counting  up  to  three)  ; 
simultaneously,  one  nostril  being  closed  by  the  nose-piece  of  the  Politzer 
bag,  the  other  by  pressure  of  the  operator's  fingers,  the  air-bag  is  compressed, 
when  the  air,  being  shut  off  from  going  elsewhere,  passes  through  the  Eu- 
stachian tubes  and  penetrates  the  tympanic  cavities.  Another  plan,  which 
almost  always  succeeds,  and  which  I  greatly  prefer  because  of  its  freedom 
from  discomfort  to  the  patient,  is  to  have  the  patient  close  the  lips  and  puff 
the  cheeks  out  forcibly,  or  he  may  be  directed  to  utter  in  rapid  succession  the 
syllables  "hick,"  "hack."  "hock."  The  crying  of  very  young  children 
usually  accomplishes  the  same  purpose.  Auscultation  in  the  Valsalva  and 
Politzer  methods  does  not  give  very  much  information  as  to  the  condition  of 
the  middle  ear,  excepting  only  if  there  is  a  perforation  of  the  tympanic 
membrane,  when  the  perforation-whistle  becomes  very  evident,  often  with- 
out,  as   well    as    with,   the  auscultation-tube. 

Comparative  Value  of  Catheterization  and  Politzerization.— 
Inflation  with  the  catheter  has,  as  a  diagnostic  measure,  the  following  advan- 
tages over  Politzerization  :  It  enables  the  surgeon  to  measure  the  force  needed 
to  propel  air  into  the  tympanum;  he  can,  by  repeating  the  inflation,  study 
the  auscultation-sounds  and  make  therefrom  valuable  deductions ;  it  depends 
for  success  upon  the  skill  <»f  the  surgeon,  and  not  upon  the  patient's  attempts 
to  close  the  naso-pharynx.     Catheterization  of  children   under  twelve  years 


682  EXAMINATION  OF  PATIENTS,    ETC. 

of  age  is  difficult,  however,  and  in  them,  fortunately,  the  Eustachian  tubes 
being  relatively  shorter  and  of  larger  caliber,  more  information  can  be 
gained  from  the  auscultatory  sounds  with  Politzerization  than  in  the  adult. 
Hence  Politzer's  method  as  a  means  of  diagnosis  should  be  limited  to  chil- 
dren, and  of  course  to  those  few  adults  in  whom,  owing  to  nasal  obstruction, 
catheterization  cannot  he  carried  out.  The  diagnostic  value  of  inflation  lies 
in  the  comparison  of  the  patency  of  the  Eustachian  tube  and  the  effect  pro- 
duced, and  has  been  so  well  summarized  by  Grant  that  E  quote  from  him: 
"Patency  much  diminished  and  improvement  on  inflation  very  considerable 
would  indicate  a  narrowing  (catarrhal)  of  the  Eustachian  tube  without  sig- 
nificant  tympanic  disease.  Patency  much  diminished  ami  improvement  >m 
inflation  very  mod,  rate  would  indicate  simultaneous  affection  of  the  tube  and 
tympanum,  in  the  more  favorable  exudative  form  of  chronic  catarrh  of  the 
middle  ear.  Patency  normal  and  improvement  on  inflation  little  or  none  would 
indicate  a  primary  affection  of  the  tympanum,  as  in  the  obstinate  dry  or 
sclerotic  form  of  chronic  catarrh.  Patency  normal  ami  hearing  made  worse 
by  inflation  would  indicate  a  healthy  middle  ear  and  pure  nerve-deafness. 
Immense  improvement  <>n  inflation,  followed  by  speedy  or  almost  immediate 
return  to  the  previous  degree  of  dulnessof  hearing,  is  characteristic  of  relax- 
ation of  the  membrane." 

3.  The  Eustachian  Bougie. — The  third  method  of  investigating 
tin  patency  of  the  Eustachian  tube  is  that  by  means  of  the  Eustachian 
bougie.  If  an  obstruction  exists,  the  procedures  already  outlined  will 
have  demonstrated  the  fact,  the  diagnostic  use  of  the  bougie  consisting 
in  locating  the  seat  mid  degree  of  such  stenosis.  My  preference  is  for 
the  flexible,  probe-pointed  celluloid  bougies,  which  come  in  four  sizes. 
The  -mailer  sizes  should  always  he  tried  first.  Before  introduction  two 
mark-  should  always  he  made,  with  ink  or  otherwise,  on  the  end  of  the 
bougie  toward  the  operator,  one  indicating  when  it  is  leaving  the  catheter 
to  enter  the  tube,  the  other,  1  j  inches  farther  hack,  indicating  the  point 
beyond  which  the  bougie  should  not  be  introduced.  The  catheter  hav- 
ing been  fixed  in  the  month  of  the  tube,  the  bougie  is  passed  rapidly  down 
to  the  firs!  mark,  then  very  gently  pushed  farther,  when,  if  it  is  entering  the 
tube,  the  sensation  conveyed  to  the  finger  becomes,  alter  a  little  practice,  easily 
recognizable,  the  patient  having  at  the  same  time  a  sensation  of  sticking 
directly  in  the  ear.  If  an  obstruction  i-  met  requiring  considerable  force  to 
overcome,  the  bougie  must  he  withdrawn  and  a  smaller  one  substituted. 
Stenoses  are  mosl  frequenl  in  the  firsl  inch  (the  cartilaginous  portion),  there 

being  always  i lerate  narrowing  a1  the  isthmus  of  the  tube.     Having  thus 

located  the  stricture,  and  at  the  firsl  attempt,  or  after  repetitions  gotten  the 
bougie  past  it,  air  will  be  found  to  enter  the  tympanic  cavity  after  its  with- 
drawal much  more  freely  than  before.  One  precaution  never  to  be  forgotten 
is  i"  examine  the  bougie  carefully  after  withdrawing  it.  and.  if  the  slightesl 
trace  of  blood  is  found,  not  to  inflate,  thus  avoiding  the  danger  of  emphysema. 
Another  general  precaution  as  to  passing  the  bougie  is  that  the  whole  opera- 
tion must  be  performed  with  the  utmost  patience,  gentleness,  and  caution,  the 
patience  extending,  if  necessary,  to  four  or  five  sittings  before  the  stricture 
;-  finally  overcome. 


EXAMINA  TIOJS   BLANK. 


6& 


No. 

Name 

Afrp 

Address                                                                                                         Dutp 

Occupation 

Nativity 

Diagnosis 

A.S.                                                                A.D. 

a.  ~ 

JZ    3 
BB  H 

C     Q. 
<J5 

RIGHT. 

LEFT. 

j  Pres. 
Comp. 

Durat. 

Tinn. 

Pain 

2  I 

in   C- 

a    n 

C   -c 
DC    o 
o  z 

a. 

Disch. 

Cause 

Course 

«  1 
<s  — 

LL.     co 

O 

1- 

Hered- 
ity 

Remarks: 

Peri-otic 
'Region 

Auri- 
cles 

Mucous  Membrane  Generally                         

Ext- 
Can. 

M.T. 

& 
Tymp 

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Pol.H.M.  Galton 

Pol.H.M,  Galton 

Notes. 

Weber 

Weber 



THE  GENERAL  THERAPEUTICS  OF  EAR  AFFEC- 
TIONS. 

By  CLARENCE  J.   BLAKE,  M.  D., 

01     BOSTON,    M  \>s. 


The  therapeusis  of  disease  in  the  ear,  while  conforming  to  that  of  sur- 
gical and  medical  practice  in  general,  still  presents  certain  points  of  differ- 
ence which   may  be  briefly  noticed  for  practical   purposes  of  reference. 

In  local  medication  departures  from  the  general  rules  are  necessitated  by 
the  peculiar  structure  of  the  external  and  middle  ear,  the  comparative  inac- 
cessibility of  the  latter,  it-  intimate  relation  to  other  important  structures 
and  cavities,  and  the  necessity  of  choice  made  important  by  these  conditions; 
while  in  general  medication  the  internal  administration  of  drugs,  the  selec- 
tion and  method  of  administration,  have  to  be  considered,  not  only  in  regard 
to  the  general  therapeutic  effect  in  which  the  ear  may  participate,  but  also 
with  reference  to  the  special  effects  which  may  be  induced  in  the  organ  of 
hearing  itself.  In  the  local  application  for  the  treatment  of  eczema,  for 
instance,  while  the  rules  to  be  observed  are  those  which  deal  with  the  treat- 
ment of  eczema  in  other  parts  of  the  body,  attention  must  be  paid  to  the 
fact  that  the  external  auditory  canal  is  not  only  a  passage  which  may  be 
easily  obstructed  by  the  detritus  of  the  skin  mixed  with  a  hard  ointment, 
but  that  the  lining  of  the  canal  itself  is  a  skin  which  changes  its  character- 
istics from  a  thick  hairy,  glandular  structure  to  a  thin  pavement  epithelium 
within  a  shorter  space  than  does  the  skin  in  any  other  part  of  the  body. 
An  example  of  general  medication  may  be  taken  in  that  administration 
of  pilocarpin  which  seeks  to  produce  an  effect  in  the  limited  area  of  the 
labyrinth   at    the  expense  of  a    very   general   constitutional   disturbance. 

Following  the  usual  course  of  arrangement  in  treatises  on  diseases  of  the 
ear.  and  proceeding  from  without  inward,  the  diseases  of  the  external  car 
for  which  other  than  surgical  treatment  is  demanded  arc  anomalies  of  secre- 
tion, inflammations  of  the  external  ear  and  of  the  external  auditory  canal, 
eczema,  herpes,   lupus,  ami  syphilitic  inflammations. 

The  anomalies  of  secretion  include,  usually,  the  evidence  of  mechan- 
ical disturbance  in  the  accumulation  of  the  secreted  mass,  and  a  simple  ceru- 
minous  pin-  mixed  with  particles  of  desquamated  epithelium  may  sometimes 
require   more   than   the   use  of  warm    water,  which   is   usually  its  sufficient 

solvent,  to  ell'eet   ii~  entire  removal.      I  Fnder  these   conditions  the  additi f 

sodium  bicarbonate  to  the  water  used  in  syringing,  or  the  previous  instilla- 
tion of  some    weak    alkaline    solution,    properly  warmed,    or   of  a    solution  of 

potassium  iodid  in  a  mixture  of  equal  parts  of  glycerin  and  water,  will  serve 
to  facilitate  the  removal  oi  the  accumulation.  In  the  cases  of  dense  accumu- 
lations of  epidermis  when'  the  eeruminous  secretion  serves  only  as  a  mask  on 
tin-  outer  surface  of  the  deeper-seated  and  more  serious  obstruction,  or  forms 

an   unimportant  element   in  the  epithelial   plug,  it  may  be  necessary,  especially 
684 


ECZEMA.  685 

if  the  plug  has  been  so  loner  retained  as  to  have  become  at  all  lardaceous,  by 
the  use  of  such  stronger  alkalies,  as  solution  of  caustic  potash,  carried  on  a 
cotton-tipped  probe  into  the  ••enter  of  the  mass,  for  the  purpose  of  forming 
with  the  fatty  acids  resulting  from  the  lardaceous  degeneration  of  the  epithe- 
lium, a  soap  which  can  be  easily  washed  away,  to  favor  the  breaking  up  of 
the  epithelial  mass  and  its  removal  piecemeal  by  syringing  or  the  forceps. 
In  all  eases  of  the  use  of  the  caustic  potash  in  this  manner  the  skin  of  the 
external  canal  should  be  moistened  with  weak  acetic  aeid  to  neutralize  the 
effect  of  any  execs-  ofeaustic  potash  which  would  otherwise  irritate  the  skin. 

In  the  fluctuating  hyperemias  of  the  auricle,  which  are  often  a 
great  source  of  discomfort  in  neurotic  subjects,  there  is  demanded  not  only  the 
local  application  of  cold  and  mild  astringent  solutions,  hut  also  an  attention 
to  the  general  health  which  comes  more  distinctly  within  the  domain  of  the 
general  practitioner;  while  for  the  chronic  hyperemia  the  application  of 
astringent  solutions  and  of  cooling  ointments  may  be  further  accompanied 
by  galvanization  of  the  sympathetic 

As  primary  erysipelas  of  the  auricle  is  very  rare,  and  as  the  implica- 
tion of  the  skin  of  the  auricle  occurs  usually  in  the  course  of  an  attack  of 
erysipelas  originating  elsewhere,  the  general  treatment  is  that  indicated  by 
the  demand  for  antipyretics  and  antiphlogistics  ;  and  the  local  treatment  may 
be  limited  to  the  application  of  cooling  solutions,  antiseptic  or  astringent,  as, 
for  instance,  of  oleates  and  powders,  oxid  of  zinc,  and  starch — exception 
being  taken  to  such  as  discolor  the  skin,  and  thereby  interfere  witli  local 
observation  of  the  progress  of  the  case. 

In  the  treatment  of  eczema  the  different  manifestations  of  this  skin- 
disease  must  be  considered,  and  these  vary  not  only  with  the  stage  of  the 
disease,  but  in  the  external  auditory  canal  with  the  portion  of  the  skin  impli- 
cated. At  the  outer  end  of  the  canal,  for  instance,  where  the  skin  is  thick 
and  studded  with  cerumen  and  oil-glands,  a  very  considerable  edema  some- 
times marks  that  stage  of  the  affection  in  which  the  skin  of  the  inner  por- 
tion may  be  bathed  in  a  serous  exudation  or  firmly  encased  in  dried  serum 
crusts.  In  the  moist  stage  the  surface  should  be  carefully  dried  and 
powdered,  either  with  simple  rice-powder  or  rice-powder  mixed  with  equal 
parts  of  powdered  calomel  ;  and  in  the  cases  of  intertrigo  in  children,  in  addi- 
tion a  light  gauze  compress  may  be  placed  behind  the  auricle,  in  order  to 
support  it  and  prevent  the  apposition  of  the  denuded  surfaces  of  the  posterior 
portion  of  the  concha  and  mastoid  region.  Where  crusts  have  formed  as  a 
result  of  the  drying  of  the  serum  mingled  with  the  desquamated  epidermis, 
they  should  be  removed  only  with  care,  and  may  require  softening  to  effect 
this,  which  may  be  done  with  vaselin  applied  by  means  of  the  cotton-tipped 
probe  or  a  canicl's-hair  brush.  After  removal  of  the  crusts  the  exposed  parts 
should  be  smeared  with  a  diachylon  ointment  or  with  some  astringent  oint- 
ment having  vaselin  for  its  base,  the  auricle  being  protected  at  night  by  com- 
presses soaked  in  ointment,  and  the  external  auditory  canal  carefully  anointed 
in  a  similar  manner  by  means  of  a  cotton-tipped  probe.  In  cases  of  obsti- 
nate exudation  at  the  inner  end  of  the  canal  pencilling  with  weak  solutions 
of  nitrate  of  silver  are  of  service,  and  this  application  i>  also  especially 
useful  in  the  squamous  stage.  Internal  treatment,  except  in  so  tar  as  direc- 
tions as  to  general  hygiene  and  diet  are  concerned,  is  rarely  demanded, 
except  in  children,  in  whom  the  administration  of  tonics,  especially  iron. 
the  iodids,  and  arsenic  are  sometimes  indicated. 

Herpes,  which  isan  exceedingly  rare  disease  and  which  requires  very  little 
local  attention,  is  accompanied  by  very  severe  pain,  which  may  be  sometimes 


686      THE  GENERAL    THERAPEUTICS  OF  EAR  AFFECTIONS 

relieved  by  local  application  of  solutions  of  coram,  or,  in  default  of  the 
operation  of  the  local  remedy,  by  the  internal  administration  of  a  narcotic. 

In  cases  of  lupus,  in  addition  to,  or  sometimes  as  a  substitute  for,  the 
surgical  procedure  of  curetting,  applications  may  be  made  of  caustic  potash, 
nitrate  of  silver,  or  of  the  thermocautery,  the  surfaces  to  be  treated  having 
been  previously  cocainized. 

The  most  common  manifestations  of  syphilis  in  the  external  ear  arc 
those  occurring  in  the  form  of  condylomata  and  ulcerations  of  the  external 
canal,  which  require,  in  addition  to  the  general  treatment,  cauterization  of 
the  granulations  with  silver  and  dusting  with  calomel,  the  latter  powder  being 
especially  useful  in  cases  in  which  the  granulations  and  ulcerations  are  accom- 
panied by  an  eczema  of  other  and  adjoining  portions  of  the  skin. 

In  furunculosis  of  the  external  canal,  in  addition  to  the  surgical  treatment 
and  the  application  of  ear-baths,  carbolized  oil  or  oleate  of  morphia  saturating 
a  sofl  pledget  of  absorbent  cotton,  is  of  service.  The  possibility  of  infection 
from  the  micro-organisms  which  have  been  found  in  the  boils  should  always 
be  borne  in  mind  ;  and  where  this  is  the  case  instillation  of  sublimate  alcohol,  of 
borated  alcohol,  and  insufflation  of  boric  acid  should  be  resorted  to  in  addi- 
tion to  the  surgical  treatment.  After  subsidence  of  the  follicular  inflamma- 
tion the  skin  is  very  apt  to  be  somewhat  thickened,  dry,  and  desquamating, 
and  there  i-.  as  would  be  expected  under  these  circumstances,  often  consider- 
able itching,  the  attempt  to  relieve  which  by  ordinary  methods  of  scratching 
or  rubbing  often  serves  only  to  bring  about  a  further  infection  of  the  skin 
and  a  repetition  of  the  furunculosis.  ruder  these  conditions,  the  gentle 
application,  on  a  cotton-tipped  probe,  of  an  ointment  of  salicylic  acid  and 
tincture  of  benzoin  with  vaselin,  lightly  smeared  over  the  skin,  is  often 
of  service;  while  other  interference  on  the  part  of  the  patient  than 
this  should  be  limited  to  pressure  upon  the  tragus  or  rubbing  only  of  the 
external   ear. 

Diffuse  inflammation  of  the  external  canal  usually  occurs  as  the 
result  of  injury  or  in  the  course  of  a  follicular  inflammation.  The  prognosis 
is  Bpeedily  favorable,  and  treatment,  in  addition  to  instillation  of  warm  anti- 
septic solutions  and  cold  applications  about  the  ear,  may  include  the  applica- 
tion of  leeches  in  front  of  the  auricle  in  the  severe  cases,  or  the  more  dis- 
tinctly local  phlebotomy  of  incisions  into  the  skin  of  the  canal   itself. 

The  plant-growth  mosl  commonly  found  in  the  external  auditory  canal 
is  the  aspergillus,  but  in  all  cases  of  parasitic  otitis  externa  the  prognosis  is 
good,  as  the  plant-growth  is  speedily  and  effectually  removed  by  frequent 
and  judicious  syringing,  and.  after  drying  of  the  ear,  the  instillation  of  alcohol 
and  the  insufflation  of  powdered  boric  acid. 

In  acute  inflammation  of  the  middle  ear  internal  medication  some- 
times plays  a  very  important  part  when  it  is  made  to  include  the  attention 
which  should  be  given  to  the  general  causative  condition,  as  well  as  to  the 
local   manifestation  in  the  ear. 

In  the  acute  congestion  of  the  tympanum  accompanying  the  closure  of 
the  Eustachian  tube,  incident  to  coryza  in  childhood,  a<  well  as  in  the  conges- 
tions which  occur  in  the  c -<■  of  the  exanthemata,  bromid  of  potassium  or 

of  -odium,  given  in  -mall  and  repeated  doses,  is  an  important  adjuvant  to 
other  treatment  ;  while  in  more  prolonged  congestions  of  the  lining  membrane 
of  the  mastoid  cells  consequent  upon  acute  otitis  media  in  the  adult,  a  small 
and  continued  dose  of  calomel  has  seemed  to  have  a  favorable  effect. 

So  large  is  the  supply  of  blood  to  the  lining  membrane  of  the  tympanum 
and   mastoid  cells,  and  so   subjeel    is   it    to  vaso-motor    influences,  thai   the 


ACUTE  INFLAMMATION  OF  THE  MIDDLE  EAM.  687 

demand  for  relief  in  acute  cases  is  one  which  sometimes  requires  medical  as 
well  as  surgical  interference  ;  ami,  while  the  latter  affords  certainly  the  readiest 
and  often  the  most  efficient  remedy,  the  fact  that  the  intimate  relationship  of 
the  middle  ear  through  the  circulatory  and  nervous  systems  with  the  general 
economy  makes  the  influence  to  l>e  exerted  upon  it  by  general  medication  a 
peculiarly  favorable  out.  due  experiment  of  Roosa  and  Hammond  upon  the 
effects  of  quinin  internally,  as  shown  by  ocular  observation  of  the  blood- 
vessels in  the  tympanic  membrane,  is  an  illustration  of  the  effect  of  a  drug 
internally  administered  under  actual  observation  of  its  ultimate  effect  ;  and 
similar  observations  upon  the  action  of  bromid  of  potassium  in  cases  of 
artificially  produced  congestion  of  the  middle  ear  show  that  while  the  larger 
doses,  from  15  to  50  gr.,  according  to  the  age  of  the  patient,  produce  a  more 
immediate  effect  in  the  lessening  of  the  capillary  circulation,  the  -mailer  and 
continuous  doses,  from  1  to  5  gr.  every  hour,  have  a  cumulative  effect  in  the 
same  direction,  which  is  desirable  in  the  more  protracted  cases.  In  the 
simple,  uncomplicated  acute  congestion  of  the  middle  car  in  childhood,  in 
addition  to  the  administration  of  the  bromids,  there  may  lie  instilled  into  the 
painful  ear,  providing  always  that  no  perforation  of  the  tympanic  membrane 
exists,  the  solution  of  sulphate  of  atropin  in  equal  parts  of  glycerin  and 
water — the  purpose  of  this  mixture  being  to  provide  a  fluid  which  shall 
not  only  retain  heat,  hut  shall  furnish  on  the  outside  of  the  tympanic  mem- 
brane a  fluid  of  greater  density  than  the  serum,  and  one  which,  therefore, 
will  favor  exosmosis  through  the  dermoid  layer;  while  such  absorption  of 
the  atropia  as  is  possible  under  the  conditions  of  blood-tension  tends  to 
allay  pain.  How  far  the  relief  experienced  in  the  cases  of  acute  earache  in 
childhood  on  instillation  of  this  solution  of  atropia,  as  recommended  by  Theo- 
bald, is  due  to  the  absorption  of  the  atropia,  and  how  much  to  the  simple 
effect  of  a  warm  application,  it  is  impossible  to  say  ;  but  the  clinical 
observation  of  its  use  certainly  commends  it.  Where  there  is  much  swell- 
ing of  the  nasal  mucous  membrane,  with  acute  closure  of  the  Eustachian 
tube,  the  intranasal  injection  of  a  lew  drops  of  a  weak  solution  of  cocain, 
by  causing  temporary  subsidence  of  congestion  and  swelling,  favors  the 
opening  of  the  Eustachian  tube,  the  drainage  of  fluid  from  the  middle 
ear,  and  makes  inflation  by  means  of  the  Politzer  air-douche  or  catheter 
more  easily  possible.  The  treatment  here  indicated  applies  equally  to  those 
cases  of  implication  of  the  middle  ear  in  the  acute  stages  of  the  exan- 
themata, but  internal  medication  may  be  of  service  also  in  the  aural  sequelae 
of  these  diseases.  In  the  persistent  swelling  of  the  tympanic  mucous  mem- 
brane which  sometime-  follows  measles  in  voting  children,  and  which  ap- 
parently lays  the  foundation  for  a  permanent  and  progressive  thickening  of 
the  mucous  and  submucous  tissues  of  the  middle  ear  in  later  life,  the  admin- 
istration of  the  iodids,  or,  preferably  of  the  syrup  of  hydriodic  acid,  is  ap- 
parently of  marked  benefit  :  the  administration  of  the  latter  drug  may  begin 
shortly  after  recovery  from  measles.  It  should  be  given  in  doses  of  a 
teaspoonful  twice  or  thrice  daily  between  meal-,  and  in  prescribing  may  be 
combined  with  one-fourth  part  of  sherry  wine  or  other  alcoholic  stimulant. 
The  effect  of  the  drug  should  be  watched,  and  in  the  event  of  the  appear- 
ance of  an  acute  coryza  or  facial  eruption  \\<  use  should  be  suspended  until 
these  symptoms  have  disappeared  ;  and,  as  a  rule,  better  effects  are  obtained 
by  giving  it  only  two  and  three  weeks  at  a  time,  with  intervals  of  one  and 
two  weeks'  abstention.  This  same  remedy  ha-  also  been  found  useful  in 
the  cases  of  nasal  and  naso-pharyngeal  catarrh  which  are  apt  to  have  an 
important  and  deleterious   influence  upon  the  noddle  ear;  and  even  in  adult- 


688      THE  GENERAL    THERAPEUTICS  OF  EAR  AFFECTIONS. 

in  cases  of  chronic  catarrhal  inflammation,  with  gradual  thickening  of  the 
mucous  membrane  in  the  tympanum,  the  continued  use  of  the  syrup  of 
hydriodic  acid  has  seemed  to  be  of  service. 

In  cases  of  acute  perforation  of  the  tympanic  membrane  in  very 
young  children,  as  well  as  in  the  suppurative  processes  accompanying  and  fol- 
lowing the  acute  exanthemata,  more  especially  scarlet  fever,  local  medication, 
which  accompanies  the  process  of  cleansing,  needs  to  be  adapted  to  one  or 
more  of  two  or  three  conditions.  I  n  the  serous  discharge  from  the  ear  which 
in  infant-,  mingling  with  the  particles  of  desquamated  epidermis  in  the  canal 
and  with  light-colored  cerumen,  often,  to  superficial  observation,  simulates 
pus,  syringing  with  a  warm  weak  solution  of  the  sulphocarbolate  of  zinc  is 
more  serviceable  than  the  alkaline  washes,  because  the  congestion  at  the 
inner  end  of  the  canal  incident  to  the  congestion  of  the  middle  ear  favors 
an  exfoliation  of  the  delicate  epidermis,  and  renders  a  slightly  astringent 
application  acceptable.  In  cases  of  perforation,  with  distinct  mucous  or 
muco-purulent  discharge  from  the  ear,  especially  if  the  discharge  has,  as  is 
not  infrequently  the  case,  a  slightly  acid  reaction  and  an  irritating  effect 
upon  the  skin  of  the  external  canal,  syringing  with  mild  alkaline  waters  or 
with  a  weak  solution  of  bicarbonate  of  soda  has  often  a  more  serviceable 
effect  than  the  use  of  astringent  solutions  or  the  insufflation  of  astringent  and 
antiseptic  powder-.  In  this  connection  it  may  not  be  improper  to  express  an 
opinion  in  regard  to  the  forcible  inflation  of  the  middle  ear  by  Politzerization 
in  cases  of  acute  suppurative  inflammation  of  the  middle  ear  with  perfora- 
tion of  the  tympanic  membrane  in  very  young  children.  This  procedure, 
which  i<  sometimes  strongly  advised,  and  which  has  for  its  purpose  the 
passage  of  a  column  of  air  through  the  Eustachian  tube  into  the  middle  ear 
and  out  through  the  opening  in  the  tympanic  membrane,  carrying  with  it  the 
accumulated  products  of' the  mucus-secreting  glands,  and  of  a  suppurative 
process — while  effective  in  it-  purpose  in  temporarily  emptying  a  cavity  of 

-mall    capacity ubjects    the   structure-   of    the    middle  ear  to  an    indefinite 

degree  of  disturbance;  and  the  cavity,  moreover,  if  the  secretion  is  copious, 
immediately  refills.  Where  the  perforation  in  the  tympanic  membrane 
is  sufficient  to  permit  a  free  egress  to  secretions  from  within,  the  outflow 
of  fluid  will  correspond  in  degree  to  the  degree  of  its  production  ;  and  the 
complete  emptying  of  the  cavity,  therefore,  has  for  its  purpose  the  oppor- 
tunity afforded  for  the  intratympanic  instillation  of  medicated  solutions 
which  may  have  a  favorable  and  deterrent  effect  upon  the  freely  secreting 
lining  of  the  middle  ear.  The  attempt  to  effect  both  these  purposes,  as 
proposed  by  Van  Millingen,  in  syringing  through  the  Eustachian  tube 
into  the  middle  car,  with  e\it  for  the  fluid  through  a  perforation  in  the 
tympanic  membrane,  was  found  to  result  in  a  degree  of  violence  to  the 
affected  part-  entirely  inconsistent  with  their  delicacy  of  structure.  In 
th(  acute  suppurative  pro,',--  i,,  the  middle  ear.  both  in  children  and 
in  adult-,  it  being  had  in  mind  that  congestion  and  edematous  infiltration 
are  prominent  conditions  of  the  early  stages,  it  stands  to  reason  that  palli- 
ative measures,  both  local  and  general,  are  first  in  order.  Locally,  these 
may  include,  in  addition  to  the  direct  surgical  phlebotomy,  the  instillation 
into  the  ear  of  mild  alkaline   ami  antiseptic    solutions,  the  applicati f  y\v\ 

warmth  or,  in  cases  of  <arly  mastoid  congestion  with  |»ain  and  rise  of  tem- 
perature, the  application  of  cold  to  that  regi sither  by  means  of  compresses, 

tin-  ice-bag,  or  the  Letter  coil,  with  internal  administration  of  the  bromids,  of 
Opiates,    if  necessary,    of    -aline    laxative-    (upon    the    value   of  which    much 

stress  i-  laid  by  the  early  English  authorities),  and  the  observance  of  a  light, 


CHRONIC  SUPPURATIVE  DISEASE  OF  THE  MIDDLE  EAR.    689 

non-stimulating  diet.  In  these  cases  in  the  adult  also  the  freeing  of  the 
bowels,  followed  by  the  continuous  administration  of  a  mild  laxative  like 
calomel,  is  apparently  a  useful  adjuvant  to  other  treatment.  The  use  of 
calomel  in  the  small  and  continued  dose  in  cases  of  localized  inflammation 
was  suggested  by  the  late  Dr.  E.  II.  Clarke,  whose  administration  of  this 
drug  was  based  upon  long  experience  at  a  time  when  a  much  higher  value 
was  put  upon  it-;  effect   than  at  present  obtains. 

Tn  chronic  suppurative  disease  of  the  middle  ear,  in  addition  to 
the  ordinary  cleansing  process  for  the  removal  of  the  discharge  both  from  the 
external  and  middle  ear,  and  the  use  of  the  alkaline  solutions  for  that  pur- 
pose, as  already  indicated  in  the  more  acute  cases,  it  is  sometimes  neces- 
sary to  apply  astringent  solutions  or  powders  for  the  purpose  of  acting  upon 
the  inflamed  or  ulcerated  surfaces  of  the  mucous  membrane  of  the  middle 
ear  or  the  dermoid  lining  at  the  inner  end  of  the  external  auditory  canal,  or 
to  act  as  a  deterrent  to  the  undue  formation  of  granulomata.  In  all  cases, 
after  the  cleansing  has  been  effected  either  by  the  ordinary  syringe  or  the 
middle-ear  syringe,  the  surfaces  to  be  medicated  should  be  dried  as  thoroughly 
as  possible  by  means  of  a  cotton-tipped  probe  or  by  pledgets  of  absorbenl 
cotton;  and  in  old  cases  of  chronic  suppurative  disease,  especially  where 
the  epitympanic  space  has  become  involved  or  where  there  arc  evidences 
of  caries  of  the  bony  wall  of  that  cavity  or  of  the  ossicles,  the  drying 
process  should  be  made  the  occasion  for  a  careful  examination  of  the  parts 
with  a  view  to  more  direct  local  application  of  astringents,  acids,  or  other 
escharotics. 

In  the  simple  uncomplicated  chronic  suppurative  disease,  after 
cleansing  and  drying,  insufflation,  with  or  without  packing,  of  antiseptic 
powders,  preferably  boric  acid,  acetanilid,  or  a  combination  of  the  two,  may. 
suffice  as  treatment  ;  although  the  instillation  of  a  saturated  solution  of  boric- 
acid  in  alcohol  or  of  alcohol  alone  diluted  with  water  to  a  point  at  which  it 
can  be  easily  borne  in  the  ear,  will  serve  to  shrink  the  smaller  granulomata, 
which,  springing  from  ulcerated  surfaces,  both  tend  to  increase  the  volume 
of  purulent  discharge  and  sometimes,  by  their  unfavorable  position  to  block 
it-  exit.  Further  and  localized  applications  to  the  granulations  or  polypi 
may  be  made  by  use  of  a  saturated  solution  of  nitrate  of  silver  on  a  cotton- 
tipped  probe,  or  of  such  astringents  as  muriated  tincture  of  iron,  ferric  alum, 
or,  in  the  case  of  firmer  polypi,  of  escharotics;  while  weak  sulphuric  arid, 
the  contiguous  surfaces  being  guarded  by  moistening  them  with  a  weak 
alkaline  solution,  may  sometimes  be  employed  as  an  application  to  carious 
bone  and  as  a  substitute  for  the  use  of  the  curette. 

In  cases  of  chronic  non-suppurative  disease  of  the  middle  ear 
local  medication,  except  such  as  is  limited  to  applications  through  the  Eusta- 
chian tube,  is  of  comparatively  little  service,  unless  we  may  include  under  this 
head  the  mechanical  operation-  which  affect  the  circulation  in  the  tympanic 
membrane  and  the  middle  car.  such  a-  the  use  of  the  Politzer  method  of  an 
air-tight  seal  at  the  outer  end  of  the  external  auditory  canal,  absorption  of 
the  enclosed  air  by  the  dermoid  lining  of  the  canal  producing  a  partial 
vacuum.  This  not  only  results  in  a  preponderating  atmospheric  pressure  on 
the  inner  surface  of  the  drumhead,  but  also  in  an  increase  of  the  capillary 
circulation  of  the  lining,  not  only  of  the  external  canal,  but  also  in  a  lesser 
degree  of  that  of  the  middle  ear.  The  various  processes  of  massage,  having 
for  their  purpose  an  increase  in  the  mobility  of  the  drumhead  and  other  por- 
tions of  the  sound-transmitting  apparatus,  tend  also  by  increasing  the  circu- 
lation in  these  parts  t<»  stimulate  the  absorbent  glands,  and  so  favor  a  decrease 
it 


THE  GENERAL    THERAPEUTICS  OF  EAR  AFFECTIONS. 

of  the  thickening  already  existing  in  the  mucous  and  Submucous  tissues  of 
the  middle  ear. 

In  tlierouiM  of  a  progressive  non-suppurative  middle-ear  disease, 
however,  general  medication  and  attention  to  general  hygiene  sometimes  play 
an  important  part,  since  the  effects  of  faulty  nutrition  which  result  from 
general  overtire  and  nervous  overstrain,  increased  still  further  by  the  fatigue 
incident  to  a  considerable  degree  of  deafntess,  interfere  with  the  nutrition  of 
the  more  delicate  structures  of  the  body,  and  so  favor  trophic  changes  which 
arc  evidenced  in  the  car  by  still  further  impairment  of  hearing.  The  cir- 
culatory tinnitus,  which  accompanies  many  cases  of  chronic  progressive  mid- 
dle-ear disease,  often  becomes  an  important  factor  in  the  general  nervous 
condition  of  the  patient  ;  and  remedies  tending  to  decrease  the  cerebral  circula- 
tion or  to  lessen  the  sensibility  of  the  nervous  system  are  often  of  important 
temporary  benefit.  This  is  especially  the  case  where  the  neurasthenic  condi- 
tion make-  both  the  impaired  hearing  for  sounds  aerially  conveyed,  and  the 
correspondingly  increased  hearing  of  the  cerebral  and  intra-aural  circulation 
a  matter  of  grave  annoyance  and  sometimes  of  detriment.  While  they  need 
nol  be  specified  here,  the  measures  applicable  to  the  treatment  of  abnormal 
condition-  in  the  nose  and  naso-pharynx  are  very  important  consideration-  as 
a  part  of  the  treatment  of  the  aural  disease. 

in  diseases  of  the  internal  ear  where  local  medication  is  out  of  the 
question,  and  dependence  for  an  effeel  upon  this  portion  of  the  organs  of 
hearing  and  of  equilibration  must  bo  placed  upon  such  drugs,  internally 
administered,  as  materially  atfeet  the  circulation  in  these  parts,  the  range  of 
remedies  al  our  disposal  is  necessarily  limited — aside  from  those  which  may  he 
employed  in  improving  the  general  hygienic  condition  of  the  patient.  One 
decided  exception  must  be  made  in  those  cases  of  syphilitic  disease  of  the 
labyrinth  where,  in  the  evenl  either  of  an  affection  of  the  cochlea  with  im- 
pairment of  hearing,  or  of  the  semicircular  canals  with  disturbance  of  equi- 
librium, prompt  administration  of  the  iodids  and  mercurials  sometimes  has  a 
markedly  favorable  effect :  a-  ha-  been  shown  by  Politzer  and  other  observers, 
the  use  of  muriate  of  pilocarpin  in  these  cases  is  also  especially  serviceable. 
In  the  non-specific  cases  of  high  grades  of  deafness  and  vertigo  the  drug 
must  "ften  We  administered  for  a  longer  time  and  in  larger  doses  than  in 
the  specific  cases;  and  Dr.  Gorham  Bacon  cite-  a  case  of  a  high  degree  of 
deafness,  with  vertigo,  following  a  chronic  suppurative  disease  of  the  middle 
ear  in  a  man  of  middle  age,  in  whom  the  daily  administration  of  this  drug 
in  gradually  increasing  doses  up  to  three-quarters  of  a  grain  finally  resulted 
in  a  marked  improvement  in  hearing  and  in  stability.  In  simple  congestion 
of  the  labyrinth,  remedies  which  serve  to  decrease  thecerebral  and  also  the 
intralabyrinthine  circulation,  such  a-  the  bromids  and  ergot,  and  in  cases  of 
anemia,  tonics  arid  stimulants  arc  indicated  ;  while  in  cases  of  auditory  vertigo, 
with  occasional  sharper  vertiginous  attacks,  consequenl  upon  sudden  suspense 
of  vaso-motor  inhibition,  the  sulphate  of  quinin,  given  in  the  -mall  and  con- 
tinued dose,  i-  often  of  value  in  equalizing  the  circulation. 


AFFECTIONS  OF  THE  EXTERNAL  EAR. 

BY  SAMUEL  THEOBALD,  M.  D., 

OF   BALTIMORE.    Ml). 


Diseases  of  the  external  oar — that  is  to  say,  of  the  auricle  and  external 
auditory  canal — constitute  about  2()  per  cent,  of  the  total  of  affections  of  the 
auditory  apparatus  as  met  with  in  hospital  practice  ;'  diseases  of  the  auricle 
are  of  comparatively  infrequent  occurrence,  and  make  up  hut  2  per  cent,  of 
the  total  ;  while  affections  of  the  auditory  canal  are  common  and  constitute 
about  24  per  cent. 


AFFECTIONS  OF  THE  AURICLE. 

Congenital  Malformations. — Many  minor  congenital  defects  of  the 
auricle  have  been  described,  such  as  anomalies  of  the  helix,  the  antihelix, 
the  lobule,  the  tragus,  etc.,  but  they  are 
not  of  sufficient  importance  to  demand 
here  especial  consideration.  The  major 
defects,  such  as  microtia  and  polyotia,  have 
frequently  associated  with  them  anomalous 
conditions  of  the  auditory  canal  (atresia, 
etc.),  and  even  of  the  middle  and  internal 
ear.  They  may  be  unilateral  or  bilateral, 
and  are  said  to  be  due  to  incomplete  closure 
of  the  two  upper  branchial  clefts,  insuffi- 
cient turning  up  of  the  auricle  during  its 
development,  etc. 

Microtia. — In  pronounced  cases  of  this 
defect  the  auricle  is  so  misshapen  and  rudi- 
mentary as  to  present  scarcely  any  resem- 
blance to  the  normal  ear,  and  in  some  in- 
stances the  deformity  involves  the  face  as 
well  as  the  ear.  The  condition  is  well 
shown  in  the  accompanying  illustration 
(Fig.  481),  for  which,  as  well  as  for  a 
number  of  other  illustrations  in  this  article,  I  am  indebted  to  Dr.  Ran- 
dall.  The  changes  of  form  are  manifold  and  at  times  fantastic.  Knapp, 
for  example,  lias  met  with  cases  in  which  the  rudimentary  auricle  was  hook- 
shaped  or  spirally  curved,  and  other  cases  have  been  reported  by  .Moos  and 
Steinbriigge  in  which  it  resembled  a  cauliflower  excrescence. 

1  Based  upon  analyses  of  19,568  case — 9670  observed  at  the  Newark  Eye  and  Ear  Infirmary, 
I486  at  the  Baltimore  Eye,  Ear,  and  Throal  Charity  Bospital,  ami  5412  tabulated  by  Dr.  Ran- 
dall, from  his  practice.  At  the  Newark  Infirmary  diseases  of  the  external  ear  comprised  30 
per  cent,  of  tin-  total ;  at  the  Baltimore  Eye,  liar,  and  Throal  Eospital,  no1  quite  28  per  cent.  ; 
and  of  I>r.  Randall's  cases,  17'.  )>er  cent.  Diseases  of  the  auricle  constituted  not  quite  1'  per 
cent,  of  the  total  at  the  first-named  institution,  slightly  more  than  :;  per  cent,  at  the  second,  and 
a  little  over  1.1  percent.  of  tin-  cases  tabulated  by  Dr.  Randall. 

691 


Pig.  181.— Microtia :  puckered  helix,  isolated 
tragus,  and  imperforate  meatus. 


692 


AFFFVTIOXS  OF   THE   FXTFRXAL    FAIL 


Polyotia. — This  term  is  applied  not  only  to  cases  in  which  two  or  more 
auricle-  exist  upon  the  same  side,  hut  also  to  cases  of  microtia  which  are 
accompanied  by  multiple  growths  in  the  immediate  neighborhood  of  the 
auricle,  luit  di-tinct  from  it.  The  most  common  form  is  that  of  a  wart-like 
excrescence  or  more  complex  "auricular  appendage"  situated  upon  the  cheek 


Fig.  482.— Polyotic  growth  present  bilaterally 
in  a  woman  of  22. 


Fig.  483.— Horn-like  auricular  appendage 
with  congenital  Mural  fistula. 


in  front  of  the  external  meatus  (  Figs.  AH'2  and  483).  These  multiple  growths, 
in  exceptional  instances,  are  found  associated  with  a  normal  auricle. 

( lartilaginous  outgrowths  from  the  auricle,  known  as  auricular  appendages, 
are  occasionally  met  with,  their  most  frequent  location  being  upon  the  tragus 
(  Fig.  483). 

Congenital  fissure  or  cleft  of  the  lobule  has  been  observed,  and  is  said 
by  Politzer  to  be  "quite  common,"1  a  statement  which,  as  to  this  pari  of  the 
world  ,ii  least,  hardly  holds  good.  A  variety  of  congenital  fistula,  usually 
located  jusl  above  the  tragus  (Fig.  483),  and  said  by  Burnett  to  connect  in 
some  instances  with  the  tympanic;  cavity,  is  an  anomaly  of  not  very  infre- 
quent occurrence.  Dench  describes  a  case  which  presented  an  opening  about 
one-sixth  of  an  inch  in  diameter,  into  which  a  probe  could  be  passed  to  the 
depth  of  half  an  inch.-  Retention-cysts  have  been  known  to  develop  in 
them,  ami  they  may  be  the  seal  of  purulent  inflammation.  The  depth  is 
usually  -light  and  the  direction  downward  and  forward. 

The  writer  has  met  with  an  instance  of  marked  congenital  difference  in 

the  conformation  of  the  right  and   left   auricles,  i  being  larger  and   more 

prominent  than  the  other,  in  which  the  defied  was  transmitted,  although  in  a 
less  noticeable  degree,  to  the  children  and  grandchildren  an  appreciable  dif- 
ference in  the  auricles  being  observable  in  four  out  of  six  children  and  in 
several  grandchildren. 

As  to  the  treatment  of  congenital  anomalies  of  the  auricle  there  is  not 
much  to  be  -.iid.  Auricular  appendages,  supernumerary  auricles,  and  mul- 
tiple growths  aboul  the  ear  may  be  readily  removed,  and  cleft  of  the  lobe 
may  be  satisfactorily  deall  with  by  operation;  but  attempts  to  remedy  by 
operative  procedure,  plastic  or  otherwise,  the  more  grave  defect  of  microtia 
have  been  attended   by  very  unsatisfactory  results,  and    in   high  degrees  of 

698. 


of  tht   /.'"< ,  En  I  'hilada.,  I  s'.<  I,  j>. 

D  of  il"  Ear,  Nev  York,  1895,  p    1 79. 


AFFECTIONS  OF  THE  AFIilCLF.  693 

this  deformity  removal  of  the  rudimentary  auricle  and  the  substitution  of  an 
artificial  ear  arc  recommended.  Congenital  aural  fistula  docs  not  require 
treatment  unless  it  be  the  scat  of  inflammatory  or  other  changes.  Undue 
prominence  of  the  auricle,  if  seen  in  infancy,  may  be  corrected  in  greal 
measure  by  any  simple  device  which  will  keep  the  car  constantly  in  close 
apposition  with  the  side  of  the  head.  Glueing  the  auricle  to  the  head  with 
collodion  has  been  recommended.  In  adults  such  procedures  are  ineffectual, 
and  the  operation  described  on  page  783   is  called  for. 

Bczema  of  the  Auricle. — This  is  a  condition  of  frequent  occurrence, 
especially  in  ill-nourished,  strumous  children.  It  often  exists  in  association 
with  phlyctenular  ophthalmia,  and  under  such  circumstances  may  be  accom- 
panied by  suppurative  middle-ear  inflammation.  In  adults  the  auditory 
canal  is  usually  involved  in  the  inflammatory  process,  and  the  disease,  which 
is  frequently  dependent  upon  a  gouty  diathesis,  is  less  amenable  to  treatment 
than  it  is  in  children.  In  bad  cases  the  whole  auricle,  and  the  neighboring 
portions  of  the  scalp  as  well,  may  be  affected,  but  oftener  the  inflammation 
is  limited  to  the  line  of  juncture  of  the  auricle  with  the  head,  to  the  concha, 
and  to  the  fossa  helicis. 

The  treatment  should  be  directed  to  the  general  condition  of  the  patient 
as  well  as  to  the  local  affection.  In  adults  the  probable  existence  of  lithemia 
should  be  borne  in  mind,  and  the  patient's  diet  and  his  bowels  should  be 
regulated,  and  the  remedies  usually  employed  to  combat  this  condition  should 
be  prescribed.  In  children  a  brisk  calomel  cathartic  is  often  indicated,  to 
be  followed  by  the  administration  of  the  elixir  or  the  syrup  of  the  phos- 
phates of  iron,  quinin,  and  strychnin — a  much  more  efficacious  remedy,  in 
the  writer's  experience,  than  the  more  frequently  prescribed  syrup  of  the 
iodid  of  iron.  The  most  useful  local  remedies  are  the  oxid  of  zinc  with 
boric  acid  and  the  yellow  oxid  of  mercury.  The  latter  should  be  used  in 
the  form  of  an  ointment  (gr.  ij  to  3j),  and  the  former  either  as  an  ointment 
(1  drachm  of  powdered  boric  acid  being  added  to  an  ounce  of  the  officinal 
oxid-of-zinc  ointment)  or  as  a  powder  (equal  parts,  by  weight,  of  boric  acid 
and  oxid  of  zinc),  to  be  dusted  upon  the  auricle,  and,  when  indicated,  blown 
lightly  into  the  auditory  canal.  When  scabs  are  present  they  should  he 
removed  by  maceration  as  a  measure  preliminary  to  other  treatment.  Paint- 
ing the  affected  part  with  a  solution  of  nitrate  of  silver  (gr.  x-xxx  to  §j)  is 
a  remedy  which  is  at  times  of  value,  especially  in  the  moist  conditions,  and 
subnitrate  of  bismuth  (in  ointment  or  powder),  oil  of  cade,  salicylic  acid, 
aristol,  and  the  different  preparations  of  lead  are  remedies  which  may  be 
tried  should  those  first  named  fail  to  effect  a  cure.  A  tendency  to  relapse  is 
characteristic  of  the  disease  :  too  early  discontinuance  of  the  treatment,  there- 
fore, is  to  be  avoided. 

Herpes  zoster  of  the  auricle  is  a  rare  condition,  but  cases  have  been 
reported  by  J.  Orne  Green,  C.  II.  Burnett,  Anstie,  Auspitz,  Gruber,  and 
others. 

Krysipelas  of  the  auricle  is  occasionally  encountered,  usually  as  an  exten- 
sion of  facial  erysipelas.  The  indications  for  treatment  are  the  same  a-  when 
these  affections  occur  in  other  regions  of  the  body,  and  there  i>  nothing  in 
their  clinical  course   worthy   of  especial   note. 

Abscess  of  the  auricle,  especially  of  the  lobule,  where  it  i-;  often  the 
result  of  piercing  the  ear,  and  where,  particularly  in  the  colored  race,  it  may 
become  cystic,  isof  rather  common  occurrence.  It  is  also  a  usual  accompani- 
inent  of  perichondritis  (Fig.   184). 

The  treatment  consists   in    free   incision,  which  in  the  cystic   cases   may 


694 


Alll'JTIOXS  OF  THE  EXTERNAL    EAR. 


- 


require  to  be  supplemented  by  curetting  <>r,  better  stall,  by  cauterizing  the 
cyst-wall  with  a  bead  <>t'  nitrate  of  silver  fused  upon  the  tip  of  a  probe. 
Perichondritis  of  the  Auricle. — Tins  condition  is  commonly  of  trau- 
matic origin,  but  may  be  due  to  the  extension  of  inflammation  from  the  audi- 
tory canal,  while  occasionally  it  occurs  with- 
out evident  cause.  The  idiopathic  cases  are 
usually  met  with  in  persons  who  are  in  a 
poor  state  of  health  and  in  whom  there  is 
general  malnutrition.  Its  starting-point 
under  such  circumstances  is  probably  in 
certain  degenerative  changes  in  the  carti- 
lage, which  have  been  described  by  Ludwig 
Meyer  and  others,  and  to  which  the  name 
chondromalacia  has  been  given  (Buck).  The 
traumatic  cases  usually  owe  their  origin  to 
blows,  or  may  arise  from  exposure  of  the 
auricle  to  extremes  of  heat  or  cold  (as  in 
frost-bite).  T-he  symptoms  are  a  burning 
sensation  in  the  ear,  followed  by  severe  pain, 
which  is  accompanied  by  swelling  and  marked 
injection  .if  the  auricle.  The  swelling,  which 
may  increase  until  the  normal  configuration  of  the  auricle  is  completely 
obliterated,  is  due  to  an  effusion  of  fluid — usually  serous  at  the  outset,  but 
tending  quickly  to  become  purulent — beneath  the  perichondrium.  The  ear 
feels  hot.  and  is  often  mix  sensitive  to  the  touch.  Left  to  itself,  the  fluid 
tend-  i"  escape  spontaneously,  but  may  be  slowly  absorbed.  A  high  degree 
of  deformity  of  the  auricle  i-  a  frequent  consequence  of  uncontrolled  peri- 
chondritis  I  Fig.  185). 

An  effusion  of  blood,  more  or  less  extensive,  between  the  perichondrium 
and  the  cartilage  (hcematoma  auris;  othcematoma)  (Fig.  486)  is  a  not  infre- 


Fie    184.— Abscess  of  margin  of  helix  ; 
Lt< una  in  pertussis. 


Pig  i-  •     Deformity  alter  perichondritis 
I  fomi 


Pig   186  —Hematoma  of  auricle 
filling  ihe  concha. 


quent    accompaniment    of  pericl dritis,    usually    preceding   the   onset  of  the 

inflammatory  process  in  traumatic  cases  (being  a  direct  consequence  of  the 
injury),  and  following  closely  or  accompanying  it  in  non-traumatic  cases. 
The  etiology  and   pathology   of  tin-   condition    have   been   widely   studied, 


A  FI'I'J  TIOXS  OF  THE  .  1  I  '/:/<  L  K.  695 

especial  interest  attaching  to  the  subject  because  of  the  frequent  occurrence 
of"  tumors  of  this  character  in  the  insane.  Some  investigators  have  attempted 
to  explain  this  association  upon  the  theory  thai  hematoma  auris  is  usually  of 
traumatic  origin,  and  that  the  insane  are  especially  liable  to  injuries  such  as 
might  give  rise  to  it,  either  self-inflicted  or  received  through  efforts  to  control 
them.  Others  maintain  that  the  lesion  is  more  directly  connected  with  the 
insanity  of  the  subject,  and  that  it  is  dependent  upon  the  pathological  condi- 
tion of  the  brain;  while  Virchow,  Ludwig  Meyer,  Pollak,  and  others  con- 
tend— and  apparently  with  greater  justification,  since  their  views  are  based 
upon  more  exact  pathological  study — that  it  has  its  origin  in  degenerative 
changes  found  in  the  cartilage  of  the  auricle,  not  only  in  the  insane,  but  in 
other  ill-nourished  individuals  as  well — changes  which  they  point  out  are 
accompanied  by  the  development  in  the  neighboring  tissue  of  capillary 
vessels  of  unusually  large  size  and  having  very  thin  walls.  With  such  con- 
ditions as  these  existing,  it  can  be  readily  understood  how  hemorrhage  mighl 
result  from  the  most  trivial  violence  to  the  auricle  or  even  without  such 
provocation.1 

Treatment. — If  seen  at  an  early  stage,  the  application  of  cold  in  the  form 
of  the  aural  ice-bag  may  be  productive  of  good  results  in  acute  perichon- 
dritis. If,  in  spite  of  this  measure,  the  effusion  beneath  the  perichondrium 
increases,  aspiration  may  be  resorted  to  under  strict  antiseptic  precautions,  to 
be  followed  by  the  application  of  firm  pressure  upon  the  auricle,  to  prevent 
if  possible — what  is  very  apt  to  occur — a  re-effusion  of  fluid  into  the  aspi- 
rated cavity.  Should  the  fluid  reaccumulate  after,  perhaps,  a  repetition  of 
the  aspiration,  or  should  suppuration  supervene,  the  sac  must  be  laid  open  by 
a  free  incision  and  packed  with  iodoform  gauze.  Should  necrosis  of  the  car- 
tilage have  occurred,  the  necrotic  parts  must  be  thoroughly  removed  by 
curetting.  The  application  of  tincture  of  iodin  to  the  cyst-like  walls  of  the 
cavity  may  be  called  for  to  promote  its  obliteration.  Massage  is  useful  after 
healing  has  taken  place  or  to  bring  about  the  absorption  of  inflammatory 
products  when  incision  has  not  been  resorted  to;  and  the  external  application 
of  iodin  is  also  of  value  under  similar  circumstances. 

In  hematoma  compression  and  massage  may  be  tried  if  the  tumor  lie 
small.  If  it  be  of  considerable  size,  aspiration,  followed  by  compression, 
may  be  employed,  or  the  sac  may  be  freely  opened  and  dealt  with  as  a  peri- 
chondritis unaccompanied  by  extravasation  of  blood.  Tonics  and  a  change 
of  diet  are  usually  indicated.  The  likelihood  of  considerable  deformity  of 
the  auricle  resulting,  even  when  the  case  has  been  judiciously  treated,  should 
not  be  lost  sight  of,  and  should  be  impressed  upon  the  patient. 

Syphilis  of  the  Auricle.— The  primary  lesion  of  syphilis,  as  mighi  be 
supposed,  is  rarely  located  upon  the  auricle,  yet  casesof  this  character  have 
been  reported  by  Pellizzari,  Zucker,  ETermet,  and  others,  the  cause  of  the 
infection  being  usually  a  bite  by  a  syphilitic  individual.  The  eruption--  of 
secondary  syphilis  are  frequently  observed  upon  the  auricle,  accompanying 
similar  eruption- upon  the  face  and  scalp.  Grummata  and  syphilitic  ulcera- 
tions are  rare,  but  cases  have  been  observed  by  Buck,  Burnett,  and  Politzer. 

The  indications  for  treatment  are  simply  those  which  apply  to  syphilis 
affecting  other  portions  of  the  body. 

I/Upus. —  In  lupus  vulgaris  of  the  face  the  auricle  is  frequently  involved, 
but  cases  in  which  tin-  disease  originates  in  or  is  confined  to  the  auricle  arc 
extremely  rare.     The  auricle  may  be  affected  in  any  of  the  various  types  "f 

1  For  a  fuller  consideration  of  tliis  subject  see  Manual  •/  l>  I    r,  by  Dr.  Albert 

JI.  Buck,  p.  56  >i  <"i ,  New  York,  1895. 


69t> 


AFFECT  in. \s  or   Till:   FXTFRNAL  EAR. 


lupus.  Ill  the  ulcerative  forms  of  the  disease  it  may  be  partially  or  even 
totally  destroyed,  and  the  auditory  canal  and  middle  ear  may  be  invaded. 

Treatment. —  In  removing  the  diseased  tissue  with  the  curette,  the  gal- 
vano-cautery,  or  with  caustics,  care  should  he  exercised  not  to  sacrifice  healthy 
structures,  otherwise  marked  deformity  of  the  auricle  will  ensue.  To  pre- 
vent involvement  of*  the  auditory  canal  and  deeper  structures  of  the  ear,  com- 
plete removal  of  the  auricle  may  at  times  he  required. 

Frost-bite.  —  In  cold  climate-  frost-bite  of  the  auricle  is  of  common 
occurrence,  and  even  actual  freezing  of  the  ear  may  take  place,  ruder  such 
circumstances  the  auricle  may  become  fragile,  and  must,  therefore,  be  manip- 
ulated with  care. 

In  the  treatment  of  this  condition,  to  prevent  too  sudden  reaction,  it  is 
advised  that  the  ear  should  be  "  thawed  out  "  gradually  by  the  application  of 
snow,  pounded  ice,  or  cold  water,  the  individual  being  kept  for  a  time  in  a 

cold  r n  or  even  ouf  of  dour-.     Subsequently  the  case  musi  he  treated  much 

as  one  would  treat  a  hum — by  the  application  of  an  emollient,  such  as 
linseed  oil  and  lime-water  or  vaselin.  Perichondritis,  with  more  or  less 
extensive  necrosis  of  the  cartilage,  may  result  from  prolonged  exposure  of 
the   auricle    to   cold. 

New  Growths  of  the  Auricle. — The  auricle  is  occasionally  the  seat 
of  malignant  as  well  as  of  benign  tumors.  The  most  frequently  met  tumor 
of  the  auricle  is  fibroma  or  keloid.  It  is  usually  located  in  the  lobule,  and 
owe-  its  origin  almost  always  to  the  operation  of  piercing  the  ear  or  to  the 
irritation  accompanying  the  wearing  of  an  ear-ring.  It  is  of  especially  fre- 
<  I  in  'iit  occurrence  in  the  negro  race  (Fig.  487),  and  is  said  to  exhibit  a  decided 


Fig   187     Fibroma  (keloid  of  lobule  (bilateral   In  a  negro  girl  after  piercing  for  ear-rings. 

tendency  to  recur  after  removal,  although  the  writer'-  experience  with  such 
ths — -not  very  extended,  it  i-  triK — would  not  lead  him  to  endorse  this 
view.  The  tumor  is  quite  firm  and  the  surface  is  usually  nodular.  Both  ears 
are  not  infrequently  affected,  the  exciting  cause  in  each  instance  being  the  same. 
Other  benign  growths  which  have  Inch  observed  are  lipoma,  angioma, 
papilloma}  and  sebaceous  cyst  (see  Fig.   162). 


AFFEVTIOXS  OF  THE  Al'FK'LE. 


697 


Horny  Growths  springing  from  the  auricle  have  been  encountered  by 
Buck,   Burnett,   Pomeroy,   Roosa,  and  others.     In  a  case  reported  by  Buck 

the  growth,  which  was  attached  to  the  upper  and  posterior  portion  of  the 
helix,  is  described  as  "a  blunted,  horn-like  protuberance,  \  inch  long  and 
nearly  as  broad  at  its  base."  The  writer  has  never  met  with  a  growth  of  this 
character  upon  the  ear,  hut  several  years  since  saw  a  precisely  similar  growth 
upon  the  upper  eyelid  near  its  free  margin.  It  was  somewhat  curved,  nearly 
1}  inches  in  length,  and  was  said  to  have  been  only  two  months  in  forming. 
Like  the  growth  observed  by  Dr.  Buck,  it  was  longitudinally  striated. 

Of  malignant  growths,  epithelioma  (Fig.  488)  is  the  one  which  has 
been  oftenest  met  with,  cases  having 
been  reported  by  (! ruber,  Wilde, 
Kramer,  Toynbee,  Demarquay,  J. 
Orne  Green,  Brunner,  Burnett, 
Roosa,  Buck,  and  others.  More 
rarely  sarcoma  of  the  auricle  has 
been  observed.  Malignant  growths 
of  the  auricle  tend  to  invade  the 
auditory  canal  and  middle  ear,  and 
death  may  be  brought  about  in 
this  way. 

Treatment. —  In  malignant  tu- 
mors of  the  auricle  early  operative 
interference  is  of  course  indicated, 
and  complete  removal  of  the  auricle 
may  be  called  for.  Lipomata,  an- 
giomata,  sebaceous  cysts,  etc.  should 
be  dealt  with  as  when  they  occur 
elsewhere.  Fibromata  of  the  lobule, 
even  when  of  considerable  size,  may 
be  readily  removed,  and  with  little 
resulting  deformity,  by  an  approximately  (inverted)  V-shaped  incision  carried 
through  the  whole  thickness  of  the  lobe. 

Wounds  Of  the  Auricle.  —  Lacerated  and  incised  wounds  of  the 
auricle  are  occasionally  met  with,  and  exceptionally  the  whole  auricle  may  be 
torn  or  even  bitten  off.  The  writer's  grandfather,  the  late  Prof.  Nathan  R. 
Smith,  of  Baltimore,  once  had  a  singular  experience  of  this  latter  kind.  A 
man,  carrying  an  ear  in  his  hand,  rushed  excitedly  into  the  office,  exclaiming 
that  one  of  his  ear-  had  been  bitten  off  in  a  tight,  and  that  he  wished  it  re- 
placed. A  few  moments  later  another  equally  excited  individual,  with  an 
auricle  missing  and  carrying  an  ear  in  his  hand,  made  his  appearance,  and 
loudly  protested  that  the  first  man  had  taken  the  wrong  ear  and  that  he  had 
brought  the  one  which  belonged  to  him.  In  the  modern  game  of  football, 
as  in  the  German  duel,  injuries  of  the  auricle  are  of  such  frequent  occur- 
rence that  special  contrivance-  for  protecting  the  ear  are  worn. 

Treatment. — When  parts  of  the  ear  are  cut  cleanly  off  (as  happen-  in  the 
duels  at  the  German  universities),  they  may  be  replaced  with  every  pro-pet 
that  union  of  the  divided  surfaces  will  occur,  and  even  when  the  entire 
auricle  is  cut  or  torn  off  an  effort  should  be  made  to  replace  it,  as  reunion  has 
occurred  under  such  circumstances.1      In   closing  wounds  of  the  auricle  or  in 

1  Yon  Troltsch  states  thai  "  in  India,  where,  as  is  well  known,  the  car-  are  s times  cm  r>ff 

in  war  and  as  a  punishment  for  crime,  thej  arc -aid  to  be  sometimes  replaced  by  transplanta- 
tion from  a  living  person"  l  Diseases  "j  tl«  /•.'<"•,  New  York,  1869,  p    51  • 


Fig.  488.— Epithelioma  of  auricle  of  20  years'  stand- 
ing, with  cicatricial  contractions. 


698  AFFECTIONS  OF  THE    EXTERNAL   EAR. 

reattaching  severed  parts  stitches  should  be  used  as  sparingly  as  possible,  and 
should  never  penetrate  the  cartilage.  Collodion,  reinforced  by  l>its  of  crepe- 
lisse  or  of  lint,  will  usually  suffice  to  maintain  the  parts  in  apposition.  Asep- 
tic precautions  arc  of  course  essential,  l>ut  strong  antiseptic  agents  should 
be  avoided. 

Cleft  of  the  I^obule. — This  condition  is  of  frequent  occurrence,  and  is 
almost  always  due  to  thai  relic  of  barbarism,  the  wearing  of  car-rings.  Oc- 
casionally  it  results  simply  from  a  heavy  car-ring  gradually  wearing  its  way 
through  the  lobe,  but  more  often  it  is  produced  by  the  ear-ring  being  acci- 
dentally or  intentionally  torn  from  the  ear.  The  writer  has  seen  instances — 
and  many  such  have  been  reported — where  the  lobe  had  been  cleft  in  this 
way  several  time-,  and  was  represented  by  three  or  four  teat-like  projections. 
The  deformity,  even  from  a  single  cleft,  is  considerable,  and  it  not  infre- 
quently happens  that  the  aural  surgeon  is  applied  to  to  remedy  it. 

The  treatment  is  by  operation  (see  page  782). 

AFFECTIONS  OF  THE  EXTERNAL  AUDITORY  CANAL. 

Congenital  Malformations. — Congenital  atresia  of  the  external 
auditory  canal  has  been  mentioned  as  an  occasional  accompaniment  of 
microtia  and  polvotia  (see  Fig.  481).  Cases  have  been  observed  in  which  this 
defect  existed  without  accompanying  malformation  of  the  auricle,  but  they  are 
comparatively  rare.    The  atresia  may  involve  a  part  or  the  whole  length  of  the 

canal,  and  maybe  of  oss -  or  membranous  character.    A  shallow  depression 

or  a  somewhat  deeper  cul-de-sac,  reaching  perhaps  to  the  point  at  which  the 
bony  meatus  should  normally  begin,  exists  in  some  instances,  while  in  others 
no  trace  of  the  meatus  is  to  be  found.  Politzer  mentions  having  dissected  a 
case  of  atresia  of  the  auditory  canal  associated  with  microtia  in  which  the 
..—-on-  and  membranous  labyrinth  were  perfectly  formed,  but  in  which  the 
external  meatus  was  represented  by  a  fibrous  cord  1  cm.  long,  and  the  tym- 
panic cavity  was  entirely  absent.1  Cases  of  congenital  narrowing  of  the 
auditory  canal,  and  also  of  hour-glass  contraction  of  the  canal  (Wilde),  have 
been  observed. 

Even  with  complete  bony  occlusion  of  the  auditory  meatus  the  hearing 
may  be  fairly  good  if  the  deeper  part-  of  the  ear  are  normal.  The  writer 
ha-  reported  a  case  of  complete  osseous  occlusion  of  both  auditory  canals  (not, 
however,  of  congenital  origin),  in  which  the  patient  could  carry  on  a  conver- 
sation very  satisfactorily  if  spoken  to  in  a  slightly  raised  tone  of  voice.2  In 
a  case  of  congenita]  occlusion  of  both  auditor)  canal-  with  microtia3the 
patient  could  distinguish  word-  spoken  in  a  low  voice  at  a  distance  of  six 
feet,  even  with  the  eye-,  no-e,  and  mouth  tightly  closed,  as  can  almost  every 
one  with  normal  ears  slightly  stopped  bv  the  lingers. 

Treatment. — In  congenital  atresia  of  the  auditory  canal  it  seldom  happens 
that  anything  Can  be  done  to  ameliorate  the  patient's  condition,  which,  how- 
ever, a-  has  been  indicated,  i-  not  usually  as  unfortunate  as  might  be  sup- 
posed. If  the  atresia  !><•  limited  In  extent,  involving  but  a  small  part  of  the 
canal  (which  is  not  often  the  case),  whether  it  be  osseous  or  membranous,  an 
effort  may  be  made  to  overcome  it  by  suitable  cutting  or  boring  instruments  ; 
but  if  it  be  more  extensive,  experience  has  shown  that  operative  interference 
i- of  no  avail,  since  the  atresia  invariably  recurs.  Possibly,  skin-grafting  by 
Thiersch's   method   might   under  such  circumstances  render  the  chances  of 

1  hi  .  i  .    ■•(  tfu   Ear.  p.  698.  "  Traiut.  Amer.  Otolog.  Soc,  vol.  iii.  p.   15. 

■  Reported  by  It.  W.  II.  Robb  in  tin-    Lmer,  ./••»/•".  .;/'  Otology,  vol.  iii    p.  278. 


AFFECTIONS  OF  EXTERNAL  A  UDITOR  Y  i'A  N. I  L.  699 

success  somewhat  better.      When  there  is  simply  congenital  narrowing  of  the 

canal,  especially  it'  it  be  circumscribed,  much  may  be  accomplished  in  time  by 
having  the  patient  wear  continually  in  the  meatus  an  elastic  plug  of  absorbent 
cotton,  sponge,  or  some  similar  material. 

As  much  rarer  congenital  anomalies  unduly  capacious  auditory  canals  are 
met  with,  and  also  a  doubling  of  the  canal.  Sometimes  there  is  a  second 
canal,  terminating  in  a  cul-de-sac,  behind  the  true  canal  and  having  no  con- 
nection with  it,  as  in  the  eases  observed  by  Velpeau  and  Macauln  ;  and 
again,  as  in  Bernard's  case,  then1  may  be  two  separate  canals,  which  after  a 
short  course  unite  to  form  a  common  canal.1 

Impacted  Cerumen. — Occlusion  of  the  auditory  canal  by  a  mass  of 
inspissated  cerumen  is  the  affection  of  the  external  ear  which  most  frequently 
demands  the  attention  of  the  aurist.  Usually  the  patient  is  entirely  uncon- 
scious of  the  presence  of  the  mass  until  the  canal  is  completely  occluded  by 
it.  Then  the  hearing,  which  before  had  not  been  appreciably  diminished, 
although  the  ceruminous  plug  may  have  all  but  filled  the  lumen  of  the  canal, 
becomes  at  once  greatly  impaired,  autophony  manifests  itself,  and  very  fre- 
quently tinnitus  makes  its  appearance  to  add  to  the  discomfort  and  alarm  of 
the  patient.  Although  the  mass  develops  very  slowly,  many  months  usually 
elapsing  before  it  becomes  inconveniently  large,  the  symptoms  just  enumer- 
ated generally  manifest  themselves  suddenly.  The  usual  explanation  of  this 
is  that  water  has  run  into  the  ear  in  washing  or  bathing1,  or  in  warm  weather 
perspiration  has  found  its  way  into  it  and  has  caused  the  plug,  which  previ- 
ously had  nearly  tilled  the  canal,  to  swell  up  sufficiently  to  make  the  occlu- 
sion complete.  Occasionally  it  is  a  fluid  which  the  individual  has  intentionally 
dropped  into  the  ear  or  some  manipulation  on  his  part  of  the  ceruminous 
mass,  which  brings  about  the  sudden  change.  Exceptionally  the  same  symp- 
toms may  result,  accompanied,  perhaps,  by  pain,  from  a  smaller  mass  of  wax 
(which  left  undisturbed  might  not  have  caused  inconvenience  for  a  long  time) 
being  dislodged  and  pushed  down  upon  the  drumhead  by  the  efforts  of  the 
patient  to  remove  it.  Again,  when  the  plug  is  very  hard  and  occupies  the 
outer  portion  of  the  meatus,  it  may,  through  the  movements  of  the  jaw,  exert 
sufficient  pressure  upon  the  canal-walls  to  cause  pain,  and  perhaps  inflamma- 
tion, before  it  has  become  so  large  as  to  interfere  with  audition. 

The  plug  varies  greatly  in  consistency  and  in  solubility,  and  frequently 
contains  innumerable  short,  pale  hairs  (from  the  walls  of  the  canal).  Very 
often  it  is  in  part  made  up  of  pieces  of  exfoliated  epidermis,  and  exception- 
ally it  has  as  a  nucleus  some  small  foreign  body  which  has  found  its  way  into 
the  ear,  or  an  old  scab  left  by  a  former  otitis.  More  frequently  than  not  both 
ears  are  involved,  so  both  should  invariably  be  examined. 

Among  the  rarer  symptoms  produced  by  the  presence  of  impacted  ceru- 
men in  the  ear  may  be  mentioned  dizziness,  reflex  cough,  perturbation  of  the 
mental  faculties  with  inability  to  concentrate  the  mind  in  intellectual  pm- 
suits,  disturbances  of  gait  simulating  those  of  locomotor  ataxia  (Risley), 
epileptiform  convulsions,  and,  in  a  case  reported  by  the  writer, 2  inability 
to  swallow,  accompanied  by  a  feeling  of  oppression  about  the  heart.  The 
added  danger  which  results  in  otitis  media  from  a  pre-existeni  occlusion  oi 
the  meatus  by  impacted  cerumen  should  also  not    be  lost  sight  of. 

With  good  illumination  it  is  usually  a  very  easy  matter  to  detect  the 
presence  of  a  ceruminous  plug  in  the  auditory  canal.  It  is  seen  as  a  dark- 
brown  mas-  tilling  the  lumen  of  the  canal,  and  with  its  outer  surface  situated 
usually  at  about  the  line  of  juncture  of  the  osseous  and  membranous  portions 

1  Politzer:  Diseases  of  the  Ear,  p.  698.  'z  Trans.  Amer.  '  Holog.  Soc,  vol.  v.  p.  508. 


700  AFFECTIONS  OF  THE  EXTERNAL  EAR. 

of  the  meatus.  Touched  with  a  probe,  it  may  appear  qtfite  hard,  or  may  be 
sofl  and  easily  indented.  Generally  the  inner  extremity  of  the  mass  reaches 
to,  and  rests  upon,  the  tympanic  membrane. 

The  etiology  of  this  affection  has  received  considerable  attention,  and, 
while  it  cannot  be  claimed  that  it  i-  as  yet  fully  understood,  there  is  a  general 
agreement  at  least  as  to  two  points:  in  the  first  place,  that,  probably  through 
reflex  influence,  the  ceruminous  glands  are  frequently  abnormally  active 
in  the  presence  of  chronic  inflammatory  affections  of  the  naso-pharynx  ;  in 
the  second  place,  that  under  such  circumstances  and  often  perhaps  inde- 
pendently of  such  condition-,  there  i-  a  disturbance  of  the  normal  outgrowth 
of  the  epidermis  which  covers  the  external  surface  of  the  drumhead  and 
line-  the  wall-  of  the  meatus.  This  in  health  tend-  to  transport  the  cerumen 
from  the  deeper  portions  of  the  canal  to  its  external  orifice,  where  it  falls  out 
or  i-  removed  in  the  ordinary  daily  ablutions.  That  catarrh  of  the  naso- 
pharynx i-  frequently  present  when  there  is  a  disposition  to  the  formation 
of  ceruminous  plugs  in  the  ears  is  a  fact  of  daily  observation,  and  there  can 
1„.  little  doubl  that  it  is  an  important  factor  in  their  causation.  And  the  com- 
position of  many  ma—  es  of  impacted  cerumen — made  up,  in  great  part,  of 
layers  of  exfoliated  epidermis,  and  sometimes  enclosed  in  a  thin  pouch  of 
epidermis  which  ha-  been  cast  off  entirely  from  the  tympanic  membrane  and 
the  walls  of  the  meatus — would  seem  to  show  that  under  certain  circum- 
stances there  i-  not  only  an  arrest  of  the  normal  outgrowth  of  the  epidermis, 
but  an  actual  reversal  in  the  direction  of  its  growth,  tending  to  a  heaping  up 
of  epithelial  d6bris  in  the  deeper  parts  of  the  canal,  as  well  as  to  an  impac- 
tion of  cerumen. 

Treatment. — It  would  seem  that  as  to  the  manner  of  dealing  with  so 
simple  a  condition  there  could  be  but  little  room  for  difference  of  opinion, 
-till  less  for  contention.  Such,  however,  is  far  from  being  the  case,  for  one 
very  high  authority  tells  us  in  his  excellent  treatise  upon  diseases  of  the  ear 
that  the  syringe  should  rarely  be  \\>v(\  for  the  removal  of  cerumen,  and  that 
with  the  curette  and  the  angular  forceps  one  may  accomplish  in  ten  or  fifteen 
minutes  what  cannot  be  done  with  the  syringe  in  an  hour's  time;  while  an- 
other excellent  authority  tell-  ns  in  his  book  that  in  four  or  five  years  he  has 
not  met  with  a  single  instance  in  which  by  means  of  the  syringe  he  has 
failed  to  remove  impacted  cerumen  from  the  ear  in  one  sitting  of  five  minutes 
or  less,  and  that  a-  to  the  curetting  method  he  feels  that  he  cannot  seriously 
argue  the  question.  At  the  risk  of  seeming  to  be  contentions  himself,  the 
writer  cannot  refrain  from  saying  that  this  last  expressed  sentiment  meets 
with  hi-  fullesl  endorsement,  lint  >till  another  very  high  authority,  whose 
example  in  most  things  we  are  glad  to  follow,  actually  commends  the  intro- 
duction of  a  strong  solution  of  caustic  potash  into  the  ear  (oft rse  with  the 

exercise  of  extreme  caution)  in  order  to  saponify  quickly  the  ceruminous 
mass  and  SO  to  facilitate  it-  removal.  A-  to  this  procedure,  it  may  be 
remarked  that  in  kindling,  and  especially  in  rekindling  a  fire,  petroleum  i-  a 
great  saver  of  time;  but,  even  so,  it  is  not  the  part  of  wisdom  to  commend 
it-  general   use  in   this  way. 

The  method  of  dealing  with  impacted  cerumen  which  the  writer  has 
found  most  convenient,  and  which  he  ha-  employed  for  many  year-,  i-  as 
follow-:  lii  the  -Teat  majority  of  cases  the  syringe  i>  chiefly  relied  upon. 
When,  however,  the  ceruminous  mass  proves  obdurate  and  doe-  not  easily 
undergo  disintegration,  the  angular  probe  or  the  instrument  for  the  removal 
of  foreign  bodies  represented  in  Fig.  190  is  brought  into  requisition  and  the 
in:,,-  i-  partly  broken  up  or  .separated  from  its  attachment  to  the  canal-wall. 


AFFECTIONS  OF  EXTERNAL   AUDITORY  CANAL. 


701 


After  this  the  syringing  is  resumed,  and  usually  with  much  better  effect. 
Bicarbonate  of  soda  is  invariably  added  to  the  warm  water  (105°— 110  I  . 
with  which  the  syringing  is  done,  as  it  unquestionably  facilitates  the  removal 
of  the  wax  and  certainly  does  do  harm  to  the  syringe,  as  ha-  been  suggested. 
The  quantity  used  is  never  accurately  determined,  bul  is  approximately  hall' 
an  ounce  to  a  quart.  The  ear  is  inspected  from  time  to  time  to  make  sure 
that  there  is  still  cerumen  in  it,  and  that  the  syringing  is  ool  being  kept  up 
unnecessarily.  As  the  mass  diminishes  in  size  and  there  is  a  likelihood  thai 
the  stream  of  water  may  impinge  upon  the  drumhead,  the  force  with  which 
it  is  thrown  into  the  ear  is  lessened.  The  exact  direction  in  which  the  stream 
strikes  the  impacted  mass  is  not  thought  to  he  of  especial  moment,  and  no 
apprehension  is  felt  that  this  may  result  in  the  plug  being  driven  by  the 
force  of  the  water  more  deeply  into  the  meatus,  as  some  have  imagined. 
When  both  ears  are  affected,  unless  the  mass  first  attacked  come-  out  very 
readily,  the  syringing  is  alternated  from  one  ear  to  the  other,  as  this  saves 
time  and  appreciably  diminishes  the  amount  of  syringing  required.  The 
intermittent  stream  of  a  piston  syringe  is  employed,  and  is  thought  to  he 
more  efficacious  than  the  continuous  stream  of  a  fountain  syringe.  The 
hard-rubber,  kidney-shaped  basin  commonly  employed  by  aurists  has  been  long 
since  discarded,  because  it  is  concave  where  it  should  be  convex,  and  so  doc- 
not  fit  well  into  the  hollow  beneath  the  ear,  and  because,  moreover,  it  is  so  long 
and  shallow  that  a  very  slight  movement  on  the  part  of  the  patient  is  likely 
to  cause  its  contents  to  slop  over  upon  the  clothing.  Instead  of  this,  a  china 
bowl  (one  made  of  hard  rubber  or  metal  might  be  better,  because  less  fragile) 
of  the  shape  represented  in  Fig.  489  is  used,  and  has  been  found  much  better 
adapted  to  the  purpose,  since  it  is  free  from  both 
of  the  faults  mentioned.  It  is  always  held  by 
the  patient,  over  whose  shoulder  a  napkin  is 
spread,  rather  than  by  an  assistant,  unless  the 
patient  be  a  young  child.  When  inspection 
with  the  speculum  and  mirror  shows  that  all  of 
the  cerumen  has  been  removed,  two  or  three 
syringefuls  of  plain  warm  water  are  gently 
thrown  into  the  ear  to  wash  out  the  previously- 
used  soda  solution.  The  ear  i-  then  dried  with 
a  spill  of  soft  linen  and  closed  with  a  bit  of  ab- 
sorbent cotton,  which  in  cold  weather  the  patient 
is  advised  to  wear  until  bedtime,  if  the  plug  proves  to  lie  exceptionally 
refractory  or  time  be  pressing,  the  patient  i-  told  to  report  the  next  day,  and 
in  the  meantime  to  drop  into  the  ear  several  times  a  little  warm  sweet  oil, 
or,  if  it  be  inconvenient  for  him  to  do  this,  the  ear  is  filled  with  a  saturated 
solution  of  soda,  and  after  perhaps  a  half-hour's  wait  the  syringing  i- 
resumed.  The  cases  in  which  the  plug  cannot  be  removed  :it  one  sitting  are 
very  exceptional,  but  the  writer  is  compelled  to  admit  thai  with  the  besl 
skill  he  can  command  it  is  not  unusual  for  him  to  spend  many  more  than 
"  five  minutes"  in  accomplishing  this  result. 

It  occasionally  happens  that  upon  inspecting  the  ear  it  can  be  seen  that 
the  mass  of  cerumen  does  not  extend  into  the  deeper  parts  of  the  canal. 
Under  such  circumstances,  if  it  is  found  to  he  of  it-  usual  firmness,  it  i-  often 
possible  with  the  traction  instrument  (Fig.  490)  to  draw  out  the  whole  mass 
at  a  single  effort,  and  BO  to  save  both  time  and  trouble.       II'.  however,  even  in 

such  a  case,  the  cerumen  prose-  to  be  of  such  consistency  that  it  can  be  re- 
moved only  bit  by  bit,  it  i-  better  to  resorf  to  the  syringe  without  further  ado. 


Fig.  489.— Deep  cup  t>>  catch  the 
outflow  in  syringing  the  ear. 


702  1 1 IF  FA  TJOXS  OF  THE  EX  TERN.  1  L  EA  R. 

The  writer  knows  of  no  means  by  which  the  well-recognized  disposition 
of  impacted  cerumen  to  recur  after  having  been  removed  can  be  overcome, 


Fig.  490. — Foreign-body  traction-hook  made  of  a  steel  hair-pin. 

except  in  so  far  as  the  cure  or  amelioration  of  any  accompanying  inflamma- 
tion of  the  naso-pharynx  tends  to  this  result. 

Circumscribed  inflammation  {Furuncle). — Furuncular  inflammation 
of  the  externa]  auditory  canal  is  of  very  frequent  occurrence.  The  furuncles 
almost  always  form  in  the  outer  third  of  the  meatus,  and  their  starting-point 
is  in  the  ceruminous or  sebaceous  glands  or  in  the  hair-follicles  which  are  situ- 
ated in  this  portion  of  the  canal.  Oftener  than  not  several  furuncles  occur 
at  the  same  time  or  in  quick  succession,  and  occasionally,  in  the  absence  of 
proper  treatment,  they  may  recur  at  brief  intervals  for  weeks.  They  give 
rise  to  severe  pain,  and  to  so  much  swelling  of  the  membranous  portion  of 
the  meatus  as  to  occlude  it  completely,  and  so  produce  a  transient  impairment 
of  hearing.  The  discharge  is  slight  and  thick,  differing  markedly  from  the 
more  copious  and  thinner  discharge  which  is  usual  in  acute  purulent  inflam- 
mation of  the  middle  ear.  The  swelling  and  sensitiveness  of  the  meatus  arc 
commonly  so  great  as  to  preclude  an  inspection  of  its  deeper  parts  and  of  the 
tympanic  membrane;  but  the  location  and  appearance  of  the  swelling,  the 
scantiness  and  character  of  the  discharge,  the  history  of  the  onset  of  the 
attack,  and  the  absence  of  tinnitus,  and  of  such  a  degree  of  deafness  as  com- 
monly attend-  acute  inflammation  of  the  middle  ear,  usually  render  a  dif- 
ferential diagnosis  from  this  latter  affection  a  matter  of  no  great  difficulty. 

Furuncular  inflammation  of  the  meatus  is  in  most  instances  traceable 
to  a  pre-existing,  perhaps  very  slight,  dermatitis  or  eczema  of  the  mem- 
branous portion  of  the  canal.  This  gives  rise  to  itching,  which  the  individual 
attempt-  to  relieve  by  scratching  the  ear  with  the  finger-nail  or  with  a  tooth- 
pick, a  match,  a  bodkin,  a  hair-pin,  or  some  such  instrument,  and  sooner  or 
later  he  succeeds  not  only  in  producing  an  abrasion  of  the  canal-wall,  but  in 
implanting  upon  this  denuded  Burface,  which  in  all  probability  involves  the 
orifices  of  several  of  t  he  ceruminous  or  sebaceous  glands,  a  pyogenic  organism 
(usually  the  staphylococcus  aureus  or  albus),  the  subsequent  development  of 
which  brings  on  the  furunculosis.  In  other  instances  the  furuncular  inflam- 
mation i-  secondary  to  otitis  media  purulenta — a  localized  infection,  from  the 
entrance  of  the  micrococci  into  the  hair-follicles  or  into  the  ceruminous  or 
sebaceous  glands,  resulting    from   the  walls   of  the  canal  being  constantly 

bathed    in    the    pus  which    How-    from    the    middle  ear.      A  depressed  state  of 

the  general  health  i-  also  frequently  an  important  factor  in  the  etiology  of 
furunculosis  of  the  external  ear  ;i-  it  is  in  furunculosis  occurring  in  other 
regions. 


AFFECTIONS  OF  EXTERNAL  AID/TORY  CANAL.  703 

Exceptionally,  small  abscesses  arc  met  with  in  the  deeper  portion  of  the 
meatus.  These  usually  run  a  more  protracted  course,  being  often  dependent 
upon  caries  of  the  underlying  bone  or  upon  tympanic  or  mastoid  disease. 

Treatment. — If  seen  in  its  incipiency,  furuncular  inflammation  of  the 
auditory  meatus  can  occasionally  be  aborted  by  the  application  to  the  walls 
of  the  canal  of  an  ointment  of  yellow  oxid  of  mercury  and  vaselin  (gr.  j-ij 
to  3J)  and  the  administration  of  a  brisk  calomel  cathartic;  and,  it  may  be 
added,  in  the  occasional  application  of  this  same  ointment  we  have  a  prophy- 
lactic measure  of  great  value,  for  the  chronic  dermatitis,  which,  as  has  been 
said,  is  so  often  the  precursor  of  i'urunculosis,  may  by  this  means  almost 
always  be  cured  or  kept  in  abeyance,  and  thus  the  disposition  to  acute  out- 
breaks be  removed. 

When  the  furuncle  is  more  fully  developed,  so  favorable  a  result  is  not  to 
be  anticipated,  but  the  yellow-oxid  ointment  is  still  useful  in  lessening  the 
likelihood  of  the  inflammation  invading  other  follicles.  For  the  relief  of  the 
severe  pain,  the  head  (in  lying  down)  should  be  kept  as  high  as  practicable, 
dry  or  moist  heat  (a  Japanese  "  stove  "  or  a  pad  of  gauze  wrung  out  in  hot 
water,  freely  sprinkled  with  laudanum  and  covered  with  a  piece  of  rubber 
protective  or  oiled  silk)  should  be  applied  to  the  ear,  and  six  or  eight  drops 
of  a  solution  of  atropia  and  cocain  in  almond  oil  '  (atrop.  alk.  gr.  j, 
cocain  alk.  gr.  ij,  ol.  amyg.  dulc.  3ij)  should  be  dropped  into  the  canal  (and 
retained  by  a  pledget  of  cotton)  three  or  four  times  in  twenty-four  hours,  or 
the  "  baume  tranquille"  of  the  French  Codex  may  be  similarly  employed. 
The  application  of  a  10  to  20  per  cent,  solution  of  menthol  in  albolene  or 
olive  oil  is  also  recommended.  Should  these  measures  fail  to  relieve  the  pain, 
as,  it  must  be  admitted,  not  infrequently  happens,  morphin  may  be  adminis- 
tered hypodermically  or  by  the  mouth. 

The  writer  is  inclined  to  agree  with  those  (Wilde,  Buck,  and  others)  who 
think  that  a  very  early  incision  of  the  furuncle  is  uncalled  for,  and  may  do 
more  harm  than  good.  When,  however,  it  is  evident  that  pus  has  formed,  its 
escape  should  be  facilitated  by  an  incision,  which  may  be  conveniently  made 
with  the  knife  represented  in  Fig.  491,  which  some  years  since  the  writer 


Fig.  I'.H.— Writer's  knife  for  incising  furuncles  of  the  external  auditory  canal  (to  be  used  with  the  angular 

handle  shown  in  Fig.  oi23j. 

contrived  for  this  purpose.  The  local  abstraction  of  blood  hardly  seems  to 
be  called  for,  although  it  is  claimed  for  it  that,  if  employed  at  the  outset,  it 
often  proves  of  much  value.  After  the  furuncles  have  opened  or  been  in- 
cised, douching  or  gently  syringing  the  ear  with  a  saturated  solution  of  boric 
acid  is  a  useful  measure.  The  state  of  the  bowels  and  the  general  condition 
of  the  health  should  be  looked  to,  and  tonics  or  laxatives  should  be  adminis- 
tered when  they  seem  to  be  indicated. 

Diffuse  Inflammation. — Diffuse  inflammation  of  the  external  auditory 
canal  occurs  as  an  acute  and  as  a  chronic  affection.  It  differs  from  furuncular 
inflammation   in  that   it  tends  to  involve  the  whole  extenl   of  the  auditory 

canal,  the  oss< g  n-  well  as  the  membranous  portion.   The  pain  which  usually 

is  present  only  in  acute  cases  is,  as  a  rule,  not  so  severe,  and  the  swelling, 

'This  solution  has  been  prepared,  at  the  suggestion  <>f  the  writer,  by  Messrs.  Hynson  <S 
Westcott,  <>f  Baltimore,  as  a  substitute  fur  the  aqueous  solutions  of  the  salts  <>f  cocain  and  atro- 
pia.     It  lias  hern  found  especially  valuable  in  the  treatment  of  acute  Otitis  media. 


704  A Fl'I'J  7VO.Y.V   < > F  THE  EX TER  V. I  L    K. I  B. 

especially  at  the  orifice  of  the  meatus,  no<  so  marked,  as  in  furunculosis. 
The  discharge  is  slighf  and  generally  serous  or  sero-purulent  in  character.  In 
the  chronic  cases  especially,  itching  is  a  prominent  symptom.     The  derma] 

layer  of  the  tympanic  membrane  is  frequently  involved  in  the  inflammatory 
process,  and,  like  the  neighboring  walls  of  the  meatus,  may  be  markedly 
hyperemia  There  is  also  a  disposition  to  exfoliation  of  the  epidermis  from 
the  drumhead  as  well  as  from  the  canal-walls. 

Frequently  the  disease  is  essentially  an  eczema  of  the  external  ear,  and  the 
auricle,  as  well  as  the  auditory  canal,  may  be  involved  in  the  inflammatory 
process.  It  i-  often  presenl  in  chronic  otorrhea,  being  excited  by  the  con- 
tinual How  of  pus  through  the  meatus.  In  other  cases  it  is  of  traumatic 
origin,  arising  perhaps  from  the  entrance  of  some  irritant  substance  or  foreign 
body  into  the  ear;  and  in  still  others  it  is  duo  to  the  presence  in  the  auditory 
canal  of  a  fungous  growth,  usually  the  aspergillus  nigricans,  and  less  often  the 
aspergillus  glaucus  or  the  aspergillus  rlaveseens.  For  this  variety  of  inflam- 
mation of  the  external  ear  Virchow  has  suggested  the  name  otomycosis. 

A  variety  of  diffuse  otitis  externa  which  deserves  especial  mention,  and 
the  etiology  of  which  is  nut  very  well  understood,  is  that  which  is  denomi- 
nated desquamative  inflammation  <>f  the  auditory  canal,  and  which  leads  to  the 
condition  known  as  keratosis  obturanx  or  cholesteatoma.  Primarily,  this  is  a 
diffuse  dermatitis  characterized  by  an  excessive  proliferation  and  desquama- 
tion of  epithelium  ;  hut  at  a  later  stage  the  periosteum  and  underlying  hone 
are  not  infrequently  involved,1  and  areas  of  caries  and  necrosis,  sometimes 
accompanied  by  the  development  of  polypi,  may  occur;  while  in  some  in- 
stances marked  absorption  of  the  bony  walls  of  the  meatus  takes  place,  result- 
ing in  a  great  increase  of  its  caliber.  Eventually,  the  auditory  canal  becomes 
completely  occluded  by  the  exfoliated  epithelium,  which  forms  into  a  tough, 
laminated  plug  containing  between  its  layers  an  admixture  of  inspissated 
cerumen.  For  a  time  this  may  give  rise  to  no  inconvenience  other  than 
deafness,  probably  accompanied  by  tinnitus  ;  hut  sooner  or  later,  through  the 
invasion  of  bacteria  (which  seems  to  be  Nature's  method  of  ridding  the 
economy  of  such  an  incubus),  an  acute  outbreak  of  inflammation  occurs, 
accompanied  by  pain, suppuration, and  partial  disintegration  of  the  laminated 
ma--.  It  i-  at  thi-  time  that  medical  advice,  if  it  has  not  previously  been 
obtained,  is  usually  sought. 

Treatment. — A-  may  be  inferred,  the  treatment  of  diffuse  inflammation 
of  the  auditory  canal  will  necessarily  vary  with  the  origin  and  character  of 
the  attack.  For  the  relief  of  pain  the  anodyne  applications  which  have  been 
described  in  treating  of  furuncular  inflammation,  and  especially  the  solution 
of  the  alkaloid-  of  cocain  and  atropin  in  the  oil  of  -weet  almond-,  will  he 
found  useful.  In  Otomycosis  the  intruding  fungus  must  begotten  rid  of  as 
Boon  a-  possibh — in  the  lii'-t  place,  mechanically,  by  means  of  the  syringe, 
forceps,  and  traction-hook  ;  and.  in  the  second  place,  by  the  insufflation  of  the 
powder  containing  equal  part-  of  oxid  of  zinc  and  boric  acid  which  has 
already  been  spoken  of,  and  which  was  recommended  for  thi-  purpose  by  the 

writer  many  year-  since.2      The  efficacy  of  this  remedy,  which    depends  upon 

the  drying  effect  of  the  oxid  of  zinc  a-  well  as  upon  the  proven  specific 
action  of  boric  acid  in  preventing  the  growth  of  aspergillus  and  other 
related  fungi,  i-  so  marked  that,  in  the  experience  of  the  writer,  a  second 
application  is  only  exceptionally  required  to  completely  destroy  the  varieties 
of  aspergillus  which  are  usually  encountered  in  the  ear.  It  has,  moreover. 
the  -real  additional  advantage  of  being  one  of  the  besl  possible  agents  for  the 
1  Perhaps  the  primary  lesion  [  Ed.].      -  Amer.  Journ.  of  Otology,  vl.  iii.  \>.  II'.',  April,  L881. 


AFFECTIONS  OF  EXTERNAL  AUDITORY  CANAL. 


705 


relief  of  the  inflammation  of  the  auditory  canal  excited  by  the  presence 
of  the  parasite,  in  this  respecl  certainly  being  far  better  than  alcohol,  which 
has  been  widely  commended  for  the  destruction  of  aural  fungi.  With  the 
eradication  of  the  aspergillus  the  inflammation  usually  subsides  promptly; 
and,  as  a  rule,  no  oilier  treatment  than  the  insufflation  of  the  zinc  and  boric 
acid,  which  may  require  t<>  be  repeated  once  or  twice,  is  culled  for. 

In  desquamative  inflammation  the  removal  of  the  mass  of  exfoliated 
epithelium,  which  sometimes  is  a  difficult  task,  requiring  several  sittings,  is 
of  course  the  first  thing  to  be  accomplished.  This  can  best  be  effected  by  the 
syringe,  aided  by  the  forceps,  traction-instrument,  and  probe.  The  removal 
of  the  plug  should  he  followed  by  the  insufflation  of  boric  acid  ami  oxid 
of  zinc,  which  the  writer  has  found  especially  useful  in  these  cases.  A 
powder  containing  equal  parts  of  aristol  and  boric  acid  has  also  been  found 
of  service.  In  the  uncomplicated  form-  of  diffuse  inflammation  of  the  audi- 
tory canal — which,  as  has  been  said,  are  frequently  eczematous  in  character — 
these  same  applications  are  indicated  if  a  drying  effect  is  desired  ;  while  in 
other  cases  the  yellow-oxid-of-mercury  and  vaselin  ointment,  previously  men- 
tioned, is  often  of  great  value  ;  and  so  also  is  an  ointment  composed  of  oxid 
of  zinc,  boric  acid,  and  vaselin,  to  which  a  small  quantity  of  balsam  of 
Peru  may  at  times  be  added.  (Zinci  oxide  gr.  xxx-lx,  acid,  boric.  .~jr 
vaselin  oj)-  Strong  solutions  of  nitrate  of  silver  (oj-iij  to  sj)  are  highly 
commended  by  Buck  and  others.  Tonics,  laxatives,  and  other  constitutional 
remedies,  such  as  the  salts  of  lithia,  arsenic,  etc.,  may  often  be  prescribed  with 
advantage.     Polypi,  if  present,  should  be  removed  with  the  forceps  or  snare 


Fig.  492.— Myxomatous  polyp  filling  the  canal. 


Fig.  193.— Large  polypoid  mass  growing  out  from 
depth*  "f  the  canal  and  tilling  the  concha 


(they  are  usually  quite  small,  but  may  be  multiple),  and  any  areas  of  carious 
bone  should  be  carefully  curetted,  or,  better  still,  perhaps,  if  limited  in  extent, 
should  be  touched  with  muriatic  acid  diluted  with  two  or  three  parts  of  water, 
which  seems  to  do  good  not  only  by  its  stimulant  action,  but  by  it-  solvent 
effect  upon  the  necrosed  bone. 

Polypi. —  In   most   instances   where  a  polypus   is  found   occupying  the 
external   auditory  canal   it    has  it- origin  in  the  tympanic  cavity,  and   grows 
from  there  (the  drumhead  being  partially  or  completely  destroyed)  into  the 
meatus.      Exceptionally,  however,  the  polypi   which   form  in  the  course  ol 
chronic  otorrhea  spring  from  the  walls  of  the  canal,  usually  in  the  aeighbor- 


45 


roo 


AFFECTIONS  OF  THE  EXTERNAL  EAR. 


hood  of  the  membrana  tympani.  They  also  are  occasionally  met  with  in  the 
absence  of  perforation  of  the  drumhead,  as  after  injuries  of  the  meatus,  caries 
of  its  walls,  furuncular  inflammation,  and,  as  has  just  been  indicated,  in  the 
course  of  desquamative  otitis  externa.      Poulticing  is  at  times  responsible. 

Their  treatment  consists  in  early  removal  (with  forceps  if  they  are  small, 
or  with  the  snare  it'  they  are  larger  and  their  point  of  attachment  cannot  cer- 
tainly be  made  out),  the  application  of  chromic  acid  to  the  pedicle,  and  the 
insufflation  of  boric  acid  by  itself  or  in  combination  with  aristol  or  oxid  of 
zinc.  Properly  carried  out,  these  measures  render  a  recurrence  of  the  polypus 
very  unlikely. 

Exostosis  and  Hyperostosis. — The  term  exostosis  is  applied  to  those 
bony  growths  upon  the  walls  of  the  external  auditory  canal  which  are  cir- 
cumscribed and  fairly  well  defined  in  contour  (Fig.  494);  while  by  hyperos- 
tosis is  meant  that  condition  in  which  the  caliber  of  the  bony  meatus  is  grad- 
ually encroached  upon  (see  Fig.  4»!Ji.  probably  throughout  a  considerable  part 
of  its  length,  by  a  diffuse  growth  of  bone,  which  is  usually  the  result  of  a  chronic 
periostitis  secondary  to  long-standing- otorrhea.  In  extreme  cases  of  hyper- 
ostosis a  complete  bony  occlusion  of  the  canal  may  result,  which,  from  its 
appearance  only,  cannot  always  be  distinguished  from  congenital  atresia.  A 
case  of  this  character  observed  by  the  writer  has  already  been  referred  to 
in  treating  of  congenital  anomalies  of  the  external  auditory  canal.  The 
growths  denominated  exostoses  are  met  with  in  all  parts  of  the  osseous 
canal,  vary  greatly  in  shape,  being  usually   mound-like,  with  a  broad  base, 

but  occasionally  distinctly  pedunculated; 
may  occur  singly  or  in  groups,  and  differ 
markedly  in  structure,  being  sometimes 
of  ivory-like  hardness  and  at  other  times 
composed  of  soft  cancellous  tissue.  They 
may  be  present  in  the  auditory  canal  for 
years  without  their  existence  being  known, 
for  they  are  usually  of  very  slow  growth 
and  quite  painless.  Their  presence  is  fre- 
quently revealed  by  some  intercurrent 
aural  affection,  such  as  acute  otitis  media 
or  an  accumulation  of  cerumen,  which 
affections,  as  may  be  readily  understood, 
they  may  greatly  complicate.  Gout, 
rheumatism,  aud  syphilis  have  been 
regarded  as  having  to  do  with  their  causa- 
tion, but  this  has  not  been  clearly  demon- 
strated. That  there  is  a  racial  predispo- 
sition to  growths  of  this  character  i-  certainly  true.  They  are  said  to  be 
more  frequent  amongthe  inhabitants  of  England  than  among  our  own  people, 

are  of  very  coi on  occurrence  amongthe  natives  of  the  Hawaiian  islands, 

and  have  been  observed  very  often  in  the  >knlls  of  the  Mound-builders. 
Treatment. — When  occlusion  of  the  meatus  is  threatened  from  a  diffuse 
hyperostosis  every  effort  should  !»<•  made  to  cure  the  otorrhea  which  usually 
ists,  as  this  of  itself  may  arresl  the  progress  of  the  affection.  It  will 
also  permil  the  continuous  wearing  of  an  elastic  plug  in  the  canal,  which  in 
time  may  he  expected  to  effed  something  in  the  way  of  dilatation.  The 
[tin-  should  not  be  harsh  in  it-  action,  however,  or  it  may  do  more  harm 
than  good,  bine  sponge  and  absorbent  cotton  have  already  been  mentioned 
a-  being  useful  for  this  purpose.     When  complete  bony  atresia  of  the  canal 


Pig    pi  —Exostosis  arising  from  the  back 

wall  Of  Hi'-  'anal. 


AFFECTIONS  OF  EXTERNAL  AUDITORY  CANAL.  707 

exists,  operative  interference  is  not  indicated  unless  there  is  good  reason  to 
believe  that  the  septum  is  quite  thin,  for  under  other  circumstances  it  is 
almost  sure  to  prove  of  no  avail. 

As  to  the  treatment  of  the  circumscribed  osteomata,  non-interference  is 
generally  advised,  unless  there  be  some  especial  indication  for  operation  ;  as, 
for  example,  when  the  enlargement  of  the  growth  is  interfering  with  audition 
or  when  some  intercurrent  trouble,  such  as  otitis  media  suppurativa,  compli- 
cates the  situation.  When  the  exostosis  is  pedunculated  and  is  so  situated 
that  its  removal  is  not  a  difficult  matter,  the  writer  thinks  that  it  is  judicious 
to  get  rid  of  it  without  waiting  for  possible  future  complications.  His 
experience  in  the  removal  of  such  growths  is  limited,  but,  so  far  as  it  war- 
rants deductions,  is  distinctly  favorable  to  the  use  of  the  gouge  and  mallet 
rather  than  the  dental  lathe,  which  has  been  recommended  for  this  purpose. 

False  Membranes. — An  occlusion  of  the  auditory  canal  of  much  less 
formidable  character  than  that  which  may  result  from  hyperostosis  is  occa- 
sionally met  with.  The  occluding  membrane  is  sometimes  composed  simply 
of  the  epidermal  layer  of  the  drumhead,  which  has  been  cast  off  entire,  and 
of  course  is  without  vitality.  When  such  a  membrane  is  located  near  the 
inner  extremity  of  the  meatus,  it  is  not  always  easy  to  distinguish  it  from 
the  true  tympanic  membrane  altered  by  disease.  It  interferes  in  some 
measure  with  the  hearing,  and  should  be  broken  through  with  a  probe  and 
removed  with  the  traction-hook  or  forceps.  In  other  cases  the  membrane 
is  of  quite  a  different  character,  being  supplied  with  blood-vessels  and  pos- 
sessing a  low  vitality.  Such  septa,  as  Buck  has  pointed  out,  are  usually  the 
result  of  granulation-tissue  springing  from  opposite  points  of  the  walls  of 
the  canal  and  uniting  in  time  to  form  a  continuous  membrane.1 

Treatment.  —  As  septa  of  this  character  interfere  materially  with 
hearing,  their  removal  is  indicated.  This  may  be  effected  by  any  suitably 
shaped  knife,  and,  as  they  show  at  times  a  disposition  to  recur,  the  subsequent 
application  of  chromic  acid  or  other  caustic  agent  to  the  marginal  remains  of 
the  membrane  may  be  called  for.  In  the  writer's  case,  to  which  reference 
has  been  made,  the  removal  of  the  membrane  and  the  subsequent  wearing  of 
a  vaselin  and  cotton  artificial  drum  resulted  in  very  marked  improvement  in 
hearing  (see  page  784). 

New  growths,  having  their  origin  in  the  external  auditory  canal,  apart 
from  osteomata  and  polypi,  are  extremely  rare.  Sebaceous  cy>t-  upon  the 
walls  of  the  meatus  are  met  with  occasionally  ;  chondromata  have  been 
observed  by  Launay  and  Politzer  ;  and  cases  of  cylindroma,  pedunculated 
papilloma,  and  of  epithelioma  and  sarcoma  have  been   reported. 

The  indications  for  treatment  are  simply  those  which  apply  to  -imilar 
tumors  located  els-ewhere. 

Syphilis  does  not  often  invade  the  external  auditory  meatus,  but  one 
case  at  least  of  primary  infection  at  this  point  has  been  observed.  Condylo- 
mata and  syphilitic  ulcers  are  more  frequently  encountered.  The  diagnosis  is 
facilitated  by  the  presence  of  syphilitic  Lesions  in  other  part-  of  the  body. 

Treatment. — Knapp  recommends  dusting  condylomata  with  calomel,  and 
subsequently  painting  them  with  a  1  percent,  solution  of  nitrite  oi  silver. 
Politzer  touches  them  with  nitrate  of  silver  or  a  concentrated  solution  oi 
chromic  acid,  and  afterwards  applies  a  1  :.".<>  solution  of  corrosive  sublimate. 
For  syphilitic  ulcers  he  uses  tincture  of  iodin,  painting  it  upon  the  ulcer  9  V- 

1  For  .-i  report  of  several  interesting  cases  of  tliis  character  observed  by  Dr.  Bnck  see  lii- 
\[a  vml  <;/'  />/.-•"•'  ■■/  "<■  /•.''(/■,  p.  llo  ,/  „,y.,  and  for  an  account  of  a  similar  ease  met  with  by 
the  writer  see  Trans.  Amer.  Otol.  Soc.,  vol.  iv.  p.  541,  L890. 


70S  AFFECTIONS  OF  THE  EXTERNAL   EAR. 

era]  times.  He  also  mentions  a  case  in  which  healing  was  brought  about  by 
keeping  a  plug  of  mercurial  plaster  in  the  meatus.  Calomel  and  the  yellow 
oxid  nt'  mercury  suggest  themselves  as  remedies  likely  to  prove  useful. 

Wounds  involving  only  the  external  auditory  canal  arc  rare  Buck 
speaks  of  the  tendency  to  persistent  hemorrhage  which  characterizes  such 
wounds,  and  gives  as  an  explanation  that  the  blood-vessels  of  the  cartilagi- 
nous framework  of  the  canal  are  capable  of  contracting  and  retracting  to  but 
a  limited  extent.  Slight  abrasions  of  the  walls  of  the  meatus  from  efforts  to 
remove  cerumen  or  to  relieve  itching  are  common,  and  are  of  importance  only 
because,  as  has  been  stated,  they  so  often  lead  to  furuncular  inflammation. 
Fractures  of  the  base  of  the  skull  not  infrequently  involve  the  walls  of  the 
bony  meatus. 

The  indications  for  treatment  arc  to  free  the  canal  from  blood  and  any 
extraneous  substances  which  may  be  present  by  syringing  with  a  warm  anti- 
septic solution  (boric  acid),  and  then,  by  the  insufflation  of  boric  acid  or 
boric  acid  and  aristol,  and  closing  the  meatus  with  a  cotton  plug,  to  keep  the 
parts  as  nearly  aseptic  as  possible. 

Foreign  Bodies. — Although  the  position  and  conformation  of  the  audi- 
tory canal  do  not  favor  the  entrance  of  foreign  bodies,  they  not  infre- 
quently find  their  way  into  the  ear.  Children  have  a  habit  of  thrusting  such 
thine-  as  beads,  beans,  cherry  stones  and  the  like  into  their  own  cars  or  into 
the  ears  of  their  playmates,  while  inanimate  objects  of  a  different  character, 
such  a-  grains  of  wheat,  -mall  pebbles,  etc.,  sometimes  find  accidental  entrance 
into  auditory  canals  of  adults.  Living  insects  also  occasionally  invade  the 
ear — sometimes  by  accident  and  sometimes  l>v  design,  being  perhaps  attracted 
l>v  the  odor  of  a  purulent  discharge.  Many  cases,  for  example,  have  been 
reported  in  which  dead  flies  have  been  found  in  suppurating  ears,  and  others 
in  which  the  living  larvae  of  the  fly  were  present. 

The  common  belie  is  that  the  presence  of  a  foreign  body  in  the  ear, 
without  reference  to  it-  character  or  its  mode  of  lodgement,  is  necessarily  a 
serious  matter.  It  is  hardly  uecessary  to  say  that  this  belief  is  groundless. 
Usually,  null'--  the  object  be  tightly  impacted  in  the  canal,  or  be  pressing 
upon  the  drumhead,  or  be  of  such  shape  or  nature  as  to  cause  exceptional 
irritation,  it-  presence  in  the  car  i-  scarcely  appreciated.    On  the  other  hand, 

if  the  aubstai which  ha-  entered  the  ear  be  of  an  irritant  or  caustic  nature, 

or  lie  jagged  in  shape  and  so  wedged  in  the  canal  that  the  movements  of  the 
jaw  cause  it  to  wound  the  wall-  of  the  meatus,  it  may  give  rise  to  severe  pain 
and  quickly  produce  inflammatory  reaction.  The  entrance  of  living  insects 
into  the  ear  usually  causes  great  discomfort,  and  sometimes  intolerable  agony, 
fur  the  e. intact  of  their  wine-  and  feet  with  the  tympanic  membrane  is  not 
only  very  painful,  but  produces  noises  which  are  almost  as  unbearable. 
Maggots  when  they  enter  the  ear  cause  severe  pain,  and  arc  difficult  to  re- 
move, because,  a-  Blake  ha-  pointed  out,  they  attach  themselves  to  the  walls  of 
the  canal  by  a  peculiar  hook-like  apparatus  which  they  possess,  and  \\'n\  upon 
the  inflamed  integument.     The  writer  once  removed  from  the  car  a  living 

tick    which   hail  attached   it-elf   In  the  wall   of  the  meatUS.        It    had  entered   the 

ear  about  two  week-  previously,  and  forsomedaysa  black,  granular  substance 
it-  excrement)  had  been  coming  from  the  canal,  while  a  sound  " like  broil- 
ing "  had  been  heard  from  time  to  time,  and  pain  was  beginning  to  make 
itself  felt.  He  has  also  removed  flies,  maggots,  cockroaches,  and  "bugs" 
of  various  kind-  and  -i/e-.  Still'  hair-  from  the  head  or  beard  occasionally 
find  their  ua\  into  the  ear,  and  if  80  placed  a-  t.i  press  upon  the  drumhead, 
may  cause  much  discomfort, 


AFFECTIONS  OF  FNTFRNAL   ACDITOltY  <    l.V.I/..  709 

It  should  bo  mentioned  that  the  presence  of  a  foreign  l>i>dv  in  the  ear 
may  excite  marked  reflex  phenomena.  Cases  hav<  been  reported,  for  ex- 
ample, in  which  cough,  vomiting,  excessive  salivary  secretion,  hemicrania, 
facial  paralysis,  and  epileptiform  convulsions  have  been  produced  in  thi<  way 
(Poulet). 

Treatment. — The  question  of  how  best  to  deal  with  a  foreign  body  lodged 
in  the  ear  depends  upon  a  variety  of  circumstances,  and  especially  upon  the 
skill  and  experience  of  the  operator.  Doubtless  it  is  best  not  to  allow  any 
foreign  body  to  remain  indefinitely  in  the  auditory  canal ;  but,  as  in  most 
instances  it  is  not  at  all  likely  to  produce  immediate  ill  consequences,  hurried 
and  unskilful  attempts  at  removal  without  proper  instrumental  aid,  whether 
undertaken  by  layman  or  physician,  are  to  be  discouraged.  The  need  for  in- 
terference is  seldom  so  urgent  that  time  cannot  be  taken  to  obtain  expert 
assistance,  and  it  should  be  borne  in  mind  that  the  cases  which  prove  to  be 
serious  and  which  tax  the  ability  of  the  aural  specialist  are  almost  invariably 
those  which  have  previously  been  subjected  to  the  well-meant  but  injudicious 
efforts  of  the  unskilful. 

At  the  outset  it  is  of  the  utmost  importance  to  make  sure  that  there  really 
is  a  foreign  body  in  the  ear,  for  it  not  infrequently  happens  that  misappre- 
hension exists  upon  this  point  ;  and  patients  are  brought  to  the  physician 
for  the  removal  of  a  foreign  body  which  has  no  existence  except  in  their 
imagination  or  in  the  imagination  of  those  who  have  them  in  charge.  If  it 
be  lodged  near  the  orifice  of  the  meatus,  it  can  scarcely  escape  detection  at  a 
glance,  but  if  it  be  near  the  tympanic  membrane,  an  ear-mirror  and  speculum 
will  usually  be  needed  for  its  discovery;  and,  indeed,  in  some  ears  (in  which 
the  upward  bend  of  the  floor  of  the  meatus  is  exceptionally  pronounced)  it 
may  be  impossible,  if  the  foreign  body  be  a  small  one  and  be  lying  in  the 
angle  at  the  lower  margin  of  the  drumhead,  to  bring  it  into  view  even  with 
the  best  means  at  command  for  aural  inspection.  It  ought  not  to  be  neces- 
sary to  utter  a  word  of  warning  against  mistaking  the  bright  surface  of  the 
tympanic  membrane  itself  for  a  foreign  body  ;  but,  as  mistakes  of  this  kind 
have  occurred,  and  at  the  cost  of  serious  damage  to  the  hearing  apparatus,  such 
a  warning  is  perhaps  not  altogether  superfluous. 

In  unskilled  hands  or  with  a  very  unruly  patient  the  syringe  is  the  safest 
instrument  to  employ  for  the  removal  of  foreign  bodies  from  the  ear,  ami 
it  is  one  which  usually  will  be  found  to  accomplish  the  end  in  view.  If, 
however,  the  foreign  body  be  tightly  wedged  in  the  canal,  from  having 
swollen,  as  beans,  peas,  ami  such  like  objects  arc  likely  to  do  after  entering 
the  ear,  from  inflammatory  swelling  of  the  canal  itself,  or  from  awkward 
efforts  to  remove  it,  the  syringe  is  not  likely  to  prove  effectual.  Whether,  under 
such  circumstances,  tin-  physician  unfamiliar  with  operative  procedures  upon 
the  ear  should  desist  from  further  instrumental  interference  and  refer  the  case 
to  an  aural  surgeon,  must  of  course  depend  in  a  great  measure  upon  whether 
such  skilled  assistance  can  be  readily  obtained  or  not.  To  introduce  any  form 
of  instrument  into  the  ear  and  grope  blindly  about  in  the  hope  of  extracting 
a  foreign  body  i>  a  most  reprehensible  procedure,  and  one  so  much  more  likely 
to  do  harm  than  good  that  it  can  hardly  be  justified  under  any  circumstances. 
Such  awkward  manipulations  have  been  known  to  resulf  not  only  in  loss  of 
hearing,  but  even  in  loss  of  life.  Without  exception,  when  any  instrument 
is  introduced  into  t  lie  ear  for  the  removal  of  a  foreign  body,  th<  auditory  canal 
should  be  illuminated  with  the  ear-mirror  (artificial  or  diffuse  daylight  being 
used  as  may  be  preferred),  and  the  foreign  body  itself  and  ever)  movement 
of  the  instrument  should  be  kept  constantly  in  view. 


710  AFFECTIONS  OF  THE  EXTERNAL   EAR. 

For  the  removal  of  foreign  bodies  which  arc  not  spherical  in  shape  and 
do  doI  till  the  lumen  of  the  canal — such  as  insects, "bits  of  wire,  chips  of 
wood,  and  the  like — the  angular  forceps  are  extremely  useful  ;  but  when  a 
glass  bead,  a  pea  or  beau,  or  other  roundish  body  is  impacted  in  the  meatus, 
they  arc  worse  than  useless,  for  they  cannot  be  opened  wide  enough  to  grasp 
the  object,  and  every  unsuccessful  attempt  to  accomplish  this  only  serves  to 
drive  it  more  deeply  into  the  car.  For  the  extraction  of  such  bodies — and 
they  arc  among  those  most  frequently  encountered — the  writer  has  found  a 
traction-hook  similar  to  Fig.  4!»<>,  but  stronger,  extremely  valuable.  The 
body  can  scarcely  be  so  tightly  wedged  in  the  ear  as  to  prevent  the  bent  tip  of 
this  instrument  (which  is  serrated  upon  its  under  surface  to  make  it  catch  the 
better)  being  at  some  point  insinuated  between  it  and  the  walls  of  the  canal ; 
and  when  this  is  accomplished  and  the  hooked  extremity,  now  beyond  the 
body,  is  turned  so  as  to  catch  hold  of  it,  there  can  be  little  excuse,  unless 
one's  efforts  are  balked  by  unruly  behavior  on  the  part  of  the  patient,  for 
failing  to  rid  the  ear  of  the  intruding  body,  either  by  simple  traction  or 
by  rolling  it   over  and  over. 

There  is  nothing  which  so  facilitates  manipulations  of  this  character  as 
co-operation  on  the  part  of  the  patient,  and  nothing  which  so  complicates 
them  as  the  lack  of  it.  Ordinarily,  with  a  ruly  patient,  the  extraction  of  a 
foreign  body  from  the  ear  is  not  a  painful  procedure;  but  if  the  walls  of  the 
canal  have  been  lacerated  by  previous  rough  usage  or  have  become  swollen 
and  inflamed  from  the  presence  of  the  intruding  body,  the  infliction  of  some 
pain  can  hardly  be  avoided.  Under  such  circumstances  the  previous  instilla- 
tion of  a  strong  solution  ( 1"  per  cent.)  of  cocain  diminishes  the  pain  in  some 
measure.  In  unruly  children  the  administration  of  a  general  anesthetic  is 
not  infrequently  called  for.  In  the  absence  of  such  an  instrument  as 
above  indicated,  or  the  loop  of  a  snare,  an  excellent  substitute  may  be 
improvised  from  a  steel  hair-pin  of  good  quality.  The  writer  is  rather 
fond  of  making  traction-hooks  in  this  way  to  suit  his  fancy,  and  the  impro- 
vised instrument  shown  has  done  mosl  excellent  service. 

\\  hen  an  insect  or  other  animate  object  has  entered  the  ear,  since  its  move- 
ments are  likely  to  cause  much  suffering,  it  is  important  that  an  end  should  be 
put  to  it-  life  as  quickly  as  possible.  Ordinarily  the  most  efficacious  and  con- 
venient way  of  accomplishing  this  is  by  pouring  into  the  ear  olive  oil  or  any 
other  bland  oil  that  may  beat  hand.  Maggots,  however,  live  for  a  longtime 
in  oil,  which,  therefore,  is  not  useful  when  they  are  present.  Dr.  Roosa  has  rec- 
ommended for  their  destruction  t  he  vapor  of  chloroform  and  also  Labarraque's 
solution,  [fa  caustic  substance  has  entered  the  auditory  canal,  the  car  should 
be  syringed  with  a  neutralizing  solution — in  the  case  of  an  alkaline  caustic, 
vinegar,  which  is  usually  at  hand,  diluted  with  warm  water  may  be  used,  and 
in  the  case  of  an  acid,  the  bicarbonate  of  soda. 

Probably,  in  dealing  with  foreign  bodies  in  the  auditory  canal,  the  writer 
has  had  more  than  his  share  of  good  luck  ;  for  he  docs  not  recall  an  instance  in 
w  Inch  he  has  failed  to  remove  a  foreign  body  from  the  car  at  one  sitting — some 
one  of  the  methods  which  have  been  described  having  been  always  relied  upon. 
I  lenee  he  has  felt  no  temptation  to  resorl  to  the  rather  radical  procedure(see  page 
786)  of  displacing  the  auricle  and  cartilaginous  meatus,  which  has  been  recom- 
mended to  facilitate  the  extraction  of  foreign  bodies  from  the  ear.  Some  years 
since,  in  writing  of  this  operation,  he  Btated  that  he  could  "  scarcely  conceive 

of  a   case  which  would  warrant    recourse  to  such    an    expedient  ;"'    and    later 

experience  has  nol  served  to  change  materially  the  opinion  then  expressed. 

Buck's  Reference  Handbook  of  tin  Medi  ••■]    i,  |.    125. 


INJURIES  AND  DISEASES  OF  THE  DRUMHEAD. 

By  II.  V.  WURDEMANN,  M.  I)., 

OF    MILWAUKEE,    WIS. 


Traumatic  lesions  of  the  Drumhead. — Considering  the  delicacy 
of  the  tympanic  membrane  and  the  relative  frequency  of  accidents  to  the 
head  it  is  seldom  liable  to  injury,  thanks  to  its  protected  situation  within  the 
skull  at  the  bottom  of  the  external  auditory  canal. 

Hemorrhage. — Sneezing  or  coughing,  especially  in  pertussis  or  in  asth- 
matics with  arterio-sclerosis,  may  produce  circumscribed  hemorrhages  in  the 
membrane  (Plate  11,  Fig.  2).  Patients  experience  transient,  slight  pain, 
and  examination  reveals  dark  red  or  brown,  circumscribed  spots,  which  can- 
not be  wiped  away.  Such  may  occur  after  Politzer's  method  of  inflation, 
catheterization,  after  sudden  condensation  or  rarefaction  of  the  air  in  the  ex- 
ternal meatus,  and  from  direct  injury  without  perforation  of  the  membrane. 
Hyperemia  and  hemorrhage  occur  in  the  course  of  myringitis  and  otitis 
media  from  acute  infectious  disease1  (due  to  rupture  of  the  small  blood-ves- 
sels causing  true  hemorrhage  in  the  dermal  layer),  in  dense  or  rarefied 
atmospheres  from  the  same  cause,  as  in  the  case  of  miners  or  divers,  and 
mountain-climbers  or  aeronauts,  or  in  persons  who  have  not  been  accustomed 
to  sudden  changes  of  atmospheric  pressure.  It  is  also  an  occasional  accom- 
paniment of  scorbutus,  typhus,  dengue,  bubonic  plague,  and  other  infection- 
diseases.2     Vicarious  hemorrhage  has  also  been  reported. 

Direct  injuries  to  the  membrane  are  oftenest  observed  after  unskilful 
attempts  to  remove  foreign  bodies  by  patients,  their  friends  or  physicians 
(Plate  11,  Figs.  3,  4).  Slight  injuries  are  sometimes  self-inflicted  by  persons 
who  are  accustomed  to  remove  wax  or  scratch  the  canal  with  ear-spoons,  tooth- 
picks, etc.  (Plate  11,  Fig.  5),  or  who  have  acquired  the  habil  of  scratching  their 
ears3  with  pencils  or  pen-holders  while  deep  in  thought  (Plate  11,  Fig.  6).  Ill- 
considered  attempts  at  removal  of  foreign  bodies  and  of  inspissated  ceru- 
men (Plate  11,  Fig.  7)  by  forceps,  scoops,  or  syringes  with  long  nozzles  may 
cause  dangerous  injuries.  In  cases  of  myringitis  or  after  gentle  removal  of 
impacted  cerumen,  the  simple  application  of  a  cotton  pledget  for  drying  the 
ear  may  rub  away  the  epidermal  layer.  If  aseptic,  such  slighl  injuries  heal 
within  a  few  hours.  The  forcible  entrance  of  water  or  foreign  bodies,  such 
as  insects,  twigs,  etc.,  into  the  canal  gives  rise  to  superficial  or  deep  injury. 
The  instillation  of  strong  medicinal  solutions,  as  caustics,  the  use  of  very  hoi 
or  very  cold  solutions,  as  hot  glycerin  (Plate  11,  Fig.  8),  olive  oil,  etc.,  may 
cause  lesion  of  the  canal  and  external  layer.  A  means  of  torture  in  ancient 
times  was  pouring  of  hot  wax  or  lead  into  the  ears,  which  produced  effects 

1  1 1 : n i ir    Krankheiten  des  Ohrt    in  ihren  Beziehung  «  den  Allgemeinen  Erkrankungen,  l£ 
-  Richardson:  "Hemorrhage  from  External  Auditory  Canal,"  Annals  of  Ophth.  am 
July,  1896. 

3  Politzer       Lilirbiich  ih-r  Olin  nlirilkn  „>/> .    Isss. 

711 


712  INJURIES  AND   DISEASES  OF  THE  DRUMHEAD. 

varying  from  superficial  injury  to  death;  and  the  membrane  may  now  be 
injured  in  metal-workers  by  the  splashing  of  molten  metal.  Direct  injury 
and  eveu  perforation  from  the  tympanic  side  has  been  produced  by  the  Eu- 
stachian bougie  (Urbantschitsch).  Direct  injuries,  such  as  punctures  and 
abrasions,  are  usually  found  in  the  anterior  half,  as  pointed  objects  slide 
off  the  more  obliquely  placed  posterior  portion  of  the  membrane  (Politzer). 

Rupturt  of  the  drumhead  is  frequently  caused  by  slapping  the  face  and  ears 
of  children  for  punishment  by  teachers  or  parents,  thus  producing  sudden  com- 
pression of  air  in  the  external  meatus.  It  occasionally  occurs  in  sparring  (Plate 
1  1.  Fig.  9),  and  is  common  1'rom  injuries  caused  by  explosions  of  gunpowder, 
dynamite,  fire-arms,  and  boilers.  Improper  inflation  methods,  such  as  the 
use  of  compressed-air  apparatus  at  high  pressure,  the  catheter  or  Politzer  bag 
by  unskilled  hands  or  in  improper  cases,  may  produce  rupture  of  the  drum- 
head. Spontaneous  perforation  frequently  occurs  in  acute  catarrhal  or  sup- 
purative otitis  media.  Fracture  of  the  base  of  the  skull  is  generally  attended 
by  bleeding  from  the  car  and  rupture  of  the  membrane  (Plate  11,  Figs.  10,  11). 
A  diseased,  inflamed,  or  weakened  drumhead  is  more  liable  to  injury  than  if 
normal,  especially  where  there  has  been  misplacement  or  thinning  of  its  struct- 
ure. The  normal  drumhead  is  resilient,  and  cannot  be  ruptured  under  a  press- 
ure. >f  \  or  5  atmospheres  (Gruber).  The  flaccid  membrane  is  seldom  broken, 
as  it  is  less  tense  and  plays  an  important  part  in  preventing  ruptures.1  The 
so-called  Rivinian  foramen  does  not  commonly  exist  in  the  normal  subject, 
and  is  not  the  safel v-valve  which  has  been  supposed.  The  situation  of 
the  rupture  i>  indifferently  placed  in  the  anterior  or  posterior  halves  of 
the  tense  membrane,  usually  near  the  handle  of  the  malleus.  It  may  be 
single  or  double,  depending  upon  the  character  of  the  injury.  Both  large 
Mini  small  perforations  may  follow  slight  blows  upon  the  head.  The  handle 
of  the  malleus  (Plate  11,  Fig.  11)  is  rarely  fractured,  although  cases  have 
been  reported,  as  well  as  of  dislocation 2  (Plate  11,  Fig.  3). 

Symptoms.  — At  the  time  of  the  injury  there  is  sharp  pain,  which  may 
last  for  several  hours,  and  is  usually  accompanied  by  dizziness  and  sometimes 
by  nausea,  [f  the  upper  part  of  the  drumhead  be  injured,  disturbance  of 
the  sense  of  taste  may  occur,  as  where  the  chorda  tympani  nerve  is  divided 
in  operations,  but  recovers  after  several  weeks.  If  seen  shortly  after  lacer- 
ating  injuries,   there   will   be  found   fresh   blood  or  clots  in   large  or  small 

an nt  in  the  meatus  or  on  the  drumhead,  or,  if  the  perforation  be  large,  in 

the  middle  ear.     The  edges  of  the  wound  are  at    first   irregular  and  covered 

with    fresh    bl I.       Twenty-four    hours   after   the    injury,    however,    there    is 

usually  hyperemia,  especially  of  the  edges  of  the  perforation,  which  appear 
more  even.  If  the  ear  has  been  tampered  with  or  not  occluded  from  the 
atmosphere,  infection  followed  by  acute  suppuration  and  sometimes  persistent 
perforation  may  occur.  Simple  puncture  by  clean  instruments,  such  as  the 
paracentesis  knife,  in  ears  that  are  aseptic  and  not  inflamed,  will  frequently 
in  a  few    hour-  heal  and  close  without  cicatrix. 

The  diagnosis  of  traumatic  injury,  perforation,  or  rupture  may  generally 
be  made  by  it-  appearance  and  the  history.  If  seen  shortly  after  the  acci- 
dent, the  edges  of  a  rupture  are  found  gaping,  so  that  the  yellowish-red  lining 
membrane  of  the  tympanic  cavity  may  be  seen.  Fresh  bleeding  is  of  course 
diagnostic.    A  differential  symptom  is  the  character  of  the  sound  on  inflation, 

a-  in  traumatic  perforation  the  whistle  is   -aid    to    be  deep  and  harsh,  while  in 

pathologic  perforation  it  is  -harp  and  shrill  (Politzer).     It  is  of  forensic  im- 

'  Bacon     Burnetl  -  Sy  U m. .  i.  p.  266. 
I  i,      tld     /  Inter.  Otol.  Soc,  1891. 


Description  of  Plate  11. 

Fig.   1-  ■-  Normal  tympanic  membrane. - 

Fig.  -'  Hemorrhage  into  the  dermal  layer  after  luisk  inflation  in  a  man  aged  thirty  with 
chronic  aural  catarrh  and  adhesions  of  membrane  to  promontory.  Sketch  made  two  days  after- 
ward.    The  clots  did  not  become  entirely  absorbed,  and  pigment  could  be  seen  for  two  years. 

Fig.  3.  Destruction  of  the  drumhead  and  dislocation  of  malleus  into  canal  from  impaction 
of  pebble  in  middle  ear,  due  to  attempts  at  removal  with  wire  loop,  which  was  broken  in  the 
operation,  in  a  child  aged  three.     Removal  by  snare,  and  healing  under  antiseptic  dressing. 

Fig.  I.  Large  rupture  of  drumhead  and  impaction  of  glass  bead  in  tympanum,  caused  by 
ai  tempts  at  its  removal  by  members  of  t  lie  family  and  physicians,  in  a  child  aged  four.  Removed 
by  snare  and  rat-tooth  forceps.  Suppurative  otitis  with  permanent  perforation  ami  partial 
deafness  ensued. 

l'i'..  •">.  Self-inflicted  wound  of  dermal  layer  from  hair-pin  used  for  removing  "artificial 
drumheads,"  in  a  woman  aged  forty  six,  subject  of  chronic  catarrhal  otitis.  Healing  in  two  days 
under  antiseptic  dressing. 

FlG.  *>.  —Penetrating  wound  of  drumhead  from  slate  pencil  in  a  girl  aired  eight.    Healing  in 

one    Week. 

FlG.  7.  Abrasion  of  dermal  layer  and  canal  from  forceps  and  eat— coop  used  by  a  physician 
in  attempted  removal  of  impacted  cerumen.     Healing  in  three  days. 

Fig.  s.  -Acute  myringitis  from  instillation  of  hot  glycerin  in  a  man  aged  forty-seven  with 
chronic  aural  catarrh  and   vertigo.      The  usual  appearances  were  restored  in  five  days. 

FlG.  9.  Double  rupture,  seen  one  hour  after  the  accident,  in  a  man  aged  twenty-six  who 
had  received  a  box  on  the  ear  during  a  sparring  contest.     Healing  in  two  weeks. 

Fig.  LO.  -Rupture  of  drumhead  in  a  managed  twenty-seven  who  had  fracture  of  the  base  of 
the  skull  following  fall  on  hack  of  head.  Total  and  persistent  deafness  with  vertigo  and  tinnitus. 
Slight  suppuration  stopped  in  four  days,  but  perforation  persisted.  Sketched  one  week  after 
accidi  ut. 

FlG.  1  1.  — Fracture  of  the  malleus  and  canal  in  a  man  who  committed  suicide  by  being  run 
over  by  a  locomotive,  sustaining  fracture  of  the  skull,  and  death  twenty-four  hours  afterward. 
Ad.r.;.  d  from  K irchner. 

Fig.  12.  Acute  myringitis  in  stage  of  maceration,  in  a  woman  aged  twenty-three,  caused 
by  aspergillus  growth  in  the  canal  after  lake-bathing. 

Fig.  13.  -Acute  myringitis  bullosa  in  a  boy  aged  thirteen,  due  to  pond-bathing.  Healing 
in  one  week  after  puncture  of  vesicles  and  antiseptic  treatment. 

Fig.  II.  \eiite  myringitis  with  sanguineous  abscess  or  hematoma  in  a  managed  thirty. 
Paracentesis  with  healing  in  several  days. 

1  i'..  15,  \<ute  myringitis  with  multiple  abscesses  under  the  dermal  layer  in  a  man  aged 
twenty-six.     Healing  in  about    one  week  after  puncture  of  the  abscesses,  without  implication  of 

the   111  i-  111  1 .     I 

Fig.  c  myringitis  granulosa  in  a  boy  aged  fifteen  who  had  discharge  from  tin  ear 

for  several  year.--.     Healing  under  cauterization  of  the  granulations  ami  antiseptic  treatment. 

17      Chalk-formation  in  chronic  suppuration  of  twenty  years1  standing  in  a  man  aged 
forty-seven.     Small  perforation  in  lower  anterior  quadrant. 

Fig.   18.  ^Chalk-formation  in  chronic  aural  catarrh  of  long  standing  in  a  woman  aged  thirty- 
five.     The  membrane  i-  greatly  retracted,  thickened,  and  nearly  immovable,  and  with  the  o>-i- 
sclerosed. 

Fig.  i'1  Chalk-formation  in  an  otherwise  normal  membrane  in  a  physician  aged  thirty- 
live  who  had  full  hearing  and  no  other  evidence  of  es 

Fig,  20     Sclerosis  of  the  middle   ear  with  thickening  and    retraction   of  the  membrana 

vihrans   in   a   woman   aged    forty-eight     who    had    chronic   aural   catarrh    of  long    Standing. 

I"n..  21.     Atrophy  of  post  i  ut  of  the  membrana  vihrans  in  a  man  aged  thirty-five 

who  had  normal  hearing  and  no  I  ear  disease.     Tie-  membrane  is  translucent  and   re- 

■  l.  showing  the  incudo-stapedial  joint. 

I'n.  perforation  of  the  membrana  vibrans  and  small  perforation  of  the  membrana 

■  la  of  t  he  right  ear  in  a  man  aged  i  h  i  it  \  -fou  r  who  had  scarlatinal  suppurat  ive  otitis  since 
infancy  The  malleus-handle  ia  sbortened  bj  necrosis;  the  stapes  and  incus  with  the  chorda 
tympani  nerve  show  through  thi    upp  the  perforation;  the  promontory  and   fenestra 

rotundum  with  the  engorged  and  swollen  mucous  membrane  of  the  tympanum  are  likewise 
visibh  .  exuberant   granulations  -how  on   the  posterior  rim  of  the  perforation. 

Fig.  jive  destrui  tion  of  membrana  flaccida  with  cicatricial  changes  in  membrana 

vibrane  of  left  i  incus,  head  of  malleus,  and  granula- 

i  the  tympanic  attic  and  osseous  ring  show  through  the  perforation;  the  malleus-handle 

1  through  previo 

Fio,  ■-' l      Th  r<  <    large  and  two  small  perforations  occurring  in  the  pallid  right  drumhead 

of  a  hi;-  ii  of  thirty-five  with  tuberculous  lar; 


Plate  n 


Injuries  and  of  the  drni 


( 'HRONIC  INFLAMMA TION  OF  THE  1)11 1  Mill-:. ID.  71  :j 

portance  to  determine  whether  or  not  a  perforation  be  traumatic  or  due  wholly 
or  in  part  to  disease,  especially  in  cases  following  blows  upon  the  head  and 
boxing  the  cars,  as  the  statements  of  patient  and  friends  are  frequently 
influenced  by  personal    motives.     Study  of  the  other  ear  may  give  valuable 

light. 

The  prognosis  of  simple  injury  and  perforating  wounds  is  good  if  the 
car  be  clean  and  secondary  infection  does  not  take  place,  as  the  arum  mem- 
brane quickly  regenerates;  in  fact,  it  is  the  experience  of  most  surgeons  that 
it  is  difficult  to  maintain  a  permanent  opening.  Simple  injury  of  the  drum- 
head, as  in  surgical  perforation,  seldom  has  any  deleterious  influence  upon  the 
hearing.  In  fracture  of  the  base  of  the  skull  attended  by  bleeding  from  the 
ear,  rupture  of  the  drumhead  and  lesions  of  the  labyrinth  usually  occur;  the 
progno>is  i-  unfavorable  as  regards  the  hearing  and  sometimes  a>  to  life. 

The  treatment  of  most  injuries  of  the  drumhead  after  removal  of  foreign 
bodies  and  cleansing  consists  in  letting  well  enough  alone;  the  car  should  not 
be  douched,  nor  should  solutions  be  instilled.  The  canal  may  be  syringed  or 
wiped  out  with  warm  saturated  boric  acid  or  1  :  5000  sublimate  solutions, 
etc.,  dried  and  dusted  with  impalpable  boric  acid,  aristol,  or  iodoform 
powder,  and  the  canal  stopped  with  iodoform  gauze  and  absorbent  cotton. 
After  twenty-four  hours  the  dressing  may  be  removed  and  renewed.  Within 
a  few  days  the  healing  will  usually  have  so  far  progressed  that  unless  exten- 
sively destroyed  the  membrane  has  been  restored.  Even  after  extensive 
operations  involving  the  removal  of  the  drumhead  and  ossicles,  although 
necrosis  may  have  occurred,  and  after  the  mastoid  operation,  if  treated  in 
this  manner,  infection  and  suppuration  rarely  ensue. 

Acute  Primary  Inflammation  of  the  Drumhead  (Myringitis 
Acutai. — A  diagnosis  of  acute  inflammation  of  the  drumhead  is  less  often 
made  than  formerly.  Its  most  common  causes  are  said  to  be  due  to  the 
entrance  of  cold  draughts  or  cold  water  into  the  external  canal.  I  have 
more  often  seen  it  after  attempted  removal  of  cerumen,  foreign  bodies,  or 
water  from  the  ears,  after  instillation  of  irritating  or  hot  solutions  (Plate  11, 
Fig.  8),  or  in  connection  with  aspergillic  inflammation  of  the  canal  (Plate 
11,  Fig.  12).  There  is  slight  pain,  tinnitus,  and  a  throbbing  sensation,  with 
but  little  deafness.  At  first  there  i-  hyperemia  and  later  effusion  of  clear  or 
bloody  serum  from  the  breaking  down  of  vesicles,  which  may  involve  a  por- 
tion or  all  of  the  dermal  layer  i  Plate  11.  Fig.  13).  Some  cases  of  otitis 
attended  by  slight  serous  discharge,  followed  by  resolution  after  a  few  days, 
are  of  this  form.  Sometimes  abscesses  (Plate  11.  Fig.  15)  develop  under 
theouter  layer,  but  are  usually  followed  by  perforation,  presenting  a  picture 
similar  to  acute  suppurative  otitis  media.  After  the  vesicular  stage  the  mem- 
brane will  have  a  macerated  appearance,  more  or  less  of  the  dermal  layer 
peeling  and  the  redness  disappearing  (Plate   11.  Fig.    1_). 

The  treatment  depends  upon  the  cause.  In  all  case-  it  i-  nec<  ssary  to 
clean-e  the  canal  by  antiseptic  solutions  to  prevent  infection.  The  vesicles 
may  be  punctured,  the  ear  insufflated  with  boric  powder,  and  the  meatus 
occluded  by  iodoform  gauze  and  cotton.  In  severe  cases,  cupping,  leeching, 
and  hot  applications  to  the  side  of  the  head  may  be  neo  •  •    ates  may 

be  given  if  the  pain  be  severe,  although  when  such  is  th<  3e  there  is  usually 
development  of  abscess,  the  puncture  of  which  will  relieve  th    pain. 

Chronic  Inflammation  of  the  Drumhead  (Myringitis  Chron- 
ica . — Chronic  inflammation  of  the  middle  ear  i-  generally  accompanied  by 
implication  of  the  drumhead.  Chronic  myringitis  alone  is  en  rare,  although 
it  is  possible  that  Buch  may  be  found  after  acute  myringitis  which   has  not 


714  TNJV  R I ES  .  1 ND  DISEA  SES  OF  THE  DB  UMHEA  D. 

gone  on  to  resolution.1  After  Inflammation  of  the  canal  has  disappeared 
the  drumhead  sometimes  remains  affected,  and  this  may  be  considered  an  in- 
dependent disease.2  The  clinical  signs  are  maceration  of  the  dermal  layer, 
redness  and  sometimes  granulations  upon  the  surface  (Plate  11,  Fig.  16). 
There  is  but  little  pain,  and  the  hearing  is  but  little  affected.  Tinnitus  and 
slight  malodorous  purulent  discharge  usually  exist.  Middle-ear  suppuration 
with  unseen  perforation  is  to  be  suspected  and  sought.  In  perforation  of  the 
drumhead  polypi  and  granulations  may  form  upon  the  edges. 

The  treatment  is  antiseptic.  It  consists  in  cleansing  the  canal  and  mem- 
brane by  injections  or  brushing  with  solutions  of  boric  acid,  bichlorid  of 
mercury,  etc.,  after  which  a  small  quantity  of  finely  powdered  boric  acid 
or  aristol  may  be  insufflated,  or  a  small  pledget  of  cotton  saturated  in  salol- 
camphor  or  naphthol-camphor  may  be  placed  in  the  canal,  to  remain  twenty- 
four  hours  and  then  be  renewed.  Granulations  may  be  touched  with  tincture 
of  ehlorid  of  iron,  nitrate  of  silver,  chromic  or  trichloracetic  acids.  Instil- 
lations of  solutions  by  patients  are  to  be  discouraged. 

Infectious  and  skin-diseases,  as  well  as  the  exanthemata,  may  affect 
the  drumhead  (Ilaug);  the  eruption  of  these  and  of  syphilis  is  sometimes 
to  be  seen  in  the  dermal  layer.  The  pustule  of  small-pox  may  have  been  the 
cause  of  several  eases  of  middle-ear  suppuration  which  I  have  seen  after  this 
affection.  Condylomata3  of  the  auditory  canal  and  drumhead  have  been 
reported  by  the  writer  and  others. 

New  Growths. — Warts  (  Burnett)  rarely  occur  on  the  drumhead,  and  are 
usually  due  to  instillation  of  fluids.  I  have  seen  true  epithelioma  of  the  canal 
involving  the  drumhead.  Pearly  growths  consisting  of  cholcsterin  crystals  and 
molecular  d6bris  were  found  in  a  case  of  chronic  suppurative  middle-ear  dis- 
ease ;  true  cholesteatomata  are  rare  (Gruber).  Calcification  in  the  drum  mem- 
brane is  frequently  found  in  the  course  of  chronic  otitis  media  (Plate  11, 
Figs.  17,  18),  although  it  is  seen  when  there  is  no  other  evidence  of  ear- 
disease  (Plate  11,  Fig.  1!»).  The  membrane  becomes  thickened  (Fig.  20), 
thinned  (Plate  11,  Fig.  21),  or  opaque  and  perforated  (Plate  11,  Figs.  17, 
22,  23,  24),  as  the  result  of  chronic  inflammation  in  the  middle  ear  and 
canal.  They  are  likewise  due  to  trauma  and  ulcerations,  such  as  occur  in 
syphilitic  or  tubercular  (Plate   11,   Fig.  21)  middle-ear  disease. 

Polypi  usually  arise  from  the  tympanic  mucous  membrane  ;  but  arc  some- 
times on  the  edges  of  perforations — mosl  frequently  at  the  posterior  superior 
quadrant.  Mucous  polypi  and  myxomata  are  most  common,  although 
fibromata  ami  angiomata  '  are  -ecu.  These  growths  are  accompanied  by 
malodorous  otorrhea,  and  are  but  part  of  a  chronic  suppurative  process  which 
i-  usually  attended  by  neei-M-i-  <,f  the  walls  of  the  tympanum  and  of  the 
ossicles,  and  their  removal  may  be  a    needed  preliminary  to  treatment   for  the 

chronic  suppuration.  Granulations  are  preferably  removed  by  the  small 
curette,  and  polypi  by  the  cold  snare,  and  their  pedicles  cauterized  by  tincture 
of  the  ehlorid  of  iron,  nitrate  of  silver,  chromic  or  trichloracetic  acid  on  a 
Bmall  pledgel  or  fused  on  the  end  of  a  probe;  but  with  these  or  with  the 
galvano-cautery  care  should  be  taken  thai  nothing  but  the  growth  be  touched. 
Granulations  recur  unless  the  suppurative  disease  be  healed. 

'Steuer:   Die  haufigsten  Ohrenkramkheiten  im  Bilde,  1895. 

'■'  Politzer:   Atlas  der  Beleucktungsbild'  /  <l<    '1'nuniii'ljrlls,  1896. 

3  Wurdemann:   Arch,  of  OtoL,  \\i..  p.  303,  L892. 

4  Buck  :   Tram.  Amer.  OtoL  Soc.,  L870. 


ACUTE  AFFECTIONS    OF  THE  TYMPANIC  CAVITY 
AND    EUSTACHIAN   TUBE 

By  HORACE  G.   MILLER,   A.M.,  M.  D., 

OF    PROVIDENCE,    K.  I. 


The  acute  affections  of  the  middle  ear  are  of  great  importance,  for  three 
principal  reasons  :  First,  on  account  of  the  pain  which  usually  accompanies 
them  ;  Second,  because  of  the  deafness  produced,  which  may  become  per- 
manent ;  and  Third,  because  they  may  endanger  life  by  extension  to  the 
brain.  Each  of  these  reasons  would  be  sufficient  to  demand  the  earnest 
attention  of  the  physician.  Together,  they  present  a  subject  which  he  can- 
not possibly  afford  to  neglect. 

Pain. — Usually  the  first  symptom  to  appear  is  "  earache,"  so  common 
in  some  families  as  to  be  thought  one  of  the  necessary  ills  of  childhood.  In 
nearly  every  case  this  is  evidence  of  an  actual  inflammation  of  the  mucous 
membrane  lining  the  middle  ear.  A  child  "  subject  to  earache"  is  in  danger 
of  deafness,  and  no  care  should  be  spared,  not  only  for  the  relief  of  present 
distress,  but  in  ascertaining  and  removing  the  cause.  It  will  rarely  be  found, 
even  after  a  single  attack  of  pain,  that  the  hearing  of  the  affected  ear  is 
normal.  This  fact  is  likely  to  escape  attention  if  one  ear  only  be  affected. 
After  the  suffering  is  allayed,  all  anxiety  on  the  part  of  the  parents  and 
friends  ceases.  But  if  the  hearing  be  compared  with  that  of  the  healthy  ear, 
the  simplest  test  will  show  the  defect;  and  a  new  interest  should  be  at  once 
awakened,  and  a  new  sense  of  responsibility  aroused. 

The  pain  may  vary  from  a  dull  ache  to  the  most  intense  anguish.  <  tften 
the  pain  is  most  severe  at  night,  causing  loss  of  sleep  to  the  patient  and  his 
family.  It  may  nearly  or  wholly  subside  by  day,  leaving  only  a  tenderness 
when  the  auricle  is  touched,  which  is  discovered  by  the  nurse  or  mother  when 
making  the  child's  toilet.  In  children  too  young  to  tell  the  cause  of  distress, 
it-  seat  will  often  lie  pointed  out  by  unconscious  movements  of  the  hand  to 
the  affected  part.  Frequently  in  young  children,  after  several  days  of  suffer- 
ing, a  discharge  of  pus  from  the  meatus  reveals  the  diagnosis  to  the  aston- 
ished friends;  so  that  when  a  child  cries  and  shrieks  from  an  unknown  cause, 
the  ears  should  be  among  the  earliest  organs  to  be  investigated.  The  pain  i< 
not  always  confined  to  the  ear  itself,  but  extends  to  the  adjacent  part- ;  almost 
all  the  nerves  of  sensation  on  the  affected  side  of  the  head  may  share  in  the 
distress,  which  is  further  aggravated  by  movements  of  the  muscles,  as  in 
mastication.  Eructation,  coughing,  and  sneezing  are  greatly  dreaded.  All 
loud  sounds  increase  the  suffering.  Frequently  the  pain  extends  to  the  teeth, 
especially  if  any  of  them  are  decayed,  until  the  patient  scarcely  knows 
whether  toothache  or  earache  most  predominates.  The  severity  of  the  pain 
i>  to  some  extent  a  gauge  of  the  violence  and  character  of  the  inflammation, 
the  severer  form,  especially  when  constant,  indicating  the  probability  of  sup- 
puration with  all    its   attendant   dangers.      A<    in    many  other   diseases,   the 

71.  • 


716  Acl'TF  AFFECTIONS  OF  TYMPANIC  CAVITY,  ETC. 

presence  of  pain,  when  rightly  interpreted,  is  fortunate,  for  it  comes  as  a 
warning  of  impending  danger  to  the  hearing,  demanding  measures  for  instant 
relief,  which  at  the  same  time  shall  furnish  a  safeguard  against  the  rapid 
impairment   of  a   delicate  and   sensitive  organ. 

Deafness. — Next  in  importance  to  the  urgent  necessity  for  the  relief  of 
pain  comes  the  prevention  and  cure  of  deafness.  Much  has  recently  been 
written  to  impress  upon  the  profession  the  need  of  the  most  careful  attention 
to  this  subject  ;  hut  it  is  a  matter  upon  which  too  much  cannot  be  said,  and 
reiteration  cannot  be  too  frequent,  since  it  has  become  known  how  much  can 
be  accomplished  in  this  direction  by  preventive  medicine  and  surgery. 
Heredity  in  this  direction  means  the  existence  of  local  causes  which  may  he 
successfully  controlled  ;  and  no  child  should  be  allowed  to  acquire  deaf- 
ness because,  as  is  said,  "it  runs  in  the  family."  On  the  contrary,  such 
a  tendency  should  lead  to  the  earlier  and  more  active  fight  against  such  a  fate. 
The  baleful  influence  of  poor  hearing  upon  the  development  of  children  is  so 
disastrous  as  to  call  for  our  warmest  sympathy  for  its  victims  and  our  most 
earnest  efforts  for  their  rescue.  Blamed  and  misunderstood  l>y  his  teachers 
for  supposed  inattention,  neglected  and  ridiculed  by  his  companions,  the  child 
who  is  deaf  often  actually  becomes  the  stupid  and  useless  creature  which  lie  is 
at  first  only  in  appearance.  He  becomes  ill-natured  and  peevish  in  disposi- 
tion, stunted  and  undeveloped  in  intellect.  His  whole  career  is  blighted. 
But  few  forms  of  employment  or  industry  are  open  to  him.  Even  his 
physical  development  is  hindered  by  his  inability  to  engage  in  the  athletic 
sports  which  his  fellows  delight  in;  and  from  the  resulting  debility  and 
malnutrition  he  readily  becomes  a  prey  to  any  cachexia  to  which  he  may 
be  constitutionally  inclined,  or  any  disease  to  which  he  may  be  exposed. 
Many  of  these  evils  might  be  avoided  or  relieved  by  a  wise  prophylaxis 
or  by  proper  treatment.  But  owing  to  the  prevalent  ignorance  on  the 
subject  most  of  the  cases  in  the  schools  are  neglected  until  the  proper 
season  for  interference  is  passed,  it  is  to  be  hoped  that  the  time  is  soon 
coming  when  the  examination  of  the  ears  and  hearing  of  children  by  compe- 
tent physicians  will  be  a  matter  established  by  law,  not  only  as  a  preliminary 
to  the  beginning  of  a  course  of  education,  but  from  time  to  time  subsequently 
a-  promotions  are  made  to  higher  grades.  The  result  of  this  would,  of 
course,  be  the  enforced  attention  of  both  teachers  and  parents  to  this  vital 
matter  and  the  consequent  medical  treatment  of  those  capable  of  improve- 
ment ;  the  better  understanding  on  the  part  of  the  teachers  of  some  scholars 
whose  -low  lie--  to  learn  ha-  been  ascribed  to  a  different  cause;  and  the 
elimination  of  those  scholars  who  would  require  the  special  training  in  lip- 
reading,  so  useful  to  those  whose  hearing  is  defective.  It  is  true  that  but  few 
children  would  We  found  suffering  from  an  acute  attack  of  inflammation  of 
the  middle  ear  at  the  moment  of  examination  ;  but  most  of  those  found  to  be 
deaf  will   have  acquired    their  deafness    from    an   acute   attack;   and  many  of 

them  will  be  liable  to  future  accessions  of  the  trouble  if  preventive  measures 

are  nut  promptly  taken. 

Danger  Of  Extension. — The  third  principal  point  of  interest  in  acute 
affections  of  the  middle  car  lie-  in  the  fact  of  their  liability  to  extend 
to  the  surrounding  part-.  Primary  inflammation  of  the  antrum  and  mas- 
toid cell-  may  occur,  but  in  nearly  every  ease  the  disease  comes  by  ex- 
tension from  the  middle  ear  proper.  This  may  be  followed  by  caries  and 
necrosis  of  the  bony  wall-  of  these  cavities,  and  the  disease  may  then  extend 
inward  to  the  membranes  of  the  brain,  causing  a  meningitis  or  abscess  of  the 

brain,  with    lethal    result.      There  may  be  a  like  extension  --till  more   directly 


CAUSES.  717 

through  the  tegmen  tympani,  where  the  attic  portion  of  the  tympanum  is 
separated  from  the  brain  only  by  the  thinnest  layer  of  bone,  perforated  by 
foramina  for  vascular  anastomosis.     Thrombosis  may  also  result  from  contact 

of  the  diseased  bone  with  the  walls  of  the  venous  sinuses,  with  a  result 
equally  fatal.  General  pyemia  may  also  ensue,  either  by  absorption  of  puru- 
lent products  or  by  rupture  into  the  walls  of  a  sinus.  These  possibilities 
should  lead  us  to  look  seriously  upon  every  painful  manifestation  of  ear- 
trouble,  and  make  us  willing  to  submit  to  criticism  for  too  much  zeal  rather 
than  have  to  blame  ourselves  for  not  having  taken  prompt  and  efficient 
measures  at  the  time  when  they  could  most  avail.  Let  us  then  remember 
that  in  every  case  of  acute  otitis  media  we  may  by  proper  treatment  be  the 
means  of  saving'  patient-  from  pain,  from  deafness,  or  from  death.  Too  often 
they  have  been  treated  with  indifference  or  neglect,  resulting  in  the  tacit  per- 
mission for  the  use  of  remedies  often  both  inefficacious  and  far  from  harm- 
less. That  these  affections  are  trivial  no  one  who  has  once  witnessed  the 
suffering  or  its  results  can  for  a  moment  maintain.  It  is  not  true  that  the  diag- 
nosis is  very  difficult.  Any  intelligent  physician  may  feel  himself  competent 
for  it.  The  use  of  that  most  important  aid  in  physical  diagnosis,  the  head- 
mirror,  should  be  familiar  to  every  medical  man,  not  for  the  ear  alone,  hut 
for  the  illumination  of  every  orifice  of  the  body,  especially  at  night  ;  and 
under  many  circumstances  where  both  hands  are  needed  for  operation  and 
manipulation.  With  this  mirror,  and  the  light  from  a  window  by  day,  or  the 
light  from  the  ever-ready  kitehen-lamp  by  night,  the  inspection  of  the  drum- 
membrane  is  usually  easy.  But  nowhere  in  the  physician's  practice  is  gen- 
tleness and  delicacy  of  touch  more  necessary.  One  careless  thrust  of  the 
speculum  or  ungentle  pull  on  the  concha,  and  all  intercourse  between  a  young 
patient  and  the  doctor  may  be  at  an  end,  except  by  the  aid  of  a  general 
anesthetic.  The  old-fashioned  bivalve  ear-speculum  should  never  lie  used. 
It  is  awkward  and  apt  to  cause  pain,  and  requires  one  hand  to  retain  it  in  its 
proper  position.  Should  it  be  necessary  in  order  to  complete  a  full  inspection 
for  the  purpose  of  diagnosis,  it  is  proper  to  resort  to  general  anesthesia  :  and 
if  operative  interference  be  found  necessary,  this  condition  may  he  taken 
advantage  of  to  complete  the  procedure. 

Types. — As  to  the  usual  distinction  between  catarrhal  and  purulent 
inflammation  of  the  middle  ear,  it  is  difficult  to  draw  the  line  in  making 
the  diagnosis.  Only  after  the  disease  has  run  its  course  can  we  tell  which 
form  we  have  had  to  deal  with.  If  we  could  always  know  the  cause  ol 
infection,  this,  with  the  severity  of  the  symptoms,  would  furnish  an  early 
indication.  But  this  is  not  always  possible.  It  is  therefore  better  sim- 
ply to  look  upon  cases  as  more  or  less  severe  and  not  of  a  wholly  different 
character. 

Causes. — The  acute  affections  of  the  middle  ear  come  mosl  frequently 
by  extension  from  the  naso-pharynx.  Consequently  the  exanthemata,  and 
especially  scarlet  fever,  are  among  the  mosl  frequent  causes  of  a  systemic 
nature.  A  large  percentage  of  the  inmates  of  the  institutions  i'^v  the  deat 
date  their  infirmity  from  an  attack  of  scarlet  fever  in  childhood.      In  measles 

the  ear  is  -till  more  frequently  affected.     It  ha-  recently  I n  shown  that  the 

ears  are  probably  involved  in  every  case  of  measles.    A.n  exudation  containing 

the  specific  organism  of  measles  is  formed  on  the  lining  mm -  membrane  "I 

the  tvmpanum  by  the  eruption,      lint  unless  tin-  lie  mixed  with  one  ol   the 
pyogenic  germs,  tin-  exudation   is  rapidly  absorbed  withoul    perforation   of 
the  drumhead  ami  without  injury  to  the  hearing.     The  deafness  of  typhoid 
fever  is  caused  usually  by  a  catarrhal  condition  of  the  middle  ear  :  hut  in  tin- 


718  ACUTE  AFFECTIONS  OF  TYMPANIC  CAVITY,  ETC. 

ease  also  it  seldom  goes  on  to  suppuration.  As  one  result  of  the  recent  epi- 
demics of  influenza  there  has  been  a  great  increase  of  acute  otitis  media. 
This  has  been  characterized  by  great  intensity  of*  pain  and  a  greater  tendency 
to  suppurate,  and  consequently  spread  to  the  mastoid,  than  is  usually  the  case 
in  acute  otitis  media.  Diphtheria  may  also  produce  inflammation  of  the 
mil  Idle  car,  the  characteristic  bacilli  being  found  in  the  discharge.  The  same 
is  true  of  tuberculosis.  Here  the  onsel  of  the  disease  is  comparatively  pain- 
less ;  but  it  may  result  in  great  dot  ruction  of  the  tissues,  both  soft  and  bony, 
contained  within  the  tympanum.  Both  a  rheumatic  and  a  gouty  diathesis 
may  favor  or  superinduce  acute  otitis  media,  either  primarily  or  by  extension 
from  inflammation  of  the  pharynx.  Syphilis,  in  the  secondary  stage,  when 
the  na-o-pharynx  is  involved,  is  often  productive  of  acute  otitis  media,  vary- 
ing in  all  degrees  of  intensity.  Later  on,  when  the  bones  of  the  nose  are 
diseased,  the  same  result  may  ensue.  Of  all  external  causes,  taking  cold,  in 
the  ordinary  sense  of  the  expression,  from  exposure  to  draughts  of  air,  or  in 
any  way  productive  of  coryza,  is  by  far  the  most  frequent.  Whooping- 
cough  and  the  catarrhal  affections  commonly  classed  under  the  head  of  hay 
fever  may  also  result  in  acute  inflammation  of  the  middle  ear.  Sea-bathing, 
if  too  frequent  or  long  continued,  is  a  common  cause;  and  the  same  is  true  to 
a  less  extent  of  bathing  in  cold,  fresh  water.  But  it  seems  that  the  surf, 
either  from  it>  violence  or  from  its  saltness,  is  directly  dangerous  to  the  ear, 
especially  it'  a  perforation  of  the  drum  membrane  exists.  Perforation  of  the 
drumhead  also  admits  air,  which,  from  its  temperature  or  from  being  laden 
with  any  of  the  infectious  germs,  produces  inflammation  of  the  mucous  mem- 
brane. Acute  otitis  media  may  be  the  result  of  adenoid  vegetations  of  the 
pharyngeal  vault ;  and  many  children  who  are  subject  to  earache  will  be 
found  to  have  this  cavity  closely  packed  with  this  form  of  hypertrophic 
growth.  This  may  act  by  causing  a  retention  of  the  natural  secretion  through 
obstruction  of  the  orifices  of  the  Eustachian  tubes,  or  by  predisposing  to 
naso-pharyngitis  which  is  propagated  by  extension,  until  it  reaches  the  cavity 
"('  the  tympanum.  The  importance  of  the  recognition  of  this  condition  can- 
not lie  overestimated. 

Hypertrophied  tonsils  undoubtedly  have  a  similar  effect  upon  the  earj 
but  the  adenoid  growths  which  so  often  coexist  with  them  are  no  doubt  more 
frequently  responsible.  Otitis  media  may  also  follow  the  intratympanic 
hemorrhage  of  Bright's  disease.  It  may  be  produced  by  the  extension  of 
erysipelas  from  without.  Trauma  figures  among  the  less  common  causes  of 
middle-ear  disease  of  acute  form  ;  the  tympanum  by  its  situation  being  greatly 
protected  from  external  violence.  I  > 1 1 1  when  a  wound  admits  in  feet  ions  germs, 
or  when  infection  occurs  from  a  rupture  of  the  drum  membrane  by  an  explo- 
sion, :i  blow,  or  any  other  violent  cause,  inflammation  of  the  middle  ear  may 
follow.  The  same  is  true  of  the  destruction  of  the  drum  membrane  by  scald- 
ing or  corrosive  liquids  or  molten  metals.  Fracture  through  the  temporal 
bone  ma\  al-o  form  an  avenue  for  infectious  germs.  Among  the  rarer  causes, 
perforations  produced  by  mycosis  or  vegetable  fungi  of  the  meatus,  or  by 
accumulations  of  dried  wax  and  epithelium,  may  lead  to  the  same  result. 
The  teeth,  both  at  the  time  of  their  development  and  eruption,  and  when  dis- 
eased, are  productive  of  much  middle-ear  trouble.  During  the  first  and  the 
second  dentition-,  at  the  eruption  of  the  8ixth-year-molars,and  at  the  appearance 
of  the  wisdom  teeth,  1 1 1 < ■  ears  are  peculiarly  liable  to  sutler  iVoiii  reflex  irrita- 
tion and  inflammation.  At  all  time-  of  life  caries  and  necrosis  of  the  teeth 
and  alveolar  processes,  with  their  accompanying  ulcerations  and  suppuration, 
are  closely  connected  with  the  production  01  disease  of  the  tympanum.     The 


SYMPTOMS.  71!) 

examination  of  the  teeth  should,  therefore,  be  a  constant  matter  of  routine  in 
the  examination  of  these  cases. 

That  the  causes,  both  immediate  and  remote,  of  the  disease  under  consid- 
eration are  so  numerous  and  varied,  shows  the  need  of  diligent  research  in 
every  case,  that  we  may  avail  ourselves  of  all  indications  from  such  sources, 
both  for  present  treatment  and  for  prophylaxis. 

Symptoms. — Of  the  symptoms  of  acute  otitis  media,  next  to  the  pain, 
which  we  have  already  considered,  comes  tinnitus.  Subjective  noises  of  some 
kind  are  rarely  absent.  A  thumping,  pounding,  or  beating  sound,  synchro- 
nous with  the  heart's  action,  is  most  common  in  the  earliest  stage  of  the  disease. 
Children  often  mistake  these  sensations  for  real,  objective  noises  ;  and  an 
inquiry  as  to  their  meaning  or  cause  is  sometimes  the  first  indication  of  the 
existence  of  disturbances  in  the  ears.  Later,  the  tinnitus  is  of  a  more  steady 
and  continuous  character,  described  as  rushing,  roaring,  singing,  or  buzzing. 
Those  sounds  of  a  pulsatory  or  rhythmic  character  are  due  to  the  increased 
circulation  in  the  arteries  and  dilated  capillaries  in  close  contiguity  to  the 
sound-perceiving  termination  of  the  auditory  nerve.  Those  of  a  steady  and 
continuous  character  are  due,  at  first  at  least,  to  increased  venous  circulation, 
which  is  heard  by  the  ear  itself  in  the  same  manner.  In  a  later  stage  there 
may  also  be  tinnitus  due  to  pressure  on  the  contents  of  the  labyrinth  through 
the  oval  and  round  windows  from  swelling  or  retained  secretion  in  the  mid- 
dle ear.  To  children  these  noises  are  often  terrifying.  In  all  cases  they  are 
productive  of  a  greater  or  less  degree  of  nervousness  and  distress. 

Deafness  is  the  next  objective  symptom  noticed  by  the  patient.  In  the 
milder  cases  some  days  may  elapse  before  the  hearing  becomes  much  im- 
paired. Slight  degrees  of  deafness  may  not  at  first  be  noticed  by  the  patient, 
especially  if  the  affection  be  unilateral.  But  soon  familiar  sounds,  like  the 
ticking  of  a  clock,  become  inaudible,  then  the  patient  begins  to  ask  for  a 
repetition  of  what  is  said  by  those  around  him,  and  finally  hearing  is  for  the 
time  almost  totally  abolished.  The  degree  of  deafness,  in  the  earlier  stages 
at  least,  depends  much  upon  the  localization  of  the  affection.  Should  the 
attic  of  the  tympanum  be  most  affected,  the  hearing  may  suffer  but  slightly 
at  first,  although  the  pain  be  most  severe.  When  the  Eustachian  tube  i-  most 
affected,  the  stopped-up  feeling  predominates  over  the  deafness.  When  the 
whole  lining  of  the  atrium  is  involved  at  the  outset,  the  deafness  is  mosf 
marked.  Besides  deafness  there  may  be  the  modified  hearing  of  autophony, 
in  which  the  patient  hears  his  own  voice  strongly  changed  and  resonant. 
There  may  also  be  diplacusis,  or  hearing  sounds  in  a  different  pitch  from 
that  perceived  by  the  unaffected  ear. 

The  constitutional  symptoms  are  sometimes  ushered  in  by  a  chill.  There 
i-  general  uneasiness,  loss  of  appetite,  and  increased  temperature  ;  sometimes 
headache,  dizziness,  and  possibly  nausea  are  present.  As  in  other  acute  dis- 
eases, the  general  disturbances  will  be  greatest  in  patients  of  a  nervous 
temperament. 

If  a  tuning-fork  in  a  state  of  vibration  be  now  applied  t"  the  vertex  or 
to  the  teeth,  the  sound  will  be  heard  more  clearly  in  the  affected  side,  the 
closed  cavity  with  its  thickened  walls  acting  as  a  sounding-board  to  intensify 

the  effect  of  the  vibrations.     Examinati f  the  drum  membrane  usually 

reveals  more  or  less  redness  ;  even  in  the  early  stages  "i  the  attack  the 
hyperemia  show-  it-elf  by  beginning  at  the  tympanic  margin  and  extending 
toward  the  center  with  more  or  less  rapidity.  The  vessels  which  follow  the 
handle  of  the  malleus,  iin-een  in  a  state  of  health,  now  become  visible.  All 
the  landmarks  may  be  lost,  as  the  hyperemia  involve-  ih  t  portion  of 


720 


ACUTE  AFFECTIONS  OF  TYMPANIC  CAVITY,    ETC. 


the  dermoid  meatus;  swelling  shows  itself  at  any  point  according  to  the 
localization  «>t'  the  inflammation,  and  may  also  extend  to  the  inner  end  of  the 
meat us  (see  Plate  11,  Fig.  8). 

A-  in  all  inflammations  of  the  mucous  membrane,  the  secretion  soon 
begins  to  increase.  A  serous  exudation  is  poured  out,  which  may  sometimes 
be  distinguished  through  the  still  transparent  membrane,  partially  filling  the 
cavity  of  the  tympanum,  Like  the  liquid  in  a  spirit  level  (see  Fig.  495).  In 
severe  cases  the  cavity  quickly  becomes  tilled,  and  a  few  hours  may  suffice  for 
the  pre-- nre  of  the  confined  liquid  to  cause  a  rupture  of  the  drum  membrane^ 
A-  the  Eustachian  tube  has  been  closed  by  the  swelling  nt*  its  lining  mem- 
brane, the  drumhead  affords  the  point  of  least  resistance,  and  becoming  soft- 
ened, yields  to  the  pressure  from  within.  Often  the  liquid  takes  on  a  puru- 
lent character,  and  may  be  seen  pointing  at  some  bulging  portion  of  the 
membrane  before  a  rupture  takes  place  (Fig.  4!Mi).  After  the  evacuation  of 
the  secretion,  whether  from  spontaneous  giving-way  (Fig.  497)  of  the  mem- 


FlG.  495. — Acute  catarrh  of 
the  middle  car.  w  Lth  bubbles 
in  the  fluid  which  nearly  fills 

the  drum  cavity. 


Fig.  196. — Injected  drumhead 
bulging  in  the  upper  back  oi 
quadrant  and  above  the  short 
process. 


Fk;.  497.— Poutine perforation 
(if  the  lower  back  quadrant, 
showing  a  mere  pin-hole  at  the 

apex  of  the  nipple. 


brane,  or  from  surgical  interference,  there  is  usually  great  relief  from  pain. 

The  amountof  discharge  may  be  very  slight,  but  is  at  times  most  profuseand 
continuous,  so  as  to  moisten  many  thicknesses  of  compresses  and  bandages. 
<  )ftni  at  first  the  secretion  i-  tinged  with  blood,  or  there  may  be  <|iiite  a  free 
hemorrhage.  In  favorable  cases  the  untoward  symptoms  now  rapidly  sub- 
side. The  pain  diminishes  and  disappears,  the  noises  become  less  violent  and 
annoying,  the  temperature  falls,  the  patient  is  able  to  obtain  rest,  and  the 
general  recovery  is  rapid.  The  deafness,  the  last  effect  to  disappear,  gradually 
or  sometimes  quite  suddenly  gives  place  to  perfect  hearing.  Unfortunately, 
many  case-  do  not  end  so  happily. 

Treatment. — The   first   point  in  the  treatment   is  to  remove,  so  far  as 

'possible,  fin  cause.  But  in  mosl  cases  the  patient  is  not  seen  until  the  disease 
i-  well  developed,  and  preventive  measures  are  now  of  no  avail.  However, 
when  a  naso-pharyngitis  which  has  spread  to  the  middle  ear  is  still  active,  it 
should  receive  prompt  ami  appropriate  attention.  Anything  unfavorable  in 
the  patient's  surroundings  should  be  looked  after,  a  mild  and  equable  tem- 
perature should  be  established  and  ihc  patient  placed  in  bed  ;  and  quiet,  both 
as  regards  freedom  from  noise  and  from  excitement,  maintained.  If  there 
be  a  rise  in  temperature,  a  saline  cathartic  should  be  administered.  Tincture 
of  aconite  may  be  given  in  small  and  frequent  doses,  where  the  pulse  is  full 
and  hard,  until  the  feverishness  is  reduced.  Opiates  should  be  used  but 
sparingly,  excepl  at  the  outset,  when  a  full  dose  may  he  employed.  When 
given  later,  by  their  anodyne  effect,  they  mask  the  symptoms,  and  may 
deceive  into  a  fancied  security  when  the  danger  i~  not  yet  passed.     Inflation 


TREATMENT.  721 

by  Pulitzer's  method  should  be  tried  with  care  and  gentleness.  It  sometimes 
gives  great  relief  to  pain  by  equalizing  the  pressure  of  air  within  and  av i 1 1 1  - 
out  the  tympanic  cavity.  With  closure  of  the  Eustachian  tube,  absorption 
of  air  takes  place  through  the  mucous  membrane  lining  the  tympanic  cavity. 
This  produces  a  partial  vacuum,  draws  inward  the  drum  membrane,  causing 
pressure  through  the  chain  of  ossicles  upon  the  labyrinthine  contents,  and  at 
the  same  time  retards  the  flow  of  blood,  causing  or  increasing  venous  con- 
gestion in  the  lining  mucous  membrane  and  exudation  into  the  cavity.  When 
the  effect  of  this  procedure  i<  favorable,  it  may  be  repeated  once  or  twice 
daily  ;  but  when  it  increases  pain  or  gives  no  relief,  its  use  musl  l»e  postponed 
until  later  in  the  treatment  of  the  case.  No  simple  measure  is  so  helpful  as  the 
application  of  "dry  heat."  The  hot-water  bag  of  India-rubber  is  the  readiest 
means  of  applying  heat.  This,  when  filled,  should  be  covered  with  -oft 
cloth  and  laid  upon  the  pillow  in  contact  with  the  ear.  But  still  better, 
because  of  its  lightness,  is  a  bag  loosely  tilled  with  common  salt  and  heated 
in  an  oven.  Moist  and  warm  applications,  like  poultices  in  all  forms,  are  to 
be  avoided.  They  soon  become  uncomfortable  by  evaporation,  and  tend  by 
maceration  of  its  dermoid  layer  to  promote  rupture  of  the  drumhead,  already 
perhaps  softened  in  its  inner  layer.  They  may  also  serve  as  the  means  of 
conveyance  of  all  sorts  of  infectious  germs,  and  in  the  end  complicate  far 
more  than  they  benefit  the  disease.  For  this  reason  are  injurious  most  of  the 
popular  remedies  and  poultices  of  all  the  vegetables  in  the  kitchen-garden. 
So,  too,  all  the  varieties  of  vegetable  oils  and  animal  greases  are  harmful, 
their  sole  value  having  been  to  carry  heat.  The  vapor  of  chloroform  may 
be  used  with  much  benefit  in  mild  cases  in  children.  A  few  drops  of  the 
liquid  may  be  placed  in  a  spoon,  and  the  vapor,  which  is  much  heavier  than 
air,  be  poured  like  a  liquid  into  the  ear.  Chloroform  liniment  applied  about 
the  ear  with  a  bit  of  flannel  is  also  valuable.  Aseptic  aqueous  solutions  con- 
taining local  anodynes  and  anesthetics  maybe  used  judiciously  in  the  early 
stage  of  an  attack.  The  sulphate  of  atropia,  four  grains  to  the  ounce  of 
solution,  is  efficacious.  Cocain  hydrochlorate,  in  solution  of  from  four  to 
twenty  grains  to  the  ounce,  is  still  more  effective  transiently  ;  and  better 
still  is  the  combination  of  these  two  with  morphin,  e.  g.  : 

1$:.  Sol.  cocain  hydrochlorat.,  10  '/,   ftj  ; 

Atropiie  sulph.,  gr.  j  ; 

Morphia?  sulph.,  \i\\  ij. 

Of  this,  five  or  six  drops  from  a  spoon  previously  dipped  into  hot  water 
may  be  poured  into  the  ear.1 

The  local  abstraction  of  blood  furnishes  one  of  our  most  effective 
measures.  The  application  of  two  or  three  leeches  to  the  tragus,  or  just  in 
front  of  it,  may  cut  short  the  whole  trouble.  After  they  have  filled  them- 
selves with  blood  and  fallen  oil",  the  bleeding  from  the  bites  may  generally 
be  allowed  to  continue  until  it  ceases  spontaneously.  Tin-  subsequent  bleed- 
hag  makes  the  natural  leech  more  effective  than  wet-cupping.  ^  hen  leeches 
are  not  ,-it  hand,  the  artificial  leech  furnishes  an  excellent  substitute,  or  any 
small  knife  can  puncture  the  skin  in  front  of  the  tragus,  and  any  -mall 
cupping-glass  will  serve  if  the  special  instrument  be  not  at  hand.  An 
ounce   or   two   of  blood    may    be   taken,  and  if  the    relief  experienced   be 

temporary,  the  process  may  be  repeated.  But  when  the  simpler  measures 
tried  in  quick  succession  have  failed,  or  when  the  onset  of  the  disease  is  such 

1  Smaller  dosage  mnsl  bo  adopted  if  perforation  h 

16 


722         ACUTE  AFFECTIONS  OF  TYMPANIC  CA  VITY,  FTC 

thai  it  Is  oof  likely  to  yield  quickly  to  the  other  remedies,  or  when  we  find  the 
earlier  stages  of  the  inflammation  have  passed  before  we  have  seen  the  case, 
paracentesis  of  the  drum  membrane  musl  be  made.  This  may  be  done  with 
any  long,  slender  knife,  such  as  v.  Graefe's  cataract-knife,  or  a  delicate  bistoury, 
which  should  be  first  carefully  sterilized.  The  most  convenient  instrument  for 
the  purpose  is  the  spear-shaped  knife  ^Fig.  498).      The  double-edged  point 


Fig.  498— Sprague's  pocket-case  and  handle  for  paracentesis,  etc 

should  be  longer  than  is  usually  made,  so  that  in  penetrating  deeply  it  will  con- 
tinue to  cut,  and  not,  alter  pricking  through  the  membrane,  fail  to  enlarge 
the  opening.  The  meatus  should  be  disinfected  by  gentle  irrigation  with  a 
1  :  5000  warm  solution  of  mercuric  bichlorid,  followed  by  mopping  with 
absorbent  cotton  moistened  with  alcohol.  A  pellet  of  cotton  dipped  in  a  10 
per  cent,  solution  of  cocain  should  then  be  laid  against  the  drum  membrane 
for  a  few  minutes  to  produce  local  anesthesia.  This  will  not  always  be  com- 
plete in  an  inflamed  membrane,  but  the  pain  of  the  cut  will  usually  be  very 
slight  and  momentary.  The  point  of  selection  for  the  incision  may  be  where 
any  swelling  or  tendency  to  point  seems  to  indicate  ;  but  if  there  be  no  such 
local  indication,  the  posterior  inferior  segment  is  usually  chosen  as  the  region 
where  less  injury  is  likely  to  be  done  by  the  knife  to  the  structures  within. 
The  cut  should  be  a  free  one  of  several  millimeters''  length  and  carried  down 
to  the  tympanic  margin  for  the  purpose  of  drainage,  and  so  as  to  divide  the 
plexus  of  engorged   vessels   which    is  usually  present  there. 

It'  the  opening  be  made  very  early,  there  may  be  little  or  no  secretion, 
and  even  the  hemorrhage  may  be  very  scanty.  If  there  be  a  purulent  dis- 
charge, this  may  be  gently  washed  away  with  the  warm  bichlorid  solution, 
otherwise  no  syringing  or  other  interference  is  necessary.  A  wick  of  absorb- 
ed cotton,  moistened  with  bichlorid  solution,  should  be  inserted,  a  small 
compress  of  iodoform  gauze  should  be  placed  over  the  meatus  and  a  larger 
one  over  the  whole  ear,  and  secured  by  a  loose  bandage.  Every  kind  of  med- 
dlesome interference  which  might  cause  reinfection  should  be  avoided.  The 
progress  of  the  disease  may  now  be  arrested.     The  opening  made  by  incision 

quickly  heal-,  the  |>:iin  is  relieved,  and  the  -welling  is  soon   dissipated.      The 

subjective  uoises  cease,  and  the  patient's  voice  as  heard  by  himself  resumes  its 
natural  tone.  The  hearing  regains  its  normal  acuteness ;  and  in  a  few  days 
there  may  be  no  remaining  sign,  either  physical  or  subjective,  of  the  serious 
disturbance  which  has  taken  place.  When  the  process  of  resolution  is  less 
rapid,  especially  if  the  pain  return-  on  the  following  night,  more  active  after- 
treatmenl  may  be  necessary.  An  anodyne  may  be  given  internally,  and 
iodic!  of  potassium  should  be  administered,  or  a  mercurial  inunction  used,  or 
both,  [f,  owing  to  a  too  rapid  healing  of  the  incision  there  be  retained  secre- 
tion, the  operation  may  be  repeated,  [fan  abundant  discharge  occur,  it  must 
be  removed  by  irrigation  with  warm  antiseptic  solution.      When  the  deafness 

doe-  not  quickly  disappear,  the  use  of  the  Politzer's  bag  may  again  be  indi- 


SALPINGITIS.  723 

cated.  For  some  weeks  at  least  after  an  attack  the  patient  should  exercise 
unusual  precaution  againsl  the  effects  of  exposure  to  the  weather,  and  over- 
fatigue. Should  the  ear  be  sensitive  to  the  cold,  a  bit  of  absorbent  wool 
should  be  tucked  into  the  meatus  before  driving  or  exposure  out  of  doors. 

SALPINGITIS. 

Thus  far  we  have  considered  the  acute  affections  of  the  middle  ear,  with 
reference  to  the  principal  cavity,  the  atrium.  The  disease  may  be  especially 
localized  in  the  accessory  cavities,  the  Eustachian  tube,  or  the  attic  of  the 
tympanum.  When  the  Eustachian  tube  is  the  seat  of  the  inflammation,  the 
most  marked  subjective  symptoms  are  produced  by  the  sudden  closure  of  the 
isthmus  of  the  tube  by  swelling.  The  effect  of  this  obstruction  is  the  forma- 
tion of  a  partial  vacuum,  causing  retraction  of  the  tympanic  membrane  in- 
ward and  the  transmission  of  pressure  to  the  labyrinth,  producing  annoying 
tinnitus  and  dizziness,  which  may  be  distressing.  Autophony  is  produced 
most  frequently  by  this  cause.  The  pain  is  located  under  the  ear  and  inward 
toward  the  throat  or  at  the  root  of  the  tongue,  rather  than  deeply  in  the  ear 
itself.  All  these  symptoms  may  be  productive  of  great  malaise  and  general 
disturbance  of  the  nervous  system.  Often  there  is  a  sensation  as  of  a  plug 
in  the  ear,  which  the  patient  endeavors  to  remove  by  thrusting  the  finger  into 
the  meatus.  Cracking  sounds  are  common,  at  times  rhythmical.  The  tym- 
panic membrane  may  show*  little  if  any  hyperemia,  but  only  great  retraction. 
At  first  there  may  be  a  thin  serous  secretion,  and  later  the  tube  may  be  dis- 
tended by  a  viscid  and  tenacious  muco-purulent  exudation,  which  may  be 
discharged  into  the  throat  and  from  the  mouth.  By  the  rhinoscopic  mirror 
the  mucous  membrane  at  the  mouth  of  the  tube  may  be  seen  to  be  swollen 
and  covered  with  secretion. 

The  object  of  treatment  will  be  first  to  relieve  the  local  congestion 
and  inflammation  of  the  tube  itself;  and  then  by  opening  i\\e  closed  pas- 
sage to  restore  the  rest  of  the  apparatus  of  the  middle  ear  to  its  normal 
condition.  Mild  aseptic  sprays  may  be  used  through  the  nose  and  fauces, 
with  gargles  of  a  similar  character  and  of  hot  alkaline  solutions,  to  modify 
any  existing  catarrhal  conditions  of  the  nasal  and  pharyngeal  cavities.  The 
gentle  use  of  Politzer's  bag  should  then  be  tried,  and  if  the  obstruction 
is  not  too  great,  may  be  followed  by  immediate  relief.  Should  the  air  not 
penetrate  by  this  means,  the  Eustachian  catheter  should  be  employed.  An 
instrument  of  pure  silver  which  can  be  bent  to  any  curve  should  be  used,  and 
should  be  heated  to  redness  in  the  flame  and  plunged  in  a  cold  boric  solu- 
tion. Its  use  should  be  preceded  by  spraying  or  mopping  the  nose  and 
the  month  of  the  tube  with  a  <i  to  10  per  cent,  solution  of  cocain.  The  air 
should  be  thrown  in  very  gently  at  first  to  evacuate  the  secretion  from  the 
tube  and  not  to  force  it  onward  into  the  middle  ear.  Soon  the  air  will  be 
heard  through  the  auscultation  tube  entering  the  cavity  of  the  drum.  Some- 
times the  sudden  change  of  pressure  causes  transient  giddiness  or  faintness. 
The  hearing  is  improved  at  once,  tin-  tinnitus  ceases  <>r  is  diminished,  the  feeling 
of  fulness  is  relieved,  and  the  tympanic  membrane  will  return  more  or  less 
completely  to  its  normal  plane.  At  the  same  time  proper  remedies  may  be 
applied  through  the  catheter  to  the  mucous  membrane  of  the  tube.  <  M  tin  se, 
none  is  more  effective  than  the  weaker  solutions  of  nitrate  of  silver.  From 
5  to  15  grains  to  the  ounce  will  usually  be  sufficiently  strong.  Only  a  lew 
drops  should  be  ux<\,  and  but  little  force  applied  in  driving  it  through  the 
catheter,  as  the  effect  is  to  be  localized    in   the  tube   itself.     This  treatment 


724  ACUTE  AFFECTIONS  OF  TYMPANIC  CAVITY,    ETC. 

should  be  repeated  daily  at  first,  and  then  at  greater  intervals  until  no  longer 
required.  In  a  few  days,  in  mosl  eases,  the  normal  hearing-  will  be  restored 
as  the  swollen  mucous  membrane  returns  to  its  natural  state.  When,  as 
sometimes  happens,  there  is  more  permanent  thickening  or  even  stricture  of 
the  tube,  dilation  by  means  of  delicate  bougies  passed  through  the  catheter 
may  be  required. 

INFLAMMATION  OF  THE  ATTIC. 

It  is  evident  from  this  description  that  localized  inflammation  of  the  tube 
is  less  serious  and  less  dangerous  to  the  hearing  than  that  of  the  atrium. 
When  the  lining  membrane  of  the  attic  becomes  inflamed,  the  condition  is 
much  more  serious.  The  anatomical  conditions  are  such  that  even  slight 
swellings  cut  off  the  communication  of  this  space  from  the  atrium  below. 
The  bulkier  portions  of  the  malleus  and  incus,  with  their  ligamentous  attach- 
ments and  folds  of  mucous  membrane,  nearly  fill  the  communicating  space 
between  the  two  chambers,  and  but  little  swelling  is  required  to  complete  the 
closure.  The  pain  from  the  tension  caused  by  the  hyperemia  alone  soon 
becomes  excruciating.  As  soon  as  inflammatory  products  appear,  the  pressure 
i-  -till  further  increased.  The  flaccid  membrane,  already  intensely  reddened 
and  contrasting  strongly  with  the  drum  membrane  proper  below,  becomes 
Induing  and  swollen  over  its  whole  extent,  or  forms  pockets  on  one  or  both  sides 
of  the  malleus  along  the  anterior  and  posterior  folds  (see  Fig.  496).  This 
condition  admits  of  little  or  uo  delay  for  tentative  treatment.  Although  spon- 
taneous rupture  may  give  ease,  it  may  be  only  temporary.  A  permanent  open- 
ing in  the  flaccid  membrane  may  result,  with  necrosis  of  the  bony  walls  of  the 
atticandof  the  ossicles,. and  the  formation  of  adhesions  which  may  impair  the 
movements  of  the  ossicles.  Here  a  free  and  prompt  use  of  the  knife,  under 
the  same  antiseptic  precautions  enjoined  for  the  incision  of  the  lower  portion 
of  the  drum  membrane,  is  both  necessary  and  effective.  Beginning  just 
above  the  short  process  of  the  malleus,  the  knife,  with  one  cutting  edge  turned 
backward,  should  be  plunged  deeply  in,  until  it  reaches  a  bony  obstruction ; 
then  the  cut  should  be  prolonged  until  it  strikes  the  posterior  insertion  of  the 
membrane.  Then  with  the  other  edge  of  the  knife  the  division  should  be 
continued  upward  and  backward  for  a  quarter  of  an  inch  or  more  along  the 
superior  margin  of  the  membrane,  still  cutting  deeply,  and  dividing  all  the 
tissues  until  the  bony  wall  is  felt.  This  can  be  done  in  a  satisfactory  way 
only  under  general  anesthesia.  After  the  incision — which  will  be  followed 
by  fiee  bleedingand  the  evacuation  of  pus  if  suppuration  be  already  present, 
ami  oozing  of  serous  effusion — the  wound  should  be  irrigated  with  warm 
bichlorid  solution  of  1  :  5000.  A  mesh  of  absorbent  cotton  should  be  left  in 
the  meatus  to  promote  drainage,  and  the  whole  ear  covered  with  iodoform 
gauze,  as  before  described.  The  resull  is  usually  prompt  improvement.  The 
hypereraic  tissues  are  relieved  of  their  engorgement,  and  the  pain  will  have 
nearly  disappeared  when  the  patienl  return-  to  consciousness.  The  incision, 
although  extensive  and  deep,  heals  with  remarkable  rapidity  and  leaves  no 
visible  cicatrix.  The  after-treatmenl  is  the  same  as  in  simple  paracentesis. 
However  harsh  and  radical  this  operation  mayal  first  sight  appear,  it  is  so 
generally  efficacious  thai   it-  performance  will   never  be  regretted. 

In  the  light  of  our  present  knowledge  of  bacteriology,  nearly  if  not  quite 
all  the  causes  of  acute  inflammation  of  the  middle  ear  are  only  the  sources 
or  excitants  of  bacteriological  activity.  No  cavity  of  the  body  lined  with 
mucous  membrane  is  i'v>-  from  organisms  of  morbific  character,  which  are 


INFLAMMATION  OF  THE  ATTIC.  725 

ready  to  develop  with  amazing  rapidity  under  favoring  conditions  ;  and  the 
mucous  membrane  is  a  soil  always  ready  to  receive  and  nurture  germs  of  the 
must  virulent  character.  The  nose  and  the  fauces  are  always  exposed  to 
infection  through  the  air  ;  and  that  such  infection  is  qo1  always  taking  place 
shows  what  a  wonderful  defensive  power  against  such  morbific  germs  must 
exist  when  not  in  abeyance  owing  to  disturbing  influences.  Usually  the  infec- 
tion is  at  first  by  a  single  organism,  either  that  of  the  systematic  disease,  of 
which  the  nasal  trouble  is  a  local  manifestation,  or  by  one  of  the  less  virulent 
forms,  which  has  for  some  reason  been  called  into  activity.  After  the  open- 
ing of  the  drum  cavity  by  spontaneous  or  artificial  means  reinfect  ion  may 
take  place,  and  a  variety  of  the  most  dangerous  coeei,  with  their  foul  odors 
and  poisonous  products,  complicate  the  disease.  Hence  the  necessity  of 
maintaining  the  strictest  antisepsis  and  of  abandoning  many  of  the  remedies 
and  means  of  treatment  which  formerly  seemed  to  be  most  strongly  indi- 
cated. 


CHRONIC  CATARRH  OF  THE  MIDDLE  EAR. 

By  EDWARD   B.   DENCH,  PH.B.,  M.D., 

OF   NEW    YORK    CITY. 


The  term  chronic  catarrh  has,  in  my  opinion,  led  to  a  very  general  mis- 
understanding among  the  medical  profession  in  regard  to  tho  changes  which 
take  place  in  the  middle  ear  in  the  disease  under  consideration.  It  would  be 
much  better  to  designate  this  affection  as  chronic  nonsuppurative  inflammation 
of  the  middle  ear.  The  word  rain rrh  is  so  universally  associated  with  some 
affection  of  the  upper  air-tract,  that  both  the  profession  and  the  laity  have  come 
to  look  upon  a  chronic  catarrhal  otitis  media  as  the  result  of  an  extension  of  an 
inflammatory  process  from  the  nose  and  naso-pharynx  into  the  tympanum  by 
contiguity  of  structure.  Catarrh  is  not  a  disease,  but  a  symptom,  and  from 
it-  derivation  mean-  a  discharge.  It  may,  therefore,  result  from  various  local 
lesions,  and  the  idea  so  commonly  entertained  that  catarrhal  inflammation 
ofthe  middle  ear  is  always  due  to  the  extension  of  an  inflammatory  process 
from  the  nose  or  naso-pharynx  is  entirely  unwarranted.  The  influence 
exerted  by  any  affection  of  the  nose  or  naso-pharynx  is  usually  purely 
mechanical.  Thus,  in  the  case  of  adenoid  vegetations  within  the  naso- 
pharvnx.  the  middle  ear  may  suller  either  from  the  direct  pressure  of  the 
Lymphatic  tissue  upon  the  mouth  of  the  Eustachian  tubes,  causing  a  rarefac- 
tion of  the  air  within  the  tympanum  ;  or  this  lymphatic  tissue  may  interfere 
with  the  return  circulation  from  the  tympanum,  thus  causing  a  dilatation  of 
the  vein-  within  tin-  cavity,  and  consequent  congestion  of  the  lining  mem- 
brane. The  obstructive  lesions  of  the  nose  and  naso-pharynx  cause  chronic 
middle-ear  disease  chiefly  through  their  influence  upon  the  tympanic  blood 
current. 

Btiology. — Chronic  non-suppurative  inflammation  of  the  tympanum 
may  follow  an  acute  inflammation  of  the  middle  ear,  or  may  be  the  result  of 
repeated  mild  attack-  of  acute  congestion  of  the  part-,  each  successive  attack 
slightly  impairing  the  function  of  the  organ.  On  the  other  hand,  the  dis- 
ea-e  may  be  so  insidiously  progressive  from  its  beginning  a-  to  give  no  symp- 
tom- until  it  ha-  existed  for  many  year-. 

Heredity  is  supposed  to  bean  important  etiological  factor.  From  my  own 
observation,  I  am  inclined  to  attach  less  importance  to  heredity  than  do  most 
writer-.  It  i-  true  that  we  often  find  impaired  hearing  in  successive  genera- 
tions of  the  same  family.  When  we  examine  these  rases,  however,  we  not 
infrequently  learn  thai  the  impairmenl  in  hearing  has  not  been  due  to  similar 
middle-ear  conditions.  The  history  is  an  unsafe  guide  in  determining  the 
etiological  importance  of  heredity.  The  patient  -imply  remembers  that  other 
members  of  the  family  have  Buffered  from  an  affliction  similar  to  his  own,  but 
can  naturally  give  no  information  as  to  the  nature  of  the  local  lesion.  It 
would  b.'  absurd  to  suppose  that  a  suppurative  otitis  media,  causing  impair- 
menl of  hearing  in  our  member  of  t In-  family,  should  be  at  all  responsible  for 


PATHOLOGY.  727 

interference  with  audition  in  successive  generations.  My  own  belief  is  that 
certain  conditions  of  the  nose  and  naso-pharynx,  such  as  enlargement  of  the 
pharyngeal  tonsil,  relaxation  of  the  turbinal  tissue,  enlargement  of  the  faucial 
tonsils,  etc.,  are  hereditary.  Any  of  these  conditions  predispose  to  inflam- 
mation of  the  middle  car;  yet,  in  many  instance.-,  they  exist  without  pro- 
ducing this  result. 

Occupation  exerts  an  important  influence,  in  that  those  who  are  obliged 
to  endure  exposure  to  sudden  and  severe  changes  in  the  weather  are  more 
commonly  affected  than  those  whose  vocation  enables  them  to  guard  against 
such  unfavorable  conditions.  For  this  reason  we  find  that  the  disease  is 
more  common  in  males  than  in  females. 

The  various  general  diatheses,  such  as  the  rheumatic  or  gouty  diathesis, 
can  scarcely  be  looked  upon  as  influencing  the  occurrence  of  the  affection. 
The  habits  of  life  are  factors,  however,  in  producing  disease.  The  abuse  of 
alcohol  or  tobacco,  prolonged  mental  or  physical  exertion,  or,  in  fact,  any- 
thing which  tends  to  lower  the  general  condition,  may  act  indirectly  as  a 
cause  for  the  disease  under  consideration.  In  certain  slowly  progressive 
cases  the  local  affection  seems  to  be  due  to  interference  with  the  trophic 
nerve-supply  of  the  middle  car.  This  causes  an  impairment  in  nutrition  of 
the  tissues,  and  certain  structural  changes  follow  which  lead  to  either  a  per- 
version or  impairment  of  function. 

As  before  stated,  a  large  proportion  of  cases  are  associated  with  some  ob- 
structive lesion  of  the  upper  air-tract.  This  is  particularly  true  where  the 
chronic  process  follows  repeated  attacks  of  acute  inflammation. 

Of  these  local  causes,  the  most  important  is  probably  enlargement  of  the 
pharyngeal  tonsil.  Enlargement  of  the  faucial  tonsils  alone  is  seldom  re- 
sponsible for  middle-ear  involvement.  As  enlargement  of  the  faucial  tonsils 
is  almost  invariably  accompanied  by  a  similar  condition  of  the  pharyngeal 
tonsil,  the  etiological  importance  of  the  former  can  hardly  be  determined 
with  certainty. 

Affections  of  the  nasal  cavities,  such  as  hypertrophic  rhinitis,  nasal 
polypi,  deformities  of  the  nasal  septum,  etc.,  act  essentially  in  the  same  way 
as  does  enlargement  of  the  pharyngeal  tonsil.  These  conditions  either  cause 
a  rarefaction  of  the  air  within  the  tympanum,  or  interfere  with  the  blood 
supply  directly. 

In  atrophic  rhinitis  I  am  inclined  to  believe  that  the  process  within  the 
middle  ear  is  a  simple  concomitant  of  the  nasal  disease,  and  not  a  sequel  to  it. 
Atrophic  rhinitis  depends  upon  impaired  nutrition  of  the  lining  membrane 
of  the  nasal  chambers.  A  similar  condition  in  the  middle  ear  would  be  more 
probably  due  to  a  cause  similar  to  that  producing  the  nasal  lesion  than  to 
this  local   disorder  itself. 

Pathology. — Nbn-suppurative  inflammation  of  the  middle  car  may  be 
either  hypertrophic  or  hyperplastic  in  character.  By  the  hyperplastic  form 
I  mean  a  condition  ordinarily  known  as  sclerosis  of  tht  middle  ear,  which 
may  occur  either  as  an  idiopathic  affection  or  as  the  result  of  a  preceding 
hypertrophic  condition. 

Hypertrophic  I  nil"  munition. — The  mucous  membrane  within  the  tym- 
panum is  swollen,  the  blood  supply  is  increased,  and  ;ii  I  ngth,  actual  tissue 
hypertrophy  occurs.  The  Eustachian  tube,  forming  a-  il  does  a  portion  oi' 
the  middle  ear,  participates  in  these  changes.  The  mucous  membrane  is 
edematous,  and  the  lumen  of  the  tube  is  diminished  in  caliber.  In  the 
earlier  stages  the  membrane  of  the  tube  i-  simply  swollen,  there  being  no 
tissue  hypertrophy.     Tin-  i-  particularly  true  "l   those  cases  which    follow 


728  CHRONIC  CATARRH  OF  THE  MIDDLE  EAR. 

acute  catarrhal  otitis  media,  or  where  there  have  been  recurrent  attacks  of 
acute  congestion.  It'  this  engorgement  continues,  there  is  a  development  of 
new  connective  tissue  within  the  walls  of  the  tube,  and  the  passage  gradually 
becomes  more  and  more  contracted.  Asa  result,  the  intratympanic  pressure 
i-  diminished,  and  the  drum  membrane  and  ossicular  chain  are  forced  in- 
ward toward  the  inner  bony  wall  of  the  middle  ear.  The  drum  membrane 
is  gradually  stretched,  so  that  when  the  caliber  of  the  tube  is  restored,  the 
drum  membrane  is  much  relaxed.  Certain  inflammatory  changes  take  place 
in  the  middle  ear,  depending  directly  upon  the  displacement  of  the  tympanic 
membrane  and  of  the  ossicular  chain.  The  crowding  of  the  ossicle-  against 
each  other  and  against  the  internal  tympanic  wall  aggravates  the  inflamma- 
tory process  within  the  middle  ear.  As  a  result,  adhesions  are  formed  be- 
tween the  inner  wall  of  the  tympanum  and  the  ossicular  chain.  The  tensor 
tympani  muscle  gradually  atrophies  from  disuse,  the  muscular  libers  dis- 
appear and  are  replaced  by  connective  tissue.  After  this  has  occurred,  even 
if  the  Eustachian  tube  regains  its  normal  caliber,  the  malposition  of  the 
ossicles  and  membrane  persists  owing  to  the  rigidity  of  the  atrophied  tensor 
tympani.  If  the  drum  membrane  is  atrophic,  it  may  bulge  into  the  canal 
upon  inflation  beyond  the  plane  of  the  annulus,  the  ossicular  chain  remaining 
immovable. 

We  have  spoken  of  the  development  of  adhesions  between  certain  por- 
tion- of  the  ossicular  chain  and  the  adjoining  bony  walls  of  the  middle  ear. 
While  this  process  may  take  place  in  any  portion  of  the  cavity,  it  occurs 
mosl  frequently  in  the  region  of  the  oval  window.  The  adhesions  are  most 
frequently  found  either  between  the  posterior  crus  of  the  stapes  and  the 
corresponding  wall  of  the  oval  niche  or  between  the  crura  and  inferior  wall. 
Less  frequently  adhesions  develop  above  the  stapes  or  in   front  of  it. 

In  certain  instances  the  inflammatory  process  is  exceedingly  slow.  It  is  in 
these  cases  that  we  often  find  a  serous  effusion  in  the  tympanum,  the  engorged 
vessels  unloading  themselves  of  the  fluid  elements  of  the  blood.  Such  an 
effusion  may  fill  either  the  entire  tympanic  cavity  or  may  be  sacculated  in 
the   reduplications  of  the  mucous  membrane. 

When  tin'  hypertrophic  process  changes  to  the  hyperplastic  variety,  the 
cellular  elements  of  the  newly-formed  connective  tissue  are  changed  into 
dense  fibrous  tissue.  In  the  Eustachian  tube  this  transformation  causes 
the  stenosis  to  disappear,  and  the  canal  may  become  even  abnormally  wide. 
We  frequently  find,  therefore,  that  although  the  tub"  i-  perfectly  free,  the 
hearing  is  greatly  impaired.  Where  the  process  is  hyperplastic  from  the 
first,  the  lining  membrane  of  the  middle  ear  is  gradually  transformed  into 
dense   fibrous   tissue. 

[ncreased  tension  within  the  middle  ear  causes  increased  labyrinthine 
pressure ;  and  in  cases  of  long  standing  the  perceptive  portion  of  the 
auditory  apparatus  seldom  escapes  entirely. 

The  actual  changes  which  take  place  within  the  labyrinth  are  sometimes 
thr  result  of  a  chronic  inflammatory  process  induced  by  this  increased  press- 
ure. Where  no  pathological  lesion  can  be  demonstrated  by  microscopic 
examination,  il  seems  that  the  function  of  the  auditory  nerve  is  to  an  ex- 
tent   ablated    from    disuse. 

The  disease  in  question  is  seldom  unilateral,  both  ears,  as  a  rule,  being 
involved.  Rarely,  however,  are  both  organs  affected  to  the  same  extent,  the 
disease  usually  beginning  upon  one  side,  and  attacking  the  other  at  a  later 
period.  In  the  slowly  progressive  cases  the  disease  maj  be  so  insidious  as 
to  entirely  escape  the  patient'-  attention  until   the  second  organ  is  involved. 


SYMPTOMS.  729 

This  secondary  process  seems  to  particularly  affect  the  perceptive  apparatus, 
although  the  middle  ear  does  not  entirely  escape. 

Symptoms. — These  depend  upon  the  particular  course  pursued  by  the 

disease.  Those  cases  following  acute  inflammation  will  naturally  give  a 
history  of  successive  attacks  of  otalgia.  In  the  .-lowly  progressive  cases, 
however,  pain  is  not  a  prominent  symptom,  whether  the  disease  is  of  the 
hypertrophic  or  hyperplastic  variety.  The  symptom  which  first  attracts  the 
patient's  notice  is  usually  the  appearance  of  subjective  noises.  These  vary 
greatly  in  character  in  different  cases.  The  patient  will  sometimes  complain 
of  a  pulsation  in  the  ear,  synchronous  with  the  cardiac  pulsations.  In  other 
instances  the  noise  may  he  described  as  a  deep  rumbling  sound  ;  again,  it  may 
be  high-pitched,  and  i-  often  compared  by  the  patient  to  the  sound  of  escap- 
ing steam.  These  noises  may  be  constant  or  intermittent.  They  are  usually 
exaggerated  by  physical  or  mental  exertion,  by  a  cold  in  the  head,  or  by 
impairment  of  the  general  condition.  Especially  in  the  hyperplastic  form  of 
the  disease  the  subjective  noises  may  attract  the  attention  of  the  patient  before 
any  defect  in  hearing  is  discovered  ;  but  sooner  or  later  the  impairment  in 
audition  will  be  recognized. 

The  hearing  may  be  considerably  impaired  before  the  patient  becomes 
conscious  of  the  fact.  For  this  reason,  cases  seldom  present  themselves  in  the 
very  early  stages  of  the  disease,  but  only  when  the  hearing  has  fallen  consider- 
ably below  the  normal  standard.  Patients  usually  notice  that,  while  in  dia- 
logue the  hearing  is  fairly  perfect,  they  are  unable  to  hear  clearly  when  several 
are  talking  at  the  same  time.  A^arious  sounds,  such  as  the  tick  of  a  watch, 
the  sound  of  the  acoumeter,  etc.,  may  be  perfectly  heard,  and  yet  the  patient 
will  be  conscious  of  a  certain  deficiency  in  hearing,  ft  often  happens  that  the 
power  of  audition  fluctuates  greatly.  At  times  the  hearing  will  be  excellent, 
while  at  other  times  the  impairment  will  be  quite  pronounced.  A  common 
complaint  is  that  the  hearing  becomes  less  acute  whenever  the  patient  ha-  a 
"cold  in  the  head,"  and  not  infrequently  that  after  each  successive  attack  it 
remains  less  acute  than  before.  It  is  not  uncommon  for  the  hearing  to  be 
greatly  influenced  by  certain  muscular  movements  ;  thus,  many  hear  less 
acutely  while  masticating  the  food  than  at  other  times.  The  act-  of 
mastication  and  deglutition  may  also  be  accompanied  by  clicking  or  snapping 
sounds  in  the  ear  due  to  the  separation  of  the  walls  of  the  Eustachian  tube 
by  the  contraction  of  the  palatal  muscles. 

Again,  the  hearing  may  vary  with  the  position  of  the  head.  In  the  erect 
posture  it  may  lie  perfectly  normal,  while  on  lying  down  or  on  tilting  the 
head  far  back  it  may  be  greatly  impaired.  This  symptom  usually  indicates 
the  presence  of  fluid  in  the  tympanic  cavity.  When  the  head  is  tilted  back- 
ward, the  fluid  flows  into  the  posterior  portion  of  the  tympanum  and  covers 
the  oval  and  round  windows,  thus  interfering  with  sound-conduction.  \\  hen, 
however,  the  head  is  bent  forward  or  held  erect,  the  fluid  changes  it-  position, 
leaving  these  regions  free. 

While  vertigo  i-  not  a  com n  symptom  in  these  cases,  it  is  occasionally 

met  with,  and  may  be  very  pronounced.  This  i-  particularly  tru<  where  there 
i-  a  collection  of  thud  in  the  tympanic  cavity,  the  vertigo  becoming  very 
severe  when  the  position  of  the  head  causes  the  fluid  to  cover  the  oval  and 
round  windows. 

It  must  not  be   under-t I   that   the  presence  "f  fluid  in  the  middle  ear  i- 

the  sole  cause  of  tympanic  vertigo.  While  dizziness  is  not  a  common  symp- 
tom in  the-e  ca-e-,  it  i-  by  no  mean-  a  rare  one,  and  i-  sometimes  exceedingly 
severe.     The  pressure  upon  the  labyrinth,  due  to  increased  tension  of  the 


730  CHRONIC  CATARRH  OF  THE  MIDDLE  EAR. 

ossicular  chain  from  the  development  of  adhesions,  is  sufficient  to  cause  the 
symptom.  It  may  be  said,  in  this  connection,  that  the  length  of  time  which 
a  vertigo  lias  persisted  is  no  indication  that  relief  will  not  be  obtained  by 
relieving  the  middle-ear  condition.  If  examination  by  means  of  the  tuning- 
forks  -hows  that  the  middle  car  alone  is  involved,  the  results  of  treatment  are 
usually  satisfactory.  It  might  appear  that,  in  cases  of  long  standing,  relief 
of  the  increased  labyrinthine  pressure  could  be  obtained  by  surgical  meas- 
ures only.  This  is  not  the  case,  however  ;  and  we  often  find  that  the  restora- 
tion of  the  Eustachian  tube  to  its  normal  caliber  -will  immediately  relieye  the 
vertigo. 

Most  of  these  patients  hear  better  in  a  noise  than  in  a  quiet  place  ;  and, 
under  the  same  conditions,  the  subjective  noises  are  often  less  seyere.  This 
i-  explained  by  the  fact  that,  when  the  ossicular  chain  is  rigid,  a  certain 
amount  of  force  is  necessary  to  set  it  in  vibration.  When,  however,  the 
resistance  has  been  overcome,  very  slight  variations  in  this  force  are  recog- 
nizable. For  this  reason,  these  patients  usually  hear  better  in  a  railroad  train 
than  does  an  individual  with  normal  hearing  (paracousis  Willisii). 

As  the  disease  advances,  the  subjective  noises,  which  at  first  have  been 
distressing,  may  become  less  severe  or  disappear  entirely.  This  is  usually 
indicative  of  labyrinthine  involvement,  and  is  probably  due  to  the  fact  that 
the  portion  of  the  perceptive  apparatus  concerned  in  the  recognition  of 
sounds  of  this  particular  character  has  been  destroyed. 

The  appearance  of  tinnitus  in  the  previously  healthy  ear  should  always 
be  looked  upon  as  a  grave  symptom.  The  sounds  are  generally  of  a  high 
pitch,  and  probably  depend  upon  certain  changes  in  the  cortical  auditory  area. 
As  we  know,  each  cortical  auditory  center  receives  fibers  from  both  auditory 
nerve-,  but  chiefly  from  the  nerve  of  the  opposite  side.  When  the  labyrinth 
of  one  side  Is  involved  as  the  result  of  chronic  middle-ear  inflammation,  the 
opposite  cortical  auditory  center  is  affected,  and,  as  the  disease  progresses,  this 
cortical  lesion  interfere-  with  the  function  of  those  fibers  from  the  labyrinth 
of  the  -nine  side,  -o  that  the  disappearance  of  tinnitus  in  the  ear  first  involved 
is  usually  followed  by  -ubjective  noises  in  the  opposite  ear. 

Diagnosis. — Physical  Examination. — The  changes  visible  upon  spec- 
ulum examination  often  give  no  indication  of  the  degree  of  impairment  of 
function.  The  drum  membrane  may  appear  fairly  normal  as  regards  posi- 
tion, color,  luster,  and  structure,  and  yet  the  hearing  may  be  very  much 
impaired.  On  the  other  hand,  fairly  good  hearing  may  exist  where  the  drum 
membrane  and  ossicular  chain  give  undoubted  evidence  of  intratympanic 
inflammation.  The  most  common  change  is  displacement  of  the  drum  mem- 
brane inward.  The  handle  of  the  malleus  is  fore-shortened,  and  the  short 
process  i-  unduly  prominent.  The  tympanic  membrane  itself  may  be  thick- 
ened over  certain  area- and  atrophic  in  other  part-.  A  fore-shortening  of  the 
handle  of  the  malleus  indicates  displacement  of  the  ossicular  chain  inward.  In 
many  cases  thi-  retraction  i-  but  slight,  and  y<t  extensive  changes  have  taken 
place  in  the  middle  ear.  Adhesions  within  tin'  tympanic  cavity  may  cause  a 
rotation  of  the  malleus  upon  it-  long  axis,  so  that  the  manubrium  may  appear 
broader  than  normal.  Here  the  direction  of  rotation  i-  from  behind  forward. 
Rotation  in  the  opposite  direction  i-  accompanied  by  considerable  retraction 
of  tln>  tympanic  membrane,  and  the  manubrium  appears  narrower  than  nor- 
mal from  the  fact  that  the  <d<_re  of  the  prismatic  shaft  i-  presented  to  view 
instead  of  the  broader  external  border. 

The  presence  of  adhesions  can  be  demonstrated  by  the  use  of  the  Siegle 
speculum.     Examination  with  thi-  instrumenl  will  -how  that  the  drum  mem- 


DIAGNOSIS.  7  51 

brane  and  ossicular  chain  no  longer  move  outward  as  a  whole,  when  the  air  in 
the  canal  is  exhausted.  With  each  act  of  rarefaction,  certain  portions  of  the 
drum  membrane  will  be  drawn  outward,  while  the  ossicular  chain  will  either 
remain  immovable,  or  more  frequently  the  handle  of  the  malleus  will  seem  to 
rotate  upon  its  long  axis,  motion  outward  being  prevented  by  adhesions  to 
the   internal  tympanic  wall. 

In  the  hyperplastic  variety  of  the  disease,  atrophy  of  the  tympanic 
membrane  is  commonly  present.  This  may  he  so  marked  as  to  render  the 
structures  in  the  middle  ear  clearly  visible.  In  the  upper  posterior  quadrant 
the  descending  process  of  the  incus,  the  posterior  crus  of  the  stapes,  and  the 
tendon  of  the  stapedius  muscle  can  frequently  be  recognized.  Owing  to  the 
tenuity  of  the  membrane  it  is  often  found  to  be  relaxed  as  the  result  of  sud- 
den and  violent  changes  in  the  intratympanic  pressure. 

Catheterization  in  the  hypertrophic  cases  shows  a  narrowing  of  the  Eu- 
stachian tube,  most  marked  upon  the  more  affected  side.  If  there  is  fluid  in 
the  tympanum,  its  presence  will  be  characterized  by  bubbling  or  crackling 
noises  as  the  air  enters  the  cavity.  Extensive  adhesions  within  the  tympanum 
will  occasionally  produce  creaking  and  strident  sounds  upon  catheter  infla- 
tiou. 

In  the  hyperplastic  variety  of  the  affection  the  Eustachian  tube  will  be 
found  abnormally  wide,  air  entering  the  middle  ear  very  freely.  Sometimes 
one  tube  will  be  abnormally  patent,  while  the  other  is  narrow.  This  simply 
means  that  the  process  has  advanced  farther  on  one  side  than  on  the  other, 
and  that  in  the  ear  first  affected  the  hypertrophic  process  has  changed  to  the 
hyperplastic  form. 

Functional  Examination. — In  investigating  the  hearing,  we  have  to 
deal  first,  with  quantitative,  and,  second,  with  qualitative,  audition. 

By  quantitative  audition  we  mean  the  distance  at  which  any  given  sound, 
such  as  the  tick  of  the  watch,  the  click  of  the  acoumeter,  or  the  sound  of  the 
human  voice,  is  heard,  as  compared  with  the  distance  at  which  the  same 
sounds  are  perceived  by  the  normal  ear.  Qualitative  audition,  on  the  other 
hand,  is  the  perception  of  all  sounds  of  the  musical  scale  between  the  certain 
limits — these  limits  being  known  as  the  lower-tone  limit  and  the  upper-tone 
limit.  The  lowest  musical  tone  perceived  by  the  human  ear  is  one  in  which  the 
sounding  body  makes  sixteen  double  vibrations  per  second,  and  the  highest 
musical  note  recognizable  is  one  in  which  the  vibrations  are  repeated  not  less 
than  32,500  times  per  second.  All  intermediate  notes  between  these  limits  are 
perceived  under  normal  conditions.  Obstruction  to  sound-conduction  is  char- 
acterized by  the  imperfect  audition  of  particular  notes  in  the  musical  scale, 
no  matter  whether  this  obstruction  is  located  in  the  external  auditory  meatus 
or  in  the  middle  ear.  The  conducting  mechanism  is  chiefly  concerned  in  the 
transmission  of  the  lower  notes  of  the  musical  register,  and  in  disease  of  the 
conducting  apparatus  hearing  is  first  impaired  for  the  lowesl  note-  of  the 
scale. 

(1)  Quantitative  Examination. — In  the  disease  under  discussion,  tests  will 
show  a  diminution  in  the  hearing  distance,  both  for  sharp  sound-,  siieh  a-  the 
watch  or  acoumeter,  and  for  the  human  voice.  Of  these  two  means  of  test- 
ing, the  human  voice  i»  always  preferable,  and  for  purposes  of  comparisoo 

the  whisper  should  be  used.      The    patient    should    not    be   allowed    to  become 

familiar  with  particular  words  or  sentences,  and,  therefore,  numbers  of  two 
figures  are  commonly  employed  in  testing.  In  examining  one  ear  the  pa- 
tient shbuld    be    directed  to  close    the    other  with    the    finger,  and   to  close    the 

eyes  also,  in  order  to  avoid  the  possibility  of  lip-reading.    The  patient  is  then 


732  CHRONIC  CATARRH   OF   THE  MIDDLE  EAR. 

requested  to  repeat  whatever  is  whispered  to  him.  In  addition  to  numbers, 
it  is  also  well  to  employ  short  sentences.  The  average  distance  at  which  the 
various  test  numbers  and  sentences  are  heard  should  be  taken  as  the  whisper- 
ing distance. 

It  will  be  found  that  these  patients  hear  sharp  sounds  relatively  better 
than  they  hear  the  human  voice. 

(2)  Qualitative  Examination. — To  determine  the  limits  of  audition,  vibra- 
ting tuning-forks  of  various  pitch  are  held  close  to  the  ear  to  be  tested,  the 
opposite  ear  being  closed  with  the  finger.  The  lowest  fork  heard  marks  the 
lower-tone  limit.  In  chronic  non-suppurative  otitis  media  the  lower-tone 
limit  will  always  be  elevated,  the  lowest  notes  of  the  scale  not  being  per- 
ceived. It  is  noticed,  however,  that  the  elevation  of  the  lower-tone  limit 
hear-  a  certain  relation  to  the  whispering  distance ;  that  is,  where  the  whis- 
pering distance  is  much  reduced,  the  lower-tone  limit  will  be  very  high; 
while,  it'  the  impairment  in  function  is  slight,  the  lower-tone  limit  will  be 
more  nearly  normal.  The  upper-tone  limit  may  be  determined  with  a  fair 
degree  of  accuracv  by  means  of  the  Galton  whistle.  hi  cases  where  the 
labyrinth  has  not  been  involved  secondarily,  the  upper-tone  limit  will  be 
normal  ;  any  appreciable  reduction  at  this  end  of  the  scale  is  indicative 
of  labyrinthine  involvement.  In  uncomplicated  cases  bone-conduction  will 
be  relatively  or  actually  increased,  and  Rhine's  test  will  be  negative.  The 
vibrating  tuning-fork  placed  upon  the  forehead  will  be  usually  referred  to 
the  poorer  ear,  although  this  i-  not  an  invariable  rule.  This  test  is  of  less 
value  in  cases  of  long  duration  than  in  those  that  have  existed  for  a  shorter 
time.  It  is  well  known  that  in  cases  of  long-standing  the  hearing  may  be 
better  upon  the  side  first  affected  than  upon  the  opposite  side ;  in  other  words, 
the  progress  of  the  disease  is  much  more  rapid  in  the  organ  involved  second- 
arily. In  such  cases,  Weber's  test  might  be  negative;  but  would  still  indi- 
cate the  side  upon   which   the  intratympanic  changes  were    more    marked. 

Prognosis. — The  prognosis  in  these  cases  varies  according  to  the  age 
of  the  patient,  the  station  in  life,  occupation,  environment,  and  the  duration 
of  the  disease.  The  prognosis  is  better  in  the  hypertrophic  than  in  the 
hyperplastic  variety.  In  the  hypertrophic  form  the  condition  of  the  upper 
air-passages  is  also  an  important  factor  in  determining  the  course  which  the 
tympanic  inflammation  will  pursue.  Where  the  disease  appears  late  in  life 
the  progress  is  much  less  rapid  than  where  it  affects  children  or  young  adult-. 
The  station  in  life  is  of  importance,  in  that  the  disease  will  be  less  likely  to 
advance  in  a  patient  so  situated  a>  to  be  able  to  guard  against  exposure  to 
inclement  weather,  and  to  avail  himself  of  the  advantages  of  a  favorable 
climate,  than  in  one  by  whom  these  precaution-  cannot  be  taken.  While  I 
do  not  believe  that  it  i-  possible  to  secure  permanent  improvement  in  these 

-  by  a  temporary  change  of  residence,  there  can  be  no  question  that,  if  a 
patient  can  live  permanently  in  a  dry  and  equable  climate,  he  will  be  aide 
materially  to  retard  or  possibly   to  stop  the   progress  of  the  disease. 

The  length  of  time  that  the  disease  has  existed  affects  to  a  greal  extent 
the  prognosis.  If  of  long  duration,  certain  structural  changes  have  probably 
taken  place  in  the  tympanum  which  cannot  be  removed  by  treatment.  ( )n 
the  other  hand,  in  the  early  stage  of  the  disease,  when  structural  changes  arc 
less  marked,  proper  treatmenl  may  restore  the  part-  to  a  more  normal  condi- 
tion, and  will  at  leasl   3top  the  further  progress  of  the  inflammatory  process. 

The  rapidity  with  which  the  affection  has  advanced  must  be  considered 
in  giving  a  prognosis.  Where  the  progress  has  been  rapid  and  both  ears 
have  become  involved  in  a  short  time,  a  much  less  favorable  opinion  can  be 


TREATMENT.  733 

given  than  when'  the  same  changes  have  taken  place  only  after  many  years, 
In  women  any  increase  in  the  symptoms  at  the  time  of  the  menopause  always 
warrants  a  guarded  prognosis. 

The  condition  of  the  upper  air-passages  exerts  an  important  influence 
upon  the  progress  of  tin-  disease  within  the  middle  ear.  In  many  of  these 
cases  we  find  either  hypertrophy  of  the  turbinal  tissues  or  a  chronic  inflam- 
mation of  the  naso-pharyngeal  mucous  membrane.  In  the  younger  patients 
the  pharyngeal  vault  is  often  filled  with  adenoid  vegetations.  All  of  these 
obstructive  conditions  tend  to  aggravate  the  pathological  process  within  the 
tympanum  ;  and  no  treatment  will  be  efficacious  that  doe-  not  include  the 
relief  of  the   upper  air-passages. 

Hyperplastic  otitis  is  but  little  influenced  by  nasal  and  naso-pharyngeal 
conditions,  and  very  little  can  be  expeeted  from  treatment  of  the  throat  or 
nose.  Most  of  these  patients  give  little  history  of  catarrhal  trouble.  It  is 
cpiite  possible  that  some  pre-existing  condition  of  the  nose  or  naso-pharynx 
may  have  induced  the  aural  affection,  but  in  the  atrophic  stage  this  influence 
is  no  longer  active. 

Treatment. — The  treatment  depends  upon  the  local  condition  found 
on  physical  examination  in  connection  with  the  information  obtained  by  a 
careful  functional  examination.  ,The  measures  to  be  employed  are  radically 
different  in  the  hypertrophic  and  hyperplastic  variety  of  the  disease. 

It  must  be  borne  in  mind  that  the  general  condition  influences  the  prog- 
ress of  any  local  inflammation.  Therefore,  the  patient  must  be  kept  in  the 
best  possible  general  condition  ;  excessive  mental  and  physical  exertion  musl 
be  avoided,  as  well  as  indiscretions  in  diet,  the  abuse  of  alcohol,  tobacco,  etc. 
In  many  of  these  cases  the  aural  symptoms  are  aggravated  by  colds  ;  certain 
hygienic  measures  should  be  adopted,  therefore,  to  render  the  patient  less  sus- 
ceptible to  sudden  changes  in  temperature.  To  this  end  the  daily  use  of  the 
cold  bath  should  be  advised,  as  well  as  the  complete  protection  of  the  body 
by  woollen  undergarments. 

In  the  hypertrophic  cases  one  of  the  first  objects  of  treatment  should  be 
to  relieve  any  obstructive  lesion  in  the  upper  air-passages.  Adenoid  growths 
in  the  naso-pharynx  should  be  removed  by  operation,  and  normal  nasal  res- 
piration should  be  secured  by  the  correction  of  nasal  obstruction.  I  do  not 
mean  by  this  that  slight  deformities  of  the  septum  must  be  corrected  by 
surgical  interference.  It  is  only  where  the  abnormality  prevents  free  respi- 
ration  that   surgical    interference   is   necessary. 

Regarding  the  treatment  of  the  middle  ear.  we  find  in  these  hypertrophic 
cases  that  the  Eustachian  tube  is  narrow.  Thismusl  be  restored  to  it-  normal 
caliber,  in  order  to  secure  the  proper  ventilation  of  the  tympanum.  While 
many  obtain  satisfactory  results  by  inflating  with  the  Politzer  bag.  I  freely 
confess  that  in  my  hands  this  instrument,  as  compared  with  the  catheter,  has 
been  of  little  value  in  chronic  case-.  By  inflation  we  not  only  restore  the 
intratympanic  pressure,  but  are  able  to  medicate  both  the  tube  itself  and  the 
lining  membrane  of  the  tympanum  by  the  introduction  of  various  vapors. 
The  current  of  air  acts  as  a  mechanical  stimulanl  to  the  mucous  membrane, 
both  of  the  tube  and  tympanum,  and  this  stimulating  effect  may  be  increased 
by  the  introduction  of  various  vapors,  as  of  menthol,  eucalyptol,  camphor, 
benzoin,  iodin,  etc. 

The  introduction  of  stimulating  vapors  causes  an  increased  flow  ol  blood 
to  the  part-,  thus  favoring  the  absorption  of  any  recent  inflammatory  deposits 
or  relieving  chronic  congestion  due  to  the  lack  of  vascular  tone.  W  hen  any 
stimulating  vapor  is  used,  it   is  wise  to  inflate  fir-t  with  air,  until  the  tube  is 


734  CHRONIC  CATARRH  OF  THE  MIDDLE  EAR. 

fairly  patent,  and  to  then  introduce  the  vapor.  In  this  way  comparatively 
little  of  the  vapor  escapes  into  the  throat,  and  irritation  of  the  air-passages  is 
avoided.  The  particular  vapor  to  be  used  is  largely  a  matter  of  individual 
preference.  I  have  employed  for  a  long  time,  with  considerable  success,  the 
vapor  given  off  by  the  following  mixture : 

I$j.  Menthol, 

Camphor,  da.  7>)  ; 

Tr.  Iodi,  ad.  3j.— M. 

A  pledget  of  cotton  saturated  with  this  mixture  is  placed  in  the  middle- 
ear  vapori/.er.  This  instrument  enables  the  operator  to  inflate  first  with  air 
and  then  with  the  vapor,  without  disturbing  the  catheter. 

If  the  obstruction  in  the  Eustachian  tube  is  of  long  standing,  it  will 
scarcely  yield  to  inflation  alone,  and  mechanical  dilatation  by  means  of 
Eustachian  bougies  will  be  necessary.  Bougies  of  celluloid,  whalebone,  cat- 
gut, etc.  are  objectionable,  as  they  cannot  be  rendered  aseptic  by  boiling. 
They  are  also  liable  to  break  during  the  operation,  thus  leaving  a  foreign 
body  in  the  Eustachian  tube.  For  the  last  few  years  I  have  resorted  to  the 
following  device  :  A  piece  of  No.  5  piano  wire,  two  or  three  inches  longer 
than  the  Eustachian  catheter,  is  selected,  and  at  one  extremity  is  bent  so  as  to 
form  a  small  hook  about  one-sixteenth  of  an  inch  long.  The  hook  is  then 
flattened  upon  the  longer  portion  of  the  wire  so  that  at  this  end  the  wire  is 
doubled  upon  it-elf  for  a  distance  of  about  one-sixteenth  of  an  inch.  The 
wire  is  then  passed  through  the  Eustachian  catheter  until  this  doubled  portion 
protrudes  beyond  the  tip  of  the  instrument  for  the  distance  of  an  inch  and  a 
half.  The  other  end  of  the  wire  is  then  bent  at  right-angles  as  it  leaves  the 
conical  portion  of  the  catheter,  so  that  its  further  passage  through  tin;  instru- 
ment is  impossible.  Both  the  catheter  and  the  wire  are  boiled  to  render  them 
aseptic.  A  little  cotton  is  then  wound  tightly  about  the  doubled  extremity  of 
this  wire,  which  is  then  drawn  backward  into  the  catheter,  so  that  the  cotton- 
tipped  end  protrudes  just  beyond  the  mouth  of  the  instrument.  The  catheter 
is  then  introduced  into  the  mouth  of  the  tube  in  the  ordinary  way,  and  the 
cotton-tipped  bougie  is  gradually  passed  through  the  Eustachian  canal  until 
it  is  felt  to  inter  the  tympanum.  As  the  isthmus  of  the  tube  lies  about  an 
inch  beyond  the  pharyngeal  orifice,  resistance  is  felt  when  the  bougie  has  been 
introduced  about  an  inch.  This  resistance  is  perfectly  normal,  and  should 
remind  the  operator  that  he  is  approaching  the  tympanic  cavity.  A  moderate 
amount  of  pressure  forces  the  instrument  through  the  bony  portion  of  the 
tube  and  into  the  tympanum.  As  the  Eustachian  canal  varies  somewhat  in 
length  in  different  subjects, greal  care  should  lie  used  in  the  final  stage  of  the 
operation.  If  the  wire  is  so  bent  that  it  cannot  be  introduced  more  than  an 
inch  and  a  half  beyond  the  month  of"  the  catheter,  it  is  practically  impossible 
to  do  any  damage.  It  is  sometimes  necessary  to  carry  the  instrument  a  little 
further,  in  order  to  he  certain  that  it  has  entered  the  tympanum.  If  this 
operation  is  performed  carefully,  it  is  impossible  to  do  any  harm.  The 
operator  usually  recognizes  by  the  sense  of  touch  that  the  bougie  has  entered 
tin  tympanum.  Frequently  the  cotton-tipped  extremity  of  the  bougie  can 
be  -ecu  in  the  tympanic  cavity,  through  the  drum  membrane,  on  speculum 
examination.  The  tip  of  the  bougie,  under  these  conditions,  appears  as  a 
white,  opaque  object,  jusl  behind  and  a  little  below  the  short  process  of  the 
malleus.  Pressure  upon  the  bougie  causes  the  drum  membrane  to  move 
-lightly  outward,  as  can  he  easily  recognized  by  the  observer. 


TREATMENT.  735 

One  of  the  advantages  of  this  device  is  that,  when  the  cotton  is  tightly 
wound  upon  the  wire  and  introduced  into  the  tube,  it  absorbs  a  certain 
amount  of  moisture  from  the  membrane,  and  thus  becomes  larger;  an  addi- 
tional amount  of  dilatation  is  secured  in  this  way.  Another  advantage  is, 
that  there  is  but  slight  friction  between  the  wire  and  the  catheter,  and  any 
resistance  to  the  passage  of  the  instrument  must  certainly  be  due  to  an 
obstruction  in  the   Eustachian  canal. 

It  is  frequently  of  advantage  to  saturate  the  cotton  pledget  with  a  solu- 
tion of  nitrate  of  silver  of  a  strength  of  from  ten  to  sixty  grains  to  the 
ounce.  In  this  way  the  tube  is  medicated  as  well  as  subjected  to  mechanical 
stimulation.  In  hypertrophic  cases  of  long  standing,  the  careful  use  of  the 
bougie  is  attended  by  the  most  gratifying  results. 

The  injection  of  fluids  into  the  middle  ear  through  the  Eustachian  tube 
has  been  attended  with  doubtful  benefit.  Personally,  I  have  no  experience 
with  this  method  of  treatment.  There  is  no  reason  why  solutions  should  not 
be  introduced  into  the  middle  ear  in  this  manner,  if  both  the  solutions  and 
the  instruments  are  aseptic.  It  has  always  seemed  to  me  to  be  more  simple 
to  medicate  the  middle  ear  directly  through  an  opening  in  the  drum  mem- 
brane, rather  than  to  inject  the  fluids  through  the  tube. 

When  the  tympanum  contains  fluid  an  attempt  should  first  be  made  to 
evacuate  this  by  means  of  catheter  inflation.  During  the  procedure  the 
patient's  head  should  be  flexed  on  the  chest,  and,  at  the  same  time,  should  be 
inclined  toward  the  opposite  side.  The  current  of  air  entering  the  middle 
ear  will  then  displace  the  fluid  and  force  it  out  through  the  Eustachian  tube 
into  the  naso-pharynx.  The  use  of  stimulating  vapors  in  these  cases  is  also 
of  advantage  in  hastening  the  absorption  of  the  effusion. 

As  the  persistence  of  an  effusion  depends  usually  upon  some  obstructive 
lesion  of  the  nose  or  naso-pharynx,  these  parts  must  be  put  in  the  normal 
condition  before  permanent  relief  can  be  hoped  for.  If  these  measures  fail, 
the  fluid  must  be  evacuated  by  incising  the  drum  membrane.  The  incision 
should  lie  in  the  posterior  segment  of  the  tympanic  membrane,  close  to  its 
periphery,  and  should  extend  from  below  the  tip  of  the  handle  of  the  malleus 
upward  to  the  posterior  fold.  The  term  so  often  used,  of"  puncturing"  the 
tympanic  membrane  to  evacuate  fluid,  is  responsible  for  many  unsatisfactory 
results.  A  small  opening  allows  but  little  of  the  fluid  to  escape,  and  does 
not  empty  the  cavity.  A  free  incision  is  necessary  in  order  to  secure  the 
desired  result.  In  performing  this  operation  it  is  well  also  to  incise  the 
mucous  membrane  over  the  inner  tympanic  wall,  thus  depleting  the  engorged 
vessels  and  rendering  recurrence  less  probable.  Such  incision  is  absolutely 
free  from  danger  if  the  canal  is  sterilized  before  the  operation,  and  if  the 
instruments  and  the  hands  of  the  operator  are  aseptic.  Moreover,  the  pro- 
cedure causes  but  very  little  pain  if  a  sharp  knife  is  used. 

After  incising  the  tympanic  membrane,  it  is  often  wise  to  inflate  by 
means  of  the  catheter  to  completely  evacuate  the  fluid;  and  in  some  cases, 
where  the  effusion  is  viscid,  it  is  well  to  wash  out  the  tympanic  cavity,  with 
normal  salt  solution,  through  the  Eustachian  catheter.  The  incision  heals 
in  from  twenty-four  to  thirty-six  hours  if  aseptic  precautions  have  been 
observed.  At  the  end  of  twenty-four  hours,  if  the  margins  of  the  incis- 
ion have  become  agglutinated,  it  is  well  to  guard  against  the  accidental 
rupture  of  the  freshly-formed  adhesions  by  means  of  a  paper  disk  applied 
to  the  surface  of  the  drum  membrane  so  as  to  cover  the  line  of  incision. 
The  disk  need  not  be  removed  by  the  surgeon,  as  it  will  be  discharged 
spontaneously  by  the  outward   growth  of  the  epithelium   covering   the   tym- 


73G  CHRONIC  CATARRH  OF  THE  MIDDLE  EAR. 

panic  membrane.  It  may  be  removed,  however,  at  any  time  by  the  use  of 
the  ear-syringe. 

A  favorite  plan  of  treatment  in  chronic  catarrhal  otitis  media  has  been 
the  systematic  use  of  passive  motion  for  the  purpose  of  either  breaking 
up  or  of  stretching  adhesions  which  have  developed  between  the  ossicles 
themselves  or  between  these  bonelets  and  the  inner  tympanic  wall. 

Lucae1  has  met  with  considerable  success  in  these  cases  by  the  use  of 
the  "  pressure  probe."  The  device  consists  of  a  small  tube,  through  which  n 
rod  terminating  in  a  cup-like  extremity  passes.  Within  the  tube  is  a  small 
spiral  spring  pressing  against  the  other  end  of  this  rod.  The  shaft  of  the 
instrument  is  introduced  into  the  canal,  and  the  cup-shaped  extremity  is  ap- 
plied to  the  short  process  of  the  malleus.  By  a  rapid  to-and-fro  motion  of  the 
instrument  the  short  process  is  pressed  inward  and  then  allowed  to  spring  out- 
ward, the  amount  of  pressure  being  regulated  by  the  tension  of  the  spring-. 
In  this  manner  it  is  claimed  that  the  adhesions  within  the  tympanum  are 
Stretched,  and  that  the  function  of  the  ear  is,  in  many  cases,  improved.  I 
have  had  no  experience  with  this  method,  and  can,  therefore,  give  no  per- 
sonal opinion  as  to  its  efficacy.  The  procedure  is  somewhat  painful,  and  has 
never  seemed  to  me  to  be  free  from  danger.  This  I  believe  to  be  especially 
true  where  the  process  within  the  middle  ear  is  not  quiescent.  Any  attempt 
to  forcibly  manipulate  the  ossicles  must  cause  a  certain  amount  of  mechanical 
irritation,  and,  therefore,  must  aggravate  the  condition  which  it  is  intended  to 
overcome.  This  same  criticism  applies,  I  think,  to  modifications  of  Lncae's 
method  of  massage,  advocated  by  Lester2  and  by  Garnault,3  who  employ  a 
small  electric  motor  for  actuating  the  masseur. 

Systematic  massage  of  the  ossicles  by  alternately  condensing  and  rare- 
fying the  air  within  the  external  auditory  meatus,  either  by  the  method  of 
Hommel,4  by  pressure  in  front  of  the  tragus,  or  by  the  use  of  either  the 
Delstanche  masseur  or  the  Siegle  otoscope,  has  also  been  looked  upon  with 
much  favor  by  sonic.  Experience  has  not  taught  me  that  valuable  results 
are  obtained  by  these  methods. 

A-  the  motions  of  the  ossicular  chain  under  the  normal  conditions  are 
caused  by  aerial  vibrations,  it  would  seem  reasonable  that  the  most  proper 
method  of  employing  massage  would  be  through  the  agency  of  some  sound- 
ing body,  and  within  the  last  few  years  various  vibrometers,  vibraphones, 
etc  have  been  devised.  All  inst  ruiuent  s  const  meted  for  t  his  purpose  have, 
I  think,  been  useless  and  worse.  There  is  no  question,  however,  that  in  certain 
cases  the  systematic  exercise  of  the  ear  by  means  of  the  human  voice  may  be 
of  great  benefit  in  improving  the  function  of  the  organ,  and  the  method  has 
been  successfully  used  by  Urban tschitsch.fi  In  employing  this  method  it  has 
been  my  practice  to  have  an  attendant  read  to  the  patient  for  a  period  of 
from  five  to  fifteen  minutes  in  a  voice  sufficiently  loud  to  enable  him  to 
understand  distinctly.  Where  the  impairment  of  hearing  is  very  marked 
tli.'  conversation-tube  may  be  used,  although  this  should  be  avoided  if  pos- 
sible.      It    i<   advantageous,  in    case    the    patient    understands    more   than   one 

language,  to  read  in  differenl  languages  on  succeeding  days,  to  accustom  the 
patient  to  recognize  sounds  varying  widely  in  character.  Such  a  method  is 
tedious,  but  i-  often  attended  with  excellent  result-.  It  is  particularly 
advantageous  where  the  ear  has  been  practically  useless  for  a  longtime  and 
ha- then  improved  somewhat  from   local  treatment.     Under  these  conditions 

[rchivfur  Ohrenheilk.,  vol.  xxi.  p.  84  J  N.  7.  Med.  Journ.,  June  8,  1896. 

/•         '.     Maladies  d<  V Oreille,  Paris,  I  895,  \>.  246. 
'  Archivfur  Ohrenheilk.,  vol.  xxiiL  p.  17.         6  Horiibungen  hex  Taubslummen,  Wien,  ]8'.»">. 


TREATMENT.  737 

the  auditory  nerve  seems  to  have  suffered  from  disuse,  and,  although  per- 
fectly healthy,  requires  a  certain  amount  of  education  before  it  can  again 
perform  its  function.  Here,  of  course,  the  procedure  is  one  not  only  of 
massage,  but,  to  a  certain  extent,  one  of  education,  familiarizing  the  patient 
-with  the  significance  of  imperfect  auditory  impressions  conveyed  to  the 
cortical  centers. 

Intratympanic  Operations. —  I  have  endeavored  to  detail  briefly  tin- 
various  methods  at  our  command  for  the  treatment  of  these  cases.  When 
seen  in  the  early  stages,  inflation,  the  use  of  the  Eustachian  bougie,  and  the 
treatment  of  the  upper-air  passages  often  yield  excellent  results.  We  fre- 
quently, however,  meet  with  cases  in  which  all  of  these  measures  fail,  the 
middle-ear  changes  being  so  advanced  as  to  render  absorption  of  the  new 
tissue  impossible.  The  Eustachian  canal  is  perfectly  patent,  the  upper  air- 
passages  are  normal,  and  the  patient  is  suffering  either  from  the  result  of  a 
previous  inflammatory  condition  or  from  a  profound  trophic  disturbance 
within  the  middle  ear. 

I  am  aware  that  I  stand  almost  alone  in  advocating  surgical  interference 
in  these  cases.  My  opinion  is  the  result  of  my  own  personal  experience, 
which  has,  perhaps,  been  extensive  enough  to  warrant  the  position  which  I 
take.  Where  other  methods  fail,  and  where  careful  functional  examination 
shows  that  the  perceptive  mechanism  is  not  greatly  involved,  I  believe  that 
it  is  always  wise  to  do  an  exploratory  tympanotomy.  Cocain  anesthesia 
suffices  to  render  the  procedure  painless,  and  at  the  same  time  is  free  from 
the  objections  attending  ether  or  chloroform  narcosis.  For  purposes  of 
exploration,  the  tympanic  cavity  is  best  entered  in  the  posterior  and  upper 
quadrant.  In  order  to  gain  access  to  the  middle  ear,  a  flap  of  the  drum 
membrane  should  be  reflected  downward  and  forward,  so  as  to  allow  inspec- 
tion of  the  incudo-stapedial  joint  and  of  the  regions  of  the  oval  and  round 
windows.  When  done  under  local  anesthesia,  the  hearing  can  be  tested  at 
various  stages  during  the  operation,  and  if  it  improves  the  surgeon  may  com- 
plete the  operation.  On  the  other  hand,  if,  after  the  stapes  has  been  li ber- 
ated by  the  division  of  adhesions  in  the  oval  niche  and  by  disarticulation  at 
the  incudo-stapedial  joint,  there  is  no  improvement  in  the  hearing,  the  flap 
of  the  membrana  tympani  can  be  replaced  and  retained  in  position  by  means 
of  a  paper  disk.  Under  aseptic  precautions  this  operation  is  absolutely  i'n  e 
from  danger.  If  liberation  of  the  stapes  improves  the  hearing,  the  operator 
may  proceed  at  once  to  remove  the  membrana  tympani,  malleus,  ami  incus 
to  secure  permanent  improvement.  Excision  of  the  two  larger  ossicles  is 
performed  with  perfect  ease  under  cocain  anesthesia.  I  have  not  infrequently 
operated  upon  both  ears  in  the  same  patient  at  different  times.  Had  the  ope- 
ration been  painful,  the  patient  would  scarcely  have  submitted  to  a  second 
operation  without  general  anesthesia. 

One  of  the  advantages  of  the  procedure  above  mentioned  is  its  value  as 
a  diagnostic  measure.  There  are  certain  doubtful  cases  in  which  functional 
examination  doe-  not  enable  us  to  exclude  labyrinthine  involvement,  and  yet 
in  which  the  condition  in  the  middle  ear  seems  to  be  sufficient  to  account  for 
the  functional  impairment.  An  exploratory  tympanotomy  enables  us  to 
determine  exactly  how  much  improvement  can  be  expected  from  removal  of 
the  drum  membrane  and  of  the  two  larger  ossicles.  I  f  the  exploratory  oper- 
ation gives  negative  results,  the  flap  can  be  replaced,  leaving  the  ear  in  the 
Same  condition  as  before  operation.  We  are  then  certain  that  the  impairment 
of  function  i<  due  to  some  lesion  of  the  perceptive  apparatus.  We  often 
find,  however,  that  we  have  underestimated  the  effect  produced  by  the 
47 


738  CHRONIC  CATARRH  OF  THE  MIDDLE  EAR. 

middle-ear  lesion — the  hearing  improving  beyond  our  expectations  after  the 
stapes  has  been  liberated.  In  these  eases  completion  of  the  operation  yields 
very  gratifying  results. 

Middle-ear  inflammation  upon  one  side  usually  leads  to  impairment  of 
audition  on  the  opposite  side.  We  have  to  consider,  therefore,  not  only 
the  possible  improvement  in  the  ear  operated  upon,  but  also  the  effect  of 
the  procedure  upon  the  opposite  organ.  From  a  number  of  my  own 
cases  I  am  convinced  that  the  relief  of  increased  tension  in  the  conducting 
apparatus  upon  one  side  either  checks  or  retards  the  involvement  of  the 
opposite  organ,  and  in  many  cases  improves  the  ear  not  operated  upon.  I 
should  attach  no  importance  to  these  cases,  had  they  not  been  so  frequent 
and  the  fact  confirmed  by  other  observers,  notably  Urbantschitsch. 

Operative  procedures  of  this  character  have  been  fairly  satisfactory  in  my 
own  practice,  and  after  stating  plainly  to  the  patient  that  improvement  cannot 
be  absolutely  promised,  but  that  an  operation  offers  the  only  chance  for  im- 
provement, and  that  in  a  large  proportion  of  the  cases  this  is  obtained,  I 
still  continue  to  perform  these  operations.  My  own  results  under  cocain 
anesthesia  are  as  follow.-:  of  (i  1  cases  operated  upon,  32  were  greatly  im- 
proved, '24  moderately  improved,  and  8  unimproved.  Jn  three  of  the  above 
cases  in  which  no  improvement  followed  the  operation,  I  should  say  that  I 
did  an  exploratory  operation  only.  The  functional  examination  had  seemed 
to  demonstrate  that  the  labyrinth  was  seriously  involved,  and  operation  was 
undertaken  only  a-  a  forlorn  hope.  Disarticulation  at  the  incudo-stapedial 
joint  and  liberation  of  the  stapes  being  followed  by  no  improvement,  the  flap 
of  tympanic  membrane  was  replaced  and  the  ear  left  in  its  original  condition. 
In  one  instance,  where  functional  examination  also  seemed  to  show  extensive 
labyrinthine  involvement,  the  hearing  was  notably  improved,  not  only  in  the 
ear  operated  upon,  but  also  in  the  opposite  ear.  The  improvement  in  general 
audition  was  so  uoticeable  as  to  be  remarked  upon  by  the  patient's  friend-. 

A  certain  number  of  cases  have  been  operated  upon  under  ether  anes- 
thesia,  and  the  results  have  been  reported  in  my  recent  work.1  For  the  rea- 
sons already  stated,  I  always  prefer  to  operate  under  cocain  anesthesia. 

Concerning  the  efficacy  of  constitutional  treatment  in  chronic  catarrhal 
otitis  litth-  can  be  said.  Measures  for  improving  the  general  health  of  the 
patient  will  naturally  suggest  themselves  to  the  medical  attendant.  Where 
the  labyrinth  has  been  involved  secondarily,  the  internal  administration  of 
pilocarpiu  may  be  tried.  The  results,  however,  are  much  less  satisfactory 
than  in  cases  of  primary  labyrinthine  disease.  In  neurasthenic  patients 
general  medication  and  attention  to  hygiene  will  often  do  much  to  improve 
defective  audition.  Here  strychnin  in  large  dose-  and  long  continued  is  par- 
ticularly valuable.  I  ordinarilv  begin  with  ,'  grain  three  times  daily,  and 
gradually  increase  the  dose  until  the  patient  is  taking -Ar  grain  four  times 
daily.  A  fad  which  i-  often  lost  sight  of  is  the  fatigue  which  impairment 
of  hearing  causes,  the  patient  making  every  exertion  and  fixing  his  whole 
attention  in  order  to  overcome  his  affliction. 

Certain  drugs  have  been  recommended  for  the  relief  of  tinnitus.  My 
own  experience  ha-  been  that  all  are  usually  unsatisfactory.  We  may  except, 
perhaps,  large  doses  of  hydrobromic  acid,  which  afford  sometimes  relief. 
Naturally,  if  the  general  condition  of  the  patienl  indicate-  the  necessity  for 
certain  medication,  such  medication  may  incidentally  relieve  the  subjective 
noises;  bin  where  the  general  condition  of  the  patient  is  normal,  very  little 
relief  can  be  obtained  by  internal  medication. 

1  Diseases  of  tfu  Ear,  New  York,  1894,  p.  512. 


CHRONIC  SUPPURATION  OF  THE  MIDDLE  EAR. 


By  ALBERT  H.  BUCK,  M.  D., 

OF   NEW   YOKK   CITY. 


IJtiology. — The  causes  of  a  chronic  discharge  from  the  middle  ear  are 
generally  to  be  sought  for  in  some  primary  acute  inflammation  of  this  region. 
In  a  few  instances — as  in  the  case  of  tubercular  disease,  there  may  be  an 
entire  absence  of  anything  like  an  antecedent  acute  stage  ;  and  if  present,  our 
knowledge  of  the  probable  protracted  continuance  of  the  discharge  justifies 
us  in  placing  these  cases  at  the  very  start  in  the  category  of  chronic  sup- 
purative affections. 

It  was  a  widely  accepted  doctrine,  ten  or  fifteen  years  ago,  that  a  chronic 
suppuration  of  the  middle  ear  almost  invariably  indicated  either  neglect  or  a 
lack  of  skill,  experience,  or  courage  on  the  part  of  the  medical  man  who  had 
the  management  of  the  primary  acute  attack.  To-day,  our  better  knowledge 
of  the  all-potent  influence  of  micro-organisms  in  inflicting  those  lesions  which 
determine,  in  most  cases,  the  feature  of  chronicity,  leads  us  to  pass  a  more 
lenient  judgment  upon  these  men.  Nevertheless,  this  earlier  doctrine  must 
still  be  accepted  as  fundamentally  correct. 

Aside  from  these  few  direct  etiological  factors,  there  are  others  which, 
although  by  no  means  direct  causes,  nevertheless  play  an  important  part  in 
perpetuating  the  suppuration.     There  are  three  such  favoring  factors,  viz.  : 

1.  Lowered  vitality. 

2.  Stagnation  (intratympanic)  of  the  fluid  and  solid  constituents  of  the 
discharge. 

3.  The  presence  of  a  mass  of  hypertrophied  lymphoid  tissue  in  the  vault 
of  the  pharynx. 

Farther  on  in  this  article  I  will  return  to  this  subject  and  give  it  further 
consideration. 

The  influence  of  diabetes  mellitus  in  favoring  the  development  of  wide- 
spread and  deep-seated  inflammation  of  the  middle  ear  has  doubtless  received 
due  consideration  in  the  article  relating  to  acute  suppuration.  It  is  in  these 
cases,  rather  than  in  those  of  a  chronic  character,  that  this  influence  makes 
itself  chiefly  felt. 

Pathology. — The  eases  of  chronic  suppuration  of  the  middle  ear  which 
are  encountered  in  practice  may  readily  be  subdivided,  for  our  convenience 
in  studying  them,  into  three  different  and  fairly  distinct  types  or  groups  : 

Group  I.  includes  all  those  cases  in  which  the  tympanic  membrane  is  usually 
perforated  somewhere  in  the  lower  half,  and  in  which  no  evidences  of  active 
inflammatory  disturbance  are  discoverable.  The  discharge  is  scanty  ami  tree 
from  any  unpleasant  odor.  It  is  sero-purulent  in  character,  but  often  has 
some  admixture  of  mucus.  At  times  it  may  cease  altogether  tor  a  period  oi 
several  days  or  week-.     Adults  are  affected  less  frequently  than  children. 

This  is  the  mildest  type  of  chronic  middle-ear  suppuration  of  which   I 


740         CHRONIC  SUPPURATION  OF  THE  MIDDLE  EAR. 

have  any  knowledge;  and  the  cause  of  the  non-subsidence  of  the  discharge 
may  be  sel  down  as  a  lack  of  tone  in  the  blood-vessels  of  the  tympanic 
mucous  membrane — a  vaso-motor  paresis.  In  so  far  as  this  lack  of  muscular 
tone  affects  the  blood-vessels  of  the  mucous  membrane  of  the  Eustachian 
tube,  we  may  expect  to  find  a  greater  or  less  quantity  of  mucus  intermingled 
with  the  discharge.  In  many  of  these  eases  a  depreciated  condition  of  the 
general  health  — a  lowered  vitality — plays  an  appreciable  part  in  the  persist- 
ence of  the  disease. 

Group  II.  differs  from  the  preceding  group  in  only  one  essential  respect: 
the  discharge  consists  largely  of  ropy  mucus,  and  the  main  cause  of  its  per- 
sistence is  to  be  found  in  the  presence  of  hypertrophied  lymphoid  tissue  in  the 
vault  of  the  pharynx.  The  latter  condition  not  only  excites  a  catarrhal  in- 
flammation of  the  tubal  mucous  membrane,  but  also  causes  the  lower  portions 
of  these  channels  to  become  so  narrowed  that  the  secretion — the  ropy  mucus — 
cannot  escape  in  the  natural  manner  into  the  pharynx,  but  finds  an  easier 
outlet  for  itself  in  the  opposite  direction — i.  e.  into  the  middle  ear  and 
through  the  perforation  into  the  external  auditory  canal.  In  these  cases,  as 
in  those  of  the  preceding  group,  the  discharge  i-  apt  to  be  intermittent,  some- 
times stopping  altogether  during  the  summer  months,  and  is  entirely  free 
from   any    unpleasant   odor. 

Group  III.  is  characterized  by  several  features  which  distinguish  it  fairly 
well  from  the  other  two  groups.  In  the  first  place,  the  discharge  is  more  dis- 
tinctly purulent  in  character,  but  not  necessarily  any  more  abundant  in 
quantity.  It  is  apt  also  to  have  an  unpleasant  odor — sometimes  positively 
fetid  in  character.  An  admixture  of  blood  is  not  rarely  observed  ;  and,  in 
addition  to  the  fluid  pus,  we  occasionally  find  some  which  has  become  inspis- 
sated until  it  resembles  soft  cheese. 

In  cases  of  long  standing,  desquamated  epithelium  is  apt  to  form  and 
accumulate  in  the  recesses  of  the  middle  ear.  Small  flakes  of  it  are  also  often 
found  in  the  discharge,  and  at  times  even  larger  masses  may  escape  spon- 
taneously from  the  tympanum. 

The  actual  lesions  which  lie  at  the  foundation  of  the  manifestations  jusl 
described  are  localized  areas  of  proliferative  activity  on  the  part  of  the  tym- 
panic mucous  membrane,  and  often,  at  the  same  time,  a  more  or  less  limited 
caries  of  the  adjacent  bone-tissue. 

Thr  location  (>f  the  perforation  in  the  membrana  tympani  is  usually 
higher  in   this   third  group  than    in   the  other  two.     The  posterior  half,  or 


]■■],.  i''1'  Righl  in'-  Bhowing  malleus- 
head  tin. .luh  ;,  ghrapnell  perforation,  and 
hi.  and  back  ■>  -lit  like  opening  wltl 

ufar  posterior  lip,  such  as  ( imonly  marks 

,.i  the  Incus  and  the  adjacenl  tym 
panic  margin. 


Fig  500  Reniform  perforation  at  umbo 
and  smaller  opening  above  short  process. 
Hyperplasia  down  and  back,  marking 
probable  caries  al  tliis  margin  and  In  the 
"  hypo  tympanic  Bpace." 


the  posterior  superior  quadrant  (Fig.    !!•!•),   is   the  common  site  in  a  large 
number  of  instances.     The  flaccid  membrane  is  perforated  (Figs.  500,  501) 


PATHOLOGY. 


741 


in  a  much  smaller  number  of  oases  ;  and,  finally,  in  comparatively  rare 
instances  a  sinus  in  the  bone,  above  or  behind  the  tympanic  membrane, 
serves  as  the  outlet  channel — the  mechanical  equivalent  of  the  perforation 
— for  all  the  products  of  intratympanic  inflammation. 

Finally,  sclerosis  of  the  mastoid  process  is  so  uniformly  found  to  be  asso- 
ciated with  chronic  suppuration  of  the  antrum  and  vicinity  that  we  arc  war- 
ranted  in  setting  it    down   as   one  of  the  fixed  characteristics  of  this  third 


Frn.  501.— Left  temporal  of  a  child  (right  figured,  showing  bulging  of  upper  back  and  lower  front  por- 
tions of  drumhead.  On  the  right  a  large  central  perforation  is  separated  by  a  narrow  band  from  the 
upper  opening  due  to  total  loss  of  the  flaccid  membrane.  All  trace  of  the  ma'lleus  is  lost,  but  the  incus 
and  stapes  seem  normal  (Dr.  Randall's  collection). 

group.  The  practical  importance  of  this  fact  becomes  apparent  when  an 
attempt  is  made,  in  a  case  of  chronic  suppuration  of  the  middle  ear,  to  deter- 
mine how  seriously  the  antrum  and  neighborhood  are  involved.  Before  this 
law  of  mastoid  bone  sclerosis,  or  hyperostosis,  was  known,  it  was  a  frequent 
thing  for  physicians  to  deny  the  exist- 
ence of  any  serious  disease  of  the  antrum 
because  there  were  absolutely  no  outward 
manifestations  of  any  such  disease — no 
redness  or  swelling  of  the  skin,  no  ten- 
derness upon  pressure  over  the  mastoid 
process.  The  sclerosed  condition  of  the 
overlying  bone  (Fig.  502),  as  we  now 
know,  offers  an  impenetrable  wall  to  the 
advance  of  any  such  central  i'ocus  of 
inflammation;  and  this  sclerosis,  as  J 
have  jut  stated,  may  be  assumed  to 
exist  in  every  one  of  the  cases  belonging 
to  this  third  group.  It  is  therefore  clear 
that  in  estimating  the  gravity  of  the 
deeper-lying  disease  in  this  class  <>f  cases  we  are  not  permitted  to  attach  the 
slightest  importance  to  the  absence  of  outward  evidences  of  inflammation. 

The  following  pathological  alterations  and  products  observed  in  the  cases 
which  belong  to  this  third  group  deserve  further  consideration  :  granulation- 
growth-  or  polypi,  bone  caries,  desquamated  epithelium,  and  accumulations 
of  cheesy  pus. 


Fro.  502.— Metal  cast  i  mastoid  in 

which  hut  iv.  lis  near  the  tip  remain 

pneumatic.    Contrast  with  I  Ran- 

dall). 


742  CHRONIC  SUPPURATION  OF  THE  MIDDLE  EAR. 

Grranulationr-growths  are  extremely  commoo  in  the  middle  car  in  cases  of 
chronic  suppuration.  They  may  develop  at  almost  any  point,  but  they  arc 
found  oftenest,  I  think,  at  the  lower  margin  of  the  entrance  to  the  mastoid 
antrum.  Their  size  is  very  variable,  the  largest  one  I  have  ever  encountered 
measuring  an  inch  and  three-quarters  in  length.  They  are  the  product  of 
an  irritation  applied  to  the  tympanic  mucous  membrane  at  the  localities  from 
which  they  spring.  This  irritation  may  have  been  applied  at  the  time  of 
the  original  acute  inflammation — an  invasion  of  micro-organisms,  for  example, 
having  stimulated  the  connective  tissue  of  the  mucous  membrane  to  assume 
proliferative  activity.  Or  the  irritation  may  be  of  later  date,  and  may  even 
still,  at  the  time  when  the  growth  is  discovered,  be  in  active  force.  Thus, 
for  example,  a  small  area  of  hone  caries  in  the  antrum,  or  at  the  point  where 
it  becomes  merged  in  the  cavity  proper  of  the  tympanum,  is  apt  to  secrete  a 
very  irritating  pus  of  an  almost  corrosive  character ;  and  the  constant  flow 
of  this  over  the  tympanic  mucous  membrane  soon  causes  the  latter  to  pro- 
liferate and  ultimately  to  form  a  mass  of  granulation-tissue,  or  a  "polypus" 
— the  term  commonly  employed  when  the  mass  has  attained  fairly  large  pro- 
portions. Then  again,  stagnating  pus  (independently  of  bone  caries),  in  which 
the  bacteria  of  decomposition  arc  active,  may  also  exert  an  irritating  influence 
strong  enough  to  cause  proliferation  of  the  mucous  membrane  with  which  it 
comes  in  contact. 

In  dealing  with  cases  of  this  character,  therefore,  we  are  warranted  in 
attributing  the  presence  of  the  granulation-tissue  either  to  bone  caries  or  to 
stagnating  and  foul  pus  escaping  from  some  point  close  at  hand,  and  we 
should   accordingly   search   for  these  conditions   in  every  such  case. 

Superficial  areas  of.&one  caries  are  very  often  encountered  in  cases  of 
chronic  suppuration  of  the  middle  ear;  in  fact,  it  is  no  exaggeration  to  say 
that  this  lesion  i-  the  main  if  not  the  exclusive  cause  of  the  chronic  discharge 
in  the  great  majority  of  instances. 

While  the  promontory  or  inner  wall  of  the  tympanic  cavity  and  the 
region  bordering  on  the  tympanic  orifice  of  the  Eustachian  tube  are  rarely 
the  -..at  df  a  bone  caries,  every  other  part  seems  to  be  predisposed  to  the 
disease  to  an  almosl  equal  degree.  The  mosl  extensive  areas  are  doubt- 
less those  which  involve  the  antrum.  Smaller  ones  are  found  in  the 
tympanic  roof,  at  the  posterior  end  of  the  tympanic  cavity,  on  its  floor, 
and  finally  on  either  the  body  of  the  anvil  or  the  head  and  neck  of  the 
hammer.  When  caries  involve-  such  slender  structures  as  the  long  process 
of  the  anvil,  the  lower  half  of  the  handle  of  the  hammer,  and  the  crura  of 
the  stirrup,  these  soon  disappear  altogether. 

It  i-  a  very  ditlicult  matter  to  determine  to  what  extent  the  ulcerative 
action  i-  progressive.     One  thing,  however,  is  certain,  viz.,  that  if  foul  pus, 

cheesj    material,  and    desquamated    epithelium    lie    not    allowed    to  remain  for 
any  great   length  of  time  upon  the  surface  of  such  an  area  of  hone  ulceration. 

all  carious  activity  promptly  ceases. 

It  is  also  not  entirely  clear  how  hone  caries  is  originally  established  in 
the  middle  car.  In  former  years  it  was  customary  to  look  upon  the  prolonged 
continuance  of  a  high  degree  of  intratympanic  pressure  as  the  chief  cause 
of  the  trouble.  Such  pressure  is  undoubtedly  competent  to  interfere  seri- 
ously with  the  nutrition  of  the  mucous  membrane  thus  pressed  upon,  and 
ultimately  with  that  of  the  underlying  bone,  which  derives  a  large  pari  of 
it-  nourishment  from  this  mucous  membrane.  Km  it  i-  now  believed  thai 
the  pressure  -imply  plays  the  pari  of  :i  favoring  circumstance,  and  that  the 
active  (actor  in   the   process   is  the  streptococcus  or  some  other  variety  of 


DIAGNOSIS.  743 

micro-organism.  These  harmful  agents  first  destroy  the  mucous  membrane 
:ii  a  given  point  by  entering  into  its  blood-  and  lymph-vessels,  thus  shutting  off 
its  supply  of  nutriment,  and  then,  as  is  almost  certain,  they  in  turn  invade 
the  adjacent  bone-tissue  and  destroy  that   to  a   Certain   depth. 

A.ccumulations  of  desquamated  epithelium  in  the  form  of  concentric 
laminae  or  sheets  are  occasionally  found  in  the  antrum  or  in  the  epitympanic 
space.  Such  masses  arc  often  bulky  enough  to  interfere  seriously  with  the 
drainage  of  the  cavity  which  they  may  happen  to  occupy,  and  by  thus 
imprisoning  the  pus  and  other  matters  discharged  they  favor  the  development 
in  them  of  putrefactive  changes,  which  in  turn  stimulate  the  further  produc- 
tion of  epithelial  laminae.  There  is  also  reason  to  believe  that  the  persistent 
expansive  pressure  exerted  by  such  an  elastic  mass  is  competent  to  cause  an 
absorption  of  the  surrounding  bony  walls,  thus  leading  ultimately  to  the 
formation  of  one  of  those  large  cholesteatomatous  cavities  containing  cheesy 
material,  cholesterin  crystals,  and  concentric  layers  of  desquamated  epithelium 
which  are  occasionally  encountered  in  dispensary,  but  rarely  in  private, 
practice  (see  pages  <>(jl  and  753). 

Accumulations  of  cheesy  pus  owe  their  existence  to  those  different  factors 
which  interfere  with  good  drainage,  as,  for  instance,  a  small  perforation  in  the 
tympanic  membrane,  an  indirect  or  tortuous  outlet  channel  (a  sinus  in  the 
bone,  or  an  opening  in  the  flaccid  membrane),  granulation-tissue,  desqua- 
mated epithelium,  etc.  This  condition  and  that  described  in  the  preceding- 
paragraph  go  hand-in-hand  and  are  scarcely  separable. 

Diagnosis.-  -The  first  duty  of  the  diagnostician  is  to  ascertain  to  which 
of  the  three  groups  enumerated  above  the  case  in  hand  belongs.     If  he  begins, 
as  very  many  men  are  apt  to    begin,  by  syringing    the   external    auditory 
canal  with  tepid  water,  he  will  not  gain  as  much  knowledge  in  regard  to  the 
character  of  the   discharge,  its   total   quantity,  and   the  particular   direction 
from  which  it  comes,  as  he  would  if  he  were  to  quietly  remove  it,  little  by 
little,  with  the  aid  of  a  cotton-carrier  and  small  mops  of  absorbent  cotton. 
By  means  of  these  he  should  have  no  difficulty  in  removing  every  particle 
of  free  fluid  discharge  from  the  walls  of  the  canal,  from  the  outer  surface  of 
the  drum  membrane,  and  even  from  a  large  part  of  the  middle  ear,  when  an 
adequately  large  perforation  gives  access  to  the  cavity.      In  addition  to  what- 
ever fluid  may  be  present,  there  arc  often  crust-like  formations  which  must  be 
removed  before  the  tympanic  membrane  and    surrounding  portions  of  the 
auditory  canal  can  be  satisfactorily  seen.     Delicately  constructed  ring-shaped 
curettes  with  nicely  rounded  edges  will  be  found  to  greatly  facilitate  the  task 
of  removing  these  obstructions.      When  once  this  has  been  accomplished,  the 
physician  will  be  in  a  position  to  determine  more  or  less  accurately  the  source 
of  the  discharge.      If  he  has  found,  on  removing  the  latter  with  his  mop-  of 
absorbent  cotton,  that   it   i-  i'v^r  from  any  unpleasant   odor  and  i-  either  sero- 
purulent  or  muco-purulent   in  character;  and  if,  besides,  the  perforation  be 
found  to  occupy  a  position  in  the  lower  half  of  the  membrane,  he  may  con- 
sider this  part  of  the  examination  as  practically  completed.      It   the  perfora- 
tion is  of  small  size — as  it  i-  very  apt  to  be  in  the  cases  which  belong  to  the 
first  two  groups — polypoid   masses  or  granulations  are  very  unlikely  to  be 
present  in  the  cavity  of  the   middle  ear,  and   he   may  therefore  abstain   from 
attempts  to  explore  the  latter  with  a  probe.    The  vault  of  the  pharynx  isthe 
region  which  next  demands  attention,  and  upon  the  results  ol   the  examina- 
tion of  this  region  will  depend  the  settlement  of  the  question  whether  the 
case  belongs  to  the  first  or  to  the  second  of  the  -roup-  mentioned. 

A.s  alreadj  stated, the  presence  in  the  external  auditory  canal  of  ;i  bad-smell- 


744  CHROXTC  SUPPURATION  OF   THE  MIDDLE  EAR. 

ing  discharge,  or  of  one  which  is  distinctly  purulent  (like  creamy  pus)  in  char- 
acter, suggests  the  likelihood  that  bone  caries,  or  granulation-processes,  or 
both,  exisl  somewhere  in  the  middle  ear  ;  and  that  with  these  pathological  proc- 
esses is  associated  some  kind  of  obstruction  to  the  free  escape  of  the  result- 
ing fluid  and  solid  products.  In  this  third  group,  therefore,  the  physician  is 
called  upon  to  enter  the  drum  cavity  with  a  suitable  probe  and  to  ascertain. 
if  he  can.  just  what  are  the  true  relations  of  things  in  each  individual  case. 

When  the  perforation  is  located  in  the  lower  halt*  of  the  drum  mem- 
brane, the  physician  will  not  he  able  to  explore  the  epitympanic  space  and 
the  vicinity  of  the  antrum,  and  fortunately  these  are  the  very  cases  in 
which  such  exploration  is  least  often  needed.  If,  however,  it  should  seem 
necessary  to  explore  these  upper  regions,  what  remains  of  the  posterior  half 
of  the  drum  membrane  may  be  excised  and  the  required  amount  of  room 
obtained  in  this  manner.  When  this  has  been  accomplished,  or  when  the 
perforation  already  existing  occupies  the  posterior  superior  quadrant,  the 
entrance  to  the  antrum  and  a  large  part  of  the  epitympanic  space  or  vault  of 
the  drum  cavity  may  be  reached  with  the  end  of  the  probe  bent  at  nearly  a 
right  angle.  The  anterior  end  of  this  vault  and  the  head  of  the  hammer  can 
only  be  reached  when  there  i<  a  perforation  in  the  anterior  superior  quadrant 
or  in  the  region  of  ShrapnelPs  membrane. 

Granulation-growths  or  polypi,  collections  of  cheesy  pus  or  of  cast-off 
epithelium,  and  an  exposed  surface  of  bone,  or  perchance  a  loose  fragment  of 
bone  are  the  objects  whose  presence  may  be  demonstrated  by  the  skilful  em- 
ployment of  a  slender  bent  probe.  The  same  instrument  may  also  give 
information  in  regard  to  the  absence  of  one  or  more  of  the  ossicles,  and  it  is 
competent  to  reveal  to  us  the  existence  of  pockets  or  sinuses  in  the  bone,  or 
of  enlargements  of  pre-existing  cavities  (like  the  antrum)  through  destruction 
of  the  surrounding  bony  walls. 

Probes  made  of  coin  silver  are  sometimes  a  little  too  stiff  for  use  in 
exploring  the  middle  ear.  We  should  therefore  have  in  our  supply  some 
which  have  been  made  of  pure  (unalloyed)  silver,  which  can  be  given  any 
desired  curve  with  great  ease.  The  tip  should  be  expanded  into  a  small 
knob;  the  stem  should  be  very  slender  for  a  distance  of  at  least  two  inches 
and  a  quarter;  and.  finally,  the  handle  part  of  the  instrument  should  be 
either   four-  or  six-sided,  and,  proportionately  to  the  stem,  fairly  thick. 

It  seems  scarcely  necessary  to  add  that  the  physician  who  thus  explore-, 
the  recesses  of  the  middle  e;ir  with  a  bent  probe  should  have  in  his  mind  a 
well-defined  picture  of  the  relation-  of  nil  the  different  parts;  and  the  im- 
portance of  delicacy  of  touch  in  the  safe  management  of  such  an  instrument 
niii-t  also  be  emphasized.  The  main  thing  is  not  to  disturb  the  connections 
of  the  stirrup,  through  fear  of  injuring  the  hearing.  Hut  if  this  little  bone 
has  already  been  destroyed  by  disease,  the  need  for  such  special  care,  as  a 
matter  of  course,  disappears. 

Prognosis. — The  cases  which  belong  to  the  firsl  group  are  of  ;;  mild 
and  harmless  nature.  Even  the  hearing  may  be  impaired  to  only  a  trifling 
degree;  and  besides,  the  interests  of  the  fellow-ear  are  in  no  degree  depen- 
dent upon  the  one  which  is  affected  with  a  discharge.  Furthermore,  if  the 
disease  is  allowed  to  run  it-  course  without  any  treatment,  the  worst  that  may 
happen  i~,  that  the  discharge  will  continue  indefinitely  to  annoy  the  patient  to 
;i  greater  or  less  extent.  The  outlook,  therefore,  is  not  in  any  sense  bad  in 
cases  "I  this  kind.  <  )n  the  other  hand,  the  arresl  of  the  discharge  may  usu- 
ally be  obtained  by  proper  treatment,  but  the  permanency  of  this  arrest  can- 
not be  guaranteed  ;  for  bo  long  as  ;i  perforation  in  t  he  drum  membrane  exists, 


TREA  TMENT.  745 

the  middle  ear  will  -how  an  increased  sensitiveness  to  sudden  changes  in  tem- 
perature, and  will  be  liable  to  the  entrance  of  irritating  matters  bv  wav  of 
the  externa]  auditory  canal.     <  lonsequently,  relapses  will  be  likely  to  occur. 

Equally  mild  and  harmless  are  the  eases  which  belong  to  the  second 
group,  but  nevertheless  they  cannot  always  be  considered — as  may  generally 
be  done  in  regard  to  those  which  belong  to  the  first  group — solely  with  refer- 
ence to  the  interests  of  the  discharging  ear.  The  fellow  ear,  if  it  posses-c- 
an intact  drum  membrane,  is  even  more  seriously  imperilled  bv  the  presence 
of  a  mass  of  hypertrophied  lymphoid  tissue  in  the  vault  of  the  pharynx  : 
and  on  this  account,  if  not  in  behalf  of  the  discharging  ear,  the  physician 
is  not  permitted  to  speak  of  the  case  as  being  of  a  mild  and  harmless  char- 
acter. 

On  the  whole,  I  believe  that  treatment  is  more  uniformly  successful  in 
these  cases  that  belong  to  the  second  group  than  in  those  belonging  to  the 
first.  The  perforation  is  more  likely  to  heal  after  the  mas-  of  lymphoid 
tissue  has  been  removed,  and  relapses  are  less  frequent  ;  for  the  lack  of 
tone  or  the  lowered  vitality,  which  plays  so  important  a  part  in  the  cases  of 
the  first  group,  is  not  an  essential  characteristic  in  these. 

Very  few  cases  which  belong  to  the  third  group  can  be  spoken  of  as 
being  entirely  free  from  elements  of  danger.  When  the  perforation  in  the 
tympanic  membrane  is  large  enough  to  afford  ample  drainage  outward  into 
the  external  auditory  canal,  and  when  the  source  of  the  discharge  is  located 
at  the  posterior  end  of  the  middle  ear  proper  (/.  < .  outside  of  the  antrum)  or 
at  some  point  in  the  floor  of  that  cavity,  we  may  pronounce  the  case  to  be 
reasonably  free  from  danger  to  life  or  health,  even  if  no  treatment  whatever 
be  carried  out.  But  when  the  lesions  upon  which  the  discharge  depends 
are  located  in  the  vault  of  the  tympanum  or  in  the  antrum,  the  danger 
to  life  and  health  must  be  looked  upon  as — from  this  point  alone — greater ; 
and  the  precise  degree  of  the  danger  depends  upon  the  extent  to  which  the 
free  escape  of  the  discharge  is  interfered  with. 

Certain  danger-signals  sometimes  appear  in  the  course  of  these  chronic 
cases  of  suppuration  of  the  middle  ear,  and  show  us  the  necessity  of  inter- 
fering promptly  and  radically  if  we  wish  to  avert  a  fatal  catastrophe.  Inter- 
current attack-  of  pain  in  or  around  the  affected  ear.  paresis  or  paralysis  of 
the  corresponding  facial  nerve,  evidences  of  disturbance  of  the  circulation  in 
the  fundus  of  the  eye,  the  development  of  metastatic  abscesses  or  of  the  con- 
dition known  as  septicemia — these  are  the  more  important  danger-signals 
which  cannot  safely  be  disregarded  and  which  call  for  a  grave  prognosis. 
They  indicate  that  at  last  the  barrier  which  separates  the  focus  of  disease 
from  the  dura  mater,  or  from  the  facial  nerve,  or  from  one  of  the  venous 
sinuses  which  are  so  closely  related  to  the  bony  surroundings  of  the  middle 
ear.  has  been  or  is  about  to  be  broken  down.  In  rare  cases  the  signals  arc 
lacking,  and  the  catastrophe  arrive-  before  we  have  time  to  ward  off  the 
danger. 

Finally,  the  condition-  present  in  these  cases  of  chronic  suppuration. 
especially  in  the  young,  are  often  such  as  to  invite  an  invasion  of  tubercle 
bacilli  :  and  tubercular  disease  of  the  bone  in  this  part  of  the  skull,  if'  not 
eradicated,  i-  sure  sooner  or  later  to  infect  the  neighboring  meninges  or 
remoter  parts  of  the  body. 

Treatment. — First  Group. —  In  case-  that  belong  truly  to  the  6rst 
group  the  leading  indication  for  treatment  i>  to  overcome  a  paretic  condition 
of  the  muscular  walls  of  the  blood-vessels  of  the  tympanic  mucous  mem- 
brane—metaphorically speaking,  to  brace  them  up,  to  give  them  tone.      I  hi- 


746  CHRONIC  SUPPURATION  OF  THE  MIDDLE  EAR. 

may  be  accomplished  in  two  ways — viz.,  by  the  employment  of  both  constitu- 
tional and  local  measures. 

< 'onstitutional  Measures. — The  so-called  tonics  often  answer  the  desired 
purpose  in  the  class  of  cases  which  we  are  now  considering.  Cod-liver  oil 
stands  foremost  on  the  list.  Teaspoonful  doses — disguised  in  the  matter  of 
flavor  by  a  few  drop-  of  crime  <h  menthe — should  be  taken  two  or  three  times 
a  day  tor  a  period  of  several  week-.  Strychnin  in  small  doses  (y^-g-  grain 
to  fa  grain )  may  also  be  utilized  to  advantage,  either  independently  or  in 
combination  with  the  cod-liver  oil.  Finally,  where  the  patient's  means  will 
permit,  the  stimulating  effects  of  a  change  of  climate  or  of  a  life  in  the  open 
air  may  he  taken  advantage  of  in  our  efforts  to  secure  a  (Mire. 

Local  Measures. — Nitrate  of  silver  is  the  most  ellieient  vaso-motor  stimu- 
lant of  which  I  have  any  knowledge.  A  solution  of  this  drug  having  a 
strength  of  from  one-half  of  1  per  cent,  to  1  per  cent,  will  best  answer  the 
desired  purpose  in  the  cases  now  under  consideration.  It  may  be  injected 
into  the  middle  ear  by  means  of  a  slender  glass  instrument  called  a  "middle- 
ear  pipette,"  the  sharply-curved  tip  of  which  is  passed  through  the  perfora- 
tion in  the  membrana  tympani.  After  the  solution  has  keen  injected,  it 
should  be  allowed  to  remain  undisturbed  in  the  cavity,  in  order  that  it  may 
be  gradually  absorbed  by  the  mucous  membrane,  and  in  this  way  reach  either 
the  muscle-cells  of  the  blood-vessels  or  the  nerve-ganglia  which  control  their 
action. 

The  same  thing  can  be  accomplished  in  a  less  perfect  manner  by  first 
cleansing  the  external  auditory  canal  thoroughly  and  then  filling  it  (while  in 
an  upturned  position)  with  the  silver-nitrate  solution.  At  the  end  of  a  few 
moments,  when  the  solution  has  become  somewhat  warmed,  pressure  should 
be  exerted,  first  backward  and  then  directly  inward,  upon  the  tragus,  thus 
forcing  the  solution  through  the  perforation.  By  performing  the  act  of 
swallowing,  the  patient  may  aid  the  physician  in  his  effort  to  force  the  reme- 
dial solution  into  the  middle  ear  and  through  the  Eustachian  tube. 

Very  often  a  single  injection  suffices  to  arrest  the  discharge,  but  in  some 
cases  it  i-  necessary  to  repeat  the  operation  several  times,  either  daily  or  on 
alternate  days. 

The  introduction  of  a  very  -mall  mass  of  finely  powdered  burnt  alum — as 
much  as  can  be  made  to  cling  to  the  wet  end  of  a  slender  probe — into  the 
middle  ear  will  sometimes  prove  effectual  where  the  silver  nitrate  has  failed. 

\-  the  blood-vessels  in  the  vault  of  the  pharynx  are  apt  to  be  in  the 
same  paretic  condition  as  those  of  the  middle  ear,  it  is  well  to  make  applica- 
tions   of  silver    nitrate    to    this    region    also.      The    mop   employed   should    be 

saturated  with  a  solution  soraewhal  stronger  than  that  injected  into  the  middle 

ear.  A  2  or  .*)  per  cent,  solution  (10  or  15  grains  to  the  ounce  of  distilled 
water)  will  In-  found  sufficiently  strong  for  most  cases. 

If  the  discharge  is  very  scanty,  a-  it  usually  i-,  no  special  provision  need 
be  made  to  remove  it  by  the  employmenl  of  the  douche  with  tepid  water. 
Nor  i-  it  advantageous  to  instruct  the  patient,  as  many  physicians  seem  to  be 
doing,  to  introduce  powdered  remedies — more  particularly  boric  acid — into 
the  external  auditory  canal.  There  are  in.  processes  of  decomposition  to 
combat,  and  the  ditl'ennt  powder-  thus  prescribed  possess  no  power,  80  far  as 
I  am  aware,  to  give  tone  to  the  paretic  blood-vessels  of  the  middle  ear.  Hut 
even   if  these  powder-  did   possess  such  stimulating  powers,  it   is  not  likely 

that  they  could  etl'eet  any  good,  :i-  it  IS  more  than  doubtful  whet  her  thev  ever, 
when  introduced  in  thi-  manner,  reach  the  middle  ear. 

Second  Group. —  Tin-  main  indication  in  thi-  class  of  cases  is  to  remove 


TREATMENT.  747 

the  hypertrophied  tissues  from  the  vault  of  the  pharynx  and  to  restore  this 
region  t<>  as  nearly  normal  a  condition  as  we  can.  How  this  is  best  to  be 
accomplished  is  a  question  which  doubtless  has  been  fully  answered  in  another 
part  of  this  work  (see  page  1203).  In  all  other  respects  the  treatment  is  pre- 
cisely the  same  as  that  described  in  the  preceding  section. 

Third  Group. — These  cases  present  so  many  therapeutical  problems  for 
the  physician  to  solve  that  only  general  principles  can  be  laid  down  here  for 
his  guidance. 

The  removal  of  nil  foul  j>><><lucfs  should  be  his  first  care.  The  slender 
probe,  bent  at  a  suitable  angle  and  introduced  into  the  middle  ear  directly 
upward  toward  the  tegmen  tympani,  or  upward  and  backward  in  the  direc- 
tion of  the  antrum,  will  be  found  of  great  assistance  in  loosening  and  dis- 
lodging solid  matters  like  desquamated  epithelium  and  cheesy  pus.  Hydro- 
gen dioxid  may  then,  by  means  of  the  slender  glass  pipette,  be  injected  in 
the  same  directions,  not  merely  for  the  sake  of  its  germicidal  properties,  but 
also  because  it  effervesces  with  such  vigor  that  if  some  of  it  can  be  forced  up 
beyond  the  mass  loosened  by  the  probe  the  expanding  bubbles  will  often  drive 
it  clown  within  reach  of  the  slender  angular  forceps.  By  the  aid  of  these 
two  procedures  one  may  gradually  rid  the  vault  of  the  tympanum,  and  some- 
times even  the  antrum,  of  all  the  obstructing  matters  which  interfere  with  the 
drainage,  and  so  perpetuate  the  processes  of  suppuration.  When  the  hydro- 
gen dioxid  almost  ceases  to  effervesce — as  it  often  does  on  the  occasion  of  the 
third  or  fourth  injection — it  may  be  assumed  that  the  middle  ear  has  been 
fairly  well  cleansed  of  its  foul  accumulations.  In  any  event  it  is  not  advis- 
able to  prolong  one  of  these  mining  and  seavengering  sittings  beyond  a 
period  of  thirty  or  forty  minutes.  Before  dismissing  the  patient  for  not 
longer  than  two  or  three  days  it  is  well  to  stow  away  in  the  newly  cleansed 
cavity  a  few  grains  of  iodoform,  aristol,  nosophen,  or  other  powder  of  a  char- 
acter discouraging  to  germ  life. 

Often,  after  three  or  four  sittings  such  as  I  have  just  described,  the  most 
careful  examination  will  fail  to  reveal  any  evidence  of  newly  formed  pus. 
The  powder  will  be  found  lying  dry  upon  the  parts,  and  we  may  dismiss  the 
patient  as  relieved,  if  not  cured.  In  a  goodly  number  of  instances  the  term 
"cure"  is  almost  warranted  in  speaking  of  the  results  obtained  by  this  plan 
of  treatment,  for  I  have  known  the  relief  thus  promptly  obtained  to  persist 
for  a  period  of  several  years.  In  other  cases  a  relapse  will  occur  in  the 
course  of  a  lew  months,  and  the  same  brief  course  of  treatment  will  have  to 
be  repeated. 

It  is  only  in  very  exceptional  cases  that  the  results  which  I  have  just 
mentioned  can  be  obtained  only  after  the  removal  of  the  malleus  and  incus, 
together  with  some  still  existing  remnant  of  the  drum  membrane.  It  is 
claimed  by  some  that  it  is  better  to  perform  this  operation  in  every  case  of 
this  kind,  ;i-  by  means  of  it  a  really  permanent  cure  may  be  obtained  in  a 
larger  percentage  of  cases.  So  fir  as  I  can  judge  from  the  published 
reports,  relapses  are  about  as  frequent  in  the  excision  cases  as  in  those  in 
which  the  ossicles  have  been  allowed  to  remain.  The  better  plan,  it  seems  to 
me,  i-  to  resort  to  excision  only  when  the  simple  cleansing  method  described 
above  fail-  to  arresl  the  discharge. 

In  a  certain  number  of  cases  we  find  the  soft  part-  above  and  behind  the 

limits  of  the  drum  membrane  ;t  g 1  deal  inflamed.     In  the  presence  ot  such 

a  periostitis,  and  presumably  osteitis,  <>ne  must  be  very  cautious  about 
indulging  in  prolonged  intratympanic  manipulations.  It  is  better  to  do  only 
a  very  little    of  this    sort    of  work    at    one   sitting,  and    the  patient  should  be 


748  (  II DO XIC  SUPPURATION  OF  THE  MIDDLE  EAR. 

instructed  to  douche  the  affected  ear  once  or  twice  a  day  with  as  hot  water  as 
ran  be  borne.  Then,  when  this  more  active  inflammation  has  been  subdued, 
we  may  proceed  with  the  regular  routine  as  already  described. 

The  second  guiding  principle  in  the  treatment  <>t"  these  eases  which  belong 
to  the  third  group  is  the  necessity  of  cutting  or  tearing  away  all  granulaMon- 
tissn,  or  polypoid  growths  which  project  above  the  level  of  the  surrounding 
mucous  membrane.  Such  imperfectly  formed  tissue  is  of  itself  a  source  of 
suppuration,  and  then,  besides,  it  often  interferes  by  its  mere  bulk  with  the 
drainage  of  parts   situated    more   deeply. 

The  various  mechanical  procedures  which  are  employed  for  the  removal 
of  polypoid  growths  are  discussed  in  another  article  of  this  work.  Caustics, 
like  chromic  acid,  nitric  acid,  silver  nitrate,  etc.,  are  of  very  little  use  except 
in  cases  where  the  ma<s  is  too  small  to  be  removed  by  mechanical  means. 

The  last  principle  to  which  I  ought  perhaps  to  call  attention  is  the  desira- 
bility  of  scraping  the  surf<i<-<>  of  <m  <n-r<t  of  hone  caries.  This  principle — at 
Leasl  in  its  applicability  to  caries  of  the  middle  ear — is  so  far  inferior  in  im- 
portance to  those  of  cleanliness,  good  drainage,  and  removal  of  all  granula- 
tion-tissue, that  a  few  words  in  relation  to  the  matter  will  suffice  in  the 
present  article.  In  the  first  place,  there  arc  not  many  eases  in  which  effective 
scraping  can  be  carried  out  ;  and  then,  on  the  other  hand,  in  the  great 
majority  of  instances,  proper  cleansing  measures  followed  by  the  application 
of  a  suitable  antiseptic  powderseem  to  be  sufficient  to  bring  about  the  desired 
cure.  These  facts,  it  seems  to  me,  show  plainly  that  the  scraping  of  a  carious 
spol  of  bone  in  the  middle  ear  is  not  a  matter  of  very  great  importance. 

When  our  efforts  to  cure  a  case  belonging  to  this  third  group  fail,  it  may 
be  safely  assumed  that  thedisease  is  not  confined  to  the  middle  ear,  but  has 
involved  other  parts  in  the  neighborhood.  'I 'his  allied  subject  has  been  eon- 
tided  to  another  writer,  ami  I  therefore  do  not  need  to  say  anything  further 
with  regard  to  it  in  this  place. 


COMPLICATIONS   OF  TYMPANIC   INFLAMMATION. 


By  HERMAN   KNAPP,  M.  D., 

OF   NEW    YORK    CITY. 


Pathological  research,  as  well  as  clinical  observation,  demonstrates  that 
inflammations  of  the  tympanic  cavity,  as  a  rule,  extend  more  or  less  to  the 
mastoid  process.  This  occurs  in  two  ways,  either  through  the  Kivinian  notch 
on  the  outside  of  the  adjacent  hone  (mastoiditis  superficialis),  or  through  the 
aditus  ad  antrum  into  the  interior  of  the  mastoid  (mastoiditis  profunda).  Both 
may  be  acute  or  chronic.  They  are  infective  diseases,  produced  l>v  the  various 
kinds  of  pyogenic  micro-organisms,  in  particular  the  staphylococcus  aureus 
and  albus,  the  streptococcus,  and  the  pneumococcus,  which  Hud  their  way 
into  the  cavities  of  the  middle  ear  by  way  of  the   Eustachian   tube. 

The  superficial  mastoiditis,  also  called  mastoid  periostitis,  is  in  the  great 
majority  of  cases  only  the  burrowing  of  muco-purulent  secretion  from  the 
tympanic  attic  and  neighboring  cavities — especially  the  pneumatic  cells  in 
the  squamous  portion  of  the  temporal  bone  above,  be/dud.  and  before  the  outer 
ear-canal — on  and  beneath  the  periosteum  on  the  outer  side  of  the  temporal 
bone.  This  variety  is  frequently  seen  in  children,  and  most  often  runs  an 
acute  course.  The  periosteal  and  cutaneous  swelling  around  the  upper  part  of 
the  ear  pushes  the  auricle  forward  ami  outward.  If  the  purulent  exudation 
finds  an  outlet,  cither  by  spontaneous  perforation  or  by  an  incision  of  the  skin, 
in  the  ear  canal  or  behind  the  ear,  there  is  often  a  rapid  and  permanent 
recovery. 

This  happy  termination  does  not  occur  so  frequently  in  the  other  variety, 
the  mastoiditis  profunda  or  interna,  also  called  mastoid  empyema,  which  of 
all  diseases  of  the  ear  is,  on  account  of  its  consequences,  the  most  dangerous. 
We  shall  describe  the  acute  and  the  chronic  forms  separately. 

ACUTE  MASTOIDITIS   INTERNA. 

Ktiology. — The  causes  are  those  producing  acute  middle-ear  disease — 
viz.  acute  rhino-pharyngitis,  a-  produced  by  various  kind-  of  exposure,  sea- 
bathing, rapid  changes  of  temperature,  and  different  general  diseases,  scarlet 
fever,  measles,  diphtheria,  influenza,  pneumonia,  typhoid,  etc.  Some  modes 
of  treatment  may  produce  mastoiditis — viz.  violent  inflation,  the  na-al  douche, 
forcible  syringing,  operation  in  the  nose  and  naso-pharynx — e.  </.  for  adenoid 
vegetations,  especially  if'  followed  by  douching. 

A  particular  disposition  for  the  propagation  of  the  inflammation  into  the 
mastoid  cavities  depend- — 

(a)  On  the  anatomical  structure  of  the  mastoid  :  the  pneumatic  variety,  it 
appear-,  being  more  disposed  than  the  diploic  and  the  compact;  and  when 
..nee  invaded,  tin-  favor-  more  than  the  two  other  varieties  the  extension  ot 
the  suppuration  into  the  cells  remoter  from  the  antrum  and  to  the  adjacent 
structures. 

(6)  On  the  kind  of  the  pathogenic  microbe,     it   seems  that  the  pneumo- 

71'.' 


750  COMPLICATIONS  OF  TYMPANIC  INFLAMMATION. 

coccus  and  streptococcus  are  more  prone  to  produce  the  severer  and  more 
extended  forms  of  disease  than   the  staphylococcus. 

(c)  ( )n  the  nature  of  the  primary  disease — scarlet  lever,  diphtheria,  and 
Influenza  being  the  worst.  Among  the  constitutional  dispositions  tubercu- 
losis and  diabetes  should  be  mentioned  as  favoring  the  development  of 
mastoiditis. 

Pathology. — In  suppuration  of  the  tympanum  and  attic  the  pus  may  by 
simple  gravity  or  chemotaxis  enter  into  the  antrum  and  adjacent  cells  without 
producing  an  active  suppuration  in  the  mastoid, just  as  in  a  corneal  abscess  pus 
accumulates  at  the  bottom  of  the  anterior  chamber.  To  wake  up  an  active  in- 
flammation infective  microbes  or  their  toxins  must  enter  the  mastoid;  ripe 
pus,  like  hypopyon,  is  inert.  Infective  purulent  mutter  may  enter  from  the 
naso-pharynx  through  the  Eustachian  tube  and  the  tympanic  cavity  directly 
into  the  mastoid  even  without  causing  perforation  of  the  drum  membrane. 
In  the  mastoid  it  produces,  according  to  its  virulence,  a  catarrhal  inflamma- 
tion— congestion,  edematous  swelling,  sero-mucous  exudation — or  a  destruc- 
tive, finrn/i  nt  inflammation  of  the  mucous  membrane,  the  periosteum,  and 
the  bone.  In  the  first  the  mucous  membrane  is  swollen,  presenting  many 
folds  and  depressions  and  scant,  ropy  secretion;  in  the  second  there  are  larger 
and  -mailer  cavities  filled  with  thin  or  creamy  pus  (abscesses),  usually  com- 
municating with  one  another  by  narrow  passage-ways  (fistulse);  but  not  infre- 
quently the  abscesses  in  the  course  of  the  disease  appear  in  different  parts  of 
the  mastoid,  first  in  the  antrum, then  either  in  the  basal  or  apical,  or  in  the 
anterior  or  posterior  cells.  In  many  cases  these  different  foci  develop  succes- 
sively, and  when  the  suppuration  is  exhausted  in  the  antrum,  it  appears  in  the 
upper,  posterior,  and  anterior  recesses  or  in  the  tip.  In  very  severe  cases  the 
suppuration  invades  with  great  rapidity  the  whole  interior  of  the  mastoid, 
destroys  the  mucous  membrane,  breaks  down  the  bony  partition  walls,  and 
converts  the  mastoid  into  one  large  cavity  lilled  with  pus,  shreds  of  mucous 
membrane,  granulation-tissue,  and  decayed  bone.  The  knowledge  and  diag- 
nosis of  these  varieties  of  the  morbid  process  are  of  great  importance,  for 
they   indicate  the  direction   in   which   the  disease  progresses. 

Varieties  of  the  Morbid  Process. — The  catarrhal  form  may  termi- 
nate by  resolution — the  most  frequent  case — or  may  only  be  a  preliminary 
stage  of  the  suppurative  form.  The  latter  in  a  multitude  of  cases  ends  by 
evacuation  of  the  pus  into  the  tympanum  or  by  perforation  of  the  outer 
table  of  tlw  mastoid,  mosl  commonly  in  the  region  behind  the  ear — the  long- 
known  post-aural  abscess — or  it  may  perforate  the  inner  table,  giving  rise, 
according  to  the  differenl  regions  it  occupies,  to  the  epidural  abscess  of  the 
posterior  or  middle  cranial  fossa,  or  to  the  cervical  abscesses,  all  of  which  we 
shall  have  to  discuss  later. 

Symptoms. — Pain  is  usual  and  occurs  (n)  spontaneously  in  all  degrees  ;  in 
-"Nic  cases,  particularly  in  tuberculous  patients,  insignificant  and  not  at  all  in 
proportion  with  the  gravity  and  extent  of  the  morbid  changes  ;  in  other  cases  it 
i-  so  severe  that  the  patient-  have  no  resl  day  and  night,  commonly  worse  at 
night.  The  pain  extends  over  the  head,  especially  in  the  parietal  region,  but 
also  in   the  occipital  and    frontal   regions,  and   not   infrequently  shoot   down 

the    neck     to    the    >houldei\ 

(6)  Pain  on pressun  (tenderness).  Tin-  symptom  is  very  important,  as 
it  demonstrates  not  onlj  the  presence  but  also  the  location  of  the  suppurative 

foci.  If  the  outer  bony  table  of  the  mastoid  is  thick  and  not  affected,  only 
firm  (deep)  pressure  may  elicit  the  pain  when  moderate  pressure  and  per- 
cussion  have  failed. 


CHRONIC  MASTOIDITIS  INTERNA.  751 

As  a  localizing  symptom  the  tenderness  is  mosf  valuable.  In  the  begin- 
ning of  the  affection  pain  from  pressure  right  behind  the  upper  wall  of  the 
meatus  (the fossuh  mastoidea  or  antrum  pit)  will  rarely  be  absent.  It  indi- 
cates suppuration  in  the  antrum.  Next  in  frequency  is  pain  over  the  tip, 
the  base,  the  posterior  and  anterior  borders  of  the  mastoid  process. 

Fever. — The  temperature  rising  from  99°  F.  to  102°  F..  sometimes 
higher,  with  moderate  acceleration  of  pulse,  thirst,  general  malaise. 

Profuse  discharge  from  the  car;  creamy,  thin,  sanguinolent,  the  latter 
in  the  severer  easts  ;  often  suddenly  lessening. 

Redness  and  prominence  (bulging)  of  the  posterior  and  upper  pari  of 
the  tympanic  membrane  and  the  adjacent  portion  of  the  ear  canal.  This 
symptom  is  absent  when  the  inflammation  has  left  the  antrum  and  continues 
in  other  parts. 

Redness  and  swelling-  of  the  integument  of  the  mastoid  process, 
differing  greatly  in  degree,  in  sonic  eases  being  almost  absent  (see  page  741), 
in  others  excessively  developed,  so  that  the  knife  enters  1  to  2  cm.  before  it 
touches  the  bone. 

Course  and  Termination. — Spontaneous  recovery  in  many  instances 
occurs  in  one  or  several  weeks ;  but  the  cases  are  not  rare  where  it  takes 
months,  particularly  when  the  course  of  the  inflammation  is  not  continuous, 
but  intermittent. 

Perforation,  spontaneous  or  by  operation,  behind  the  ear  or  in  the  ear 
canal.  Even  in  these  cases  the  intermittent  character  is  frequently  manifest. 
It  means  that  the  suppuration  exhausts  itself  in  the  antrum  and  appear-  in 
another  place  later  on.  Not  rarely  do  we  see  cases  in  which  the  opening  of 
the  antrum  is  followed  by  an  immediate  improvement,  but  this  does  not  lead 
to  a  permanent  recovery  ;  the  fever  returns,  the  painfulness  moves  to  another 
place,  and  on  opening  there  we  strike  another  abscess,  macroscopically  with- 
out any  communication  with  the  antrum.  This  is  particularly  exemplified 
by  collections  of  pus  in  the  tip. 

Caries  in  greater  or  less  extent.  This  is  commonly  a  protracted  process, 
but  in  some  cases  of  unusual  severity  it  may  develop  over  a  large  area  in  a 
few  weeks. 

Transition  into  the  chronic  state  may  lull  us  into  false  security. 

Extension  into  the  Neighboring  Parts. — This  and  the  preceding  con- 
dition will  be  considered  presently. 

The  prognosis  of  acute  mastoid  empyema  is  good  if  the  proper  treat- 
ment (rest, antiphlogosis, operation) is  not  neglected.  If,  however,  the  disease 
becomes  chronic,  it  is  dangerous  to  life  in  a  degree  we  shall  point  out  in 
treating  of  the  intracranial  complications  of  ear  disease.  Mastoid  disease 
proper  has  no  direct   influence  on  audition. 

CHRONIC  MASTOIDITIS  INTERNA. 

We  distinguish  the  following  varieties: 

Condensing  Mastoiditis;  Eburnation.— When  muco-purulenl  mas- 
toiditis runs  a  chronic  course  without  external  perforation,  or  with  recurrent 
otorrhea  and  outward  perforation,  as  we  notice  so  often  after  the  scarlatinal 
otitis,  the  mastoid  process  by  plastic  osteitis  is  gradually  converted  into  a  mass 
of  compact  bone,  per  hap-  of  reduced  dimensions  (see  page  741).  Before  or  after 
the  condensation  of  the  bone  is  completed  or  comes  to  a  standstill,  many  patients 
complain  of  neuralgic  pain,  radiating  from  behind  the  ear  over  the  adjacent 
side  of  the  head  (miititow.  neuralgia),  incapacitating  them  for  prolonged  men- 


752  COMPLICATIONS  OF  TYMPANIC  INFLAMMATION. 

tal  labor  (aproseand).  Neither  by  palpation  nor  pressure  can  any  focus  of 
disease  be  detected,  and  the  otorrhea  has  stopped  for  months  or  years.  The 
distress  of  such  patients  is  so  great  that  they  willingly  consent  to  surgical 
treatment.  It'  the  operation  is  done,  the  supposed  deep-seated  focus  of  pus 
is  not  found,  even  it',  as  I  have  done,  the  chiselling  is  pushed  through  the 
whole  thickness  of  the  hone,  laying  the  [healthy]  dura  mater  hare;  yet  these 
patient-,  according  to  the  testimony  of  many  aurists,  lose  their  pain  and 
aprosexia.  Jt  is  not  even  necessary  to  go  through  the  whole  thickness  of  the 
bone  to  obtain  this  welcome  effect. 

Empyema  of  the  Anterior  Mastoid  Cells,  with  Perforation  into 

the  External  Meatus. — The  preliminary  symptoms  are  those  of  acute  sup- 
purative otitis  media  with  mastoid  involvement,  the  swelling  and  pressure-pain, 
however,  being  not  so  much  over  the  mastoid  as  on  the  posterior  wall  of  the 
ear  canal.  The  swelling  is  diffuse  and  the  painfullness  rather  dull  when  com- 
pared with  the  pointed  swelling  and  the  sharp  pain  of  the  furuncle.  Any 
doubt  in  the  diagnosis  can  be  dispelled  by  a  large  and  deep  incision  down  to 
the  bone  in  the  whole  length  of  the  posterior  wall  of  the  meatus,  as  it  was 
done  in  a  successful  case  of  mine  reported  in  a  paper  published  in  1893.1  If 
such  an  opening  does  not  give  permanent  relief,  the  diagnosis  should  be  veri- 
fied by  the  usual  opening  of  the  mastoid,  as  was  done  by  A.  Broca.2 

This  variety  is  apt  to  complicate  a  more  frequent  and  graver  extension  of 
mastoid  suppuration — viz.  : 

Empyema  of  the  Apex  of  the  Mastoid  with  Perforation  into 
the  Digastric  Fossa,  the  so-called  Behold  Variety.— When  the 
purulent  tympano-mastoiditis  has  lasted  several  weeks  or  months  or  longer, 
there  is  swelling  and  sharp  painfullness  over  the  tip  of  the  mastoid,  the  head 
of  the  sterno-cleido-mastoid  muscle,  and  in  the  grave  eases  along  the  muscle 
down  the  neck  into  the  mediastinum  (terminating  fatally,  case  of  Voltolini). 
In  a  ease  of  Guye's3  pressure  on  the  neck  and  on  the  mastoid  brought  forth 
pus  through  a  fistula  in  the  posterior meatal  wall.  Guye  opened  the  swelling 
at  the  head  of  the  muscle  and  liberated  a  great  deal  of  pus.  Water  injected 
into  the  abscess  cavity  escaped  through  a  fistula  in  the  car  canal  :  recovery. 
The  perforation  of  the  hone  -how-  usually  only  a  small  opening  in  the  lower 
medial  wall  of  the  tip.  When  the  mastoid  is  opened  and  the  tip  laid  bare 
by  detaching  the  tendon  of  the  muscle,  pus  occasionally  will  ooze  through  the 

upper  end  of  the  detached  muscle  when  the  latter  is  held  between  the  fingers 
and  st roked  from  below  upward. 

I  n  some  cases  the  pus  escaping  through  a  perforation  at  the  medial  surface 
of  the  tip  of  the  mastoid  into  the  digastric  fossa  does  not  travel  down  the 
neck  along  the  sterno-mastoid  muscle,  but  backward  toward  the  spinous 
processes  of  the  cervical  vertebrae.  Of  this  variety  the  writer  has  seen  only 
two  cases.  The  pus  followed  a  deep  and  wide  fistulous  canal  from  the  mas- 
toid underneath  a  thick  layer  of  muscles,  which  were  laid  bare  by  a  long 
incision,  with  recovery.  A  good  case  is  published  by  Dr.  Henry  F.  Swain  of 
New  Haven,  Conn.,  under  the  name  of  splenius  abscess.* 

Caries  and  necrosis  of  the  mastoid  are  in  the  majority  of  eases  the 
results  of  a  chronic  destructive,  usually  suppurative,  inflammation  which 
breaks  down  the  bone  and  form-  smaller  or  larger  cavities  filled  with  cheesy 

"'Otitic  Brain  Disease;  its  Varieties,  Diagnosis,  and  Treatment,  illustrated  by  Cases  from 
the  Writer's  Practice,"  Archil*    of  Otolorpj,  vol   x\ii.  pp.  1  i::  162. 

Se<  \ .  Broca  el  Lubet-Barbon :  "  Les  Suppurations  <lc  I'Apophyse  Mastoide,''  Pans,  1  s '.)."> ; 
<  Observation  X  :  "Mastoiditis  restricted  i"  the  Anterior  Cells,"  p.  64. 

■  Arrh.  of  OloL,  xxi.  p.  320.  *  Arch,  of  Otol.,  sxvi.,  No.  1,  1897. 


CHRONIC  MASTOIDITIS  INTERNA.  753 

masses — debris  of  mucous  membrane  and  bone  mixed  with  putrescent  or 
dried-up  products  of  secretion.  They  keep  up  a  steady  or  intermittent  offen- 
sive discharge. 

A  peculiar  formation  is  the  so-called  cholesteatoma  of  the  ear.  This 
formation  has  been  found  as  a  globular  mass  in  the  temporal  bone,  a  genuine 
tumor  independent  of  any  inflammation  of  the  ear;  bul  by  far  the  greater 
number  of  cases  present  a  scaly  deposit  which  lines  the  cavities  of  the  middle 
ear,  especially  those  of  the  mastoid,  and  i-  always  connected  with  chronic 
otorrhea.  If  the  scaly  masses  form  only  thin  layer-  lining  the  cavities,  they 
represent  the  initial  stage  of  cholesteatoma  which  Wendt  ha-  termed  <l<.«jn<t- 
mative  otitis.  The  theory  of  lie/old  and  Habermann  is  that  epidermis  pene- 
trates through  a  perforation  of  the  tympanic  membrane  into  the  middle  ear, 
proliferates,  and  gradually  fills  and  expands  the  neighboring  cavities,  form- 
ing scaly  masses  of  a  pearly  color  in  concentric  layers  like  an  onion. 

Their  course  varies  in  three  directions  :  (1 )  They  produce  purulent  inflam- 
mation, destroy  the  structures  of  the  auditory  apparatus,  creating  on  the  one 
hand  large  sinuses  by  converting  mastoid,  tympanum,  and  meatus  into  one 
large  cavity  which  communicates  with  the  air  through  the  meatus  or  through 
a  permanent  opening  in  the  mastoid — spontaneous  recovery. 

(*2)  They  lead  by  proliferation  of  bone-tissue  to  eburnation  of  the  mastoid 
— spontaneous  recovery. 

(3)  They  penetrate  the  cranial  cavity  and  cause  death  by  one  of  the 
otitic  complications. 

Another  consequence  of  caries  and  necrosis  is  tin-  separation  of  larger  or 
smaller  portions  of  bone  (sequestra1.  Their  formation  in  the  mastoid  is  com- 
mon. They  are  eliminated  through  perforations  of  the  skin  (fistula;)  either 
spontaneously  or  artificially.  Exfoliation  of  larger  portions  of  the  meatal 
wall  and  the  petrous  hone,  including  the  whole  inner  ear,  have  been  observed, 
and  it  is  surprising  how  people  can  live  and  how  severe  and  latal  conse- 
quences are  absent  in  so  many  cases  and  for  so  long  a  time. 

In  my  collection  there  is  :i  specimen  of  which  the  accompanying  illustrations  l  FLr<. 
503,  504)  give  a  true  and  life-size  illustration. 

Fig.  503  presents  the  o///>  ,■  surface  of  the  left  temporal  bone  of  an  adult.  On  the  pos- 
terior part  the  mastoid  process  is  totally  corroded  from  the  posterior  wall  of  the  external 

auditory  meatus  (b)  up  to  the  base  of  the  pr iss    c  .     In  the  center  a  strip  of  the  outer 

hone  table  (a)  i-  preserved,  the  tip  (x),  however,  and  the  whole  lower  (d)  and  medial 
(e)  surface  of  the  tip.  as  well  as  the  adjacent  bone  substance,  are  totally  corroded.  The 
tip  itself  has  a  large  hole  (x)  leading  into  the  interior  of  the  mastoid. 

Fig.  504  shows  the  internal  surface  of  the  p>tr<>us  bone  evenly  and  deeply  corroded 
from  the  base  if)  along  the  anterior  surface  to  the  hiatus  Fallopii  [g).  The  corroded 
part  extends  on  the  anterior  surface  to  the  medial  side  of  the  eminence  of  the  superior 
semicircular  canal  [h  .  to  the  middle  of  the  sigmoid  groove  £),  backward  almost  to  the 
meatus  audit,  int.  (n).  Laterally  the  sigmoid  groove  is  deeply  and  coarsely  corroded 
l/-i.  and  fistulous  passages  lead  through  the  decayed  bene  into  the  digastric  foss  i  Fig. 
504  .  The  tegmen  tympani  {t)  et  mastoidei  m)  is  corroded  in  it-  full  extent.  On 
the  whole  the  mastoid  process  is  totally  decayed  and  the  petrous  bone  in  its  entire 
lateral  half. 

It  is  a  wonder  that  people  can  live  when  the  caries  has  produced  such 
ravages.  A  greater  wonder  it  is  that  we  can  operate  on  such  people  in  such 
a  -tate.  preserve  their  lives,  and  -tamp  out  the  destructive  disease.  In  a  child 
I  operated  on  more  than  twenty  years  ago,  the  whole  mastoid  was  destroyed, 
tie  place  was  occupied  by  crumbling  pieces  of  bone  and  exuberant  larda- 
ceous  granulations.  I  removed  the  whole  decaying  ma--  of  morbid  over- 
growth. The  dura  lav  extensively  bare.  The  operation  seemed  to  be  an 
ante-mortem  autopsy,  yet  the  child  recovered.  Ten  months  ago  I  removed 
carious  and  necrosed  bone  from  the  mastoid  and  petrous  bone  of  a  child,  which 


To  I 


COMPLICATIONS  OF  TYMPANIC  INFLAMMATION. 


Pig.  503.— Caries  of  the  mastoid  and  lateral  half  <>f  the  petrous  bone  of  an  adult  (lite  size):  Outer 
surface  showing  a,  part  of  the  outer  table,  preserved;  6,  posterior  wall  of  external  meatus;  c,  base;  d, 
lower  wall;  e,  medial  wall;  and  x,  tip  of  tin-  honeycombed  mastoid  process. 

in  the  Living  presented  all  the  symptoms  exhibited  by  the  specimen  depicted 
above  ;  and,  although  tuberculosis  was  at  the  bottom  of  the  affection3  the  child 
was  perfectly  cured.     The  tolerance  by  the  organism  of  such  deep  and  exten- 


i  ■!'.    504.     Inner  aspecl  "i    specimen  Bhown  In  Fie.  SOS,  showing  b.  base  of  pyramid ;  tj,  hiatus  Fal 
ft,  eminence  ol  superior  semicirculai  canal;  t,  sigmoid  groove;  fc,  deep  holes  in  corroded  bone; 
i.  tegmen  tympanl :  m,  tegmen  mastoldei. 

give  ravages  cannot  be  depended  on,  however,  and  these  destructive  processes 
are  the  chief  causes  of  the  disastrous  intracranial  complications  of  ear  disease 
which  we  small  now  discuss. 


INTRACRANIAL   GOMPLICA  TIONS. 


755 


INTRACRANIAL  COMPLICATIONS  OF  PURULENT  OTITIS  MEDIA. 

Etiology. — The  intracranial  complications  of  ear  disease  arc  almosl 
exclusively  produced  by  the  propagation  of  purulent  inflammation  of  the 
different  parts  of  the  middle  ear. 

Occurrence. — They  are  met  with  in  only  a  small  percentage  of  ear  diseases, 
but  are  most  dangerous.  According  to  Biirkner,1  who  found  101  deaths  in 
•">■").  1 1 )7  ear  eases,  as  well  as  according  to  Randall,2  who  found  15  in  5000,  three- 
tenths  of  one  per  cent,  of  all  the  ear  patients  die  from  otitic  intracranial  dis- 
ease. Schwartze3  found  in  the  Prussian  army  .*!<>  deaths  in  8425  diseases 
of  the  middle  and   inner   ear — i.  e.  0.35   per  cent. 

The  death-rate  from  purulent  ear  disease,  compared  with  the  death-rate 
from  all  diseases  treated  in  a  large  general  hospital,  has  been  ascertained  by 
X.  Pitt,'  who  found  among  9000  successive  autopsies  in  (Juy's  Hospital 
(London)  during  the  years  1869—1888,57  deaths  from  purulent  ear  disease, 
which   is   1    out  of  158,  or  very  nearly    §   of  1    per  cent. 

Prof.  J.  Gruber3  examined  the  poxf-mortcm  records  of  the  Vienna  Gen- 
eral Hospital  and  found  232  deaths  from  otitic  intracranial  disease  among 
40,073  autopsies — i.  e.  0.58  per  cent. 

Propagation. — In  the  great  majority  of  the  cases  ear  disease  extends 
into  the  brain  through  destructive  inflammation  of  the  bone  (Fig.  505),  by 
which  infective  material  enters  the  cranial  cavity,  accumulates  between  bone 
and  dura,  and  causes  pachymeningitis,  leptomeningitis,  sinus  thrombosis,  cere- 


■  ■    w 


Fig.  505.— Caries  of  the  tympanic  roof.  The  open- 
ings were  sealed  by  the  thickened  dura  ami  the 
brain  was  not  here  involved.  Death  by  basal  men 
inf,'itis  from  infection  through  internal  meatus. 


Pig.  506. — Outer  aspect  of  the  same  specimen, 
showing  loss  of  the  back  wall  of  the  canal  and 

openings  into  the  facial  and  semicircular  canals 
above  t  in-  empty  oval  u  indow 


bral  and  cerebellar  abscess.  The  infective  material  may,  though  rarely,  be 
conveyed  into  the  skull  by  offshoots  of  the  dura  mater,  the  aqueducts  I  Fig. 
506),  and  the  canals  through  which  blood-vessels,  lymphatics,  and  nerve- 
pass    from    the   tympanic    into   the   cranial    cavity. 

The  infective  material  consists  of  the  dill'ereiit  species  of  pyogenic  micro- 

1  Anh.  (.  ohm,/,.,  xx.  p.  81.  Trans.  Am.  Otol.  Soe.,  v.  p.  L01. 

3  Arch./.  Ohrenh.,  wi.  p.221.  '  Brit.  Med.  Journ.,  1890,  vol.  i.  pp.  643,  771,  827 

-  Arch,  of  <>tnl.,  xxv.  p.  401,  IS 


756  COMPLICATIONS  OF   TYMPANIC  INFLAMMATION. 

organisms  —  staphylococcus     pyogenes,    streptococcus^     pneumococcus,    and 

others,  the  same  thai  cause  the  primary  car  disease — and  their  products, 
the  toxins. 

Causes. — Generally  only  the  severer  forms  of  otitis  media  are  complica- 
ted with  brain  disease,  such  tonus  as  are  caused  either  by  certain  acute  general 
diseases — scarlet  lexer,  diphtheria,  influenza,  measles,  variola,  and  typhoid — 
or  by  some  chronic,  debilitating,  constitutional  affections — tuberculosis,  dia- 
betes, syphilis.  Sometimes  grave  cases  01  purulent  otitis,  terminating  fatally 
by  brain  complications,  are  caused  by  accidental  atmospheric,  chemical,  and 
mechanical  influences;  for  instance,  blizzards,  sea-bathing,  foreign  bodies  in 
the  ear,  rough  and  unclean  methods  in  removing  foreign  bodies  and  diseased 
deposits  from  the  ear,  forcible  syringing  in  acute  suppuration,  all  devices  and 
remedies  tending  to  pen  up  secretions,  such  as  tampons  and  coagulating  pow- 
ders, morbid  formations  in  the  middle  ear  and  auditory  canal — e.  <j.  polypi, 
sequestra,  exostoses,  cutaneous  membranes,   cystic  and  other  tumors. 

Acute  purulent  otitis  leads  more  rarely  to  intracranial  complications  than 
chronic;  yet  by  no  means  so  exceptionally  as  was  formerly  believed. 

Passageways  of  Infection. — The  channel  of  invasion  of  the  skull 
cavity  most  frequently  passes  through  the  medial  and  superior  walls  of  the 
mastoid  into  the  posterior  cranial  fossa  ;  next  in  frequency  it  passes  through 
the  tegmen  tympani  into  the  middle  cranial  fossa,  then  through  the  media/ 
wall  of  the  drum  by  way  of  the  labyrinth  and  the  internal-ear  canal,  or 
directly  through  the  posterior  wall  of  the  petrous  bone  into  the  posterior 
cranial  fossa  ;  rarely  through  the  lower  and  (inferior  trails  upward  along  the 
fossa  for  the  bulb  of  the  jugular  vein  or  the  carotid  canal.  Exceptionally 
the  infective  material  travels  through  the  tympanic  ostium  of  the  Eustachian 
tube  or  the  semicanal  for  the  tensor  tympani  muscle  forward  and  inward, 
forms  a  ret n (-pharyngeal  abscess,  and  penetrates  through  one  of  the  crevices 
at  the  base  of  the  skull  into  the  cranial  cavity,  as  in  a  case  of  Troltseh  '  and 
another  of  the  present  writer.2 

INFLAMMATION  OF  THE  MENINGES. 

.Meningitis  in  general  may  result  front  a  constitutional  infective  disease, 
such  as  tuberculosis  or  syphilis,  or  it  may  originate  in  a  neighboring  structure, 
from  a  wound  of  the  skull,  or,  what  concerns  us  here,  a  diseased — i.  e.  suppu- 
rating ear.      We  may  distinguish  pachymeningitis  from  leptomeningitis. 

Pachymeningitis  may  be  external,  the  common  kind,  or  internal. 

Pachymeningitis  Externa;  Epidural  or  Extradural  Abscess. 
— The  infection  may  be  carried 

(a)   Through  vascular  and  membranous  canals  from  the  inflamed  tympanic 

cavity  through  healthy  1 e   into  the  cranial   cavity,  which  is  very  rare;   (l>) 

through  a  line,  fistulous  eanal,  not  always  macroscopically  discoverable,  through 
apparently  healthy  bone;  or,  the  mosl  frequent  condition  and  (c)  through 
bone  broken  down  by  caries,  necrosis,  or  erosion  and  atrophy  from  chole- 
steatoma and  t  Minor-.  .Ian-en  ;  describes  a  peculiar  channel — namely,  through 
tin-  labyrinth  and  the  OOUed UCtuS  nsiihuli  to  the  posterior  surface  of  the 
petrous  bone  with   formation   of  an   empyema   in    the  endolymphatic  sac 

\-  pachymeningitis  externa  leads  to  thrombophlebitis  and  abscess,  the 
reverse  emu--.'  may  occur;  thrombophlebitis  and  abscess  may  induce  pachy- 
meningitis and  leptomeningitis,  which  then  commonly  prove  fatal  in  a  short 
time. 

1  Arch.  (.   Ohrenh.,  iv.  p.  121,  Fall  6.  -  Arch,  oj  Oiot.,  xxiv   p.  125,  1895. 

Berl.  Win.    WW,.,  1891,  No.  49. 


INFLAMMATION  OF  THE  MENINGES.  757 

Pathology. — When  we  expose  the  dura  in  cases  of  acute  purulent  otitis 
media  we  usually  find  it  either  normal  <>r  slightly  reddened  and  <lull  ;  in 
more  advanced  inflammation  it  is  vascular,  thickened,  and  beset  with  granu- 
lations. In  chronic  cases,  with  circumscribed  caries  or  necrosis  of  the  under- 
lying bone,  it  is  blackish  like  the  hone,  softened,  gangrenous,  and  perforated, 
bathed  in  serum.  In  purulent  destruction  of  the  bone  it  is  separated  from 
the  latter  by  pus  which  has  the  characteristics  <>1'  the  pus  in  the  middle  ear, 
creamy  and  sweet  in  the  acute,  thin,  greenish,  and  offensive  in  the  chronic, 
cases.  In  a  very  chronic  course  the  dura  may  he  greatly  thickened  and 
fibrous  or  sarcomatous  looking.  Zaui'al  '  describes  a  case  in  which  the 
dura  was  1.5  cm.  thick;  and  the  writer  has  seen  a  similar  case  where  chronic 
empyema  of  the  sphenoidal  and  ethmoidal  sinuses  showed  perforation  of  the 
optic  groove  at  the  sella  turcica  and  the  greatly  thickened  fleshy  dura  looked 
like  a  flat  sarcoma,  hut  gradually  thinned  down  and  was  attached  to  the 
healthy  neighboring  hone.  The  pus  hetween  dura  and  hone  does  not  collect 
in  a  circumscribed  cavity,  but  spreads  in  different  directions,  following  readily 
the  sigmoid  sulcus  into  the  jugular  foramen,  and  up  along  the  transverse 
sulcus  toward  the  torcular  HerophUi,  also  at  the  bend  of  the  sinus  into  the 
middle  cranial   fossa. 

Epidural  ahscess  may  he  recovered  from  by  a  spontaneous  opening  into 
the  ear  through  the  medial  wall  of  the  mastoid,  the  roof  of  the  tympanum, 
the  squama  temporalis,  or  through  the  occipital  hone  above  and  behind  the 
ear  canal.  The  writer  ha-  -ecu  spontaneous  perforation  of  the  occipital  hone 
4  or  5  cm.  behind  and  about  1  em.  above  the  ear  canal  in  two  cases.  He 
opened  the  subperiosteal  abscess,  and  could  introduce  a  probe  through  the 
hone  fistula  into  the  posterior  cranial  fossa.  One  case  made  a  spontaneous 
recovery,2  and  has  been  under  observation  these  three  years ;  the  other  died 
from  sinus  thrombosis  and  leptomeningitis  fifteen  years  ago.  The  autopsy 
showed3  that  the  hone  fistula  was  about  in  the  middle  of  the  transverse 
sulcus.  In  the  great  majority  of  cases  of  epidural  abscess  the  dura  per- 
forates and  the  patient  die-  from  consecutive  cerebral  abscess  or  purulent 
r-inus  thrombosis  and  leptomeningitis.  All  these  grave  affections  may  occur 
together  in  one  case.' 

Diagnosis. —  In  most  cases  the  presence  of  an  epidural  abscess  is  ascer- 
tained only  during  the  operation,  when  the  broken-up  medial  wall  of  the 
mastoid  or  a  fistula  either  in  this  wall,  in  the  roof  of  the  drum  and  mastoid 
or  in  some  other  part  of  the  skull  leads  into  the  collection  of  pus.  In  many 
cas< — ymptoms  of  meningeal  irritation  are  present — namely,  headache,  slight 
rise  of  temperature,  pressure-pain,  somnolence,  -lowing  of  pulse,  vomiting, 
stiffness  of  the  Deck,  choked  opticdisk;  but  these  symptoms  are  too  indefinite 
to  make  a  diagnosis.  If  after  the  opening  of  a  subperiosteal  abscess  a  probe 
can  he  passed  through  a  bone  fistula  into  the  cranium,  we  may  he  assured  of 
the  presence  of  an  epidural  collection  of  pus.  In  a  number  of  cases,  how- 
ever, doughy  swelling  and  tenderness  on  pressure  about  one  inch  behind  the 

•  -ill* 

ear  canal,  the  place  of  exit  of  the  mastoid  emissory  vein,  and  the  history  and 
other  symptoms  make  a  cranial  complication  probable,  and  we  may  fairly 
suppose  that  we  have  to  deal  with  an  epidural  abscess. 

Prognosis. —  If  we  know;  that,  with  the  few  exceptions  of  a  spontaneous 
perforation,  epidural  abscess  i-  always  fatal,  the  indication  of  operative  inter- 
ference is  imperative.  As  in  the  majority  of  cases  the  diagnosis  i-  uncertain, 
the  operation  should  he  begun  in  an  exploratory  way.  and  desisted  from  or 

1  Prnger  .1/-/.  Woeh.t  1893,  No.  •">".  :  Arch,  of  6tol,  xii.  p.  1 

*Arch.qf  '»"/.,  xii.  p.  II.  l  Arch,  of  Otol,  vol.  x\i.  p. 239,  l^'."J. 


758  COMPLICATIONS  OF  TYMPANIC  INFLAMMATION. 

continued  and  terminated  according  to  the  conditions  revealed.  When 
operated  on,  almost  all  cases  recover. 

Pachymeningitis  interna  (subdural,  01  intradural  abscess)  is  not  often 

met  wiili.  When  in  :i  circumscribed  place  the  externally  inflamed  dura  is 
corroded,  softened,  and  perforated,  exudation  is  deposited  on  its  inner  side 
in  the  subdural  space.  [f  during  this  process  the  arachnoid  and  pia  are 
agglutinated  to  the  dura,  pus  may  accumulate  in  this  place  and  form  a  sub- 
dural abscess,  with  softening  and  ulceration  of  the  adjacent  brain-substance — 
circumscribed  encephalitis.  W.  Macewen,  in  his  classical  treatise  on  the 
"Infective  Diseases  of  the  Brain  and  Spinal  Cord,"  described  several  cases 
of  this  variety,  one  of  which  (Case  X.,  p.  75)  was  cured  by  an  operation.1  If, 
on  the  other  hand,  this  agglutination  does  not  occur,  the  infective  exudation 
spreads  in  the  subdural  space  and  leads  to 

Purulent  leptomeningitis. — The  pathogenic  substances  may  he 
carried  into  the  arachnoid  space  in  various  ways— (a)  after  perforation  of  the 
dura,  as  we  have  seen,  or  (6)  without  perceptible  perforation.  Leptomeningitis 
is  developed  chiefly  in  the  neighborhood  of  the  diseased  dura,  on  the  base  of 
the  brain,  travelling  thence  to  the  convexity  of  the  same  side,  and  to  the  base 
and  convexity  of  the  other.  In  rare  cases  the  convexity  only  shows  macro- 
scopic changes,  whereas  the  base  appears  healthy,  as  it  was  in  the  ease  de- 
scribed and  depicted  by  the  writer  in  the  Archives  of  Otology,  1895.  p.  125. 
The  pus  is  collected  in  the  furrows  between  the  convolutions  and  also  in  dis- 
seminate patches.  The  pia  is  hyperemic  and  edematous.  In  addition  to  the 
purulent  meningitis  we  frequently  find  the  tubercular  kind;  and  lately  atten- 
tion has  been  called  by  Quincke,  Levi,  and  others  to  serous  meningitis. 

Meningitis  purulenta  may  be  general  or  partial  (circumscribed).  It  has 
been   found  oftener  on   the  righl   side  than  on  the  left  (Korner). 

Etiology. — Meningitis  may  be  induced  as  well  by  acute  as  by  chronic 
purulent  otitis,  with  or  without  caries.  It  may  be  uncomplicated  or  accom- 
panied and  caused  by  sinus  thrombosis  and  cerebral  abscess.  Otitis  in  tuber- 
cular and  syphilitic  subjects  leads  more  readily  to  meningitis  than  otitis  in 
healthy  subjects.  It  rarely  occurs  in  small  children,  which  is  remarkable. 
The  author  has  operated  on  children  between  one  and  four  years  old  where  the 
greatesl  ravages — cariesand  necrosis — destroyed  the  mastoid  and  petrous  and 
laid  the  dura  bare  to  a  very  large  extent  ;  yet  the  children  had  no  symptom 
of  leptomeningitis  and  recovered. 

Duration. — Otitic  meningitis  may  be  acute — in  exceptional  cases  fulmi- 
nating, setting  in  almost  suddenly  and  terminating  fatally  in  four  or  five 
hour-  or  in  several  <lays — or  chronic,  with  mild  symptoms  and  intermissions 
at  first,  then  developing  into  the  regular  course,  which  usually  lasts  one  week 
or  less,  more  rarely  'wo  or  three  weeks. 

Symptoms. — Headache  is,  as  a  rule,  the  earliest  ami  most  pronounced 
symptom.  At  first  it  is  parietal,  occipital,  or  frontal,  and  on  the  same  side, 
later  general. 

Dizziness,  restlessness,  irritability,  auditory  and  visual  hyperesthesia,  men- 
tal weakness,  loss  of  appetite,  constipation,  drowsiness  without  regular  Bleep, 
nausea,  vomiting,  optic  neuritis  (rare),  more  or  less  constant  acceleration  of 
pulse  and  elevation  of  temperature,  delirium,  convulsions,  and  coma  are  the 
chief  symptoms  of  the  regular  course.  They  may  be  modified  by  complication 
with  abscess  (temperature  high,  pulse  -low)  and  septic  -inn-  thrombosis 
(rapid  diurnal  changes  of  temperature). 

Prognosis. —  Purulent  meningitis  due  to  ear  disease,  like  that  due  to  other 

I       l     McKennon,    Wch.   •/   OtoL,  June,  L898. 


INFLAMMATION  OF  THE  MENINGES.  759 

causes,  terminates  fatally  in  the  great  majority  of  cases.  How  numerous  in 
well-established  diagnosis  the  exceptions  are  must  be  left  to  future  observa- 
tions in  brain  surgery  to  decide.  The  cases  of  diffuse  purulent  meningitis 
thus  far  reported  as  cured  by  operation  d<>  not  stand  criticism  ;  whereas 
partial  meningitis,  epidural  and  subdural  abscess,  and  the  serous  meningitis, 
which  shows  a  majority  of  the  symptoms  of  diffuse  meningitis,  have  undoubt- 
edly l>ecn  cured  by  operation,  and  some  have  recovered  spontaneously. 

Sinus  Thrombosis  and  Pyemia. — Patholog-y,  Course,  and  Termina- 
tion.— The  destruction  of  mucous  membrane  and  hone-tissue  in  the  middle 
ear  and  mastoid  process  by  way  of  pachymeningitis,  epidural  abscess,  and 
phlebitis  frequently  induces  sinus  thrombosis.  If  the  thrombus  is  parietal 
and  uninfected  it  causes  no  appreciable  disturbance  of  the  patient's  health; 
if,  however,  it  becomes  contaminated  with  pyogenic  matter  through  pervious- 
ness  of  the  vessel-wall  by  erosion,  softening,  and  perforation,  the  thrombus 
becomes  septic,  decays,  and  causes  pyemia.  The  lateral  sinus  is  the  one  most 
exposed,  but  small  bone  veins  may  carry  the  infective  material  into  the 
sinuses  from  different  parts  of  the  temporal  hone.  The  thrombus  may  he 
partial  or  total  (occlusive),  uninfected  or  septic,  single  or  multiple,  limited 
to  one  sinus,  or  extending  over  almost  all  sinuses  and  veins  of  both  cerebral 
and  cerebellar  hemispheres.  The  lateral  sinus  is  more  frequently  thrombosed 
than  any  other,  particularly  its  sigmoid  segment ;  then  the  inferior  and  supe- 
rior petrosals,  the  cavernous  sinus,  the  hull)  and  the  whole  length  of  the 
internal  jugular. 

Non-infected  thrombi  may  disappear  by  absorption,  or  may  by  a  kind  of 
"organization"  obliterate  the  vessel  and  do  no  harm.  Infected  thrombi  may 
in  rare  cases,  by  destruction  of  the  sinus-wall,  he  evacuated  through  a  fistula 
of  the  destroyed  bone,  without  causing  disastrous  consequences.  Not  quite 
so  rarely  they  are  carried  by  the  blood-current  into  distant  organs,  especially 
the  lungs,  and  produce  larger  and  smaller  metastatic  abscesses  and  pyemia. 
Even  in  such  cases  recovery  by  and  even  without  surgical  interference  is 
possible.  In  the  majority  of  cases,  however,  if  the  affected  sinus  is  not 
operated  on,  septic  sinus  thrombosis  proves  fatal  by  metastatic  abscesses, 
pyemia,  cerebral   or  cerebellar  abscess,  and  purulent  meningitis. 

Sinus  thrombosis  is  more  frequent  in  men  than  in  women,  and  more  fre- 
quent on  the  right  than  on  the  left  side.  It  occurs  more  rarely  in  acute  than 
in  chronic  cases,  and  the  predisposition  to  it  is  greatest  in  the  second  and  third 
decades  of  life. 

Symptoms. — Arranged  according  to  their  frequency  and  importance  we 
note:  (1)  Headache. — It  corresponds  more  or  less  to  the  situation  of  the 
thrombus,  usually  2  or  •*'>  cm.  behind  the  upper  vd^  of  the  external  ear 
canal,  over  the  knee  of  the  lateral  sinus  where  infective  otitic  thrombosis 
most  often  begins.  It  may,  however,  radiate  over  the  parietal  region  of  the 
head  or  be  marked  in  the  occiput,  rarely  in  the  forehead  of  the  same  side. 
The  headache  may  be  most  intense,  depriving  the  patient  of  all  sleep  during 
twenty-four  hours. 

('!)  Acceleration  ami  weakness  of  the  pulse,  more  or  less  constant. 

(3)   Rapid  changes  of  temperature,  running  from  near  the  normal  up  to 
104o-l<><;°  F.  in  several   hours,  and   filling  again   to   the  original  level  the 
same  day — the  characteristic  steep-peaked  temperature  chart  of  pyemia.     9 
the  accompanying  chart  (Fig.  507),  taken  from  :i  recent   publication  ol    Fred. 
Whiting  of   New  York:    "Three   Successfully  Operated   Cases  oi 
Sinus  Thrombosis." ' 

1  Arch,  of  OloL,  xxvii.  p.  26,  L89a 


"00 


COMPLICATIONS  OF  TVJfl'AXIC  rXFLAVMATIOX. 


(4)  Rigors. — Quotidian  <>r  tertian  chills  lasting  halt'  an  hour  or  longer, 
followed   by  profuse  perspiration. 

(5)  Swelling  and  tenderness  over  and  behind  the  posterior  edge  of  the  mas- 
toid (sigmoid  sinus  thrombosis) ;  further  back,  half-way  between  the  car  and 
the  occipital   protuberance  (transverse  sinus);  in  the  depth  and  around  the 


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(Whiting). 


orbit  with  protrusion  of  the  eyeball  (cavernous  sinus);  below  the  tip  of  the 
mastoid  and  down  the  anterior  border  of  the  sterno-cleido-mastoid  muscle 
(bulb  and  internal  jugular  vein,  which  in  its  upper  portion  and  sometimes  in 
it-  whole  extent  is  fell  as  a  hard  and  tender  cord. 

(6)  The  tongue  is  dry  and  coated,  and  the  appetite  lost,  in  marked  eases  to 
the  refusal  of  all  food. 

(7)  Diarrhea  in  most  cases,  constipation  in  some. 

(8)  Comprehension  -low;  stupor  and  optic  neuritis  only  in  complication 
with  encephalic  abscess  and  meningitis. 

The  diagnosis  in  uncomplicated  infective  sinus  thrombosis  is  easy  ;  in 
complicated  cases  (abscess  and  meningitis)  the  marked  and  characteristic 
symptoms  (steep-peaked  temperature  curve  and  rigors)  of  pyemia  over- 
shadow those  oi  abscess  and  meningitis,  so  thai  in  complicated  cases  it  is 
easier  to  recognize  the  presence  or  absence  of  thrombosis  than  thai  of  abscess 
and  meningitis. 

The  prognosis  is  bad  if  the  disease  is  allowed  to  take  it-  natural  course  ; 
onlya  few  well-established  cases  of  spontaneous  recovery  are  on  record.  The 
prognosis  is  much  better  since  the  advance  of  otology  and  surgery  has  led  to 
the  early  recognition  and  the  operative  cure  of  this  disease.  The  mortality 
even  now  is  -till  considerable, and  the  records  of  well  described  cases  at  pres- 
enl  at  our  disposal  do  not  suffice  reliably  to  express  the  percentage  of  mor- 
tality. The  prognosis  in  any  given  case,  shorl  of  deep  emu;!,  is  nol  absolutely 
hopeless,  since  even  patients  with  the  severesl  cephalic  Bymptoms  and  severe 
metastatic  pneumonia  have  recovered. 

Prof.  0  Kiirner,  in  his  exhaustive  monog  raph  :  "  The  Otitic  Affections  of  the  Brain, 
the  Meninges,  and  the  Venous  Sinuses,"  describes  two  additional  varieties  of  pyemia  : 


INFLAMMATION  OF  THE  MENINGES. 


761 


Osteitic  Pyemia  with  Sinus  Phlebitis  (Osteo-phlebitis  of  the  Temporal  Bonej.— 
This  disease  is  rare.  It  is  caused  by  the  entrance  of  j >u-  from  the  primary  focus  in  lin- 
ear or  the  temporal  bone  into  the  general  circulation  through  small  veins.  The  symp- 
toms are  like  those  of  pyemia  from  sinus  thrombosis.  Its  existence  as  distincl  from  tin- 
latter  is  doubted,  but  any  one  who  has  ever  seen,  like  the  writer,  a  fatal  ease  of  pyemia 
from  osteomyelitis  of  the  thigh,  will  ask  with  Kiirner:  Why  should  such  a  disease  not 
originate  in  an  acute  inflammation  of  the  mastoid?  Rigors  are  not  so  frequent  as  in 
sinus  thrombosis;  metastases  are  rare  in  the  lungs,  but  occur  in  the  joints,  muscles,  ami 
the  subcutaneous  connective-tissue,  and  the  streptococcus  ha-  been  found  in  them  a-  the 
pathogenic  germ.  The  prognosis  is  better  than  that  of  sinus  phlebitis;  and  the  treat- 
ment should  be  conducted  according  to  general  surgical  principles;  some  cases  in 
which  the  internal  jugular  was  ligated  have  ended  fatally  (Lane,  Deansley,  Langen- 
buch  |. 

Septic  Affections  from  Suppuration  of  the  Ear  and  Temporal  Bone.— Tins 
variety  is  distinguished  by  a  very  rapid  course  (sometimes  in  a  few  day-1,  severe  cerebral 
symptoms,  especially  delirium,  high  continuous  fever,  septic  endocarditis  and  aephritis, 
hemorrhages  in  the  endocardium,  the  muscles,  the  retina,  etc.  Kiirner  describes  two 
cases  of  his  own  practice  in  which  he  dwells  on  the  rapidly  increasing  edema  in  the 
region  of  the  diseased  bone  and  the  infected  cervical  glands,  while  the  sinuses  and 
emissary  veins  were  entirely  intact.  In  a  case  under  Frankel's  care,  which  ran  its 
fatal  course  under  the  pictureof  a  dermato-myositis,  the  tissue-juice  and  the  muscles 
wrere  filled  with  streptococci  in  pure  culture.  Kiirner  says  that  this  supports  the  suppo- 
sition  that  these  septic  processes  spread  chiefly  through  the  lymph-channels,  not  like 
the  pyemic  through  the  blood-vessels.  The  present  writer  cannot  suppress  Ids  impres- 
sion that  the  above  observations  might  have  been  cases  of  primary  otitis  purulenta 
complicated  with  erysipelas 

Brain-abscess  (Cerebral  and  Cerebellar). — This  severe  affection  is 

induced  in  the  great  majority  of  the  cases,  not  by  disease  of  the  mucous 
membrane,  but  "by  disease  of  the  bone  which  almost  always  extends  to  the 
dura  mater.      In  !)  per  cent,  it  lias  been  caused  by  acute,  in   91  per  cent,  by 


Fig.  ")08. — Right  anteroinferior  aspect  "f  brain,  showing  cerebellar  abscess  and  spheno-temporal  hernia 

cerebri. 


chronic  otitis.  Tin-  dura  is  almost  always  united  to  the  surface  ol  the  brain 
at  a  point  where  the  cerebral  abscess  is  nearest  to  the  diseased  bone.  Hie 
brain-substance  which  separates  the  abscess  cavity  from  the  place  ol  union 
between  dura  and  bone   i-.  as  a   rule,  only  a  few  millimeter-  broad,  and  has 

almost   alwavs — in   si   out   of  90  cas< been   found  diseased"  (Korner). 

The  abscesses  are  found  in  the  neighborhood  of  the  diseased  bone,  about 
66  p<-i-  cent,  in  tin-  temporo-sphenoidal  lobe,  over  tin   tegm  n  h  mpani  el  mas 


762 


COMPLICATIONS  OF   TYMPANIC  INFLAMMATION. 


toidei,  upon  which  the  fusiform  gyrus  is  situated  ;  ."><>  per  cent,  in  the  cerebel- 
lum, near  the  sigmoid  groove,  where  the  anterior  surface  of  the  cerebellar 
hemisphere  i-  situated  i  Fig.  508) ;  the  remaining  I  per  cent,  arc  found  in  the 
crura  cerebelli  ad  pontem,  the  pons,  or  very  rarely  in  the  occipital  or  frontal 
lobes.  Iu  children,  statistics  show  that  S2  per  cent,  are  in  the  cerebrum, 
18  per  cent,  in  the  cerebellum;  in  advanced  years  we  find  <!•">  per  cent,  in  the 
cerebrum,  37  per  cent,  in  the  cerebellum,  all  of  which  is  explained  by  the 
development  of  the  pneumatic  spaces  in  the  mastoid  with  advancing  years. 
In  15  per  cent,  more  than  one  abscess  has  been  found  in  the  brain. 
The  size  of  the  abscess  varies  from  the  smallest  dimensions  to  the  occu- 
pancy of  almost  the  entire  temporo-sphenoidal  lobe.  Among  the  largest  is 
the  one  described  and  depicted  by  the  writer  in  1895.1  It  was  8  cm.  long 
and  (')  cm.  high.  They  contain  usually  the  same  kind  of  pus  as  the  otorrhea 
shows,  thick  and  creamy  or  thin,  frequently  greenish  and  offensive.  The 
majority  being  chronic  are  capsulated.  The  capsule  has  been  found  from  1 
to  5  mm.  in  thickness.  Those  non-capsulated  are  commonly  surrounded  by 
a  zone  of  softened  brain-substance,  which  easily  ruptures  when  the  brain  is 
removed.  Not  only  abscesses  that  are  free  from,  but  also  most  of  those 
invested  with,  a  capsule  continue  to  grow  nevertheless. 

Abscesses  may  in  their  growth  communicate  with  the  mastoid  or  the  mid- 
dle ear  and   give   off  continuously  some  of  their   contents;    they   may  also 

erode  and  perforate  the  cranial 
capsule  and  discharge  pus  through 
a  fistula,  as  in  the  ease  of  Schede, 
one  of  the  earliest  to  be  success- 
fully operated  on.  Spontaneous 
evacuation  through  the  ear  has 
been  noticed  by  Randall2  (Fig. 
509)  and  many  others,  yet  it  did 
not  cure  the  abscess.  A  notable 
fact  is  that  a  constant  otorrhea 
from  central  abscess  often  sud- 
denly stops  during  the  course  of 
an  operation  without  any  signif- 
icance as  to  the  result.  The  only 
case  of  spontaneous  recovery  of  a 
cerebral  abscess  on  record  is  by 
Sutphen,  of  Newark,  N.  •!..  who 
found  at  the  autopsy  of  a  patient 
dead  from  arrosion  of  the  carotid 
an  old  abscess  which  had  emp- 
tied itself  previously  by  a  carious 
perforation  of  the  temporal  bone. 
Tin'  almost  unexceptional  termi- 
nation of  an  encephalic  abscess,  if 
not  operated  on,  is  death,  caused 
either    by    cerebral    pressure    and 

edema,   by   perforation    into    the   ventricles  or  the   subarachnoid    .-pace,  or 
through  complicating  sinus  thrombosis  ami  meningitis. 

Symptoms,  Course,  and  Termination. —  In  many  cases  we  may  distin- 
guish four  stages  :  the  initial,  with  fever,  headache,  vomiting,  etc.  ;  thelcUent, 
with  milder  discomfort  :  the  manifest)  with  the  lull  development  of  a  severe 

'  Arch,  of  Otol.,  sxiv.  p.  121.  '-'  Tram.  Amer.  OtoL  Soc,  IV-'. 


•  aries  of  the  tympanic  roof,  with  uli 
through  tin-  dnra,  communicating  with  a  large  abscess 
in  the  overlying  temporal  ]"!><■.  emptying  through  the 
tympanum  just  before  death 


INFLAMMATION  OF  THE  MENINGES.  763 

brain  disease ;  and  the  terminal,  with  exhaustion  and  coma,  or  sudden  ap- 
pearance  of  the  fatal  phenomena  from  perforation  into  the  ventricular  or 
arachnoid  cavities. 

According  to  v.  Bergmann  '  three  groups  of  symptoms  may  be  < I i r~t i 1 1 — 
guished — viz.  : 

1.  General  Symptoms. — Weakness,  loss  of  appetite,  foul  tongue,  pale  or 
yellow  color  as  in  all  grave  disease-  ;   fever  moderate  or  absent. 

"_'.  ( 'erebral  and  pressure  symptoms,  generally  more  pronounced  in  cerebel- 
lar than  in  cerebral  abscess. 

Headache  is  the  earliest,  most  conspicuous,  and  most  constant  symptom. 
It  is  usually  in  the  neighborhood  of  the  abscess,  but  not  infrequently  in  other 
regions,  particularly  the  occiput  and  forehead  and  all  over  the  head. 

Tenderness  on  percussion  is  frequently  but  by  uo  means  generally  present. 
Macewen's  symptom,  that  one  ear  applied  to  the  vertex  of  the  patient  hears 
the  percussion-sound  stronger  from  the  diseased  than  from  the  healthy  side, 
is,  as  far  as  my  experience  goes,  unreliable.  Nausea  and  vomiting  arc  almosi 
always  present,  but  not  characteristic.  Dizziness  <m<l  disturbance  of  equilib- 
rium are  frequent. 

Disturbance  of  the  functions  of  the  brain  is  a  frequent  and  marked  symp- 
tom. Slow  comprehension,  apathy,  incoherence  of  ideas,  weakness  of  memory  : 
at  night  frequently  great  mental  excitement,  crying,  restlessness,  delirium, 
alternating  with  drowsiness,  optic  neuritis,  earlier  and  more  pronounced  od 
the  diseased  side;  convulsions;  elevation  of  temperature,  moderate,  usually 
with  evening  exacerbations  ;  pulse  slow  ;  respiration  regular. 

3.  Localizing  Symptoms. — Deafness  in  the  non-suppurating  ear  has  been 
observed  several  time-,  and  is  explained  by  the  fact  that  the  auditory  center 
of  the  right  ear  is  situated  in  the  temporal  lobe  of  the  left  side,  and  >■]<■,  versd. 
Word-deafness — mental  or  sensory  deafness — i.  e.  the  patient  hears  the  word 
but  does  not  understand  it.  Amnesic  aphasia,  agraphia,  anarythmia  are  rare, 
and  motor  aphasia  has  not  yet  been  noticed  in  uncomplicated  brain-abscess. 
Word-blindness,  dyslexia  (Berlin),  letter-blindness,  and  "word-"  without  "let- 
ter-" blindness,2  condition-  in  which  with  normal  vision  the  patient-  cannot 
understand  written  or  printed  language,  arc  referred  to  the  visual  memory 
center  situated  in  the  angular  and  supramarginal  gyri  on  the  left  side  of 
the  brain. 

Crossed  paresis,  crossed  clonic  and  tonic  spasms,  and  convulsions,  crossed 
facial  paresis  and  crossed  hemianesthesia,  all  due  to  a  lesion  of  the  internal 
capsule,  arc  occasionally  met  with. 

homonymous  hemianopsia  has  been  recorded  seven  times.  It  would  proba- 
bly have  been  found  oftener  had  it  regularly  been  sought  after.  In  a  caseof 
abscess  of  the  temporo-sphenoidal  lobe  operated  on  by  the  author.  December 
1  1,  1893,  it  was  one  of  the  determining  symptoms.'  The  abscess  was  found 
at  the  first  exploratory  puncture  and  the  patient  i-  now  perfectly  well,  but 
the  homonymous  hemianopsia  is  permanent.  This  symptom  is  produced 
by  a  destruction  of  the  optic  tract,  somewhere  along  the  optic  radiation  be- 
tween the  region  around  the  calcarine  fissure  and  the  optic  chiasm.  In 
bra!  abscess  it  refers  chiefly  to  the  optic  radiation  in  its  subcortical  passage 
through  the  temporo-sphenoidal   lobe. 

Cerebellar  ataxia  and  vertigo  arc  due  to  lesions  of  the  worm. 

1  Die  ehirurgisehi  Behandlung  <l-r  EfirnkranlcheUen,  2d  edition,  p.  40, 
See  a  case  reported  by  J.  Hinschelwood,  Lancet,  Feb.  12,  1898,  ai  iptical  Apha- 

sia, a  symptom  of  spbeno-temporal  abscess  cured  by  operation,  described  by  P.  Mana 
„/  Old.,  \|.ril,  1-    -  'Arch.  ofOl  I,  vol.  xxiii.  p.  156,  1894 


764  COMPLICATIONS  OF  TYMPANIC  INFLAMMATION. 

Opisthotonos,  partial  or  total  paralysis  of  the  motor  communis  oculi  and 
the  abducens  nerves,  conjugated  deviation  of  the  eyes  in  some  cases  toward 
the  affected,  in  others  toward  the  unaffected,  side,  and  nystagmus,  are  rare  and 
indefinite  symptoms. 

Differential  Diagnosis  of  Purulent  Mastoiditis  and  its  Differ- 
ent Intracranial  Complications. — In  children  it  is  often  difficult  to 
ascertain  whether  the  mastoid  is  diseased  alone  or  together  with  the  intra- 
cranial structures.  Meningeal  irritation  caused  by  congestion  and  edema  is 
not  rare,  but  difficult  to  distinguish  from  infective  intracranial  inflammation. 
The  course  will  show  ;  and  if  on  account  of  the  persistence  of  alarming 
symptoms  an  operation  is  decided  on,  the  conditions  exposed  by  the  chisel 
will  lead,  to  the  diagnosis. 

In  children  and  adults  the  most  important  helps  in  the  diagnosis  are  the 
kind  and  seat  of  the  original  (ear)  affection.  Here  also  an  exploratory  opera- 
tion will  frequently  be  the  decisive  step.  The  diseases  in  the  middle  cranial 
fossa  are  induced  by  disease  of  the  tegmen  tympani  and  tegmen  tubce.  (The 
author  has  seen  purulent  meningitis  of  the  anterior  and  middle  lobes  imi- 
tating a  brain-abscess  from  attic  suppuration  with  extension  to  the  pharynx 
l>y  way  of  the  semicanal  of  the  tensor  tympani  muscle.)  Disease  of  the  cere- 
bellum is  produced  chiefly  by  mastoid  suppuration,  rarely  by  disease  of  the 
petrous  bone,  in  which  case  the  infection  is  carried  through  the  labyrinth 
and  inner  auditory  meatus  into  the  cerebellum.  The  latter  variety  can  be 
recognized  by  the  total  deafness  it  produces  in  the  affected  ear. 

The  diagnosis  is  difficult  if  tuberculosis,  nephritis,  diabetes,  etc.  arc  com- 
plicated with  chronic  otorrhea.  The  author,  in  a  case  of  supposed  brain- 
abscess,  decided  to  open  the  skull,  hut  desisted  when  he  found  that  the  inner 
table  of  the  mastoid  was  healthy.  The  patient  died  of  tuberculous  menin- 
gitis (autopsy). 

If  cerebral  disease  exists  together  with  suppuration  in  h<>tl\  ears,  it  maybe 
difficult  to  ascertain  in  which  hemisphere  the  brain  lesion  is.  Local  pain, 
tenderness  on  percussion,  and  other  local  symptoms  such  as  edema  and  redness 
over  mastoid,  etc.,  may  help  in  making  the  diagnosis. 

A  cerebral  tumor  may  coexist  with  purulent  otitis  media.  The  diagnosis 
will  usually  he  possible.  The  tumor  has  a  slow  development,  no  fever,  no 
rigors,  almost    always  optic   neuritis,  and   constant   headache. 

The  diagnosis  between  abscess  <in<!  menmgitis  is  made  by  the  high  tem- 
perature and  acceleration  of  the  pulse,  without  remissions, and  the  irritability, 
general  excitement,  restlessness,  and  hyperesthesia  of  the  organs  of  sense  in 
meningitis,  contrasted  with  the  slow  cerebration,  apathy,  and  drowsiness  in 
abscess.  Slow  pulse  with  meningitic  temperature,  etc.,  may  indicate  coexist- 
ent abscess  I  Randall  |. 

Infective  sinus  thrombosis  is  characterized  by  mental  depression,  rigors, 
constipation,    anorexia,   apathy,   and    the   steep-peaked    pulse   chart. 

Two,  three,  or  all  the  intracranial  complications  may  be  present    in  the 

-aine  patient.  The  writer  ha-  had  under  observation  a  patient  in  whom  the 
autopsy  showed  mastoid  empyema,  perforation  of  the  lower  mastoid  wall 
and  extension  of  the  pus  down  the  neck,  epidural  abscess  in  middle  and  pos- 
terior cranial  fossa?,  septic  thrombosis  of  all  the  sinuses  of  both  internal  jugular 
anil   mosl  of  the  cerebral  veins,  an  abscess  in   the  teraporo-sphenoidal  lobe, 

another    in    the    cerebellum,   and    to    render    the    morbid    collection    complete, 

diffuse  purulent   meningitis.1 

1  Described  in  Arch.  •>/  Otology,  vol.  \\i   |>   239. 


DISEASES  OF  THE  SOUND-PERCEIVING  APPARATUS. 

By  HENRY  A.  ALDERTOK,  M.  D., 

OF     BROOKLYN,   N.   V. 


The  sound-perceiving  apparatus  consists  of  all  those  portions  of  the 
acoustic  nerve-apparatus  central  to  the  peripheral  nerve-cells  in  the  laby- 
rinth, but  is  usually  considered  to  include  all  of  the  labyrinthine  structures. 
About  10  per  cent,  of  all  aural  cases  show  evidences  of  pathological  changes 
in  some  part  of  this  apparatus,  or  of  functional  disturbances  of  the  same  ; 
some  authors  (Biirkner,  Randall)  make  this  percentage  rather  less.  Middle 
age  is  the  period  of  life  relatively  most  free  from  such  alterations. 

Morphology. — Complete  absence  of  the  labyrinth  (Michel,  Schwartze) 
or  of  the  auditory  nerve  (Michel)  may  exist  congenitally,  or  there  may  he  an 


,^s 


Fig.  510.— Section  of  normal  C'orti's  organ:  .V,  basilar  membrane;  3ft,  tectorial  membrane ; N,  fibers 
of  cochleal  nerve  ;  0,  osseous  spiral  lamina;  J\  pillars  of  Corti ;  1),  Deiters's  cells  ;  II,  hair  cells. 


arrest  of  development  in  these  parts  producing  corresponding  deformities. 
Arrested  labyrinthine  development  rarely  occurs;  but  when  it  does,  the 
cochlea  is  the  part  most  frequently  affected  (IT.  Mygiud).  Malformation  of 
the  osseous  labyrinth  has  heretofore  been  found  mosl  frequently,  bill  it  is 
probably  true  that  with  further  observations  the  membranous  labyrinth 
(Figs.  510,  511)  will  be  found  to  be  the  part  mosi  commonly  malformed; 
in  fact,  it  is  possible  for  the  arrest  in  development  to  be  confined  t"  it 
(A.  Scheibe).  The  malformations,  when  congenital,  are  usually  the  same  on 
both  sides  (Michel  and  Claudius),  and   mayor  may  not   be  associated   with 

similar  changes  in  the  s< l-conducting  apparatus.     Should  these  defects  be 

slight  in  character,  the  hearing  ability  may  be  very  little,  if  at  all.  impaired, 

765 


760      DISEASES  OF  THE  SO  VXD- PERCEIVING  APPARATUS. 

as  in  a  case  of  Voltolini's  ;  but  when  the  defects  are  more  extensive,  they 
arc  generally  combined  with  great  or  total  deafness  (A.  Politzer). 


Fig.  511.— Section  through  the  organ  of  Corti  of  a  deaf-mute,  showing  arrest  of  development  (Scheibe). 

Pathology. — Of  the  circulatory  disturbances  occurring  in  the  laby- 
rinth, oligemia  or  anemia,  if  of  limited  duration,  produces  very  little,  if  any, 
alteration  in  the  anatomy  of  the  part.  It  is  possible  that  prolonged  oligemia 
or  anemia  may  give  rise  to  degenerative  changes  (A.  Politzer).  Hyperemia 
of  moderate  intensity  and  duration  is  not  likely  to  induce  anatomical  altera- 
tions, but,  if  long  continued,  may  lead  to  increased  pigmentary  deposits  (a 
moderate  quantity  of  which,  however,  may  be  considered  as  not  abnormal), 
to  deposit  of  calcareous  salts,  to  hypertrophy  of  the  membranous  labyrinth, 
to  dilatation  of  the  vascular  structures,  to  serous  saturation.  Tf  of  great 
intensity,  hyperemia  may  cause  rupture  of  the  vascular  walls  with  consec- 
utive hemorrhage4.  Hemorrhages  and 
ecchymoses  (Fig.  ol2)  may  occur  in  any 
part  of  the  labyrinth,  and  there  may 
have  been  no  pre-existing  hyperemia. 
Hemorrhagic  extravasation  may  either 
be  completely  absorbed,  become  organ- 
ized, undergo  fibrous  or  calcareous  degen- 
eration, may  cause  atrophy  and  degenera- 
tion of  the  epithelium,  connective  tissue, 
and  nerve  elements,  with  an  abundant 
formation  of  granular  cells,  hyaline  cor- 
puscles, and  pigmentary  deposits,  or  may 
induce  inflammatory  changes  terminating 
in  suppuration.  Ehnboli  may  lodge  in 
the  labyrinth,  as  in  Friedreich's  case  of 
embolus  of  the  arteria  auditiva  interna, 
or  infectious  thrombi   may  form. 

I n  regard  to  the  inflammatory  changes 
taking  place  in  the  labyrinth,  the  w  liter 
i-  inclined  to  believe  thai  a  classification 
according  to  the  ideas  expressed  by 
Gruber  is  most  reasonable  and  scientific, 
and  wmild  do  much  to  dissipate  the  confusion  now  existing  in  most  text- 
book- ..n  the  subjeel  of  diseases  of  the  internal  ear.  The  inflammations 
affecting  the  labyrinth  are,  therefore,  <liri,h,l  into:  (  I  |  hyperplastic  {labyrinthitis 
hypefrploLsticd)  and  (2)  exudative  (labyinnthitis  exudativa).  In  the  former  we 
may  have  hypertrophy  of  the  auditory  nerve  stem,  due  to  infiltration  and 
proliferation  of  the  neurilemma  t  Politzer) ;  deposits  of  calcareous  salts  or  of 


l  id.  512.     Hemorrhage  Into  the 

ciilur  canal  (Polit  Ion  of  1 1"  o la 

semicircular  canal  ;  >>,  ted  blood ;  c, 
membranous  canal. 


PATHOLOGY.  707 

amyloid  bodies  in  and  about  the  nerve;  hyperostosis  of  the  petrous  bone 
narrowing  the  labyrinthine  cavities  ,  thickening  of  the  periosteum  ;  increased 
quantity  of  the  perilymph  and  endolymph  (Steinbrugge)  ;  infiltration   with 

small  cells  and  hyperplasia  of  the  connective  tissue  between  the  membranous 
and  osseous  labyrinth  (Moos);  a  similar  condition  affecting  the  membranous 
labyrinth  (Moos) ;  development  of  osseous  tissuefrom  chronic  inflammation 
of  the  labyrinthine  periosteum  ;  excessive  epithelial  growth  on  the  inner  side 
of  the  membranous  labyrinth  in  chronic  inflammation  (Politzer);  chronic 
endarteritis;  depositions  of  concretions  of  phosphate  of  lime  and  of  corpora 
amylacea  within  the  labyrinth.  ///  the  exudative  form  of  info  munition  we 
have  intense  hyperemia  which  may  produce  a  serous  saturation  of  the  struct- 
ures of  the  labyrinth;  an  infiltration  with  small  lymphoid  cells  (Moos)  or 
round  cells  (Schwabach) ;  a  hemorrhagic  exudation,  as  from  a  pachymen- 
ingitis haemorrhagica  (Moos);  a  purulent  inflammation,  due  either  to  the 
direct  propagation  of  pus  from  neighboring  structures,  or  by  way  of  the 
blood-vessels  or  by  the  lymph-spaces  (Politzer),  or  by  dehiscences  in  the 
bony  wall  between  the  superior  semicircular  canal  and  the  cerebral  cavity 
(J.  Dunn),  or  to  infection  by  the  immigration  of  micro-organisms  (Stein- 
briigge). 

These  inflammatory  processes  produce  various  alterations  of  the  ana- 
tomical elements  of  the  labyrinth:  the  effect  of  the  invasion  by  micro- 
organisms is  manifested  by  a  mycotic  fatty  degeneration  of  the  endothelium 
of  the  blood-vessels,  causing  coagulation  and  thrombosis  and  colloid  de- 
generation of  the  labyrinthine  tissues  (Moos);  injury  of  the  acoustic  nerve 
apparatus  by  hemorrhages  or  mycotic  degeneration — the  axis  cylinders  re- 
sisting longest  (Moo-)  ;  stasis  and  thrombosis  of  the  periosteal  blood-vessels 
(Steinbrugge);  rapid  destruction  of  the  connective-tissue  elements;  destruc- 
tion of  the  osseous  tissue  through  entrance  of  the  micro-organisms  into  the 
periosteum,  the  bone-corpuscles,  and  the  blood-vessels  of  the  Haversian 
canals.  In  addition,  the  poisonous  products  of  metabolism,  the  toxalbumins, 
probably  play  an  important  part  (Moos).  The  micro-organisms  (strepto- 
coccus,  staphylococcus  and  Frankel's  diplococcus  of  pneumonia  (Schwabach) 
gain  entrance  to  the  labyrinth  through  the  aqueducts,  the  periosteal  blood- 
vessels and,  probably,  also  along  the  sheath  of  the  auditory  nerve,  a-  d< >es  the 
pus.  In  the  beginning,  the  perilymphatic  cavity  i-  almost  exclusively  the 
seat  of  the  disease,  which  later  extends  to  the  endolymphatic  cavity  (Haber- 
raann).  The  micro-organi-m-  seem  to  collect  and  to  develop  their  greatest 
working  power  in  the  most  dependent  parts  of  the  labyrinth  (Habermann). 
The  inferior  portions  of  the  cochlea  are,  therefore,  mosl  affected  (Politzer); 
Steinbrugge,  however,  thinks  the  proneness  to  location  in  tin-  region  is  rather 
due  to  the  propagation  of  the  affection  from  the  cranial  cavity. 

A-  a  result  of  the  inflammation  of  the  labyrinth,  the  nerve  liber-,  cells, 
and  ganglia  (see  Figs.  51  1,  519)  are  destroyed  or  atrophied  from  pressure, 
their  place  being  taken  by  newly  formed  connective  tissue,  or  left  vacant, 
thus  forming  a  system  of  lacunae  corresponding  in  arrangement  to  the  normal 
nerve  distribution  of  the  part  *  Moo-.  Scheibe,  Steinbrugge)  ;  the  membranous 
labyrinth  maybe  totally  destroyed,  likewise  the  structures  of  the  labyrin- 
thine window-,  with  displacement  of  the  stapes  (Habermann);  coagulation 
necrosis  of  the  labyrinthine  ligaments  may  be  produced,  with  consequent 
collapse  of  the  membranous  semicircular  canals  Moos);  the  osseous  capsule 
may  be  more  or  less  destroyed.  If  the  quantity  or  virulence  of  the  infection 
!»■  great,  there  may  be  absence  of  all  tendency  to  reactive  inflammation  and 
the  production  of  new  formation-  (Moo-). 


768      DISEASES  OF  THE  SOUND-PERCEIVING  APPARATUS. 

Should  reactive  inflammation  be  established,  it  results  in  the  production 
of  newly   formed   granulation-  (Habermann)  (Fig.    513),  connective  (Moos, 


Fig.  513. —Section  of  semicircular  canal  of  a  buy  dead  from  cerebro-spinal  meningitis  of  seven  weeks' 
duration  (Habermann).  Canal  is  filled  with  granulation-tissue  (d),  and  in  its  periphery  (c)  the  bone  (a)  is 
eroded. 

Scheibe),  fibrous  (Gradenigo),  or  osseous  (Toynbee)  tissue;  these  new  forma- 
tions at  times  going  so  far  as  to  produce  complete  obliteration  (Fig.  514) 


u  Section  throngb  tbi  cochlea  of  a  deaf-mute  (Politzer) :  <',  intact  capsule;  b,  cavity  of 
cochlea  entirely  rilled  with  newly  formed  osseous  tissue;  c,  auditory  nerve,  whose  fibers  continue  only  a 
short  distance  Into  the  newly  formed  osseous  mass  i  d,  vestibule,  narrowed  by  the  hyperplastic  process  to  a 
small  angulai  space  lined  uith  roundish  epithelial  cells 

of  the  labyrinthine  cavities  (Politzer),  of  the  foramina  cribrosa,  of  the  aque- 
ducts (Scheibe),  and  of  the  oval  and  round  windows  (Toynbee).     Ossification 


AcorsTic  x /•:/,'  i  v:. 


709 


proceeds  from   the  remnants  of  periosteum  (  Fig.  515)  and  from  the  newly 
formed  connective  and   fibrous  tissues. 

Acoustic  Nerve. — Among  the  pathological  alterations  of  the  acoustic 
nerve  apparatus  we  will  first  take  up  changes  in  the  stem  of  the  auditory 
nerve.  Hyperemia  and  ecchymosis  may  exist  (Politzer);  deposition  of 
corpora  amylacea  or  concretions  of  phosphate  of  lime ;   fatty  degeneration 


Fig.  515.— Sections  of  the  semicircular  canals  of  a  boy  dead  of  hydrocephalus  interims  (Steinbrugge). 
The  canals  are  filled  with  connective  and  osseous  tissue.  The  ossification  is  more  advanced  on  the  right 
at  (a),  beginning  from  detached  periosteum. 

(Politzer) ;  gray  degeneration  (Wernicke) ;  atrophy  ;  leukemic  small-celled 
infiltration  (Alt) ;  purulent  infiltration  (Heller) ;  embedding  of  the  nerve  in 
meningeal  exudation  (Schwartze).  Tumors,  principally  sarcoma,  fibroma, 
and  so-called  neuroma,  may  invade  the  internal  auditory  canal  (  Fig.  516), 
exerting  pressure  with  consecutive  atrophy  or  even  solution  of  continuity 
(Politzer).     The  auditory  nerve  is  more  frequently  the  seat  of  morbid  growths 


:■'/■, l- $nr 


Jam 


Via.  516.— Spindle-celled  sarcoma  of  the  auditory  nerve  (Politzer) :  0,  tympanic  cavity  with  malleus 

and  incus;  V,  vestibule  ;  ''.cochlea;  T,  tumor  of  the  acoustic  nerve  ;  .V,  itsexteiision  into  the  auditory 
meatus. 

than  any  other  cerebral  nerve  (Virehow).  The  changes  must  likely  to  occur 
in  the  region  of  the  acoustic  nerve  origin  in  the  medulla  arc  due  to  thicken- 
ing and  purulent  inflammation  of  the  ependyma  of  the  fourth  ventricle  and 
softening  of  the  flour  (Knapp);  effusion  into  the  fourth  ventricle,  either 
serous  (Stuart),  aqueous  (Jackson),  sero-purulenl  (Armstrong  and  Clarke),  or 

49 


770      DISEASES  OF  THE  SOUND-PERCEIVING  APPARATUS. 

purulent   (Ames);  tumors  in  or  about   the   fourth  ventricle.      Disease  of  the 

first   and   s< ml   convolutions  of  the    left    temporal   lobe  also   interfere  with 

audition  (Wernicke),  the  cortical  center  for  hearing  probably  being  located  in 
this  region.  Of  course,  any  pathological  condition  along  the  course  of  the 
cerebral  acoustic  oerve-fibers  also  induces  disturbances  <>f  function.  1  ncreased 
intracranial  pressure  may  cause  secondarily  increased  labyrinthine  pressure 
with  depression  of  Reissner's  membrane  (Steinbrugge)  and  bulging  outward 
of  the  membrane  of  the  round  window  (Moos).  Many  cases,  however,  of 
increased  intracranial  pressure,  as  in  chronic  hydrocephalus,  show  no  such 
change  in  labyrinthine  pressure  nor  any  impairment  of  the  function  of  hear- 
ing ( Pomeroy). 

Htiology. — Anemia  or  oligemia  of  the  labyrinth  has  been  noted  in  con- 
nection with  general  anemia  (Miot  and  Herck),  with  continued  fevers  (Roosa), 
with  gestation  and  parturition  (Pomeroy),  with  aneurism  of  the  basilar  and 
atheroma  of  the  internal  auditory  artery  (Miot  and  Herck),  with  changes  in 
the  middle  ear  exerting  pressure  upon  the  labyrinthine  structures  through  the 
round  and  oval  window-  (Pomeroy). 

Hyperemia  of  the  labyrinth  occurs  in  all  conditions  producing  congestion 
of  the  head  (Hartmann) ;  in  conditions  exerting  pressure  on  the  venous  chan- 
nels of  the  brain  and  consequent  obstruction  to  the  return  flow  of  blood  from 
the  ear  (Politzer),  on  the  vessels  of  the  internal  auditory  canal  (Politzer),  or 
exerting  pressure  on  the  large  veins  of  the  neck  (Schwartze) ;  in  disturbances 
of  the  circulation  originating  in  the  heart,  lungs  (Schwartze),  or  kidneys;  in 
prolonged  exposure  to  sharp  sounds  (Roosa) ;  in  the  gouty  or  rheumatic  diath- 
esis. Any  hyperemia  of  the  labyrinth  occurring  in  connection  with  inflam- 
mation of  the  external  or  middle  ear  musl  certainly  be  considered,  since  Eich- 
ler's  recent  anatomical  confirmation  of  Schwartze's  clinical  observations,  as 
the  result  of  a  reflex  action  through  the  sympathetic  upon  the  vaso-motor 
nervous  system  of  the  labyrinth,  rather  than  a  direct  influence  through  anasto- 
moses. Kidder  found  that  the  vascular  supply  of  the  labyrinth  was  entirely 
distinct  from  that  of  the  surrounding  tissues,  and  that  the  connection  between 
the  vessels  of  the  tympanum  and  those  of  the  labyrinth,  which  Politzer  main- 
tain-, does  not  exist.  Schwartze  had  long  ago  held  that  even  in  the  very 
highest  degrees  of  inflammation  of  the  tympanum  it  is  only  exceptionally 
thai  a  simultaneous  hyperemia  is  met  with  in  the  labyrinth.  It  is  a  matter 
of  observation  that  in  chronic  middle-ear  suppuration  with  granulomata  and 
polypi  the  functional  tests  show  no  impairment  of  function  of  any  importance 
in  the  sound-perceiving  apparatus. 

Hemorrhages  and  ecchymoses  arc  prone  to  happen  in  all  conditions  pro- 
ducing hyperemia  of  the  labyrinthine  structures;  in  the  infectious  diseases 
causing  changes  in  the  vascular  walls  ;  in  pachymeningitis  hemorrhagica 
(Moo-);  in  leukemia  (Steinbrugge);  in  typhoid  fever  (Barclay)  ;  in  nephritis, 
gout,  and  rheumatism  ;  in  fracture  or  concussion  of  the  skull  ;  in  diabetes  ; 
sometimes  in  embolism  of  the  arteria  auditiva  interna  (Gruber). 

Atrophy  and  degeneration  of  the  acoustic  nerve  apparatus  maybecaused 
by  syphilis;  by  any  labyrinthine  inflammation  of  sufficient  gravity  to  inter- 
fere with  nutrition  ;  by  changes  in  chronic  otitis  media  exerting  long-con- 
tinued    pressure the     labyrinth    and    thus    producing    anemia,    which,    if 

continued  for  a  sufficienl  time,  will  result  in  nutritive  changes  of  the  nature 
of  atrophy  (Pomeroy)  and  the-,,  secondary  nerve  affections  may  remain 
although  the  tympanic  disease  disappears  (Gruber) ;  by  acute  hydrocephalus 
internus,  leading  to  softening  and  shrivelling  of  the  nuclei  of  the  auditory 
nerve  (  Politzer) ;  by  fetal  ependymitis  (Meyer)  doing  the  same;  in  chronic 


i:\rn.\ri\i:  lxii.ammaiio.x.  771 

hydrocephalus,  tumors  of  the  brain  and  the  nerve  from  pressure  (Politzer); 
gray  degeneration  and  atrophy  in  t;il>es  dorsalis  (Pierrot,  Wernicke,  Haber- 
inann)  ;  in  old  age  by  calcareous  deposits  (Bottcher)  and  corpora  amylacea 
(Pulitzer);  by  hemorrhage  ;  by  nephritis  and  influenza  (Gradenigo)  ;  by  con- 
traction of  the  basilar  artery  (  Politzer);  by  apoplectic  and  inflammatory  proc- 
esses involving;  the  Moor  of  the  fourth  ventricle  (Politzer);  by  professional 
concussion  of  sound  (Roosa);  by  purulent  inflammation  of*  the  ependyma 
(Politzer);  by  purulent  inflammation  of  the  stein  of  the  auditory  nerve  from 
a  similar  condition  of  the  meninges  (Politzer);  by  emboli  and  embolic  soften- 
ing along  the  acoustic  nerve  tracts  (Politzer).  Among  the  nerves  of  sense, 
the  auditory  is  the  most  "impressionable" — that  i>,  its  function  i-  more  fre- 
quently impaired  by  general  diseases  and  by  chemical  changes  in  the  blood 
in  infectious  diseases  (Politzer).  Affections  of  the  auditory  nerve  attack,  in 
the  majority  of  cases,  both  organs  of  hearing.  It  is  probable  that  degenerative 
processes  involving  one  auditory  nerve  will  in  time  pass  over  to  the  other, 
'flie  view  that  atrophy  of  the  auditory  nerve  can  take  place  purely  from  inac- 
tion, as  in  ankylosis  of  the  stapes,  has  not  yet  been  corroborated  by  experience 
(Politzer);  in  fact,  the  results  of  post-mortem  examination-  point  the  other 
way.  The  changes  which  occur  in  presbycusis  and  otitis  media  sclerosa  seem 
to  be  due  to  a  coincident  trophic  disturbance  similar  to  that  in  the  middle 
ear  rather  than  to  any  atrophy  from  disuse  (Alderton).  Central  atrophy 
depends  almost  without  exception  upon  cerebral  disease,  whilst  the  periph- 
eral is  most  often  a  consequence  of  disorders  of  the  auditory  organ  itself 
(Gruber).  The  occurrence  of  the  disturbances  of  hearing  in  these  processes 
depends  less  upon  the  extent  than  upon  the  seat  of  the  pathological  accu- 
mulation (Politzer). 

Hyperplastic  inflammation  (labyrinthitis  hyperplastica)  may  occur  in 
syphilis,  which  is  causative  in  most  of  the  forms  of  this  affection  ;  in  the 
first  stages  of  exudative  inflammation  of  the  labyrinth  due  to  infectious  dis- 
eases, and  the  inflammatory  process  may  advance  no  further  (Moos) ;  in  goul 
and  rheumatism;  in  rachitis;  in  typhoid  fever  and  leukemia  and  in  old  age. 


V 

\  ' .  -  •    .     •  ■ 

••■- 

Fir;.  517.— Section  of  the  basal  coil  of  the  cochlea,  from  a  deal  man  who  died  of  leuk 
osseous  growth  on  the  median  wall  of  the  scala  tympani ;  b,  leukocythemic  plaqu 
<■,  lamina  spiralis  ;  </,  connective  tissue  and  osseous  growth  in  the  scala  vestibuli    • .    tr  >pl 
cells  in  Rosenthal's  canal  (Politzer), 

Exudative    inflammation  (labyrinthitis  exudativa)    may    be  caused    by 
obstruction  in  the  internal  auditory  meatus  to  the  outflow  of  blood  from  the 


772      DISEASES  OF  THE  SOlWD-ri.ltcF.rVIXG  APPARATUS. 

labyrinth  (Politzer);  by  typhoid  fever  (Barclay) ;  leukemia  (see  Fig.  517) 
|  Politzer)  [epidemic  cerebro-spinal,  hemorrhagicj  pachy-  and  simple  meningitis 
(Heller,  Moos,  Politzer)  ;  syphilis,  tuberculosis, measles,  diphtheria,  scarlatina, 
scarlatina]  diphtheria,  mumps,  variola  ;  by  an  extension  from  an  otitis  media 
purulenta  of  long  standing  (Bezold).  This  form  of  inflammation  occurs  more 
frequently  in  children  than  in  adults,  because  of  the  more  frequent  occurrence 
in  children  of  the  acute  exanthemata,  etc.  Further,  the  anastomotic  connections 
between  the  middle  ear  and  the  labyrinth  on  the  one  hand,  and  between  the 
labyrinth  and  the  cranial  cavity  ou  the  other,  are  more  numerous  in  children 
than  in  adults;  and  further,  because  in  the  child's  ear  through  the  aqueducts 
there  is  a  freer  communication  between  the  labyrinthine  fluid  and  the  cerebro- 
spinal cavity  than  in  the  adult  (Politzer). 

Symptomatology. — Functional  Reactions  in  General. — Before  tak- 
ing up  the  departures  from  the  normal  reactions  to  functional  tests  in  diseases 
of  the  sound-perceiving  apparatus  it  is  necessary  to  devote  some  attention  to 
the  normal  decline  in  hearing  evidenced  in  advancing  age.  Zwaardemaker 
has  tabulated  the  average  responses  for  the  upper-tone  limit  at  the  different 
periods  of  life  about  as  follows: 

( ialton's  whistle  (see  Fig.  472)  is  heard  under  10  years  at  the  mark    ....  1.22 

"  "  is  heard  from  20  to  30       "         "         "        ...  1.39 

"        "      40  to  50      "        "        "        ....  2.23 

over  60       "         "         "        ....  3.03 

A  presbycusis  (hearing  of  old  age)  may,  however,  be  considered  as  normal 


Pig.  518.-  Section  "f  Rosenthal's  canal  and  the  spiral  ganglion  (normal),  showing    a,  ganglion  cells  in 
Rosenthal  -  canal ;  '>,  nerve-fibers  of  the  cochlear  branch  entering  into  the  ganglion  (Politzer). 


which  i-  not  lower  than  Galton  L8  (Zwaardemaker).  The  lower-tone  limit 
is  elevated  to  about  the  same  extenl  in  old  age  (N.  J.  Cuperus).  In  old  age 
tin  B.-C.  (bone-conduction) does  not  alone  experience  a  reduction,  but  sinks 
proportionately  with  tli^  lessening  of  the  hearing  distance,  the  A..-C.  (air- 
conduction  >,  etc.  (  Bezold). 


S  )  Ml '  TO  MA  TO  LOG  Y. 


773 


Tn  diseases  of  the  sound-perceiving  apparatus,  the  upper-tone  limit,  ob- 
tained by  means  of  the  Galton  whistle,  is  lowered — i.e.  the  highest  notes 
elieited  by  the  whistle  being  denoted  by  one  or  fractions  of  one,  and  the  lower 

notes  by  multiples  of  one  and  their  fractions;  as  the  obturator  is  withdrawn 
the  note  deepens  or  lowers  at  the  same  time  that  the  indicator  or  graduated 


?*?o.«>V 


Fig.  519.- Section  through  Rosenthal's  canal  of  a  boy  dead  of  acute  encephalitis,  who  became  sud- 
denly deaf  five  years  previously,  showing  marked  atrophy  of  nerve-cells  and  fibers  ;  a,  Rosenthal's  canal 
(Politzer). 


scale  shows  higher  and  higher  numbers,  and,  therefore,  a  higher  number  on 
the  scale,  as  4.8,  indicates  a  much  lower  note  than  a  lower  number,  as  1.'_'2. 
The  lower-tone  limit  by  A.-C.  (air-conduction),  as  obtained  by  a  clamped 
tuning-fork  vibrating  from  26  to  64  double  vibrations  in  the  second,  is  im- 
paired very  little  or  nut  at  oil.  The  absolute  duration  of  B.-C.  (bone-con- 
duction), Schwabach's  test,  is  shortened  or  abolished  for  all  or  for  certain  tones. 
A ,-C.~>B.-C.  (air-conduction  is  better  than  bone-conduction), both  in  intensity 
dint  in  duration  throughout  the  musical  scale,  Rhine's  test.  If  the  disease  is 
unilateral,  the  vibrating  tuning-fork  (',  placed  in  contact  with  the  vertex,  mid- 
way between  the  ears,  should  be  heard  in  the  unaffected  ear,  Weber's  test  ;  or 
in  the  better-hearing  ear  if  the  disease  is  bilateral.  This  test  is  not  so  reliable1 
as  those  previously  described.  In  labyrinthine  disease  the  patients  hear  the 
deeper  tones  <>j  speech  veri/  well,  while  the  higher  tones  are  no  longer  perc* 
(O.  Wolf).  It  is  well  in  testing  with  the  whisper  or  speech  to  remember  O. 
Wolf's  division  of  the  voice-sounds  into — 

1.  The  (!<•<•]).  like  R  and  V  ; 

2.  The  middle,  like  the  explosives  B,  1\.  and  T: 

3.  The  high  and  strong,  like  S,  Sh.  and  <J  ;  and  the  high  and  weak. 

like  F.   L,  X.  and   II  (which  are  excluded  as  dependent  on 
other  tone- — tone-borrowing). 

Wolf  devotes  particular  attention  to  the  consonants.  Bezold  employs 
the  names  of  numbers  a-  test-words,  as  these  are  familiar  to  both  children 
and  adults.     Equal  intensity  of  sound  can  be  obtained  by  using  the  reserve 


774     'DISEASES  OF  THE  SOUND-PERCEIVING  APPARATUS. 

air  lefl  after  a  forced  inspiration  followed  by  a  normal  expiration  (.1.  E. 
Sheppard).  To  test  the  hearing  for  speech  thoroughly,  it  is  quite  sufficienl 
in  most  cases,  after  testing  a  few  word-,  to  note  the  distance  for  those  words 
perceived  with  the  greatest  difficulty  (Lucae). 

Disturbances  of  equilibrium  are  apt  to  be  observed  in  any  process  jjrodiichu/ 
irritation  of  the  nerve-endings  in  tin  vestity.de,  the  semicircular  en  mils,  ,,r  in  the 
stem  'iml  origin  of  the  auditory  nerve.  In  testing  for  disturbances  of  equilib- 
rium, it  is  well  first  t<>  determine  the  static  (the  body  at  rest)  equilibrium  and 
then  the  dynamic  (the  body  in  motion)  equilibrium.  The  author  tests  the 
former  by  mean-  of  the  apparatus  shown  in  Plate  12,  consisting  essentially  of 
a  movable  inclined  plane,  after  the  method  of  v.  Stein.  A  person  with  nor- 
mal powers  of  equilibrium  should  be  able  to  maintain  his  erect  position  until 
the  hoard  reaches  an  inclination  of  35°  to  40°  to  the  horizontal  when  facing 
toward  the  apex  of  the  angle — anterior  inclination.  Posterior  inclination,  with 
the  back  turned  toward  the  apex,  varies  from  20°  to  30°;  lateral  inclination, 
with  the  side  toward  the  apex,  from  37°  to  38°.  In  patients  with  labyrinthine 
disease,  giving  rise  to  vertigo,  etc.,  the  angle  measures  20°  or  less  by  anterior 
inclination,  etc.,  and  this  i-  much  decreased  when  the  eyes  are  closed.  The 
static  equilibrium  is  also  tested  with  the  eves  open  and  shut,  with  the  legs 
close  together,  while  standing  on  the  toes,  and  while  standing  on  one  leg.  A 
healthy  person  can  stand  in  these  positions  for  some  time,  with  slight  balanc- 
ing, while  the  eyes  are  closed;  hut  a  person  with  imperfect  powers  of  equi- 
librium immediately  begins  to  show  disturbances  of  these  powers.  The 
dynamic  equilibrium  is  tested  by  walking  forward  and  backward  on  a  level, 
by  turning  on  the  vertical  axis  of  the  body  to  the  right  or  left  with  legs 
together,  and,  finally,  by  turning  about  on  one  leg  alone.  The  last  move- 
ment is  the  most  difficult,  but  a  healthy  person  can  go  through  these  various 
motions  with  little  if  any  trouble;  whereas  aural  patients  with  disturbance 
of  the  powers  of  equilibrium  find  it  more  or  less  difficult  or  impossible,  and 
their  movement-  are  attended   by  great  weariness. 

Given  these  reactions,  the  inference  is  well-founded  that  we  have  to  do 
with  an  affection  of  the  sound-perceiving  apparatus.  Still  other  tests  have 
been  devised  by  Bing,  Brenner,  Gradenigo,  Gelle,  and  others;  hut  the  above 
have  been  more  universally  tried,  are  sufficienl  for  the  purposes  of  diagnosis, 
and    are    more    reliable. 

flic  symptoms  of  affections  of  the  sound-perceiving  apparatus  are  more 
particularly  described  as  follow- : 

Anemia. — There  is  usually  some  dulness  of  hearing,  which  is  manifested 
either  as  a  Blowness  of  perception  only,  or  as  a  real  impairment  of  the  hear- 
in-   [lower.      The  impairment    in  the  hearing  ability  follows  along  the  line  of 

the  test-responses  as  given  above,  especially,  however,  being  noticeable  in  the 
curtailmenl  of  the  duration  of  B.-C.  Annoying  tinnitus  of  a  low  pitch  is 
commonly  present.  The  patient  may  he  subject  to  occasional  attacks  of 
vertigo,   ami    usually    is   the    victim    of  general    anemia. 

Hyperemia. — There  is  very  little  if  any  impairment  of  the  hearing 
power,  and  there  may  he  present  hyperesthesia  of  the  nerve  to  certain  sound-. 

<  >ften  there  is  :i  feeling  of  fulness  and  distention  in  tl ars  or  in  the  head, 

with  dulness  of  intellect  or  even  giddiness  or  vertigo  at  times.  With  this 
i-  usually  associated  ;i  high-pitched  tinnitus.  The  functional  tests  show  a 
limited  involvement  of  the  sound-perceiving  apparatus.  Paresthesia?  are 
likely  to  he  complained  of. 

Hemorrhage  is  usually  immediately  followed  by  marked  vertigo,  aggra- 
vated   on    closure   of  the    eyes,    with    possible    falling   or    unconsciousness  (the 


Plate  12. 


•-I 

— 

O"  ~ 

^ 

- 

c 

- 

EC    - 

pi 

J. 

CO 

re" 

9 

: 

— 

B 

—  - 

~ 

IS 

P8 

C. 

- 

S    P 

- 

c 

N»       »n  .9 


~ '  a 
2r 

3'  =  *  " 

0   _  ~  po 

§*2   0   e+ 

R  2 

11.0* 

2,2 

CO  -• 

5  —  o  "■ 

w    O 

';;  S  _ 


LABYRINTHITIS  EXUDATIVA.  775 

latter  is  rather  rare)  unless  the  hemorrhage  is  confined  to  the  cochlea,  in 
which  case  vertigo  is  absent  (Gradenigo).  With  or  immediately  following 
this  occur  nausea  or  vomiting,  severe  tinnitus  (in  some  cases  preceding  the 
attack),  occasionally  profuse  perspiration,  and  impairment  of  the  hearing  up 
to  complete  deafness.  The  symptoms  thus  given  constitute  whal  was 
formerly  generally  designated  as  Meniere's  disease,  and  is  the  only  condition 
to  which  that  name  should  be  given.  Amelioration  of  these  symptoms  takes 
place  in  a  short  time,  the  vertigo,  hardness  of  hearing,  and  tinnitus  continu- 
ing longest.  The  hardness  of  hearing  rarely  disappears  entirely,  and  the  tin- 
nitus is  likely  to  persist,  although  diminished  in  intensity.  There  is  always 
danger  of  a  repetition  of  the  hemorrhage.  The  functional  tests  give  varying 
responses  according  to  the  locality  and  the  extent  of  the  hemorrhage,  bul 
always  confirm  a  diagnosis  of  involvement  of  the  sound-perceiving  apparatus. 

The  symptoms  of  embolism  and  thrombosis  are  presumably  similar  to 
those  of  hemorrhage,  and  serous  effusion  can  give  the  same  more  fleetingly 
(Gruber). 

Labyrinthitis  Hyperplastica. — The  most  marked  form  of  this  inflamma- 
tion is  seen  in  connection  with  syphilis,  usually  as  a  late  manifestation  in  the 
acquired,  or  around  puberty  in  the  hereditary,  and  gives  rise  to  deafness, 
appearing  gradually  or  suddenly,  subject  to  periods  of  quiescence  and 
exacerbation;  also  to  loud  aural  tinnitus.  Vertiginous  attacks  and  disturb- 
ances of  equilibrium  are  usually  slight  unless  the  exudative  form  of  inflam- 
mation is  induced.  It  is  likely  to  be  accompanied  by  very  violent  headache 
(Charazac),  often  nocturnal  (Pomeroy)  when  due  to  syphilis.  Both  ears  are 
usually  affected.  The  sudden  deafness  coming  on  with  serous  saturation  or 
lymphoid  infiltration  may  disappear  almost  completely;  but  usually  the 
hyperplastic  formations  are  causative  of  a  certain  amount  of  permanent 
deafness.  The  functional  tests  leave  no  doubt  as  to  the  seat  of  the  trouble 
in  the  sound-perceiving  apparatus. 

Labyrinthitis  exudativa  in  its  most  acute  form  comes  on  very  suddenly 
with  perhaps  a  rigor;  with  fever,  nausea,  or  vomiting  very  commonly  ;  with 
profound  deafness,  marked  derangement  of  co-ordination  ;  at  times,  stupor  or 
delirium  (although  usually  the  mind  is  clear)  ;  intense  tinnitus  and  vertigo, 
and,  in  some  cases,  pain.  This  very  acute  form  occurs  with  epidemic  cerebro- 
spinal meningitis  (Voltolini  described  this  form  of  inflammation  as  a  primary 
inflammation,  but  there  is  not  much  doubt  that  it  i>  an  affection  secondary  to  a 
more  or  less  localized  meningitis),  with  the  acute  infectious  diseases  (measles, 
scarlet  fever,  diphtheria,  etc.)  m  epidemic  parotitis,  etc.  Most  of  the  symp- 
toms abate  or  disappear  in  a  few  days  to  a  few  week-,  but  the  staggering  gail 
and  deafness  are  more  persistent — the  latter  rarely  improving  to  any  greal 
extent.  Functionally,  the  upper-tone  limit  is  greatly  lowered ;  B.-C.  mark- 
edly reduced  throughout  or  destroyed  for  part  or  ail  of  the  musical  scale; 
A .-<  \  I J.-C  \  ;  the  |io\\cr  of  equilibrium  much  impaired.  The  less  acute 
forms  of  exudative  inflammation  of  the  labyrinth  give  rise  to  vertigo  (unless 
confined  to  the  cochlea),  to  sudden  loss  of  hearing  power,  intense  tinnitus, 
lowering  of  the  upper-tone  limit,  with  B.-C.  reduced  or  absent,  A. -<  B.-C, 
and  to  disturbances  of  equilibrium. 

In  affection  of  the  nerve-trunk  the  most  prominenl  symptom  is  impair- 
ment of  hearing.  There  are  also  presenl  tinnitus,  vertigo,  staggering  wit, 
and  excessive  functional  exhaustibility  (Gradenigo).  I  idly  unilateral,  u 
may  be  bilateral,  as  in  tabes  dorsalis.  Hardness  of  hearing  is  usuallv  most 
pronounced  for  the  tuning-forks  of  middle  register  (Gradenigo),  perception  for 
high  and  low  notes  being  fairly  well  preserved.     B.-C.  is  very  much  impaired. 


776      DISEASES  OE  THE  80UND-PEBCEIVINQ  APPARATUS. 

Word-deafness  (sensory  aphasia)  furnishes  the  most  reliable  sign  of 
involvement  of  the  cortical  area,  usually  of  the  left  first  temporal  convolu- 
tion. The  function  of  both  ears  is  usually  impaired  ;  tinnitus  is  more  com- 
monly absent  ;   B.-C.  is  reduced  in  duration  (see  page  779). 

Concussion  of  the  bead  may  provoke  symptoms  indicating  an  involve- 
ment of  the  sound-perceiving  apparatus  even  up  to  complete  deafness,  and 
ibis  latter  maybe  induced  without  any  recognizable  changes  being  necessarily 
found  in  the  labyrinth  on  post-mortem  examination  (Gruber).  The  symp- 
toms usually  present  arc  diminution  of  hearing,  tinnitus,  vertigo,  headache, 
unconsciousness,  pain  occasionally,  occasionally  acoustic  hyperesthesia  or 
alteration  in  pitch  of  certain  tones,  etc.,  one  or  all.  These  symptoms  have 
been  explained  as  due  to  shock  to  the  acoustic  nerve  (Buck),  basilar  inflam- 
mation resulting  from  a  blow  (Buck),  or  hemorrhage  at  the  point  of  origin 
of  the  acoustic  nerve  (Moos). 

Fractures  of  the  petrous  bone,  involving  the  labyrinth,  are  accompanied 
by  hemorrhage  from  the  meatus,  or  if  the  tympanic  membrane  is  not  rupt- 
ured, the  blood  may  pass  through  the  tympanum  and  the  Eustachian  tube 
into  the  throat  (Buck);  serous-looking  discharge  in  considerable  quantity ; 
very  pronounced  subjective  noises  ;  disturbances  of  equilibrium  and  vertigi- 
nous symptoms  :  facial  paralysis  in  55  per  cent,  of  the  cases  (Schmidt).  In 
both  concussion  and  fracture  the  functional  tests  of  involvement  of  the 
sound-perceiving  apparatus  are  present. 

Neurotic  disturbances  of  the  sound-perceiving  apparatus,  which  may  be 
unassociated  with  pathological  anatomical  alterations,  arc  by  no  means  uncom- 
mon, and  are  described  below. 

Acoustic  neurasthenia  lias  as  symptoms  impairment  of  hearing,  vary- 
ing from  mere  slowness  (acoustic  torpor  or  lassitude)  to  considerable  deafness, 
especially  marked  under  any  prolonged  strain  or  confusion  of  sound,  mental 
anxiety,  or  extreme  physical  fatigue  (Poli),  and  improving  rapidly  after  rest. 
Tinnitus  may  or  may  not  be  present,  and  is  increased  by  fatigue;  paresthesia; 
are  common,  witb  great  fluctuation  of  the  ability  to  bear;  the  upper-tone 
limit  is  not  apt  to  lie  impaired;  but  the  duration  of  B.-C  is  lowered 
throughout  the  musical  scale,  and  there  is  great  functional  exhaustibility  of 
the  aeon-tie  nerve.  Either  one  or  both  ears  may  be  involved,  though  usually 
both.  The  patients  are  generally  neurasthenic,  and  any  circumstance  which 
aggravates  this  condition  is  the  cause  of  marked  decrease  in  the  hearing 
((telle).     This  condition   i-  frequently  associated  with  that   following. 

Acoustic  hysteria  i-  usually  associated  with  great  deafness,  which 
appears  suddenly  and  i>  not  subject  to  the  fluctuations  noticeable  in  neuras- 
thenia ;  it  i-  the  -ami'  throughout  the  continuance  of  the  attack.  Vertigo  is 
never  present  (  Rohrer),  and  tinnitus  is  not  frequent  ;  one  or  both  ears  may  be 
affected  or  the  attack  may  pass  from  one  em-  to  the  other;  paresthesia?  or 
anesthesia  of  the  external  auditory  canal  and  the  tympanic  membrane  may  be 
present  (Wiirdemann);  functional  tests  are  apl  to  lie  contradictory,  the  most 
constant  being  lowering  of  the  upper-tone  limit. 

Hyperacusis  is  an  overexcitable  condition  of  the  acoustic  nerve,  some- 
times even  painful,  occurring  generally  periodically  in  connection  with  great 
nervous  or  mental  excitement,  with  neuralgia',  or  after  partaking  of  stimu- 
lants (Politzer).     It  also  occurs  in  the  incipiency  of  inflammatory  affections 

of  the  car. 

Paracusis  consists  in  the  false  perception  of  the  pitch  of  a  sound.  l'<ir<<- 
0U81S  lod   is   the    inability  to  tell   the  direction    from  which  the  sound   comes, 

and  depends  upon  the  difference  in  the  acuteness  of  perception  of  the  two 


DEAF-MUTISM.  777 

oars.  As  our  judgment  of  the  direction  of  sound  depends  upon  binaural 
hearing,  in  unilateral  deafness  the  apparent  source  of  the  sound  will  he  pro- 
jected in  the  direction  of  the  normal-hearing  ear  (Politzer). 

Diplacusis  is  a  form  of  paracusis  in  which  a  single  tone  i>  heard  double  ; 
either  each  ear  perceives  the  tone  differently  and  it  seems  doubled  1 1),  binau- 
ricularis — Knapp),  or  a  double  perception  of  a  single  tone  is  gol  by  one  ear 
(I).  monauricularis) :  the  two  tones  differ  from  each  other  in  time  (I). 
echoica)  or  in  interval  (D.  harmonica  or  disharmonies — II.  Daae). 

"Nervous  tinnitus"  (  Politzer)  may  exist  as  a  pure  neurosis  without  diffi- 
culty of  hearing.  It  is  observed  as  an  irritable  condition  of  the  nerve  in 
convalescence  from  severe  febrile  affections;  in  connection  with  sexual  ex- 
cesses, intemperance,  overfatigue  of  the  auditory  nerve,  and  extreme  mental 
disturbance.     It  may  continue  indefinitely,  the  hearing  remaining  unimpaired. 

Hallucinations  of  hearing-  may  occur  rarely  in  ear-diseases  without  a 
changed  condition  in  the  brain  (Politzer). 

Color-hearing  is  a  term  employed  to  define  that  phenomenon  by  which 
certain  tones  always  excite  in  some  people  the  sensation  of  color. 

Deaf-mutism. — One  of  the  most  important  results  of  labyrinthitis  is  the 
production  of  deaf-mutism.  In  the  United  States  there  were  about  38.2  deaf- 
mutes  to  every  100,000  inhabitants  (v.  Troltsch),  but  this  proportion  is 
apparently  diminishing.  They  belong,  to  a  great  extent,  by  birth  to  those 
classes  of  society  which  are  least  favorably  situated  economically  as  well  as 
socially  (H.  Mygind).  In  the  majority,  the  deaf-mutism  develops  before  the 
end  of  the  third  year  (Robertson),  but  may  develop  as  late  as  the  eighth  year 
(Lemcke).  The  pathological  seat  of  the  causative  process  is,  almost  without 
exception,  in  the  labyrinth  (H.  Mygind).  In  connection  with  the  labyrinth, 
the  middle  ear  is  surprisingly  often  found  to  be  affected,  only  exceptionally 
as  regards  lack  of  formation,  but  almost  regularly  by  violent  inflammation, 
generally  of  a  purulent  nature  (H.  Mygind).  Deaf-mutism  occurs  more  fre- 
quently in  the  male  sex  (v.  Troltsch).  More  than  half  the  cases  are  due 
to  acquired  deafness  (H.  Mygind),  and  epidemic  diseases  are  probably  most 
often  the  cause  of  the  deafness  (H.  Mygind).  Bezold  is  probably  nearly 
right  in  his  statement  that  about  43  per  cent,  are  totally  deaf,  and  it  is  the 
general  opinion  that  among  these  the  acquired  are  greater  in  number  than 
the  congenital  (Hartmann).  There  is  noticeably  a  very  frequent  occurrence 
of  partial  defects  in  the  musical  scale,  in  which  sometimes  the  upper  and 
sometimes  the  lower  limits  of  tone  are  absent  ;  sometimes  single  or  multiple 
gaps  or  islands  are  found  which  show  no  perception  at  all  (Bezold).  Only 
about  8.4  per  cent,  have  hearing  power  sufficient  for  intercourse  with  other 
people)  Lemcke).  Disturbances  of  equilibrium  (static  or  dynamic)  are  present 
in  50  per  cent.  (A.  Bruck),  and  those  showing  normal  equilibrium  are  also 
much  more  apt  to  have  normal  speech  (L.  W.  Stern).  Heredity  exerts  a 
■jic.it  influence,  especially  in  those  families  in  which  there  arc  many  cases  "f 
hardness  of  hearing,  but  direct  transmission  is  absent,  as  Mygind  found  that 
not  a  single  child  of  deaf-mute  parents  was  itself  deaf  and  dumb.  <  tonsan- 
guineous  marriages  are  only  causative  when  joined  to  hereditary  and  other 
influences  (as  constitutional  disease) — (L.  Blau).  Deaf-mutism  is  especially 
apt  to  occur  in  those  families  in  which  many  children  have  been  born  in  rapid 
succession  (II.  Mygind).  Gillespie  has  drawn  attention  to  the  frequency  oi 
goiter  in  deaf-mutism ;  and  Lemcke,  of  affections  of  the  naso-pharyngeal  tract. 
especially  adenoid  vegetations.  The  bodily  growth  keeps  pace  with  that  oi 
normal  persons,  bul  there  is  defective  brain  development  (Lemcke);  a-  a 
rule,  however,  they  are  endowed  with  organic,  mental,  and  normal  sensitive- 


778      DISEASES  OF   THE  SOFXD-FEIU'ELVIXG  APPARATUS. 

ness  but  Little  inferior  to  the  normal  (Ottolenghi).  They  do  not  exhibits 
higher  mortality  than  normal  individuals  living  under  the  same  circumstances 
(11.  Mygind),  but  they  are  especially  prone  to  lung-diseases.  Nearly  half  of 
all  deaf-mutes  over  20  years  of  age  are  obliged  to  tall  back  on  the  help  of 
others  for  their  maintenance  (II.  Mygind).  Marriages  contracted  by  deaf- 
mutes  exhibit  a  very  small  degree  of  fertility  (II.  Mygind). 

Diagnosis. — The  diagnosis  has  been  almost  sufficiently  indicated  in  the 
symptomatology,  but  there  arc  a  few  points  that  it  seems  well  to  emphasize. 

In  any  case  of  hardness  of  hearing  the  first  thing  to  be  determined  is 
whether  the  lesion  is  located  in  the  sound-conducting  or  in  the  sound-per- 
ceiving apparatus.  The  antagonistic  reactions  to  the  functional  tests  may  be 
tabulated  as  follows  : 


Diseases  of  the  Sound-conducting  Apparatus. 

Upper-tone  limit  very  little,  if  any, 
lowered. 

Lower-tone  limit  by  A.-C.  elevated. 

Absolute  duration  of  perception  of 
B.-C.  increased  throughout  the  musical 
scale. 

B.-C.  >  A.-C.  both  in  intensity  and  dura- 
tion in  the  lowest  part  of  the  musical 
scale,  and  ascending  with  the  gravity  of 
the  disease  (Rhine). 

Weber's  test  heard  in  the  diseased  or 
the  harder  hearing  ear. 

Deeper  tones  of  speech  not  heard ;  higher 
tones  well  heard. 


Diseases  of  the  Sound-perceiving  Apparatus. 
Upper-tone  limit  noticeably  lowered. 

Lower-tone  limit  by  A.-C.  not  elevated. 

Absolute  duration  of  perception  of  B.-C. 
diminished  or  abolished  throughout  all  or 
in  parts  of  the  musical  scale. 

A.-C>B.-C.  both  in  intensity  and  dura- 
tion throughout  the  musicalscale(iRinne). 


Weber's  test  heard  in  the  normal-  oi 
better-hearing  ear. 

Deeper  tones  of  speech  well  heard 
higher  tones  not  heard. 


In  order  to  bring  these  differing  reactions  more  graphically  before  the 
eye,  the  author  has  arranged  them  below  in  the  schema  originally  devised  by 
himself,  firs!  giving  the  normal  reaction  in  the  healthy  ear  for  comparison — 
the  numerals  representing  the  duration  of  perception  in  seconds,  the  Rhine 
showing  whether  the  respective  forks  are  heard  louder  by  A.-C.  or  B.-C.  at 
the  initial    point. 

In  marked  disease  of  the  sound-conducting  apparatus  the  reaction  will  be 
approximately  as  below  : 


A.-C. 

A.-C. 

A.-C. 

A.-C. 

A.-C. 

A.-C. 

22 

14 

Rinne. 

Schwabach  1  }\'('; 
Tuning-fork. 

B.C. 

B.C. 

B.-C. 

B.-C. 

B.-C. 

Equal 

22 
12 

25 
L3 

15 

:::■: 
13 

il- 
ls 

0 
14 

8 
14 

8 
11 

13 

17 

15 
16 

13 

14 

c- 

1 

c 

r" 

C.n 

1 

(T 

C 

c 

C" 

CT 

c,v 

i  ralton  1  ,:, 

Web)  t 

(Jalton  '   ■! 

Weber  in  the  af 
fected  ear. 

■  normal  car. 


Average  case  of  otitis  media  purulenta  re 

currens. 


1  li  will  be  noticed  that  the  upper  tone  limit  is  slightly  impaired  in  the  scheme :  tliis  is  in 
keeping  with  the  author's  findings  as  described  in  the  article  "  The  Upper-tone  Limit  in  the 
Normal  and  1  diseased  Kur  " 


DIAGNOSIS. 


779 


In  disease  of  the  sound-perceiving 
serve  as  a  type  : 


apparatus  the  following  reaction.-  will 


A.-C. 

A.-C.  A.-C. 

A.-C. 

A    < 

A.-C. 

12 

4 

17 
6 

18 

7 

21 

6 

15 
4 

10 

c- 

C 

C 

C" 

C" 

cIV 

Galton  2.7 

Weber  in  the  bet- 
ter-hearing ear. 

Rinne. 


Schwabach  j  £"£• 


Tuning-fork. 


Average  case  of  otitis  interna. 

In  eases  in  which  there  is  an  affection  of  both  the  souud-conducting  and 
sound-perceiving  apparatus,  both  upper-  and  lower-tone  limits  are  contracted, 
the  duration  of  B.-C  is  impaired,  B.-C.  is  better  than  A.-C.  (  -  -  Ilium' j  for 
the  lower  forks,  while  A.-C.  is  better  than  B.-C.  (-f-Rinne)  for  the  higher 
forks,  and  both  the  higher  and  deeper  tones  of  speech  are  imperfectly  heard. 
The  degree  in  which  one  or  the  other  apparatus  is  responsible  for  the  hard- 
ness of  hearing  is  indicated  by  the  closeness  of  the  resemblance  of  the  results 
of  the  functional  tests  to  the  reactions  given  by  the  one  or  the  other  tvpeof 
disease. 

In  the  matter  of  locating  the  lesion  in  any  particular  portion  of  the  sound- 
perceiving  apparatus  much  has  yet  to  be  learned,  but  the  following  deductions 
seem  to  be  well  established  as  the  result  of  post-mortem  examinations  of  cases 
clinically  observed  before  death  :  word-deafness  points  to  involvement  of  the 
cortical  areas;  lower- and  upper-tone  limits  fairly  well  preserved  with  deaf- 
ness for  forks  of  middle  register  and  greatly  impaired  B.-C.  indicate  involve- 
ment of  the  nerve-stem  (Gradenigo);  disturbances  of  equilibrium  may  occur 
in  the  course  of  any  pathological  process  causing  irritation  of  the  terminal 
filaments  in  the  vestibule  or  ampullae,  of  the  nerve-fibers  in  the  auditory 
nerve-stem  (Kreidl),  or  of  the  central  origin  of  the  nerve  (Hillairet)  ;  patho- 
logical processes  involving  the  cochlea  alone  do  not  induce  vertigo  (Gradenigo) ; 
the  cochlea  is  the  only  part  specialized  for  the  perception  of  sound,  as  the 
retina  is  for  light,  and  its  total  destruction  is  followed  by  total  deafness  ;  it  is 
probable  that  the  lower  notes  are  perceived  at  the  cupola,  and  the  higher 
notes  at  the  base. 

In  attempting  to  make  a  diagnosis  these  deductions  should  be  borne  in 
mind  while  studying  the  results  of  the  functional  testing,  remembering  always, 
however,  that  it  i>  often  impossible  to  determine  whether  the  disease  is  in  the 
labyrinth,  nerve-trunk,  or  central  course  (Politzer). 

In  fracture  of  the  petrous  hone,  the  escape  of  cerebro-spinal  fluid  is  not 
essential  (Gruber),  and  no  certain  conclusions  with  respect  to  the  anatomical 
situation,  gravity,  or  the  subsequenf  behavior  of  the  fracture  can  be  drawn 
from  the  external  appearance-;  in  the  ear  and  from  the  functional  disturbances 
(Schmidt).  In  mosl  cases  both  the  internal  and  middle  ear  arc  affected 
together  (Schmidt).  Fracture  may  occur  without  loss  of  hearing  (J.  E.  Shep- 
pard)  it'  the  labyrinth  i-  not  involved  in  the  fracture  line. 

The  diplacusea  are,  in  the  author's  experience,  usually  due  to  affections  of 
the  middle  car,  as  in  a  case  recently  observed  of  diplacusis  echoica  coming  "ii 
during  the  acme  of  an  attack  of  otitis  media  Bubacuta. 

The  neuroses  are  recognized  by  their  Bymptoms  and  the  peculiar  constitu- 
tional condition  of  the  pal  ient. 


780    DISEASES  OF  THE  SOUND-PERCEIVING  APPARATUS. 

Bearing  in  mind  the  above  few  remarks  in  connection  with  those  on 
symptomatology,  the  diagnosis,  according  to  our  present  knowledge,  should 
not  offer  insuperable  obstacles  to  the  conscientious  observer. 

Prognosis. — The  prognosis  is  always  hopeful  in  those  cases  in  which 
there  has  been  no  destruction  of  the  anatomical  elements,  as  in  anemia,  neuras- 
thenia, etc.;  always  unfavorable  in  those  cases  in  which  such  destruction  has 
taken  place.  The  condition  remaining  after  a  trial  of  treatment  of  moderate 
duration  is  apt  to  be  the  condition  that  will  remain  permanently,  except  in 
the  case  of  hemorrhage,  where  repeated  attacks  will  tend  to  further  impair- 
ment of  hearing. 

Amelioration  may  and  usually  does  take  place  in  the  other  symptoms, 
such  as  vertigo;  but  the  hearing  improves  only  so  far  as  the  anatomical  ele- 
ments develop  recuperative  power,  and  when  that  power  is  exhausted,  im- 
provement ceases. 

Treatment. — The  treatment  of  anemia  of  the  labyrinth  is  in  most  cases 
practically  that  of  the  treatment  of  general  anemia,  as  in  the  anemia  and 
oligemia  following  gestation  ami  parturition.  In  the  local  anemia  due  to 
aneurvsm  or  atheroma  very  little  can  be  done;  when  due  to  pressure  brought 
on  by  changes  in  the  middle  ear,  operative  interference  to  relieve  that  pressure, 
if  possible,  should  be  undertaken. 

Hyperemia,  if  acute,  should  be  met  by  local  blood-letting,  purgation,  and 
rest  at  the  same  time  that  the  diet  is  limited  and  stimulants  interdicted.  The 
causative  agency  should  always  be  searched  for  and  corrected  as  far  as  possi- 
ble on  general  lines.  Regulation  of  the  diet  and  bowels,  curtailment  or  denial 
of  stimulants,  and  correct  ordering  of  the  care  of  the  body  and  method  of 
life  are  always  indicated  and   produce  the  best   results. 

Hemorrhages  into  the  labyrinth  should  be  treated,  until  the  acute  symp- 
toms subside  and  absorption  begins,  by  complete  bodily  rest,  local  blood- 
letting, purgation,  hot  foot-baths,  limitation  of  diet,  and  abstinence  from  the 
use  of  all  stimulants,  alcohol,  tobacco,  etc.  Later,  comparative  rest  and 
abstention  from  mental  or  physical  work,  with  the  regulation  of  the  diet  and 
bowels,  will  do  more  to  favor  absorption  than  the  administration  of  drugs. 
Should  this  method  of  treatment  be  found  impracticable,  or  conjointly  with 
it,  iodid  of  potassium  in  gradually  increasing  doses  has  given  the  best  result- 
in  the  author'-  hand-.  Pilocarpin  has  been  strongly  advocated  by  some 
authors,  given  either  by  the  mouth  or  hypodermatically,  beginning  with  one- 
eighth  of  a  grain  two  or  three  time-  daily  and  working  up  until  the  physio- 
logical effecl  i-  obtained,  when  the  patient  is  held  to  that  dosage  for  a  shorter 
or  longer  time. 

In  the  hyperplastic  form  of  labyrinthitis,  regulation  of  diet  and  digestion, 
of  the  bowels,  and  denial  of  stimulants,  counter-irritation  over  the  mastoid, 

and    attempt-    to    provoke    derivation    and,    -t    important,    the    attempted 

removal  of  the  cause.     Resolution  may  be  encouraged  by  the  administration 

of  iodid  of  potassium    or  of  pilocarpin,  if  these  are   not    contra-indicated    by 
the  condition  causing  the  lesion  or  by  the  state  of  health  of  the  patient. 

During  the  acute  stage  of  the  exudativt  form  of  labyrinthitis  as  much 
should   be  done  as  possible  i"  decrease  tin'  intensity  of  the  attack-  and  to 

limit  the  extension  of  the  pi' ISS.      This  in  mo-t  cases  amounts  to  very  little. 

Resl   in   bed   is  imperative,  limitatii I'  the  diet,  cardiac  sedatives,  diapho- 
retics, regulation  of  the  bowels,  ami  derivatives  not  contra-indicated  by  the 
general  condition.     After  the  acute  symptoms  have  subsided,  resolution  is  to 
be  encouraged  by  the  continuance  of  rest,  lighl  but  nourishing  diet,  the  reg 
ulation  of  the  excretory  organ.-,  and  the  administration  of  those  remedies 


TBEA  TMENT.  78] 

known  to  have  an  effecl  on  the  pathological  deposits  and  new  formations, 
such  as  the  iodid  of  potash,  mercury,  pilocarpi  n,  etc. 

The  regeneration  of  the  affected  uerve-elements  ma)  be  encouraged  by 
the  administration  of  the  various  nerve-stimulants  and  nerve-foods,  ~i h -h  as 
strychnia,  phosphorus,  etc. 

The  principal  treatment  for  concussion  and  fracture  is  resl  and  the  me<  t- 
ing  of  symptoms  as  they  arise. 

The  treatment  of  acoustic  neurasthenia  is.  of  course,  that  of  the  general 
neurasthenic  condition.  The  general  health  should  be  improved  by  all  the 
mean-  at  our  command.  The  author  has  found  that  the  feeling  of  well-being 
produced  by  the  administration  of  gelsemium  is  a  very  important  aid  in 
inducing  the  patient  to  attempt  and  to  adhere  to  those  regulations  necessary 
to  the  attainment  of  this  much  hoped-for  improvement;  it  should  be  admin- 
istered in  the  form  of  the  fluid  extract.  Strychnia  has  produced  only  a 
temporary  improvement  in  the  author's  hands.  The  general  health  musl  be 
improved  if  any  permanent  betterment  is  to  be  attained,  and  gelsemium  has 
the  power  of  stimulating  the  ambition  of  the  neurasthenic  to  the  extent  of 
accomplishing  the  tasks  necessarily  set  for  this  purpose. 

Hysteria  requires  the  administration  of  those  remedies — pharmaceutical, 
psychical,  and  physical — usually  recommended  for  use  in  the  general  con- 
dition. 

The  various  other  neuroses,  reflex  and  otherwise,  are  to  be  treated  from 
the  standpoint  of  the  cause. 

It  will  be  noticed  that  the  subject  of  the  treatment  of  affections  of  the 
sound-perceiving  apparatus  by  means  of  electricity,  phono-massage,  and 
various  other  more  or  less  imperfectly  tried  remedies  has  not  been  touched 
upon  by  the  writer.  The  reason  for  this  lies  in  the  fact  that  the  advantage 
to  be  derived  from  these  remedies  has  been  much  doubted  by  very  many 
competent  otologists  who  have  given  them  fair  trial,  and  that  certain  dis- 
advantages in  their  use  have  been  discovered  in  some  conditions.  Further 
attention  needs  to  be  devoted  to  them  as  remedial  agencies. 

The  treatment  of  deaf-mutism  consists  in  the  removal  of  any  curable 
pathological  conditions  found  to  exist  in  the  sound-conducting  apparatus  and 
the  improvement  of  what  hearing  power  still  remains  in  the  sound-perceiving 
apparatus.  Chronic  suppuration  of  the  middle  ear  is  especially  prevalent 
among  those  mute  from  acquired  deafness,  and  should  receive  competenl 
attention  to  prevent  fatal  results.  Urbantschitsch  has  recommended  sys- 
tematic acoustic  instruction  by  the  pronunciation  of  vowels,  consonants, 
single  word-,  and  sentences  :  the  instruction  to  be  given  for  a  short  time  two 
or  three  times  daily.  Politzer  is  of  the  opinion  that  this  may  be  the  means 
of  effecting  a  modulation  in  speech,  but  that  the  hearing  cannot  be  affected 
thereby,  because  it  has  generally  been  lost  through  processes  which  have  run 
their  course  and  '  ave  left  behind  irreparable  anatomical  chai :. 


OPERATIONS. 

By   .1.  ORNE  GREEN,  A.M.,   M.D., 

OF    BOSTON,    MASS. 


OPERATIONS  ON  THE  AURICLE. 

Auricular  appendages  arc  composed  cither  of  fat  or  cartilage  covered 
witli  skin  (Fig.  520).  Their  removal  for  cosmetic  effect  by  an  elliptical 
incision  is  usually  simple.  If  they  are  cartilaginous,  the  cartilage  often 
extends  inward  quite  deeply,  but  the  removal  of  the  whole  is  unnecessary; 
it  is  sufficienl  to  cut  off  the  cartilage  just  below  the  level  of  the  surrounding 
surface  and  suture  the  skin. 

Coloboma  of  the  lobule  may  be  congenital  or  acquired,  the  latter 
usually  caused  by  heavy  ear-rings,  which  have  slowly  cut  their  way  out. 
The  operation  for  both  varieties  is  practically  the  same  (Fig.  521).  Cut 
a  strip  of  skin  from  a  to  the  lower  edge  of  the  lobule  and  turn  it  down  ;  from 
the  same  point,",  freshen  the  edges  as  far  as  6  by  removing  a  thin  strip; 


Pig  521.— Operation  for  coloboma  of  loimlc. 


Potyotia   "i   auricular  ap 
penda  '  ing  of  the  nipple  like 

outgrowths    in    front    "f  the  ear    (v. 
Amnion). 


i  ig    >--'     Snellen  •  clamp  for  bloodless  operation 

..ii  i he  li'l--  or  lobule. 


suture  the  lobule  at  c  and  d  by  transfixing  sutures,  then  suture  a  to  b  by  fine 
sutures,  and  the  skin  at  any  gaping   spots  also  by  fine  sutures.     The  results 


ANGIOMA.  783 

in  the  acquired  fissures  are  almost  perfect;  but  in  the  congenital  variety  are 
not  so  good,  as  the  edges  of  these  fissures  are  apt  to  be  somewhat  atrophied. 
Hemorrhage  during  the  operation  can  be  wholly  avoided  by  enclosing  the 
lobule  in  a  Snellen's  clamp  (Fig.  522). 

Fissures  of  the  auricle,  either  congenital  or  tin-  result  of  traumatism, 
may  lie  corrected  in  the  same  manner  as  those  of  the  lobule. 

Maerotia,  or  abnormally  large  auricle,  has  been  improved  by  Schwartze 
in  the  following  way  :  An  elliptical  piece  of  the  cartilage  was  removed  from  the 
fossa  of  the  helix,  and  then  a  triangular  piece  from  the  helix  well  into  the 
concha;  the  edge-  were  then   united  by  deep  sutun-. 

Projecting  Auricle. — To  tie  down  an  auricle  which  i-  protruding  from 
the  head  make  two  concave  incisions  5  cm.  long  behind  the  ear,  one  on  the 
mastoid  1  cm.  backward,  and  one  on  the  auricle  1  cm.  forward,  with  the  con- 
cavities facing  each  other,  the  cuts  uniting  above  and  below  at  acute  angles. 
Dissect  off  this  skin,  loosen  the  remaining  skin  at  the  edges  for  0.5  cm., 
unite  the  edge  by  sutures,  press  firmly  into  position  by  iodoform  gauze,  and 
bandage  the  auricle  firmly  against  the  skull.1 

Grooving  or  excising  a  segment  of  the  cartilage  in  the  fossa  of  the  helix 
is  needful  in  some  cases,  as  in  the  previous  operation. 

Defects  of  the  auricle  can  rarely  be  benefited,  because  the  defecl  i- 
usually  too  great  to  be  improved  by  plastic  surgery.  In  exceptional  cases, 
however,  a  fairly  well-formed  auricle  is  simply  adherent  to  the  skull  and  can 
be  dissected  off;  a  flap  of  skin  can  then  be  inserted  behind  and  a  consider- 
able gain  in  appearance  thus  obtained. 

Congenital  fistula,  a  remnant  of  the  fetal  first  branchial  cleft,  only 
requires  surgical  interference  when  the  secretion  is  so  abundant  as  to  be  a 
serious  inconvenience,  when  there  is  retention  and  the  format  ion  of  a  large 
cyst,  or  when  the  fistula  become-  infected  and  suppurates.  In  such  cases  the 
only  effectual  course  is  to  dissect  out  the  entire  epithelial  lining  of  the  tract, 
which  usually  extends  quite  deeply,  one-half  inch  or  more.  In  two  cases 
which  I  operated  upon  the  removal  of  the  deepest  portion  of  the  fistula 
exposed  the  capsular  ligament  of  the  temporo-maxillary  articulation. 

Wounds  of  the  auricle  usually  heal  wonderfully  well,  even  if  deep  in 
the  cartilage.  Wounds  at  the  orifice  of  the  meatus,  if  granulating,  are  liable 
to  cause  stenosis  or  atresia,  which  must  be  guarded  against  by  packing,  cau- 
terization, removal  of  granulations,  or  by  grafting  of  -kin. 

Fibroma  of  the  lobule,  ear-ring  tumor  or  keloid,  requires  complete 
removal  by  taking  out  a  triangular  piece  of  the  lobule;  any  portion  of  the 
new  growth  left  will  cause  a  recurrence  of  the  tumor.  Pass  a  oarrow-bladed 
knife  through  the  lobule  in  healthy  tissue  above  the  middle  of  the  tumor  ami 
incise  through  the  base  of  the  lobule  in  healthy  tissue;  do  the  same  on  the 
opposite  side  and  bring  the  parts  together  by  deep  sutures.  The  operation  is 
practically  the  -a  me  a-  that  for  coloboma,  except  in  the  <  a  re  necessary  to  excise 
all  of  the  growth  ;  and  if  it  is  possible  to  get  a  narrow  flap  of'  healthy  -kin 
and  in-eii  it  on  the  edge  of  the  lobule,  a-  described  above  for  coloboma,  the 
disfiguring  notch  in  the  contour  of  the  lobule  will  be  avoided. 

Atheromatous,  dermoid,  and  serous  cysts  require  the  removal  of 
the  entire  cyst-wall  by  disseel ion. 

Angioma. — The  treatment  must  vary  according  i"  the  size  of  the 
growth  :  if  -mall  it  can  be  dissected  oil'  and  the  -kin  sutured  over  the 
wound,  or  it  may  be  destroyed  by  the  thermocauter)  or  by  electropuncture. 
Large  growth-  involving  the  whole  thickness  of  the  auricle  may  require 

1  Gruber  :   Monatachrifl  fur  Ohrenheilkunde,  Feb     '■  - 


784  OPERATIONS. 

putation  of  the  portion  of  auricle  involved.  Occasionally  the  whole  auricle 
is  involved  in  a  mass  of  large  tortuous  blood-vessels  which  communicate 
freely  with  enlarged  and  irregular  arteries  arising  from  the  carotid.  In  these 
amputation  by  slow  dissection,  ligating  the  vessels  as  they  are  cut,  is  our  only 
resource  ;  and  ligation  of  the  common  carotid  artery  must  precede  the  ampu- 
tation. After  removal  of  the  auricle  the  deeper  tortuous  veins  can  be  dis- 
sected out.  Then,  as  in  every  wound  involving  the  orifice  of  the  meatus,  an 
attempt  should  he  made  to  turn  a  flap  of  skin  into  the  meatus  to  prevent 
atresia  from  granulation-tissue. 

Bpithelial  Carcinoma.— Our  only  resource  is  early  extirpation  by  ex- 
cision ;  if  -mall,  excise  the  growth  with  the  whole  thickness  of  the  cartilage; 
if  large,  amputation  of  the  entire  auricle  is  necessary,  and,  if  the  tissues 
within  the  orifice  of  the  meatus  are  involved,  the  entire  cartilaginous  meatus 
should  he  removed  with  the  auricle.  Any  infiltrated  glands  should  he  dis- 
sected out.  If  the  orifice  of  the  meatus  is  involved,  a  plastic  operation 
should  supply  a  surface  of  skin,  at   least  on  one  side,  to  prevent  atresia. 

Some  cases  do  well,  and  I  have  followed  such  for  several  years  without 
there  being  any  recurrence  ;  in  other  cases  there  is  a  rapid  return,  either  in  the 
cicatrix  or  in  the  meatus,  which  is  usually  fatal  in  a  few  months  from  involve- 
ment of  the  deeper  ear  and  brain  or  of  the  parotid  region.  A  recurrent 
growth,  small  and  isolated,  justifies  a  second  operation ;  but  a  rapid  recur- 
rence in  the  form  of  a  diffuse  infiltration,  usually  in  front  of  the  tragus,  is, 
in  my  opinion,  beyond  surgical   relief. 

OPERATIONS    ON    THE    MEATUS. 

Congenital  atresia  is  usually  associated  with  malformation  of  the 
auricle,  and  in  most  cases  also  with  malformation  of  the  middle  and  inner 
ears  from  imperfect  development.  This  internal  malformation  renders  sur- 
gical interference  inadvisable  except  in  the  rare,  simplest  forms  where  the 
closure  is  merely  by  a  thin  layer  of  skin  and  where  an  exploratory  puncture 
shows  there  is  no  fibrous  or  osseous  closure  further  in.  'Flic  skin  can  then  be 
excised  by  a  circular  incision  as  near  the  periphery  as  possible,  or  quartered 
by  two  cross-cuts  and  the  triangular  Haps  excised  with  curved  scissors.  By 
either  method  great  difficulty  is  experienced  in  maintaining  the  opening, 
which  can  only  be  done  by  keeping  a  tube,  metallic  or  rubber,  in  the  passage 
until  the  skin  has  united  over  the  wound,  or  else  by  a  plastic  operation  insert- 
ing skin  from  the  concha  or  tragus.  Secondary  contraction  may  occur  unless 
combated  long  after  apparent  healing. 

Acquired  atresia  is  the  result  of  granulation-tissue  within  the  meatus. 
which,  uniting  across  the  passage,  has  fused  into  a  connected  mass,  under- 
gone fibrous  organization,  and  been  covered  with  epidermis.  A  success- 
ful operation  here  depends  very  much  on  the  same  conditions  spoken  of 
under  congenital  atresia,  excepl  that  there  is  no  question  of  malformation  of 

the  middle  and  inner  ear-.  In  many  of  these  cases  the  occluding  membrane 
i-    thin,  .,'.,  to   |,||  of  an  inch  in  thickness;   but   occasionally  the  entire   meatus 

i-  converted  into  a  dense  fibrous  tissue.  If  the  membrane  is  thin,  the  same 
operation  described  for  congenital  atresia  holds  good ;  but  where  a  consider- 
able portion  of  the  meatus  is  occluded  by  fibrous  tissue,  I  do  not  believe  any 
operation  will  succeed  in  making  a  permanent  opening. 

Carcinoma  of  the  meatus  is  usually  of  the  epithelial  variety  and  an 
extension  of  the  same  disease  from  the  auricle.  If  it  involves  only  the  car- 
tilaginous meatus  it  can  be  removed  together  with  the  auricle  (see  Carcinoma 


H  YPER  OSTOSIS.  785 

of  the  auricle)  ;  if  it  involves  the  osseous  meatus,  however,  an  operation  is, 
in  my  opinion,  unjustifiable,  as  it  cannot  be  successful  and  i>  liable  to  set  up 
increased  activity  in  the  morbid  growth.  Varieties  of  carcinoma  of  the 
meatus  other  than  epithelial  are  extension-  of  the  disease  from  neighboring 
parts,  usually  from  the  parotid  gland. 

Granulations,  inflammatory  growths  of  granulation-tissue,  are  usually 
an  expression  of  some  other  trouble — deep-seated  inflammation  and  often 
caries;  but  their  removal  is  demanded  to  give  exit  to  pus  or  to  get  at  the 
deeper  disease.  If  pedunculated  they  can  be  cut  off  with  a  No.  •'!()  or  33 
copper  wire  in  a  Wilde's  snare,  or  removed  by  evulsion  with  forceps  or 
curetted  away.  Cocain  in  10  per  cent,  solution  is  useful  both  for  local 
anesthesia  and  to  diminish  the  bleeding.  After  the  removal  the  underlying 
disease  requires  its  appropriate  treatment;  and  until  this  is  cured  the  possi- 
bility of  recurrence  is  not  excluded. 

Exostoses. — Their  removal  is  demanded  only  when  they  close  the 
meatus,  thus  producing  serious  impairment  of  hearing,  or  when  there  is  sup- 
puration of  the  deeper  structures  and  the  growth  prevents  the  evacuation  of 
pus. 

If  distinctly  pedunculated,  it  may  be  possible  to  separate  them  by  placing 
a  small  osteotome  against  the  pedicle  and  fracturing  this  by  a  sharp  blow  from 
a  mallet,  then  removing  the  growth  with  forceps.  If  not  pedunculated,  the 
growth  can  be  best  reached  by  deflecting  the  auricle  and  cartilaginous  meatus 
forward.  This  is  done  by  beginning  at  the  extreme  upper  anterior  edge  of 
the  auricle  and  carrying  an  incision  ^  cm.  from  the  auricle  behind,  around, 
and  down  to  the  lower  wall  of  the  meatus  through  the  skin  ;  then  dissecting 
off  the  auricle  without  the  periosteum  until  the  meatus  is  reached,  when  the 
periosteum  is  incised  close  to  the  meatus  above  and  behind  and  separated  to- 
gether with  the  cartilaginous  meatus  from  the  bone  until  the  exostosis  is 
reached.  This  can  then  be  thoroughly  exposed  by  drawing  the  separated 
auricle  and  meatus  forward  with  a  long  flat  hook.  The  growth  can  now  be 
removed  by  chisels  and  mallet  or  by  burrs  on  a  surgical  engine.  Strict 
asepsis  is,  of  course,  necessary.  After  removal  the  periosteum  should  be 
carefully  replaced  together  with  the  cartilaginous  meatus,  the  auricle  stitched 
into  position,  a  light  packing  of  dry  iodoform  gauze  placed  in  the  meatus  to 
retain  the  periosteum  firmly  against  the  bone,  and  an  aseptic  dressing  applied 
over  the  whole  ear  and  mastoid.  The  frequency  of  dressings  musl  depend 
upon  the  condition  of  the  ear  :  with  suppuration,  daily  dressings  are  necessary. 

Hyperostosis,  a  general  hyperplasia  of  the  bone,  is  particularly  liable 
to  occur  with  chronic  suppurations  of  the  tympanum  ;  and  if  the  hyperostosis 
closes  the  meatus  an  operation  may  be  a  vital  indication  to  prevent  retention 
of  pus. 

In  such  cases  two  method-  are  applicable.  One  is  to  drill  through  the 
growth  in  the  meatus  with  a  surgical  engine  and  enlarge  the  opening  by 
burr-.  This  has  been  done  with  success  :  but  the  opening  thus  obtained  i-  a 
small  one  which,  becoming  covered  with  granulations,  is  kepi  open  with  diffi- 
culty; and,  as  the  hyperplastic  process  in  the  bone  will  probably  continue,  a 
renewed  closure  i-  likely  to  occur  even  when  the  seat  of  operation  has  healed 
well. 

The  other  method  i-  to  do  a  full  tympano-mastoid  exenteration  (see  page 
T'.Mj),  removing  all  the  hyperostosis  <>n  the  posterior  wall.  This  has  the 
advantage  of  making  a  large  meatus,  of  enabling  one  to  treal  the  underlying 
tympanic  disease,  if  there  is  one,  as  is  usually  the  case,  and  is  much  more 
likely  to  put  a  -top  to  further  hyperplasia  of  the  bone. 

50 


786  OPERA  TJONS. 

Exostosis  Cartilagineae. — Still  a  third  form  of  osseous  growth  is 
occasionally  found  in  the  meatus,  apparently  congenital  and  probably  de- 
veloped from  a  remnant  of  fetal  cartilage.  To  the  American  OtologicaJ 
Society  in  July,  1893  ami  1894,  I  reported  four  eases  of  osseous  growth, 
three  on  the  mastoid  wall  of  the  meatus  and  one  apparently  arising  from  the 
tympanum  ;  they  differed  from  ordinary  exostoses  in  being  covered  with 
cartilage  and  in  lying  free  or  bul  slightly  attached  to  the  cavities  of  the  sur- 
rounding bone.  They  were  removed  by  exposing  them  by  displacement  of 
the  auricle  forward  and  then  extracting  them  with  forceps,  without  any  cut- 
ting of  the  hone.  A  full  description  and  discussion  of  them  can  he  found  in 
the  Transactions,  1893  and  1894. 

Foreign  bodies  can,  in  most  cases,  he  removed  by  syringing,  and  this 
should  he  tried  in  all  cases  ;  instrumental  interference  is  unjustifiable  except 
when  syringing  fails,  either  from  the  body  being  firmly  impacted  or  becoming 
impacted  by  swelling  from  moisture.  In  these  exceptional  cases  the  ingenuity 
of  the  surgeon  is  sometimes  taxed  to  the  utmost  to  adapt  his  instrument  to  the 
peculiarities  of  the  foreign  body  and  its  position  in  the  meatus.  ///  children 
and  nervous  adults  a  general  anesthetic  is  often  required,  especially  if  the 
meatus  is  irritated  from  previous  injurious  manipulations. 

Angular  toothed  forceps  are  adapted  to  bits  of  wood,  grass,  or  similar 
objects.  The  wire  loop  of  a  snare  can  sometimes  he  passed  around  a  pebble, 
and  it  can  thus  he  gradually  rolled  out,  A  small  sharp  hook  is  very  useful 
for  peas  and  beans;  a  blunt  hook  for  head-. 

These  are  perhaps  the  most  common  instruments;  but  in  a  difficult  case 
the  surgeon's  armamentarium  can  scarcely  he  too  large.  Occasionally  a  foreign 
body  is  so  firmly  impacted  in  the  deeper  meatus  or  tympanum  that  it  cannot 
he  displaced  by  any  instrument  through  the  meatus,  either  through  lack  of 
space  to  exert  sufficient  force,  or  through  the  body's  having  been  forced 
beyond  the  narrowest  part  of  the  meatus  and  then  having  swollen,  or  through 
its  having  been  impacted  within  the  tympanum.  In  such  cases  the  auricle 
and  cartilaginous  meatus  should  he  displaced,  as  already  described  under 
exostoses  ;  \'v<'  access  is  thus  gained  to  both  osseous  meatus  and  tympanum, 
and  instruments  adapted  to  the  body  can  now  he  used  with  success.  By  this 
method  I  have  successfully  removed  impacted  glass,  a  tooth,  and  several  flat- 
tened bullets  from  the  tympanum,  and  swollen  vegetable  substances  from  the 
deeper  canal,  which  it  was  physically  impossible  to  have  got  out  through  the 
cartilaginous  meatus. 

OPERATIONS    ON    THE    TYMPANUM. 

Paracentesis. — Good  illumination  by  means  of  a  reflector  and  specu- 
lum i-  necessary.  Asepsis  in  regard  to  meatus,  auricle,  hands,  and  instru- 
ments should  he  practised.     The  pain  of  tl peration  is  very  variable;  if 

the  drum  membrane  is  bulging  extremely  from  the  pressure  of  secretion,  its 
sensitiveness  i-  often  so  reduced  that  hut  little  pain  i-  felt  ;  if,  on  the  con- 
trary, it  is  very  much  thickened  by  infiltration,  the  pain  is  often  severe.  The 
natural  sensitiveness  varies  also  in  different  parts,  being  least  in  the  lower 
half  of  the  membrane  ami  greatesl  in  the  posterior  superior  quadrant  just 
behind  the  short  process.  The  operation  i-  so  rapidly  performed  that  narco- 
sis is  often  unnecessary  :  hut  with  children,  with  the  timid,  or  where  the 
drum  membrane  is  much   infiltrated,  primary  etherization   i-  desirable. 

The  object  to  he  attained  i- n  cut  through  the  drum  membrane,  in  length 
from  one-quarter  to  one-half  of  it-  diameter,  and  made  in  such  a  direction  t  hat 


OPERATIONS  OX   Till:   T)' Ml 'A  NUM.  787 

both  the  radial  and  circular  fibers  of  the  membrana  propria  shall  be  incised, 
thereby  insuring  a  slightly  gaping  wound  from  the  contraction  of  both  sete 
of  fibers,  facilitating  drainage.     The  chief  difficulties  of  the  operation  are 

(1)  the  judging  of  the  distance,  a-  only  monocular  vision  can  be  used,  and 

(2)  getting  the  incision  lout;-  enough,  allowance  not  being  made  for  the  incli- 
nation of  the  membrane.  The  firsl  can  he  overcome  by  keeping  the  point  of 
the  knife  in  slight  motion  as  it  is  passed  down  the  meatus,  when,  as  the  point 
touches  the  membrane,  its  motion  is  arrested  and  the  puncture  i-  immediately 
made  by  a  slight  thrust.  The  second  is  obviated  by  continuing  to  pass  tin- 
knife  slightly  inward  as  the  cut  is  made  downward.  Before  withdrawing  the 
knife  the  edges  of  the  wound  should  be1  pressed  apart  to  prevent  their  adher- 
ing with  the  slight   bleeding  which  ensues. 

Although  various  instruments  with  and  without  guards  have  been  pro- 
posed, nothing  in  my  opinion  is  so  simple  and  good  as  the  original  paracente- 
sis-needle  of  Schwartze,  a  small  lance-shaped  knife,  the  shank  of  which  is 
5  cm.  long,  bent  at  an  angle  of  50  degrees  and  inserted  in  a  handle  10  cm. 
long.  For  enlarging  an  existing  perforation  or  an  insufficient  puncture  the 
blunt-pointed,  slightly  curved  dilatation-knife  of  Schwartze  cannot  be  im- 
proved. 

The  point  of  election  for  the  operation  will  depend  upon  the  object  sought 
to  be  accomplished.  The  most  common  object  is  evacuation  of  secretion,  and 
for  this,  if  the  drum  membrane  is  greatly  bulging,  the  cut  should  be  made 
through  the  most  prominent  projection  ;  if,  however,  there  is  no  very  con- 
spicuous bulging  it  should  be  through  the  posterior  lower  quadrant,  beginning 
a  little  above  the  umbo,  midway  between  that  and  the  periphery,  and  con- 
tinued slightly  obliquely  downward  to  the  lower  periphery  ;  this  secures  the 
most  thorough  evacuation  and  drainage.  In  paracentesis  of  the  upper  poste- 
rior  quadrant,  which  is  never  advisable  except  with  a  bulging  at  that  point, 
the  risk  of  injuring  the  ossicles,  especially  the  articulation  of  the  incus  and 
stapes,  requires  that  the  operation  be  done  with  great  caution  against  too  deep 
a  thrust  into  the  tympanum.  A  paracentesis  of  the  anterior  half  of  the 
membrane  is  never  advisable  except  where  there  is  a  distinct  bladder-like 
protrusion  of  the  membrane  at  that  situation,  which  is  extremely  rare  ;  an 
opening  at  this  point  evacuates  very  insufficiently  the  secretion  collecting  pos- 
terior to  the  opening.  When  the  drum  membrane  is  much  infiltrated  it  may 
be  advisable  in  exceptional  cases  to  make  a  cross-cut,  thus  giving  a  triangular 
flap,  which,  being  pressed  back,  will  keep  the  opening  patent  for  a  longer 
time. 

The  tympanum  having  been  thus  opened,  it'  the  secretion  i-  thin  and  under  any  d 
of  pressure,  it  will  evacuate  itself  freely;  and  if  the  Eustachian  tube  !»•  open,  slight 
inflation  by  Valsalva*-  method  will  complete  the  evacuation,  and  the  air  will  pass  out 
without  rales,  with  the  characteristic  perforation-whistle.  If  the  secretion  is  thick  and 
adhesive  or  if  the  Eustachian  tube  i-  closed,  it  may  be  necessary  to  use  the  cat! 
through  which  injection-  of  warm  sodium-chlorid  solution  (|  of  1  percent.),  boric-acid 
solution  (o  per  cent.),  or  some  other  mild  and  warm  antiseptic  solution  may  be  used. 
My  own  practice  varies  with  the  case.  In  otitis  media  acuta  with  a  thin  bloody  serum 
I  content  myself  with  following  the  paracentesis  by  simple  drainage  by  mean-  of 
a  wick  of  corrosive-sublimate  cotton,  without  inflation  of  any  kind:  with  a  simple  acute 
effusion  without  congestion  and  with  marked  retraction  of  the  drum  membrane  due  to 

closure  of  the   Eustachian  tube  (hydrops,  ex   vacuo),   I  use   lerate  inflation — most 

commonly  by  the  catheter,  because  the  force  of  the  inflation  with  this  is  so  completely 
under  the  control  of  the  Burgeon — although  with  children  or  timid  persons  Polif 
inflation  may  be  necessary.  In  chronic  catarrhal  cases  where  the  secretion  i-  thick, 
often  jelly-like  and  adhesive,  injections  by  the  catheter  are  frequently  necessary  to 
soften  and  wash  out  the  masses,  and  aspiration  from  the  meatus  by  means  of  Siegle's 
Bpeculum  will  sometimes  assist  the  evacuation ;  bul  care  should  he  use. I  to  avoid  any 


T.s.s  OPERATIONS. 

extreme  congestion  from  the  suction.  In  acute  suppurations  1  avoid  inflations  at  first; 
and  it"  the  secretion  is  too  abundant  and  thick  to  be  absorbed  by  a  short  wick,  use  hot 
syringing,  especially  if  there  is  much  pain. 

Although  paracentesis  is  most  frequently  used  for  evacuation  of  serum, 
mucus,  and  pus  from  the  tympanum  (and  in  all  of  those  conditions  is  indis- 
pensable, and  in  the  case  of  the  last  often  life-saving),  it  is  also  occasionally 
useful  for  enabling  us  to  get  into  the  tympanum  for  the  purpose  of  (1)  divid- 
ing synechias,  (2)  removing  intratympanic  polypi,  (3)  relieving  anomalies  in 
tension  of  the  drum  membrane. 

To  get  at  synechia  a  short  incision  should  be  made  as  near  their  attach- 
ment as  possible  and  the  adhesions  divided  by  passing  a  curved  or  right- 
angled  knife  through  the  opening.  For  intratympanie  polypi  a  large  opening, 
Dften  with  an  extended  cross-cut,  is  necessary — its  situation  dependent  on 
the  scat  of  the  polypus.  Anomalies  in  tension  may  be  either  increased  or 
diminished  tension.  For  the  former,  incision  of  the  posterior  fold  as  pro- 
posed by  Lucae  requires  that  the  fold  should  be  pierced  close  to  the  periphery 
directly  behind  the  short  process  and  the  cut  continued  downward  through 
the  whole  fold  ;  although  injury  of  the  chorda  tympani  may  result,  it  is  of 
absolutely  no  importance.  For  diminished  tension  numerous  small  incisions 
in  the  most  relaxed  portion  of  the  membrane  have  been  advised  with  the 
object  of  increasing  the  tension  by  the  resulting  cicatrices.  Neither  of  these 
operations  for  tension  have,  however,  received  general  approval,  as  they  but 
imperfectly  relieve  a  single  one  of  several  pathological  conditions  which 
produce  the  deafness. 

Tenotomy  of  the  tensor  tympani  muscle  for  the  relief  of  deafness 
and  subjective  noises  produced  by  sclerosis  or  adhesive  processes  in  the 
tympanum  is  of  slight,  if  any,  value.  In  my  own  hands  it  proved  so  worth- 
less that  I  gave  it  up  years  ago.  It  can  only  relieve  the  retracted  condition 
of  the  drum  membrane  ;  while  we  now  know  that  the  important  pathological 
changes  are  on  the  inner  wall,  especially  about  the  base  of  the  stapes,  and 
that  these  cannot  be  influenced  by  the  operation.  Almost  the  same  thing 
can  be  said  of  tenotomy  of  the  stapedius  muscle;  in  a  few  exceptional  cases 
I  have  seen  a  certain  degree  of  relief  to  subjective  noises  and  vertigo  by 
tlii~  operation,  where  the  stapedius  was  greatly  thickened  by  cicatricial  tissue 
resulting  from  previous  suppurations  and  where  the  condition  could  be  diag- 
nosticated by  direct  inspection  through  a  large  perforation  of  the  drum 
membrane. 

Tenotomy  of  the  tensor  is  performed  best  in  the  posterior  superior  quad- 
rant by  incising  the  membrane  parallel  with  the  manubrium,  just  behind  and 
a  little  below  the  short  process;  the  tenotome  is  then  inserted  through  the 
opening  toward  the  tympanic  roof  and  with  its  edge  forward  until  the  head 
of  the  malleus  is  felt  ;  it  is  then  rotated  forward  until  it  engages  the  tendon 
of  the  muscle,  which  can  be  severed  with  a  slight  sawing  motion.  As  the 
tendon  is  cul  through  it  is  felt  to  yield,  and  the  manubrium  with  the  drum 
membrane  will  be  lilt  and  seen  to  move  outward  more  freely  than  before. 
I'.\  far  the  best  tenotome  is  Schwartze's. 

Tenotomy  of  the  Stapedius  can  be  done  with  any  small  straight 
knife  or  with  a  paracentesis-needle  when  the  stapes  lies  low  and  is  exposed 
through    a    large    perforation. 

Excision  of  Parts  or  the  Whole  of  the  Conducting  Mechanism. 
— These  operations  3houkl  be  carefully  divided  into — 

(1)   Excisions  for  the  relief  of  deafness  otherwise  incurable. 
' '_' i    Excisions  for  existing  tympanic  suppurations. 


EXCISION  OF  OSSICLES.  789 

Under  the  first  head  the  operations  are  undertaken  with  the  objecl  of 
removing  parts  of  the  conducting  apparatus  which  have  become  so  immovable 
by  disease  that  they  prevent  vibrations  from  reaching  the  auditory  nerve. 
The  diseases  producing  this  immobility  are  (a)  adhesive  inflammations 
(thickenings,  calcifications,  adhesions),  the  result  of  previous  tympanic  sup- 
purations and  catarrhs  ;  (/>)  the  obscure  pathological  process  known  as  sclerosis. 
the  important  characteristics  of  which  are  changes  on  the  inner  (labyrinthine) 
wall  of  the  tympanum  and  about  the  niche  and  foot-plate  of  the  stapes. 

It  is  impossible  here  to  give  the  full  history  of  the  various  operations 
which  have  been  proposed;  they  can  be  briefly  summarized  as  follows: 
excision  of  the  tympanic  membrane  and  malleus;  of  the  incus;  of  the  long 
process  of  the  incus  ;  of  the  tympanic  membrane,  malleus,  and  incus  ;  of  the 
stapes  ;  of  the  tympanic  membrane,  malleus,  incus,  and  stapes. 

The  methods  of  operating  will  be  considered  later,  as  they  are  the  same 
whether  done  for  deafness  or  for  suppurations,  except  that  in  the  former, 
with  a  healthy  drum  membrane,  the  strictest  asepticism  is  absolutely  nec- 
essary. 

In  regard  to  the  operations  for  deafness,  I  think  it  can  be  said  that  in 
neither  the  adhesive  nor  the  sclerotic  diseases  have  the  results  equalled  the 
expectations  of  their  originators  or  received  general  recognition  by  otologists. 
In  adhesive  inflammations  occasionally  fair  and  even  good  results  are  ob- 
tained (see  page  738) ;  but  only  in  a  small  proportion  of  cases  as  yet,  and  the 
indications  for  or  against  the  operation  are  not  established.  In  sclerosis  any 
degree  of  success  is  so  rare  and  the  failures  so  many  that  for  my  own  part 
I  have  given  up  all  varieties  of  the  operation  for  this  disease. 

With  our  present  pathological  knowledge  only  two  of  the  operations  for 
deafness  are  worthy  of  consideration  : 

(1)  Excision  of  the  tympanic  membrane,  malleus,  and  incus,  leaving  the 
stapes  in  position. 

(2)  Excision  of  the  tympanic  membrane,  malleus,  incus,  and  stapes. 
Which  to  adopt  must  depend  upon  the  condition  of  the  individual  case.  If 
the  rigidity  exists  in  the  malleus  and  incus  and,  after  their  removal,  the 
stapes  is  found  by  the  probe  to  be  freely  movable,  it  should  be  left  in  por- 
tion ;  if,  however,  it  is  immovably  tixed  and  not  to  be  released  by  the  sepa- 
ration of  adhesions  of  the  crura  to  the  niche,  the  only  hope  of  success  is  in 
removal  of  this  bone  also. 

For  tympanic  suppurations,  removal  of  parts  of  the  conducting  mech- 
anism is  merely  fulfilling  the  well-recognized  surgical  laws  of  removing 
obstructions  to  the  thorough  evacuation  of  pus  so  as  to  get  surgical  cleanli- 
ness and  remove  diseased  bone  (microbic  foci)  which  keeps  up  the  infection. 
It  is  especially  indicated  where  the  suppuration  is  in  the  epitympanum  or 
attic;  for  the  head  of  the  malleus,  the  incus  and  stapes,  the  tensor  tympani 
and  stapedius  muscles,  the  ossicular  ligaments  and  many  folds  of  mucous 
membrane  are  crowded  into  or  below  this  narrow  space;  and  a  suppuration 
of  the  mucous  membrane,  which  covers  all  of  these  structures,  with  it- 
resulting  swelling,  often  so  interfere-  with  free  drainage  that  recovery  is 
absolutely  impossible  without  an  evisceration  of  the  cavity.  Iii  addition  to 
this,  the  retention  of  pus  is  very  apt  to  produce  caries  of  the  ossicles  or  ot 
the  petrous  bone,  which  keeps  np  the  suppuration.  For  both  pns-reteiit ion 
and  ossicular  caries  the  Operation  18  indicated  and  successful  in  a  large  pro- 
portion of  cases.  In  performing  it  the  whole  of  the  existing  drum  mem- 
brane, together  with  the  malleii-  and  ineii-,  should  be  removed  ;  for  any  ol 
these  being  removed  the  others  become  useless  and  merely  act  as  obstructions 


■'.Ill 


OPERA  TIONS. 


to  cleanliness;  while  in  caries  of  the  ossicles,  pathological  statistics  show  that 
both  ossicles  arc  usually  diseased,  bul  the  incus  more  extensively  than  the 
malleus. 

The  different  steps  of  the  operation  arc  as  follows  :  (1)  Separation  of  the 
drumhead  by  incision  around  it-  periphery  as  near  the  tympanic  ring  as 
possible. 

(2)  Tenotomy  of  the  tensor  tympani  muscle  by  passing  ;l  Schwartze's 
tni, .tome  over  the  tendon  and  dividing  it,  as  already  described  on  page  788. 
Alter  severing  the  tendon  the  knife  should  be  passed  downward  along  the 
inner  edge  of  the  manubrium  in  order  to  separate  any  adhesions  which  are 
tying  that   hone  down. 


Instruments  for  Intratympanic  operations:  a,  adjustable  handle;  b,  angled  knives;  c,  Lud- 
incus-hooks;  d,  dilatation-kn  nechia-knives    p,  Sextonl  forceps. 

Disarticulation  of  the  incudo-stapedial  joinl  l>\  incising  it  by  short  cuts 
witi,  :i  small  sharp-pointed  knife  sel  al  nearly  m  righl  angle  with  it-  -hank — 
the  incisions  being  made  in  the  plane  of  the  joint,  perpendicular  to  the  axis 
,,)'  |||(.  stapes.      It   the  stapes  is  situated   low  in  the  tympanum,  the  joint  can 


EXCISION  OF  OSSICLES.  791 

be  seen;  if  high,  the  disarticulation  nm.-t  be  done  by  feeling.     A  free  move- 
ment of  the  long  process  of  the  iiu-u-  proves  the  siicce—  of  the  disarticulation. 

(4)  Removal  of  the  hammer  by  seizing  it  in  strong  forceps  ;it  or  near  the 
short  process, carrying  it  slightly  inward  to  bring  the  Deck  out  from  its  inser- 
tion in  the  Rivinian  notch,  and  then  bringing  the  bone  downward  into  the 
meatus  and  withdrawing  it  together  with  the  drum  membrane.  Occasionally 
the  incus  conn-  away  with  the  hammer,  bul  usually  it  remain-;  if  it-  long 
process  i-  visible,  it  can  be  seized  with  forceps  and  withdrawn;  if  it  is  not 
seen,  it  must  he  brought  down  into  view  by  an  incus-hook,  as  described  below 
(Fig.  523)  in  regard  to  carious  ossicles,  and  then  withdrawn. 

(5)  Separation  of  adhesions  about  the  crura  of  the  -tape-,  if  any,  can  be 
accomplished  by  any  -mall  sharp-pointed  knife  or  by  a  paracentesis-needle. 

(6)  Removal  of  the  stapes,  it'  that  he  desirable,  i-  accomplished  by  insert- 
ing a  small,  blunt  steel  hook  between  the  crura  and  drawing  the  hone  out 
gently.  Unless  the  foot-plate  is  ankylosed  this  can  he  done  readily  ;  hut 
with  ankylosis  the  crura  fracture  and  removal  of  the  foot-plate  is  then  im- 
possible. 

The  whole  operation  can  be  done  tinder  cocain  with  scarcely  any  pain  if 
the  patient  is  steady;  hut  each  successive  portion  of  tissue  require-  to  be 
cocainized  by  a  pledget  of  cotton  on  an  applicator.  In  an  intact  drum  mem- 
brane the  first  puncture  must  necessarily  cause  pain,  hut  from  that  puncture 
the  saturated  cotton-point  inserted  in  the  opening  will  thoroughly  anesthetize 
about  one-eighth  of  an  inch  of  tissue  ;  the  cut  can  then  he  continued  that 
distance  and  then  another  application  of  cocain  made.  Solutions  of  5  per 
cent,  are  sufficiently  strong.  Absolute  immobility  of  the  head  is  required, 
and  in  a  nervous  patient  general  anesthesia  is  necessary. 

In  the  operation  for  suppuration  certain  modifications  may  he  necessary. 
In  these  suppurative  cases  there  is  often  much  granulation-tissue  which  bleeds 
freelv,  masses  of  inspissated  pus  and  cholesteatomatous  material,  and  the 
o--icles  are  often  reduced  to  mere  fragments,  with  calcifications  fixing  them 

so  that  considerable  force  is  required  for  their  removal.     The  most   « imon 

spot  for  caries  in  the  ossicles  is  the  long  process  of  the  incus,  which  in 
60  cases  of  my  own  had  produced  a  natural  disarticulation  in  75  per  cent., 
thus  doing  away  with  the  operative  disarticulation.  With  mere  fragmentsof 
ossicles  adherent  by  calcification,  the  Ludwig's  incus-hooks  are  often  neces- 
sary; and  in  removal  of  the  incus,  which  is  often  reduced  to  a  portion  of  the 
body  only,  these  instruments  I  consider  indispensable  and  prefer  them  to  any- 
thing I  have  yet  seen  (Fig.  523).  The  malleus  and  tympanic  membrane 
having  been  removed,  the  incus-hook  should  he  passed  into  the  anterior 
superior  portion  of  the  epitympanum,  with  its  concave  surface  backward  ;  it 
should  then  he  swept  backward  so  as  to  engage  the  body  of  the  incus  and 
bring  it  down  into  the  meatus,  whence  it  can  he  withdrawn  by  forceps.  With 
a  broad  and  deep  attic  several  -weep-  of  the  hook  may  he  uecessary  in 
different  portions  of  the  cavity  before  the  incus  is  dislodged,  and  in  sweep- 
ing along  the  medial  (labyrinthine)  wall  the  position  of  the  fallopian  canal 
should  he  home  in  mind  and  hut  slighl  force  \\<c{\  at  tin-  point  :  any  twitch- 
ing <»f  the  facial  nerve  is  a  signal  of  danger.  Occasionally  the  incus  is 
not  brought  into  view  by  the  backward  sweep,  hut  can  he  found  by  reversing 
the  process  and  sweeping  from  behind  forward.  After  removing  the  incus, 
the  cavity  should  be  thoroughly  cleansed  of  cholesteatomatous  masses,  inspis- 
sated pus,  and  granulation--  by  the  Ludwig  hook-,  by  snare  and  forceps. 
Bleeding  can  he  greatly  reduced  by  the  use  of  cocain,  and  before  beginning 
the  operation   I  always  inject  the  cavity  with  a  5  per  cent,    solution.       In    the 


792  OPERATIONS. 

operation  for  suppuration  I  have  generally  found  etherization  necessary,  as 
the  tissues  are  inflamed.  The  after-treatment  consists  of  cleansing  with  the 
tympanic  syringe  and  the  use  of  antiseptics  applied  directly  to  the  tympanum: 
a  saturated  solution  of  boric  acid  in  absolute  alcohol  for  granulations,  simple 
boric-acid  powder  for  a  slight  serous  discharge,  and  a  solution  of  carbolic  acid 
in  glycerin  (1  :  25)  for  simple  suppuration. 

Polypi  and  granulations  should  be  carefully  distinguished  from  sar- 
comata  or  epitheliomata.  Their  removal  is  required  because  they  keep  up  the 
inflammation  of  the  parts  to  which  they  are  attached,  and  because,  if  large, 
they  cause  retention  of  pus.  Whatever  their  attachment,  whether  on  meatus, 
tympanic  membrane,  ossicles,  or  tympanum,  they  must  be  got  rid  of  before 
the  inflammation  can  subside.  They  are  almost  without  exception  inflamma- 
tory granulation-tissue,  soft  or  firm  according  to  the  amount  of  fibrous  tissue 
which  they  contain  ;  occasionally  they  contain  cysts  and  exceptionally  assume 
a  teleangiectatic  character  from  excessive  development  of  blood-vessels.  They 
usually  are  pedunculated,  but  occasionally  arc  broad-based  ;  and  they  vary 
in  size  from  a  (tin's  head  to  one  inch  or  more  long.  They  arc  the  result  of 
inflammation  of  the  underlying  tissue,  often  of  a  simple  suppuration,  often 
of  a  caries  of  the  bone. 

The  choice  of  methods  for  removing  them  must  depend  upon  their  >ize, 
shape,  character,  and  attachment.  Small  soft  granulations  can  be  destroyed 
by  caustics,  preferably  argentic  nitrate  fused  on  a  probe,  or  shrivelled  by 
alcohol  ;  but  in  most  cases  immediate  removal  is  the  quickest,  surest,  and 
least  painful  method.  This  can  be  accomplished  with  snares,  forceps,  or 
curettes. 

Small  pedunculated  granulations  can  be  seized  and  removed  bv  evulsion 
with  appropriate  forceps  if  their  situation  admits  of  it;  small  broad-based 
ones,  if  soft,  can  be  crushed  by  the  same  means  ;  if  linn  and  their  attachment 
admits  of  it,  they  can  be  removed  with  a  small  curette.  In  either  variety 
where  evulsion  is  undesirable,  as  in  attachment  to  the  ossicles  or  drum  mem- 
brane, a  delicate  snare  will  cut  them  off.  Pedunculated  granulations  in  the 
epitympanum  or  aditus  can  often  be  swept  down  and  removed  with  the 
Ludwig  incus-hook. 

Large  polypi  attached  to  the  walls  of  the  meatus  can  also  be  removed 
with  forceps  by  evulsion,  but  only  exceptionally  can  their  attachment  be 
made  out  with  such  certainty  as  to  justify  this  method  ;  in  almost  all  of  these 
cases  the  snare  is  the  only  appropriate  instrument. 

The  snare  can  be  used  cither  a-  an  evulsor  or  as  an  ecraseur,  according  to 
whet  her  the  wire  is  drawn  againsl  a  cross-bar  at  the  end  of  the  instrument  or 
completely  into  the  tube  in  the  absence  of  a  cross-bar.  The  canula  of  the 
snare  should  be  small  and  delicate  for  small  granulations  attached  to  delicate 
part-;  much  larger  and  heavier  for  large,  especially  for  fibrous  polypi.  The 
size  ami  quality  of  the  wire  should  be  adapted  to  the  work  also;  for  small 
growths  on  the  tympanic  membrane  or  ossicles  I  prefer  a  -oft.  malleable  cop- 
perwire,  even  a-  -mall  a-  \m.  ::ii;  for  large  growths  copper  wire.  No.  28  or 
30;  occasionally  for  large  fibrous  growths  steel  piano-wire, No.  2,  i-  ncces- 
sary.  The  malleable  copper  wire  seems  to  adapt  itself  to  the  base  of  the 
growth  better  than  a  -tiller  material,  ami  I  prefer  it  in  almost  all  cases.  The 
loop  of  wire,  being  made  a  little  larger  than  the  growth,  is  passed  around  it, 
bearing  in  mind  the  anatomical  peculiarities  at  it-  attachment;  the  loop  IS 
then  tightened  or  drawn  into  the  tube  and  the  tumor  removed.  Evulsion  is 
to  be  preferred  a-  more  thorough  where  it  i-  not  liable  to  tear  away  important 

part-  ;    where    it    is  liable    to  do  tin-   the  .'•era-cur  action  is  to  be  used.       With 


ANTRUM  OPERATION.  793 

large  polypi  it  is  often  difficult  to  pass  the  loop  completely  down  to  the  base. 
As  much  as  possible  is  removed  at  the  first  insertion  and  the  remainder  l>v 
subsequent  insertions.  Except  with  very  nervous  persons  general  anesthesia 
is  unnecessary,  thorough  cocainizing  with  a  10  per  cent,  solution  being  suffi- 
cient. 

The  subsequent  treatment  consists  in  destroying  all  remnants  of  the  growth 
and  getting  the  seat  of  it  healed.  If  caries  exists,  the  only  course  is  to  uet 
rid  of  the  process,  for  without  this  the  growth  is  certain  to  recur,  and  the  object 
of  removing  the  polypus  is  to  enable  us  to  get  at  the  caries.  Without  caries 
the  remnants  should  be  disposed  of  by  cauterization  or  by  shrivelling;  for 
the  former  I  confine  myself  almost  entirely  to  argentic  nitrate  fused  on  a 
probe,  applied  superficially  in  case  of  a  small  remnant  of  a  soft  growth,  or 
bored  directly  into  the  growth  if  the  remnant  is  largeand  firm.  For  shrivel- 
ling, alcohol  (95  per  cent.)  and  glycerite  of  carbolic  acid  (1:25)  are  very 
useful,  applied  either  by  instillation,  by  injection  through  a  tympanic  syringe, 
or  by  painting. 

Mastoid  operations  are  required  for  two  pathological  conditions  :  (1) 
pus  in  the  pneumatic  cavities  of  the  mastoid,  the  retained  products  of  suppura- 
tion of  the  mucous  membrane  lining  the  cells  (empyema) ;  (2)  different  varieties 
of  ostitis,  including  suppuration  of  the  diploe,  inflammation  of  the  cortical 
substance,  caries,  and  necrosis.  They  are  of  two  kinds  :  (a)  opening  of  the 
mastoid  antrum  (Schwartze's  operation) ;  (6)  cleaning  out  the  whole  interior 
of  both  mastoid  and  tympanum,  a  tympano-mastoid  exenteration  (Sehwartze- 
Stacke  or  Schwartze-Zaufal  operation). 

The  antrum  operation  consists  in  opening  the  antrum  through  the 
external  mastoid  cortex,  and  in  so  doing  exposing  the  whole  interior  of 
the  mastoid  so  as  to  remove  all  diseased  tissue,  whether  osseous  or  soft. 
The  antrum  is  the  objective  point  to  be  reached,  for  it  is  the  only  constant 
cavity  within  the  mastoid  ;  the  rest  of  the  bone  may  be,  instead  of  pneumatic, 
as  usually  described,  diploeic  or  sclerosed.  There  is  no  method  of  deter- 
mining beforehand  the  condition  of  the  interior  of  the  bone  ;  a  large  promi- 
nent mastoid  is  more  likely  to  be  pneumatic  than  a  small,  depressed,  ill- 
developed  one  ;  the  bone  in  a  dolichocephalic  skull  is  more  likely  to  be  well 
developed  and  pneumatic  than  in  a  brachycephalic  skull.  It  is  equally  im- 
possible to  foretell  whether  we  shall  find  empyema,  ostitis,  or  osteomyelitis  ; 
the  opening  of  the  bone  finally  settles  the  question.  Osteosclerosis  can  be 
excluded  in  acute  mastoiditis  resulting  from  acute  tympanic  suppurations, 
unless  the  mastoid  has  been  inflamed  from  some  previous  disease  ;  it  is  un- 
likely in  a  mastoiditis  which  has  shown  symptoms  of  extension  outward  as 
subperiosteal  abscess  or  extension  downward  into  the  neck  ;  it  can  be  strongly 
suspected  in  chronic,  long-continued  tympanic  suppurations. 

Certain  irregularities  of  formation  may  be  found  in  any  mastoid,  ap- 
parently regardless  of  its   perfect   or   imperfect    development. 

(1)  The  roof  of  the  antrum,  which  forms  the  floor  of  the  middle  fossa  of 
the  skull,  may  vary  as  much  as  2  cm.  up  or  down  ;  the  lima  temporalis 
marks  the  line  of  this  roof  fairly  well  externally,  and  measurements  on  large 
numbers  of  skulls  show  that  the  floor  of  the  middle  fossa  is  never  1  cm. 
below  the  linea  temporalis.  A  safe  rule,  then,  to  avoid  opening  the  middle 
fossa  is  to  keep  I  cm.  below  the  linea  temporalis,  but  a-  this  linea  i-  some- 
times imperfectly  developed,  another  rule  is  to  make  the  upper  edge  oi  our 
opening  3  mm.  below  an  imaginary  line  drawn  horizontally  backward  from 
the  upper  edge  of  the  meatus,  which  is  well  marked  by  the  sjiimi  snj>r<i- 
iitcufinn. 


794 


o /'/■:/,'. i  rio.xs. 


{'2)  The  outward  curving  of  the  sigmoid  groove  which  carries  the  Lateral 
sinus  varies  very  much  ;  it  may  projecl  even  to  the  external  cortex,  and  such 
a  possibility  must  always  be  borne  in  mind,  and  possible  wounding  of  the 
lateral  sinus  guarded  against  by  the  use  of  chisel  and  mallet  worked  slowly 
and  carefully,  and  by  the  omission  of  all  boring  instruments,  like  trephine 
or  drill. 

(3)  The  extent  of  cancellated  structure  varies;  it  sometimes  extends  far 
hack  ward  and  far  inward  ;  and  as  in  osteomyelitis  especially,  the  removal  of 
nearly  all  cancellated  structure  is  desirable,  the  possibility  of  this  peculiarity 
should  not  be  forgotten. 

The  floor  of  the  antrum,  roughly  stated,  is  on  a  level  with  the  upper  wall 
of  the  meatus,  and  the  cavity  itself  is  from  i  to  |-  inch  back  of  the  superior 
posterior  ^\gc  of  the  tympanic  ring. 

Method  of  Opening  the  Antrum. — Expose  the  mastoid  by  an  incision 
through  the  periosteum  1  cm.  behind  the  attachment  of  the  auricle,  beginning 
1  cm.  above  the  linea  temporalis  and  extending  the  cut  down  nearly  to  the 
tip  of  the  process.  Separate  the  periosteum  forward  so  as  to  expose  the 
swprameatal  spine,  and  backward  so  as  to  expose  the  surface  of  the  mastoid. 
From  the  spine  draw  an  imaginary  horizontal  line  backward  (Fig.  524),  and 


;     Operation  i"i  opening  the  antrum    externa]  wound  Btretched  byAUport'a  retractor,  and  bone 
opened  behind  suprameatal  spine. 

begin    the  upper  edge  of  the  opening  3  mm.  below  this  line  and   about   1  cm. 

back   from  the  posterior  edge  of  the  meatus,  removing  the  cortex  by  thin 

chips  with  a  gOUge  and  mallet.      The   -cut  of  election  is  usually  marked    by  a 

flal  and  slightly  depressed  surface.  The  cortex  of  the  bone  varies  in  thick- 
ness from  ,-i  thin  shell  to  I  cm. ;  remove  it  by  thin  chips  overa  suffice  7  to  |o 
mm.  In  diameter,  taking  care  to  work  parallel  with  the  meatus,  or,  if  any- 
thing, a  little  more  forward  and  upward.    A.s  soon  as  the  cortex  is  cut  througn, 


METHOD   OF  OPENING    '1111.   ANTRIM.  795 

examine  with  a  probe ;  there  may  he  Unyc  pii<iiiii<ifi<-  m  rifles,  in  which  case 
feel  for  landmarks,  upward  for  the  roof  of  the  mastoid  to  define  the  floor  of 
the  middle  fossa,  backward  and  inward  to  define  the  posterior  fossa.  Now 
break  down  all  the  partition-walls  between  the  cells  with  a  curette  till  the 
antrum  is  reached  at  a  depth  of  not  over  15  mm.  (-}-{!-  inch)  from  the  outer 
anterior  edge  <»t'  the  surface  opening ;  clear  out  the  involved  interior  of  the 
mastoid  with  curettes,  removing  the  walls  of  the  cells,  granulations,  pus, 
and  detritus,  douche  gently  with  corrosive  sublimate  (1:5000),  pack  with 
iodoform  gauze,  and  bandage. 

In  other  cases  on  opening  the  cortex  the  interior  is  found  to  he  partly  or 
wholly  diploetic  ;  more  careful  work  is  then  necessary,  and  the  diploe  should 
be  removed  straight  inward,  parallel  with  the  meatus,  to  the  depth  of  6  to  !t 
mm.  Q-  to  §  inch),  and  then  it  is  necessary  to  work  slightly  forward,  inward, 
and  upward  to  reach  the  antrum;  but  never  go  beyond  15  mm.  (^-J!  inch) 
from  the  external  surface  at  the  seat  of  election  for  fear  of  wounding  the 
facial  nerve  or  posterior  semicircular  canal.  Having  opened  the  antrum,  the 
whole  diploe  of  the  mastoid  should  be  removed  with  curettes,  then  cleanse, 
pack,  and  dress. 

In  still  other  cases  no  pneumatic  or  diploetic  structure  is  found  ;  the 
deeper  the  opening  is  carried  the  harder  the  bone  become.- — osteosclerosis. 
These  are  by  far  the  most  difficult  operations  ;  one  gets  no  guide  from  the 
probe  as  in  the  other  varieties  of  bone,  and  the  greatest  care  is  necessary  to 
keep  the  proper  direction  of  the  opening.  The  bone  should  be  removed  in 
small  chips,  the  opening  carried  straight  in,  parallel  to  the  meatus,  to  the 
depth  of  5  to  8  mm.  (i  to  §  inch),  and  then  continued  upward  and  slightly  for- 
ward not  deeper  than  15  mm.  (1^  inch)  from  the  external  surface.  Often 
after  going  through  sclerosed  bone  for  7  to  14  mm.  (^  to  |-  inch)  diploe  is  met ; 
this  should  be  removed  by  curettes  as  thoroughly  as  possible  ;  then  cleanse 
and  pack. 

it  is  the  exception  to  find  the  pathological  condition  as  clearly  defined  as 
is  here  given;  caries  is  very  apt  to  complicate;  and  if  during  the  operation 
carious  bone  is  found,  it  should  be  thoroughly  removed,  care  being  taken  to 
avoid  wounding  the  dura  mater,  the  facial  nerve,  and  the  labyrinth.  Not 
infrequently  the  roof  of  the  mastoid  next  the  cerebrum  is  carious,  also  the 
inner  posterior  wall  next  the  lateral  sinus  and  cerebellum;  these  carious 
spots  should  be  removed  by  a  curette,  the  dura  being  pushed  back  from  the 
bone.  Narrow  gauze  strips  can  be  carried  into  any  crevice  to  stay  the  bleed- 
ing, and  cleanse  for  thorough  inspection.  At  any  stage  of  any  operation  the 
removal  of  a  small  chip  of  hone  may  expose  a  gray  shining  membrane,  which 
i-  a  signal  of  danger;  it  may  be  cholesteatoma,  pyogenic  membrane,  or  dura, 
and  must  be  examined  carefully  before  proceeding.  Extensive  caries  may 
require  enlargement  of  the  whole  original  opening. 

The  only  cases  which  are  exceptions  to  the  above  general  rules  of  oper- 
ating are  those  in  which  there  has  been  extension  of  the  internal  suppuration 
through  a  carious  fistula  <;/'  the  cortex — outward  through  the  external  cortex, 
forward  through  the  anterior  cortex,  or  downward  into  the  neck  through  the 
mastoid  floor.  With  extension  outward,  incise  the  periosteum  as  in  the  regular 
operation,  expose  the  fistula  and  follow  tin-  in.  clearinj  away  all  softened 
bone,  and  within  the  mastoid  he  guided  by  the  existing  conditions  as  described 
above.  With  extension  forward,  after  the  firs!  incision  expose  the  posterior 
wall  of  the  osseous  meatus  by  pushing  the  periosteum  forward,  ami  the  fistula 
can  be  -ecu  and  followed.  With  extension  downward,  fistula  are  to  he  looked 
for  in  the  base  of  the  mastoid  ;  this  can  be  done  by  deflecting  the  periosteum 


796  OPERATIONS. 

from  the  posterior  aspect  of  the  mastoid  tip  and  then  passing  a  bent  probe 
or  director  beneath  the  periosteum  along  the  digastric  fossa  which  constitutes 
the  base  of  the  mastoid.  Having  thus  found  the  fistula,  remove  the  outer 
surface  of  the  tip,  exposing  the  interior  of  the  bone  together  with  the  fistula, 
and  cleanse  as  in  the  other  varieties. 

These  fistulse  are  always  to  be  suspected  and  carefully  looked  for  when  the 
external  tissues  are  edematous  and  swollen  ;  they  are  almost  certain  to  exist 
whenever  any  pus  is  found  between  the  periosteum  and  the  bone;  with  ex- 
tension outward  the  edema  begins  on  the  external  surface;  with  extension 
forward,  on  the  posterior  wall  of  the  meatus;  with  extension  downward, 
beneath  the  mastoid  in  the  neck,  early  assuming  the  characteristics  of  a 
cellulitis,  which  may  form  an  abscess  anywhere  in  the  neck  beneath  the 
deep  fascia  and  burrow  extensively,  even  into  the  pleura.  Next  to  the  exten- 
sions to  the  brain  these  inflammations  in  the  neck  are  the  most  serious  com- 
plications of  mastoiditis,  sometimes  requiring  deep  dissections  of  the  neck, 
even  to  the  vertebrae,  in  order  to  evacuate  the  pus. 

With  extensions  toward  the  brain  upward,  inward,  and  backward,  the 
tvmpano-mastoid  exenteration  is  usually  necessary. 

The  tympano-mastoid  exenteration  is  well  described  by  the  name  ; 
it  is  an  evisceration  of  the  interior  of  the  bone  by  making  the  mastoid, 
antrum,  tympanum,  epitympanum,  and  meatus  one  large  cavity  with  perfectly 
smooth  and  healthy  walls,  by  removing  the  external  cortex  of  the  mastoid,  its 
entire  cancellated  structure,  the  posterior  osseous  meatus-wall,  the  tympanic 
membrane,  the  malleus  and  incus,  and  the  outer  wall  of  the  epitympanum.  It 
is  indicated  for  simple  caries  of  the  bone  which  cannot  be  reached  by  the  ordi- 
narv  antrum  operation — i.  e.,  caries  of  the  tympanum,  epitympanum,  adit  us 
and  extensive  caries  of  the  mastoid,  and  also  for  cholesteatoma  of  the  mas- 
toid and  tympanum.  The  variations  in  formation  of  the  bone,  the  low-lying 
roof,  the  outward  curvature  of  the  lateral  sinus,  the  extensive  cancellated 
structure,  are  of  as  much  importance  to  the  surgeon  in  this  as  in  the  antrum 
operation.  The  same  may  be  said  of  the  measurements  given  in  speaking  of 
the  antrum  operation.  In  addition,  in  this  operation  the  danger  of  wound- 
ing the  facial  nerve  is  much  increased  ;  and  the  course  of  the  Fallopian  canal 
;ui' I  its  relations  to  the  floor  of  the  aditus  and  to  the  posterior  osseous  meatus 
should  be  continually  in  mind,  as  well  as  the  relations  of  the  external  semi- 
circular canal. 

There  are  two  methods  of  getting  at  the  antrum  and  aditus:  one  advo- 
cated by  Sch wart zc,  Zaufal,  and  their  followers,  who  open  from  behind  for- 
ward .  the  other  advocated  by  Stacke,  who  opens  from  in  front  backward. 
The  former  extirpate  the  posterior  superior  membranous  lining  of  the  osseous 
meatus  ;  the  latter  saves  it  to  make  a  flap  for  covering  the  exposed  bone. 

The  former  operation  is  divided  into  seven  steps: 

( 1 1   Exposure  of  the  operative  field  ; 

(2)  Extirpation  of  the  posterior  and  superior  lining  of  the  osseous 
meatus  ; 

(.",)  Exposure  of  the  antrum  by  chiselling  away  the  mastoid  and  pos- 
terior osseous  meatus  ; 

(  1)   Removal  of  the  par-  epitympanica  ; 

(•">)   Exenteration  of  the  tympanum  and  mastoid  ; 

(6)  Stitching  and  bandaging  ; 

(7)  After-treatment. 

For  i  he  firsl  step  incise  over  the  middle  of  the  mastoid  from  2  cm.  above 

the  lmea  temporalis  to  '1  cm.  below  the   tip,  and    from    (lie   upper  end  of    this 


T  \  rMPA  NO-MA  STOID  EXENTERA  Tl  ON. 


797 


cut  make  a  horizontal  incision  forward  for3to4  cm.  and  backward  also  for  '■'>  to  1 
cm.  From  these  cut-  expose  the  entire  mastoid  by  making  a  skin-periosteal  flap 
forward  to  the  meatus  and  the  same  backward.  Secondly,  separate  the  car- 
tilaginous from  the  osseous  meatus  on  its  posterior  and  superior  circumference, 
then  incise  the  skin  of  the  upper  anterior  wall  of  the  osseous  meatus  from  the 
tympanic  ring  outward  ;  parallel  with  and  opposite  this  make  a  similar  incision 
along  the  posterior  lower  wall  of  the  meatus;  separate  from  the  hone  all  of 
the  skin  included  between  these  incisions  on  the  upper  wall  from  wit  limit 
inward  and  remove  it  with  scissors,  thus  thoroughly  exposing  the  upper  and 
posterior  walls  of  the  meatus.  Thirdly,  enter  the  antrum  as  already  de- 
scribed in  the  antrum  operation,  and  then  remove  the  wedge  between  this 
opening  and  the  tympanum  by  chisels,  or  else  chisel  away  the  bone  at  once 
from  the  antrum  surface  (place  of  election  for  the  antrum  opening)  forward 
into  the  osseous  meatus,  without  first  entering  the  antrum,  going  deeper  and 
deeper  until  mastoid,  antrum,  aditus,  tympanum,  and  meatus  are  united  by  a 
deep  groove  in  the  bone  (Fig.  525).  Check  all  bleeding,  and  the  tympanic 
membrane  or  its  remnants  are  now  visible.    Fourthly,  separate  any  portions  of 


Fig.  525.—  Tynipano  mastoid  exenteration  (soft  parts  not  shown).  The  wall  of  the  sigmoid  sulcus  is 
seen  in  the  back  of  the  mastoid  opening,  and  the  ridge  of  the  bone  protecting  the  facial  is  preserved 
between  this  and  the  meatus.  If  the  mastoid  is  diseased,  Its  whole  external  cortex  should  be  removed 
to  the  very  tip. 

the  drum  membrane  which  exist  at  the  tympanic  ring  and  remove  them  to- 
gether with  the  malleus  by  forceps  ;  disarticulate  the  incus  from  the  stapes  and 
remove  it  by  forceps  (see  Operation  for  Carious  Ossicles,  page  791)  \  it  is 
usually  buried  in  swollen  mucous  membrane  and  granulations.  Now  push  the 
mucous  membrane  of  the  epitympanum  inward  and  remove  the  whole  floor  oi 
that  cavity  by  gouge  and  mallet  and  curette  till  the  roof  of  the  epitympanum 
passes  without  any  ridge  into  the  upper  wall  of  the  meatus  (Fig.  526). 
Fifthly,  clean  out  all  the  cavities,  removing  all  cancellated  structure,  all 
prominences  and  ridges,  making  every  pari  smooth,  beginning  with  the  mas- 
toid, then  respectively  antrum,  epitympanum,  roof  ,<{'  tympanum  and  its 
walls.       Examine  every  portion   of  the  remaining   walls   for   caries   with   a 


r98 


OPEL' A  TIOXS. 


Fig  526.—  Section  of  tympanum  and  canal, 
showing  by  dotted  line  at  (d)  the  wedge  of  bone 
removed  to  open  the  attic 


right-angled  probe,  especially  the  posterior  wall  of  the  antrum  and  its 
lower  inner  corner  next  the  lateral  sinus;  and,  if  anything  suspicious  is 
found,  remove  it,  even  if  it  exposes  the  dura.     Wipe  dry  with  pledgets  of 

gauze,  taking  care  to  remove  all  bits 
of  bone.  Finally,  split  the  cartilag- 
inous meatus  from  near  the  concha 
throughout  its  length  along  its  pos- 
terior wall,  thus  making  two  triangu- 
lar Haps  (Fig.  526).  Sixthly,  stitch 
the  horizontal  wounds  and  2  to  3  cm. 
of  the  upper  part  of  the  perpendicular 
wound,  laying  the  skin-periosteal  Hap 
carefully  against  the  bone;  stitch  the 
corners  of  the  meatus-ilaps  above  and 
below  into  the  skin  so  as  to  stretch 
them  up  and  down,  and  then  pack  the 
tympanum  and  antrum  with  iodoform 
gauze  from  the  meatus,  and  similarly 
till  the  mastoid  from  the  wound  ;  add 
an  aseptic  dressing  and  bandage. 
Seventhly,  the  after-treatment  requires  the  most  careful  personal  attention  of 
the  surgeon.  The  healing  must  take  place,  not  by  the  cavities  filling  with 
granulations,  but  by  granulation  of  the  entire  surface  merely,  which  must 
then  become  covered  by  a  firm,  dry  epidermis.  The  two  chief  points  are  to 
keep  the  wound  aseptic  and  to  keep  down  redundant  granulation-tissue,  which 
can  only  be  done  by  keeping  the  whole  cavity  packed  firmly  with  iodoform 
or  sterile  gauze,  every  little  crevice  receiving  attention.  If  granulations  be- 
come prominent,  they  must  be  removed  by  the  snare,  by  argentic  nitrate,  or 
by  the  galvano-eautery. 

The  details  of  Stackers  operation  are  as  follows  : '  Make  a  curved  incision 
at  the  insertion  of  the  auricle  or  close  to  it  from  the  temporal  region  to  1  em. 
below  the  tip  of  the  mastoid  through  the  skin  and  subcutaneous  tissue  only. 
Dissecl  oil'  the  -oft  parts  above  the  linea  temporalis  outside  of  the  temporal 
fascia  and  draw  them  downward.  From  the  linea  temporalis  downward  ex- 
tend the  firsf  cut  through  the  periosteum  and  along  the  linea,  make  a  cross- 
cut forward  through  the  periosteum,  thus  making  a  triangular  flap  of  perios- 
teum, which  is  then  raised  by  a  raspatory  as  far  as  the  v^ixc  of  the  osseous 
meatus;  then  with  a  narrow  elevator  raise  the  membranous  meatus  from  the 
bone  deeply  into  the  osseous  meatus  till  the  whole  posterior  and  upper  osseous 
meatus  i-  visible  by  drawing  the  parts  forward.  The  whole  mastoid  should 
then  be  exposed  by  pushing  its  periosteum  backward,  if  necessary  making  a 
cross-cut.  If  a  fistula  or  discolored  cortex  exists,  follow  this  into  the  antrum ; 
then  remove  the  posterior  wall  of  the  meatus  and  epitympanum. 

If  no  fistula  exists,  with  a  small  curved  scalpel  cul  the  posterior  and 
upper  membranous  meatus  as  near  the  tympanic  ring  as  possible,  and  draw 
this,  together  with  the  loosened  auricle,  forward  by  a  blunt  hook.  After 
checking  bleeding,  the  membrana  tympani  is  visible;  and  the  whole  mem- 
branous meatus  is   retained  to  cover  the  bone. 

'fhe  ue\t  stage  is  the  exenteration  of  the  tympanum  by  removing  the 
drum  membrane  or  it-  remnants,  together  with  the  malleus.  Then  place  a 
gouge,  benl  slightly  backward  (Fig.  527),  some  millimeters  above  the  free 
edge  of  the  epitympanum  and  separate  the  bone  by  short  light  blows  with  a 

1  Die  operative  Freilegung  der  Mittelohrraume,  Tubingen,  1897. 


TYMPANO-MASTOID   EXENTERA  TION. 


799 


mallet,  measuring  the  depth  of  the  epitympanum  with  a  benl  probe,  and 
continue  removing  the  bone  till  the  roof  df  the  epitympanum  is  smooth  and 
continuous  with  the  upper  wall  of  the  meatus.  The  incus  is  now  .-ecu  and 
removed. 

Next  pass  a  probe  along  the  tegmen  tympani   into  the  aditus  and  with  a 
small  gouge,  bent  backward,  remove  the  posterior  superior  meatus-wall  into  the 

Ilium  H  ill  1 1  Vi'n:nTmTTCTnl 


Fig  527. — Stacke's  gouge  for  removing  the  canal  wall 

aditus  until  the  probe  freely  enters  the  antrum  and  a  good  orientation  of  every 
part  is  obtained.  Instead  of  the  probe,  Stacke  uses  a  protector,  as  he  calls 
it.  The  external  cortex  and  lateral  portion  of  the  posterior  meatus-wall  is 
now  removed  in  large  pieces  by  the  chisel,  the  position  and  size  of  the  antrum 
being  known,  and  the  antrum  changed  from  a  fistulous  cavity  into  a  narrow 
trough,  which  passes  smoothly  into  the  upper  and  lower  meatus-walls  without 
corners  or  sinuses.  Medialwards  the  so-called  spur  between  the  antrum  and 
tympanum  must  be  smoothed,  the  now  visible  facial  prominence  forming  the 
lower  limit,  which  it  is  impossible  to  touch  without  endangering  the  facial 
nerve.  From  the  height  of  this  prominence  the  spur  must  be  sloped  off  till 
it   entirely  disappears   laterally  in   the   lower   meatus-wall.     Here  a   minute 


Fig   528— Auricle  and  cartilaginous  canal  turned  forward  for  Stacke-Schwartze  operal  loued 

lines  at  I  shown.  removed, and  at  P,S.  the  flaps  to  be  transplanted  into  the  gap(Vuipiusj 

The  writer  makes  hut  one  flap  withoul  cutting  at  /'.  as  do  most  operators. 

artery  of  the  b ■  is  often  encountered  ;  and  bleeding  from   it  can  be  besl 

checked  by  rubbing  it-  orifice  with  a  blunt  instrument.  All  pathological 
products  can  now  be  removed  under  inspection,  working  carefully  in  the 
tympanum  to  avoid  the  stapes.  The  hypotympanum,  as  it  i-  called  by 
Kretschmann,  only  remains,  and,  except   with  caries  of  the  tympanic  floor, 


800  O  PER  A  TIOJVS. 

it  is  unnecessary  to  remove  it  ;  the  danger  to  the  facial  nerve  is  very  greal 
here.  With  cholesteatoma,  after  removing  everything  macroscopically 
pathological,  Stacke  grinds  down  the  bone  -with  burrs  on  an  electromotor 
engine  to  remove  any  pathological  masses  in  the  Haversian  canals.  Lastly, 
if  the  cells  of  the  mastoid  toward  the  tip  are  involved,  they  should  be 
cleaned   out. 

Finally,  the  last  stage  of  the  operation  is  to  make  a  Hap  from  the  mem- 
branous meatus  to  cover  the  bone  as  far  as  possible.  This  is  done  by  making 
a  horizontal  cut  parallel  with  the  axis  of  the  meatus  and  along  the  middle 
of  its  upper  wall  from  close  to  the  concha  to  its  inner  end;  perpendicular 
to  this,  close  to  the  concha,  make  a  second  cut  downward  and  backward  so  as 
to  make  a  rectangular  Hap  (  Fig.  528).  Now  tampon  tympanum,  epitympauum, 
and  aditus  with  small  pieces  of  gauze,  and  then  through  the  meatus  tampon 
this  rectangular  Hap  to  cover  the  bone  between  the  meatus-wall  and  the  floor 
of  the  antrum.  The  upper  part  of  the  wound  is  sutured  into  position  and 
an  aseptic  dressing  applied. 

The  final  result  by  either  method  of  operating  is  the  same  ;  the  mastoid, 
antrum,  aditus,  tympanum,  epitympanum,  and  meatus  are  turned  into  one 
large,  continuous  cavity  with  smooth  walls  which  must  become  covered  with 
a  dry,  firm  epidermis.  This  epidermis  can  only  grow  from  other  epidermis 
which  must  extend  inward  from  the  external  edges  or  be  transplanted  into 
the  cavity.  This  transplantation  can  be  by  Thiersch  grafts  after  the  bone 
ha-  become  covered  with  small,  firm  granulations,  and  also  by  turning  into 
the  cavity  a  flap  of  skin  taken  from  the  outside  ;  the  latter  implies  a  perma- 
nent opening  behind  the  auricle.  There  is  necessarily  a  large  surface  of 
exposed  bone  from  tin-  operation,  and  the  more  this  can  be  covered  at  the 
time  the  quicker  the  healing  and  the  less  the  risk  of  caries;  and  the  more 
epidermis  there  is  in  the  cavity  the  more  rapidly  will  epidermization  of  the 
whole  take  place.  Various  methods  of  covering  the  bone  and  obtaining  epi- 
dermis have  been  proposed.  One  is  in  the  first  exposure  of  the  mastoid  to 
cut  down  to  the  tip  in  front,  then  around  the  tip  and  upward  at  the  posterior 
edge  of  the  mastoid,  then  dissect  up  the  skin  alone  and  turn  it  upward  for 
one  flap  ;  next  dissect  up  the  entire  periosteum  of  the  mastoid  from  above 
and  turn  it  down  for  a  second  flap,  so  that  after  completion  of  the  operation 
these  flaps  can  be  tamponed  over  the  bone.  Another  is  to  turn  in  a  Hap 
of  -km  taken  from  the  neck;  while  still  another  is  to  dissect  up  the  skin 
behind  the  mastoid,  to  take  from  this  place  as  large  a  Hap  of  periosteum  as 
i-  desirable  to  turn  in,  and  then  replace  the  skin  againsl  the  bone,  where  it 
-(ion  adhere-.  I  have  practised  the  first  two  methods  with  satisfaction.  The 
last  I  have  never  used  ;  it  has  the  disadvantage  of  not  supplying  any  of  the 
desired  epidermis. 

Although  the  operation  for  cholesteatoma  is  the  same  as  for  caries,  the 
surface  affected  by  the  growth  requires  special  treatment  ;  not  only  the  whole 
investing  membrane,  if  any,  should  be  thoroughly  curetted  away,  but  the 
surface  of  the  underlying  bone  should  be  a-  thoroughly  curetted  as  its  posi- 
tion admits  t<>  remove  any  growth  in  the  Haversian  canals.  Zaufal  advocates 
cauterizing  it  with  :i  Paquelin  cautery  ;  Stacke  uses  an  electromotor  engine 
instead  of  the  curette. 

The  after-treatment  of  the  cavity  is  tedious,  lasting  from  three  to  six 
month-;  the  tamponing  must  be  kept  up  till  epidermization  has  covered  the 
greater  part  <»('  the  cavitv  ;  it  cannot  be  omitted  till  at  least  one  of  any  two 
Opposing  surfaces  :ire  skin-COVered.  When,  however,  epidermization  i<  well 
advanced,  the  omission  of  the  tampon-  and  exposure  t<>  the  air  will  hasten 


( >  Tl  Tit '  B /.'.  I  IN- nisi:.  I SES. 


801 


the  cure.  Aristol  and  dermatol  in  powder  are  important  aids  to  epidermiza- 
tion  and  to  proted  the  young  epidermis  from  maceration. 

The  tympano-mastoid  exenteration,  whatever  method  of  performing  it 
experience  may  finally  determine  to  be  best,  seems  to  me  destined  to  take  an 
important  position  not  only  in  the  surgery  of  chronic  otorrheas,  but  also  in 
the  surgery  of  the  otitic  brain-diseases. 

The  otitic  brain-diseases  are  : 

(1)  Pachymeningitis  externa  purulenta,  with  extradural  aba 

(2)  Leptomeningitis  purulenta,  or  arachnitis; 

(3)  Phlebitis  and  thrombosis  of  the  sinuses  and  of  the  jugular; 

(4)  Abscess  of  the  brain,  or  encephalitis. 

The  brain-disease  is  due  to  infection  of  the  brain  from  the  infected  ear, 
the  infectious  material  reaching  the  brain  through  disease  of  the  bone  next 
the  dura,  through  the  natural  communications  which  lead  from  the  ear  to  the 
inside  of  the  cranium,  or  through  some  of  the  tissue-connections,  blood-ves- 
sels, or  connective-tissue  fibrils,  which  pass  into  and  through  the  bone  from 
both  tympanum  and  dura.  If  the  extension  takes  place  through  the  roof 
of  the  temporal,  tin1  brain-disease  is  in  the  cerebrum  ,  if  through  the  inner 
wall,  the  brain-disease  is  in  the  cerebellum. 

The  following  table  of  otitic  diseases  from  Korner '  has  a  most  important 
bearing  on  the  surgery  of  these  diseases  : 


Sinus  diseases  . 
Brain-abscesses. 
Meningitides.    . 


Total. 


39 
40 
30 


109 


Bone  diseased  to 
dura. 


32  =  82  per  cent. 
37  -  92 
17  =  o7 


86  =  79  per  cent. 


Bone  diseased,  but 
not  to  dura 


3=   7.7  per  cent. 
1=   2  5 
4=13.3 


8=   7.3  percent. 


Bone  healthy. 


4  =  10  per  cent. 
2=   5       " 
9  =  30       " 


15  =  13.7  p 


■nt. 


The  tympano-mastoid  exenteration,  with  modification  for  circumstances, 
in  many  cases  is  the  best  operation  for  these  intracranial  diseases  ;  for  as  the 
ear  is  the  original  pus-focus,  still  active  and  still  infecting,  it  should  be  the 
first  point  to  attack.  This  is  the  only  operation  which  exposes  at  once  the 
entire  roof  of  the  antrum,  aditus,  and  tympanum,  and  also  the  inner  wall  of 
the  mastoid,  thus  allowing  a  thorough  exploration  of  most  of  the  spots 
whence  transmission  of  infection  to  the  brain  occurs.  It  also  allows  the 
most  perfect  drainage  by  evacuating  the  pus  at  its  most  dependent  position. 
In  many  cases,  moreover,  while  we  may  feel  confident  of  the  existence  of 
intracranial  disease,  we  are  unable  to  define  its  nature  exactly  ;  in  other  cases, 
while  reasonably  certain  of  our  diagnosis  of  the  brain-trouble,  we  cannot  be 
sure  of  its  exact  location  ;  again,  in  a  very  considerable  proportion  of  cases 
the  surgeon  first  sees  the  patient  when  the  brain-disease  is  so  active  that  time 
is  more  important  than  an  accurate  diagnosis.  In  all  of  these  classes  of  cases 
a  thorough  exposure  of  the  interior  of  the  bone  is  the  primary  step  for  diag- 
nosis, localization,  and  treatment;  in  this  sense  the  operation  on  the  bone  i-^ 
often  exploratory.  If  any  justification  of  this  course  is  necessary,  it  is  seen 
in  the  fact,  shown  in  the  table  above,  that  in  7!t  per  cent,  of  all  otitic  brain- 
diseases  the  bone  i-  diseased  directly  upon  the  dura,  and  the  operation  on  the 
hone  means  following  the  disease  inward.  I  would  emphasize  this  necessity 
of  operating  early  in  intracranial  disease  without  waiting  for  an  accurate 
diagnosis;  for  in  a   large  number  of   cases  the  full  < rplex  of  symptoms 

1  Die  Otitische  Erkrankmujiu  >!,,  Hints,  drr  Hirn/tiiutr  und  <h:r  B  rankfort,   LJ 

51 


802 


OPERA  TIONS. 


necessary  for  a  perfect  localized  diagnosis  only  appear.-  a  few  hours  before 
death. 

Having  performed  the  tympano-mastoid  exenteration  in  a  case  showing 
brain-symptoms,  disease  of  the  bone  next  the  brain  should  be  sought  by  a 
careful  examination  of  the  whole  superior  and  interior  walls  of  the  cavity. 
The  diseased  bone  may  be  only  a  point  not  larger  than  the  end  of  a  probe  ; 
if  found,  it  should  be  removed  with  curettes,  and  the  opening  enlarged  l>y 
curettes  or  rongeurs. 

With  pachymeningitis  externa  (extradural  abscess),  pus  is  immediately 
evacuated  and  the  dura  cleansed.  If  the  disease  is  in  the  middle  fossa  the 
only  complications  are  arachnitis  and  brain-abscess;  a  fistula  through  the 
dura  renders  one  or  the  other  probable,  and  such  a  fistula  should  then  he 
sought  :  it'  not  found,  the  opening  in  the  hone  should  he  enlarged  so  far 
a-  the  anatomical  situation  will  allow,  thorough  drainage  established  by 
wick-  of  sterile  gauze,  and  the  wound  dressed  often  enough  to  keep  it  free 
from  collection-  of  pus,  usually  daily.  The  dura  becomes  bovered  with 
granulations  which  adhere  to  the  edges  of  the  hone,  and  finally  is  covered 
by  epidermization  of  the  cavity. 

Sinus-thrombosis. — If,  however,  the  pachymeningitis  is  in  the  cere- 
bellar fossa,  besides  the  possibility  of  arachnitis  and  brain-abscess,  phlebitis  of 
the  lateral  nuns  should  he  looked  for,  as  it  is  a  very  common  complication.  It 
can  usually  be  recognized  by  feeling  the  cord  of  a  thrombus;  hut  in  case  of 
doubt  the  sinus  can  he  explored  by  aspiration,  when  we  get  purulent  serum  if 
the  thrombus  is  broken  down  at  the  point  of  puncture,  no  fluid  of  any  kind  if 
the  thrombus  is  firm,  and  venous  blood  if  there  is  no  thrombus,  if  throm- 
bosis exists,  the  -inns  should  he  exposed  from  its  upper  to  its  lower  curve  by 
removing  the  hone  with  curettes,  rongeurs,  or  an  engine,  laid  open  freely, 
and  the  thrombus  withdrawn  hoth  from  behind  and  from  below  SO  far  as  it 
i-  broken  down,  and  the  vein  cleansed.  Hemorrhage  from  removal  of  the 
thrombus  has  never  been  reported,  I  believe;  should  it  occur.it  can  he 
checked  by  a  tampon  of  iodoform  gauze.  Before  opening  the  -inns,  how- 
ever, the  internal  jugular  had  better  he  ligated  to  prevent  displacement  of 
thrombi  and  general  infection  ;  hut  the  dangers  of  a  prolonged  operation 
or  infiltration  of  the  neck  from  a  gravitation-abscess  through  the  base  of 
the  mastoid,  or  from  periphlebitis,  may  render  this  ligation  inadvisable  or 
impossible. 

fhc  following  table  from  Korner  is  certainly  in  favor  of  the  ligation  : 


Operations  <>n  the  Lateral  sinus 


With  ligation  of  jugular 
Withoul  lii::iU'>ii  ><(  jugulai 


Cured 


26  =  63.4  per  cent. 

16  =  42       per  cent. 

42  per  cent. 


Cured 

Dii 

■i 

Total. 

Ligation  before  evacuation  of  Binus 

on  after             " 
Ligation  without         '" 

n  between  beginning  and  end 
of  evacuation      ■ 

19 

ti 
1 

0 

per  cent 
60     per  cent. 
50     per  cent. 

4 

1 

1 

10 

per  cent. 

per  cent 
per  rent. 

28 

10 

1 

41 

CA  t  rSF  OF  J)  /•;.  i  77/  OF  L  E  TIL  I  /.    CA  SES.  803 

('a use  of  Death  <>/'  Above  87  Gases: 

Pyemia  with  Lung-abscess<  - 12 

Pyemia  without  lung-abscesses 5 

Leptomeningitis \\ 

Leptomeningitis  and  pyemia 3 

Brain-abscess 2 

Shock ] 

Not  determined      3 

37 

If  a  fistula  through  the  dura  is  found,  arachnitis  or  brain-abscess  is  prob- 
able; to  distinguish  which  is  present  is  often  impossible.  II'  the  former,  the 
case  is  hopeless;  if  the  latter,  there  is  a  possibility  of  cure.  If  the  fistula  is 
toward  the  cerebrum,  the  dura  should  be  exposed  over  an  extended  surface, 
if  possible,  as  large  as  ."!  cm.  in  diameter,  by  cutting  away,  if  Decessary,  the 
linea  temporalis;  if  toward  the  cerebellum,  by  cutting  away  the  posterior 
portion  of  the  mastoid.  The  dura  should  then  be  opened  by  a  crucial  in- 
cision, and  if  the  abscess  lias  reached  the  surface,  as  is  often  the  ease,  pus  is 
immediately  evacuated  and  the  abscess  can  be  freely  opened.  If  only  a  small 
fistula  is  seen  in  the  brain-tissue,  or  if  no  fistula  is  seen,  the  brain  musl  be 
explored  with  a  director.  J  low  dee])  this  exploration  can  be  carried  without 
injuring  specially  important  parts  is  of  great  consequence.  These  special 
part-  are  the  anterior,  inferior,  and  posterior  horns,  the  lenticular  nucleus, 
and  the  inner  capsule  ;  these  can  beavoided  by  confining  the  exploration  to  2\ 
cm.  (1  inch)1  perpendicularly  inward  from  the  surface  of  the  dura  and  4  cm. 
(11  inches)  at  an  angle  of  45  degrees  with  the  surface;  from  the  base  of  the 
brain  upward  the  exploration  can  be  carried  to  any  distance,  provided  it  i- 
kept  outside  of  2?,  cm.  from  the  lateral  surface.2 

Exploration  having  proved  the  presence  of  an  abscess,  the  exploratory 
puncture  should  be  enlarged  by  tearing,  the  abscess  thoroughly  evacuated, 
drained  by  gauze  wicks,  and  subsequent  drainage  provided  for  in  the  dressing. 

In  case  of  doubtful  diagnosis  or  localization,  this  plan  of  following  the 
disease  inward  by  a  tympano-mastoid  exenteration  or  some  modification  of  it 
i-  often  best   in  my  opinion  ;  but  it  has  its  distinct  limitations  due  (  1  )  to  the 

condition  of  the  1 e,  (2)  to  theabscess   lying  beyond   reach  from  the  ear. 

Under  the  first  we  may  have  such  a  bony  sclerosis  or  such  a  low  roof  and 
projecting  Fallopian  prominence  or  such  an  outward  and  forward  curvature 
of  thr  sigmoid  groove  as  to  forbid  an  opening  sufficiently  large  for  the  brain- 
operation.  Under  the  second  are  the  very  exceptional  abscesses  in  the  frontal 
or  occipital  lobes,  abscesses  in  the  upper  convolution  of  the  temporal  lobe, 
and  some  abscesses  of  the  cerebellum. 

If  the  condition  of  the  bone  forbids  the  opening  through  the  ear,  bearing 
in  mind  the  statistics  which  show  that  the  chances  are  SO  in  100  tin'  brain- 
disease  is  directly  connected  with  the  bone,  any  exploration  should  be  close 
to  the  bone.  To  get  at  the  mastoid  and  tympanic  roof  the  skull  may  be 
opened  ;it  a  point  \  em.  horizontally  backward  from  a  point  2  em.  above  the 
upper  edge  of  the  osseous  meatus,  the  dura  opened  and  exploration-  made  as 
already  described.  To  get  al  the  inner  surface  of  the  mastoid  the  posterior 
portion  of  that  bone  can  be  removed  till  the  dura  i-  fully  exposed  for  at  least 
2  em.  behind  the  lateral  -inns  ;  exploration-  can  then  be  made  in  the  cerebel- 
lum in  any  direction  to  the  depth  of  3.5  em.  inside  the  lateral  -inn-.  Another 
method  of  exposing  the  cerebellum,  where  the  mastoid  is  so  1 1<  .1  \  \  or  sclerosed 
as  to  make  the  above  operation  inadvisable,  is  to  stnke  a  basal  line  from  the 

1  Hansberg:  Archive*  "f  Otology,  Jan.,  1895.  Measun  •■      ts  for  an  adult  brain 


804  OPERATIONS. 

inferior  osseous  edge  of  the  orbit  to  the  occipital  protuberance,  and  to  open 
the  skull  on  this  line  5  to  7  cm.  back  from  the  edge  of  the  osseous  meatus, 
just  below  the  superior  curved  Line  of  the  occipital  bone. 

Abscesses  beyond  reach  from  the  car  can  only  be  diagnosticated  by  a  com- 
plete complex  of  Localizing  symptoms;  where  such  a  diagnosis  can  be  made, 
the  skull  must  be  opened  over  the  -cat  of  this  abscess.  To  reach  the  upper 
or  first  temporal  convolution,  enter  the  skull  2  cm.  back  from  a  point  3  to 
3.5  cm.  above  the  upper  edge  of  the  osseous  meatus;  to  get  at  frontal  or  occi- 
pital abscesses,  open  over  their  -cat  as  determined  by  previous  localizing  symp- 
toms :  for  them  no  rules  can  be  given. 

I  would  here  utter  a  caution  about  the  dangers  of  the  trephine,  at  least 
on  the  squamous  portion  of  the  bone,  which  varies  very  much  in  thickness  in 
different  parts,  and  the  trephine  may  easily  enter  the  brain  at  one  part  of  its 
circumference  some  time  before  it  has  penetrated  the  bone  in  another  part. 
In  my  opinion  the  only  proper  instruments  are  chisel  and  mallet,  round  burrs 
for  thinning  the  inner  cortex,  and  rongeurs  to  enlarge  the  first  opening  made. 

Hesitation  should  always  be  felt  in  regard  to  opening  the  dura;  it  is 
justified  only  by  the  existence  of  a  fistula  in  it  or  by  urgent  symptoms  point- 
ing to  the  encephalon,  exclusive  of  arachnitis.  Explorations  can  be  carried 
to  the  dura  with  very  little  risk  ;  it  is  a  fibrous  membrane  not  easily  infected  ; 
but  its  incision  exposes  the  arachnoid  and  pia,  which  are  extremely  sensitive 
to  infection,  and  prolapse  of  the  brain  is  very  apt  to  follow  withdrawal  of  the 
support  afforded  by  the  dura. 

Where  the  ear  cavities  are  not  opened  primarily,  they  must  receive  atten- 
tion after  the  brain-operation,  or  at  a  subsequent  operation  it  should  never  be 
forgotten  that  they  are  the  original  cause  of  the  brain-disease. 


THE  NOSE  AND  THROAT. 


NOSE   AND  THROAT. 


ANATOMY  OF  THE  UPPER  AIR-PASSAGES,  INCLUD- 
ING HISTOLOGY  AND  EMBRYOLOGY. 

By  HARRISON  ALU  ;\.  M.  1>.,  LL.D.,  and  ARTHUR  A.  BLISS,A.M.,M.D., 

<>F    PHILADELPHIA. 


EMBRYOLOGY  OF  THE  NOSE,  PHARYNX,  LARYNX, 
AND  TRACHEA. 

By  Dr.  Arthur  Ames  Buss. 

The  Nose. — The  development  of  the  nose  begins  about  the  fourth  week 
of  fetal  life. 

On  either  side  of  the  fore-brain  the  epiblast  becomes  thickened,  and  in 
the  center  of  the  nffactori/  arvu  thus  formed  a  depression  appeals,  the  olfac- 
tory depression.  This  assumes  a  pyriform  shape,  the  larger  opening  external, 
the  smaller  extending  backward  as  a  groove  toward  the  buccal  invagination, 
where,  very  early,  appear  the  rudiments  of  Jacobson's  organ. 

The  rudimentary  base  of  the  nose,  the  fronto-nasal  process,  appears  in 
the  median  line  at  the  lower  margin  of  the  fore-brain  (Fig.  529).  A  depres- 
sion exists  in  the  center  of  this  process,  and  on  either  side  of  the  depression 
are  the  mesial  nasal  processes,  their  bases  being  united  to  the  fronto-nasd 
process,  while  their  free  margins  terminate  in  tubercles — the  globvlar  ///"- 
cesses.     These  eventually  approach  one  another  until  they  unite  in  the  median 


l  n.  .-'  Stead  of  human  embryo,  show- 
ing above  the  oral  cavitj  thi  fronto  nasal  and 
mesial  nasal  pro* -    1 1 1 


I   [G 

tl,,-  development  "i  thi  'i  i"-" 

II: 


line  and  form  the  intermaxillary   process  and   middle  portion  of  the  upper 
lip.     A  depressed  surface  i-  left   between   them,  and  from  this  i-  formed  the 


M  )S 


ANATOMY  or  the  rm:i:  air-passages. 


i      Headofembryo,  partly  sec- 
tioned to  show  the  beginning  palatal 

processes  growing  inward  (His). 


lower  pari  of  the  nasal  septum.     During  this  development  the  globular  pro- 
cesses extend  backward,  also  bordering  the  space  which  will  become  eventually 

the  r.x.t'  of  the  mouth  (Fig.  530).  This  backward  extension  constitutes  the 
nasal  laminae,  by  the  development  of  which  the  nasal  septum  is  completed. 
Two  processes,  tin-  lateral  nasal  'processes,  with  bases  attached  to  the  fore- 
brain  on  either  side,  external  to  the  fronto-nasal  process,  grow  forward  around 
the  olfactory   depressions,  unite   in   the   median   line,  and  form   the  a  he  nasi. 

In  their  development  they  meet  the  maxillary 
processes,  also  growing  forward  to  the  median 
line,  and  between  the  maxillary  processes  and 
the  lateral  nasal  processes  is  found  a  groove  on 
either  side  of  the  head,  extending  from  the  eye 
to  the  nose — the  laervinal  groove.  The  maxil- 
lary  processes  as  they  approach  one  another 
come  in  contact  and  unite  with  the  free  ends  of 
the  globular  processes,  a  junction  which,  to- 
gether with  the  hrfcrma.viHcu-ji  process,  forms 
the  lip  and  upper  jaw,  thus  making  the  division 
between  the  anterior  part  of  the  nasal  passage 
and  the  buccal  cavity  (Fig.  531).  Posterior  to 
this  now  closed  anterior  part,  the  olfactory 
depressions  still  open  into  the  mouth  ;  but 
from  the  outer  sides  of  these  depressions  pro- 
cesses are  thrown  out  (Fig.  531)  which  develop 
into  the  turbinal  bodies,  while  gradually  the 
developing  palatine  processes  of  the  superior  maxilla,  outgrowths  from  the 
embryonic  maxillary  processes,  approach  the  lower  part  of  the  nasal  septum, 
and  unite  with  it  and  with  one  another  to  form 
the  roof  of  the  mouth  and  floor  of  the  nose.  The 
nares  and  buccal  cavity  are  thus  separated  from 
one  another  (Fig.  532),  except  in  the  extreme  pos- 
terior part  <»f  the  nasal  passages,  where,  in  the 
naso-pharynx,  is  found  the  fret'  opening  from  the 
nares  to  the  oro-pharynx. 

The     Mouth,     Pharynx,     Larynx,     and 
Trachea. — In    the   process   of  evolution   of  the 

embryo    from    the    blastoderm    the  three  embryonic 
layers  gradually  enfold  three  distincl  cavities,  called 

the  fore-gut,  the  hind-gut,  and,  between  them,  a 
-pace  which  long  remains  in  free  communication 
with  the  yolk-sack.  The  cephalic  portion  of  the 
embryo  is  bent  at  a  righl  angle  around  the  anterior 
part  of  the  fore-gut.  Below,  the  latter  is  bounded 
liv  the  heart.  A  thin  epithelial  membrane  sepa- 
rates the  fore-gut  from  the  involution  of  the  epiblasl  which  forms  the  buccal 
cavity,  or  stomodaum.  This  deepens,  projecting  upward  into  the  angle 
between  the  fore- and  mid-brain-,  where  the  pituitary  body  is  formed;  the 
epithelial  Beptum  between  the  buccal  cavity  and  the  fore-gut  disappears;  ami 
the  process  of  development  already  described  in  treating  of  the  growth  oJ 

the  nose  completes  the  formation  of  the  face  and  mouth.  The  anterior  pari 
of  the  fore-gut,  the  area  of  the  pharynx,  enlarges,  and  the  hypoplastic  layer 
throws  out  four  projections  on  either  side  in  order  from  above  downward. 
( Opposite  these  outgrowths  the  epiblastic  layer  projects  inward,  and  four  clefts 


Fk;.  532.  Head  oi  embiyo, 
showing  the  completed  union 
,.i'  the  constituents  of  the  nose 
and  lip  litis  ami  Quain), 


DIVISIONS    OF    THE    PHARYNX. 


809 


in  the  pharyngeal  wall  arc  thus  formed,  the  cephalic  visceral  clefts.     About 

them  the  pharyngeal  wall  thickens  into  five  curved  ridges,  the  cephalic  visceral 

arches.    A  forked  elevation  termed  the furcula separates  the  second  and  third 

visceral  arches(Fig.  533).    A  groove  passes  through 

its  center,  and  immediately  in  front  of  this,  in  the 

receding  angle  between  the  two  arms  of  the  second 

arch,  a  tubercle   projects,  the    tubercle  impar    (see 

Fig.  533).       The  second  and   third  arches  coalesce 

at  their  receding  angles  td  form  one  mass  with  four 

projecting  arms.      The    latter  grow  forward  into  a 

V-shaped   projection,  enclosing  the   tubercle  impar 

and   uniting    into    one  mass   to   form    the    tongue. 

The  epiglottis  is  developed  from  the  furcula,  and 

from   it  also  develop  the  ary-epiglottic  folds   and 

arytenoid  cartilages.     The  groove  seen  in  its  center 

extends  to  the  entrance  of  the  larynx. 

Of  the  visceral  clefts  the  first,  called  the  hvo- 
mandibular  cleft,  is  an  important  element  in  the 
formation  of  the  Eustachian  tube  and  middle  ear. 
The  median  base  of  the  branchial  rudiments  gradually  separates  from  the 
esophagus,  serving  as  a  partition-wall  between  the  latter  and  the  larynx 
and   trachea. 


Fig.  533.— Posterior  aspect  of 
the  visceral  arches  as  seen  from 
the  interlorof  the  pharynx  (His). 


ANATOMY    OF    THE    NASOPHARYNX,    PHARYNX,    LARYNX,    AND 

TRACHEA. 

The  Pharynx. — The  pharynx  is  the  common  entrance  to  the  respiratory 
and  digestive  tracts.  For  purposes  of  description  and,  also,  clinically,  it 
may  be  divided  into  three  distinct  areas — the  naso-  or  rhino-pharynx,  the 
oro-pharynx,  and  the  laryngo-pharynx  (Fig.  536). 

The  rhino-pharynx  lies  immediately  posterior  to  the  nasal  chambers  or 
posterior  nares.  It  is  slightly  quadrilateral  in  shape,  its  transverse  diameter 
measuring  about  one  and  three-eighths  inches,  while  its  antero-posterior  and 
vertical  diameters  are  about  three-quarters  of  an  inch. 

In  front  it  is  bounded  by  the  two  oval  openings  of  the  posterior  nares, 
with  the  rear  margin  of  the  vomer  in  the  median  line  (see  Figs.  535  and 
562).  This  margin  is  thin  below,  but  widens  into  two  lateral  arm-  or  wings 
above,  where  the  vomer  is  attached  to  the  body  of  the  sphenoid  bone.  The 
upper  surface  of  the  naso-pharynx  or  vault  is  formed  by  the  basilar  process 
of  the  occipital  bone  and  a  portion  of  the  body  of  the  sphenoid  bone  (see 
Fig.  434).  On  either  side  it  is  Hanked  by  the  pharyngeal  openings  of  the 
Eustachian  tubes  (see  Figs.  451,  562).  Its  floor  is  formed  by  the  sofl  palate 
and  by  the  opening  into  the  oro-pharynx. 

The  mouths  of  the  Eustachian  tubes  present  prominent  projections  on 
either  side  of  the  naso-pharynx,  formed  mainly  from  the  cartilage  of  the 
tube.  The  orifice  of  each  tube  lies  about  on  a  plane  with  the  posterior 
margin  of  the  vomer.  Its  exact  position  varies  in  different  subjects.  A 
well-defined  ridge  of  cartilage  roofs  the  tube  and  forms  it-  posterior  lip. 
The  ridge  is  less  prominent  in  front  than  above  and  behind  the  Eustachian 
opening.  It  i-  not  -ecu  below  the  orifice.  The  mucous  membrane  of  the 
oaso-pharynx  forms  a  distinct  fold  where  it  is  reflected  over  the  posterior 
lip  oi  the  tube  and  passes  thence  to  the  pharynx.  Luschka  terms  thi-  fold 
the  plica  salpingo-pharyngea.  \  similar  fold,  less  marked  however,  extends 
from  the  anterior  lip  of  the  tube  to  the  sofl  palate,  termed   by  Luschka  the 


810 


ANATOMY  OF  THE   UPPER   A  IB-PASSAGES. 


plica  salpingo-palatina.  A  crescent-shaped  depression  is  .-ecu  immediately 
behind  the  posterior  lip  of  the  Eustachian  opening — the  fossa  of  Rosenmuller. 
It  is  of  considerable  clinical  importance,  as  it  is  a  valuable  guide  in  the 
introduction  of  a  catheter  into  the  Eustachian  opening.  The  Eustachian 
openings,  closed  during  a  state  of  rest,  are  opened  by  the  contractions  of  the 
tensor  ami  levator  palati  muscles.     The  tensor  muscle,  termed  also  thespheno 


Sagittal  section  of  the  head  ami  neck,  showing  the  upper  air-passages,  beginning  al  tin'. 
DOBtril  <  l  >.  including  tin-  superior (5),  middle  (6),  and  inferior  (7)  nasal  meatus  beneath  the  corresponding 
turbinals,  the  sphenoid  sinus  (8),  the  Eustachian  tube  (10),  the  rhino-pharynx  and  Rnsenmuller's 
'ii  ai« .vi- iii, ■  soft  palate  (12),  the  oro-pharynx  (26),  and  fauces  (22),  and  the  laryngo-pbarynx  (27).  The 
trachea  i-  uol  Bnown  below  the  cavity  of  the  larynx  (2fi  with  its  ventricle  (29)  bordered  by  tin-  vocal 
cord  below  and  the  ventricular  band  above.  The  relation  of  the  epiglottis  (30)  to  the  larynx  below 
it  and  the  hyoidbone  (31  in  fronl  is  well  shown;  but  the  tongue  (17)  really  tills  the  mouth  normally 
and  lies  in  ('.intact  with  the  sofl  and  hard  palate  (14),  the  uvula  (21)  reaching  to  the  epiglottis,  as  the 
mouth  i--  nut  properly  a  part  of  the  air-passages  (Leidy). 

8alpingo-staphylinu8y  or  dilator  muscle,  arises  from  the  scaphoid  fossa  and 
base  of  the  internal  pterygoid  plate  of  the  sphenoid  hone,  and  from  the  front 
of  the  entire  cartilaginous  portion  of  the  Eustachian  tube.  Its  fibers  pass 
downward,  winding  around  the  hamular  process  of  the  sphenoid  hone,  and 
are  inserted  in  the  sofl  palate.  It-  contraction  dilates  the  tube  by  drawing 
the  anterior  margin  of  it-  cartilage  and  the  membranous  front  wall  dovi  nward 
and  forward  (see  Fig.  150).  The  levator  palati  muscle  arises  from  the  petrous 
portion  of  the  temporal  bone  and  from  the  cartilaginous  pari  of  the  Eustachian 
tube.  It-  fibers  are  inserted  by  a  broad  tendon  into  the  median  line  of  the  sofl 
palate  |  Fig.  535).  It-  function  is  to  lift  the  lower  wall  of  the  Eustachian  tube, 
which  tend-  to  separate  the  lateral  walls  and  open  the  tube.  The  palato- 
pharyngeu8  muscle,  described  Inter,  i-  also  partially  attached  to  the  cartilag- 
inous part  of  the  Eustachian  tube.  It  acts  as  an  aid  to  the  levator  palati 
muscle. 


STRUCTURE   OF    Till-;    NASO-PHARYNX, 


N]   1 


The  covering  of  the  naso-pharynx  consists  of  mucous  membrane  richly 
supplied  with  mucous  glands  and  having  a  covering  of  columnar  ciliated 
epithelium.  Beneath  the  mucous  membrane  lies  a  dense  fibrous  aponeurosis. 
which  is  the  upper  part  of  the  general  pharyngeal  aponeurosis.  It  is  firmly 
attached  to  the  basilar  process  of  the  occipital  hone  and  to  the  petrous  por- 
tion of  the  temporal  bone. 

In  certain  subjects  suffering  from  sclerotic  or  atrophic  rhinitis,  a  well- 
defined  ridge  is  seen  to  project  from  the  posterior  and  lateral  walls  of  the 
naso-pharynx  about  at  the  level  of  the  free  margin  of  the  sofl  palate.  Act- 
ing with  the  palate,  when  the  latter  is  raised,  this  ridge  becomes  very  prom- 


Naso-pkaryn 


Oro-pharyn 


Laryngo-pharyv  i  > 


Fig.  535.— Pharynx  from  behind,  showing  its  muscles.  The  levator  palati  l  is  seen  to  arise  beneath 
tin-  Eustachian  tube  B),  to  be  inserted  into  the  velum,  as  i-  the  tensor  2  afti  r  hooking  around  the  ham 
ulusato.    The  pa  md  the  palato-pharyngeus  (4)  form  the  anterior  and  posterior  pillars 

enclosing  the  tonsils   5),  and  the  azygos  (6)  passes  down  upon  1 1 1 1-  uvula   7).    The  inferior  (9  .  raidd  • 
and  superior  ill-  constrictors  of  the  pharynx  are  shown  partially,  and  tin-  posterior  nares,  the  oral  cavity 
normally  filled  by  the  tongue),  and  the  larynx    L2   (Browne). 


inent,  "  Passavant's  cushion,"  and  help-  to  close  the  opening  from  the  naso- 
to  the  oro-pharynx,  as  strings   pucker   up  and   close   the  month  of  a    purse. 

Its  existence  often  interferes  with  the  escape  of  secretions  downward  from 
the  naso-pharynx,  and  thus  causes  their  retention  and  crust-formation  .-it  this 
point.  This  ridge  is  caused  by  the  prominence  of  the  contracting  upper 
fibers  of  the  superior  constrictor  muscle  of  the  pharynx  as  they  pass  down- 
ward .- 1 1 1 <  1  backward  along  the  l'v<-<-  superior  margin  of  the  muscle  from  it- 
wide  attachment  above  to  the  median   line  of  the  pharyngeal  aponeurosis. 

The  lymphoid  structure  in  the  naso-pharynx  is  of  great  clinical  impor- 
tance. This  tissue  is  a  pari  of  "the  lymphoid  ring"  of  the  pharynx.  It 
is   located   in   the  center  of  the    superior  and    posterior  walls  of  the   naso- 


812  ANATOMY  OF  THE  UPPER  ATR-PASSAGES. 

pharynx,  and  spreads  laterally  on  cither  side  to  the  recesses  above  the  lips 
of  the  Eustachian  openings  and  even  into  the  fossa?  of  Rosenmiiller.  Nor- 
mally, it  is  about  one-fourth  of  an  inch  in  thickness,  and  should  not  cause 
occlusion  of  the  naso-pharyngeal  space  or  pressure  upon  the  Eustachian 
opening;.  In  structure  it  is  a  collection  of  lymph-follicles,  or  adenoid  tissue, 
held  together  in  a  loose  fibrous  network  of  connective  tissue  and  covered 
with  mucous  membrane  having  columnar  ciliated  epithelium.  In  rather  rare 
instance-  an  opening  is  observed  leading  to  a  closed  sac  in  the  center  of  the 
mass,  termed  the  bursa  pharyngea.  Its  very  existence  as  a  normal  structure 
has  been  questioned  by  many  writers.  When  present  it  is  doubtless  an 
abnormal  phase  of  development  (see  page  94!)). 

'The  blood-supply  of  the  naso-pharynx  comes  through  the  ascending 
pharyngeal  artery,  a  branch  of  the  external  carotid  ;  through  the  ascending 
palatine,  a  branch  of  the  facial  :  and  through  the  spheno-palatine,  a  branch 
of  the   internal   maxillary  (see  Fig.  549). 

Tin   veins  pass  into  the  internal  jugular  vein. 

The  nerve-supply  comes  from  the  superior  maxillary  nerve  (second  branch 
of  the  fifth  nerve)  and  from  the  pneumogastric  and  glosso-pharyngeal  nerves. 

The  Oro-pharynx  and  Laryngo-pharynx. — The  oro-pharynx  may  be 
said  to  extend  downward  from  the  projection  on  the  posterior  wall  of  the 
pharynx  caused  by  the  tubercle  on  the  anterior  arch  of  the  first  cervical 
vertebra.  An  imaginary  line  from  this  point  to  the  base  of  the  uvula  serves 
as  a  dividing-line  between  the  naso-  and  oro-pharynx  (Fig.  534).  We  shall 
refer  to  the  oro-  and  laryngo-pharynx  as  the  pharynx  proper.  It  is  quadri- 
lateral in  shape,  its  antero-posterior  diameter  being  much  more;  narrow  than 
it-  tran-verse.  Its  anterior  wall  extends  from  the  base  of  the  uvula  and 
thi'  free  margin  of  the  soft  palate  downward  across  the  oral  cavity  to  the 
posterior  extremity  of  the  greater  horn  of  the  hyoid  bone.  Its  posterior 
wall  extends  from  the  tuberosity  on  the  anterior  arch  of  the  first  cervical 
vertebra  to  the  orifice  of  the  esophagus.  Its  lateral  walls  are  in  relation 
with  the  common  and  internal  carotid  arteries,  the  internal  jugular  vein,  the 
sympathetic  nerve,  and  the  eighth  and  ninth  cranial  nerves. 

In  general  structure  the  pharynx  is  a  musculo-membranous  sac  eonsist- 
ing  of  three  layers,  an  inner  mucous  membrane,  a  middle  fibrous  layer, 
ami   an   outer  layer  of  muscular  tissue. 

The  mucous  m< mbrane  of  the  pharynx  is  thin,  and  in  the  naso-  and  oro- 
pharynx adheres  closely  to  the  fibrous  layer  beneath  it.  Like  the  mucous 
covering  of  the  alimentary  tract  in  general  its  epithelial  layer  consists  of 
squamous  cell-.  As  the  pharyngea]  vault  is  approached  the  epithelium 
changes  more  and  more  to  the  type  found  in  the  respiratory  tract,  and,  in 
the  purely  respirator}  tract  of  the  naso-pharynx,  it  becomes  columnar  and 
ciliated.  Two  varieties  of  glands  are  found  in  the  pharyngeal  mucous  mem- 
brane. <  me,  the  ordinary  muciparous  gland,  exists  in  greatest  Dumber  in  the 
oro-pharynx  and  upon  the  aofl  palate.  The  glands  of  the  second  variety  lie 
deeper  in  the  mucous  membrane  and  belong  to  the  lymphoid  type.  These 
ductless  follicle-  are  scattered  irregularly  throughout  the  mucous  membrane, 
but  exisl  in  greatest  uumberalong  the  lateral  surfaces  of  the  pharyngeal  wall, 
lying  closely  behind  the  so-called  posterior  faucial  pillars. 

The  fibrous  layer  <;/"  the  pharynx,  or  pharyngeal  aponeurosis,  external  to 
the  mucous  membrane  is,  in  the  upper  pharyngeal  region,  very  dense  in 
structure;  but  in  the  laryngo-pharynx  it  become-  thinner,  until  it  is  scarcely 
to  be  traced  nt  the  entrance  of  the  esophagus.  In  the  naso-pharynx  it 
adhere-  closely   to  the  basilar  process  of  the  occipital  (Fig.  536). 


THE    CONSTRICTORS    OF    THE    PHARYNX. 


813 


The  muscular  coat  of  the  pharynx,  it-  third  and  deepest  layer,  consists  of 

three  flat   constrictor  muscles,  so  arranged  as   to  form  a  sheath  around  the 
posterior  and    lateral   walls. 

The  superior  constrictor  muscle  arises  from  the  lower  portion  of  the  margin 
of  the  internal  pterygoid  plate  and  from  it-  hamular  process,  from  the  portion 
of  the  palate-bone  adjacenl  and  from  the  reflected  tendon  of  the  tensor  palati 
muscle,  from  the  pterygo-maxillary  ligament,  from  the  alveolar  process  of 
the  superior  maxilla  above  the  posterior  extremity  of  the  mylo-hyoid  ridgi  . 


Rhino-pharynx. 


Oro-pharynx. 


>  Laryngo-pharynx. 


Fig.  536. — Lateral  view  of  the  pharynx,  larynx,  and  esophagus,  showing  the  superior  11 |,  middle  1 10  . 
and  inferior  9  constrictors,  arising  from  the  pterygo-maxillary  ligament  (4),  the  hyoid  bone  ''.ana  the 
larynx  (7  .  respectively,  to  pass  back  to  the  posterior  raphe.  The  arrangement  of  the  6bers  dearly  sug- 
gests the  action  of  the  superior  constrictor  in  closing  off  the  rhino-pharynx  before  deglutition  through 

action  of  the  lower  constrictors. 


and  from  the  sides  of  the  tongue,  where  a  few  fibers  of  the  superior  constrictor 
are  in  connection  with  the  genio-hyoglossus  muscle.  From  this  very  widely- 
distributed  attachment  the  filter-  of  the  main  body  of  the  muscle  curve  back- 
ward to  he  attached  to  the  raphe  in  the  median  line  of  the  pharyngeal  apo- 
neurosis. The  superior  fibers  curve  backward  and  upward,  blending  with  the 
fibrous  aponeurosis  which  covers  the  pharyngeal  vault,  and  is  attached  to  the 
pharyngeal  spine  of  the  occipital  bone.  The  projecting  ledgi  caused  by  the 
free  upper  margin  of  this  muscle,  already  mentioned,  assists  in  closing  the 
naso-  from  the  oro-pharynx,  and  is  of  clinical  importance  in  some  cases  "I 
atrophic  rhinitis.  The  superior  constrictor  is  quadrilateral  in  form,  and  its 
fibers  are  thinner  than  are  those  of  the  middle  and  inferior  constrictors.  It- 
inferior  fibers  are  partially  overlapped  by  the  tipper  fibers  of  the  middle 
constrictor. 


814  ANATOMY  OF  THE  UPPER  AIR-PASSAGES. 

The  middh  constrictor,  arising  from  the  greater  and  lesser  horns  <>f  the 
hyoid  bone  and  from  the  stylo-hyoid  ligament,  is  a  fan-shaped  muscle,  its 
fibers  passing  up,  hack,  and  down  to  the  median  raphe\ 

The  inferior  constrictor,  the  largest  of  the  three,  arises  from  the  thyroid 
and  cricoid  cartilages,  its  attachment  to  the  thyroid  being  at  the  interior 
cornua  and  along  the  oblique  line-  on  the  .-ides  of  the  ahe  and  on  the  surfaces 
immediately  behind  these  lines,  almost  as  far  as  the  posterior  borders.  From 
the  cricoid  cartilage  it  arises  in  the  interval  between  the crico-thvroid  muscles 
in  trout  aiid  the  facet  for  the  crico-thyroid  articulation  behind.  The  fibers 
pa--  backward  and  slightly  upward,  and  are  attached  to  the  raphe'  in  the 
median  line  of  the  pharyngeal  aponeurosis,  the  ascending  filters  overlapping 
the  lower  fibers  of  the  middle  constrictor,  while  the  lower  fibers  fiend  with 
the  circular  muscular  fibers  of  the  esophagus.  Beneath  the  constrictor  mus- 
cles are  found  the  longus  colli  and  the  rectus  capitis  <tnti<-ns  muscles,  with  the 
cervical  vertebrae  beyond. 

'Idie  three  constrictor  muscles  are  the  chief  elements  in  the  formation  of 
the  muscular  layer  of  the  pharynx.  Certain  other  muscles,  however,  con- 
tribute to  the  formation  of  this  muscular  coat,  and  are  classified  among  the 
muscles  of  the  pharynx.  These  are  the  stylo-pharyngeus,  the palato-glossus, 
the  palato-pharyngeus,  and  the  stylo-hyoid. 

The  stylo-pharyngeus  (see  Figs.  535,  536)  is  a  long,  narrow,  muscular  hand, 
round  and  cord-like  above,  where  it  arises  from  the  inner  side  and  base  of 
the  styloid  process,  hut  flattened  and  widened  as  it  descends  by  the  side  of  the 
pharynx,  passing  between  the  superior  and  middle  constrictors.  Most  of  its 
fibers  terminate  beneath  the  mucous  membrane  of  the  pharyngeal  wall,  some 
merging  with  fibers  of  the  constrictor  muscles.  Other  lifers  descend  farther 
and  are  inserted  into  the  thyroid  cartilage  on  its  posterior  border. 

The  palato-pharyngeus  muscle  (see  Figs.  534,  535)  is  a  broad  thin  hand, 
widening  as  it  descends,  apparently  from  the  base  of  the  uvula,  and  passes 
down  and  hack,  to  he  lost  in  the  lateral  pharyngeal  walls.  It  forms  with  the 
covering  mucosa  the  ••  posterior  pillar  of  the  fauces."  Its  superior  origin  is  by 
two  fasciculi  in  the  soft  palate,  joining  their  fellow-  of  the  opposite  side  in 
the  median  line.  It  i-  inserted  with  the  stylo-pharyngeus  into  the  posterior 
border  of  the  thyroid  cartilage.  A  few  of  its  fibers  spread  along  the  sides  of 
the  pharynx  and  cross  the  latter  to  .join,  in  the  median  line,  those  from  the 
opposite  side. 

The  palato-glossus  muse/,  (see  Figs.  534,  535)  forms  the  so-called  "anterior 

pillar  of  the  fauces."  It  i-  a  narrow  fibrous  hand,  narrower  and  thinner 
than  the  palato-pharyngeus  muscle,  or  ■■  posterior  pillar."  Its  upper  attach- 
ment i-  the  anterior  surface  of  the  -oft  palate.  It  passes  in  front  of  the 
tonsil  downward,  forward,  and  outward,  and  is  inserted  into  the  sides  and 
hack  <>f  the  tongue. 

Blood-supply  of  the  Pharynx. — Arteries. — The  ascending  pharyngeal 
arteries,  branches  of  the  external  carotid,  supply  the  constrictor  muscles  and 
the  mucous   membrane.      They  ma\    he   of  abnormal    -i/e.  not    rarely  -o    large 

as  to  cause  :t   distincl    pulsati n   one  or   both  side-  of  the   pharynx,  just 

behind  the  posterior  faucial   pillar-. 

The  Vidian  and  descending  palatine  arteries,  branches  from  the  internal 
maxillary  artery,  also  supply  the  pharyngeal  tissues,  as  do  branches  from  the 
facial,  the  tonsillar,  and  ascending  palatine  arteries. 

Veins. — A  thief  network  of  veins  is  found  in  the  fibrous  layer  of  the 
pharynx,  forming  the  pharyngeal  plexus  in  the  posterior  and  lateral  walls. 
from  these  the  blood  i-  led  by  the  pharyngeal  vein  into  the  internal  jugular. 


TONSILLAR  STRUCTURES  OF  THE  I'll M;  Y.xx.  815 

Lymphatics. — The  lymph-vessels  follow  the  course  of  the  pharyngeal 
plexus  and  veins  and  enter  the  chain  of  lymphatic  glands  along  the  sheath  of 
the  carotid,  terminating  on  the  right  side  in  the  right  ductus  lymphaticus  ;  on 
the  left  in  the  thoracic  duct. 

Nerves. —  Che  sensory  nerves  of  the  pharynx  come  from  the  glosso-pharyn- 
geal.  The  motor  nerves  are  derived  from  the  glosso-pharyngeal  and  pneumo- 
gastric.     These,  with  the  sympathetic,  unite  to  form  the  pharyngeal  plexus. 

Lymphoid  Structure  of  the  Pharynx. — Reference  has  been  made  already  to 
the  ductless  follicles  in  the  pharyngeal  mucous  membrane  and  to  their  special 
-••at-  of  location  on  the  lateral  and  postero-lateral  walls  of  the  pharynx. 

At  certain  points  in  the  pharynx  are  found  conglomerate  masses  of  lym- 
phoid tissue,  forminga  continuous  "lymphoid  ring"  around  the  entrance  to 
the  alimentary  and  respiratory  tract-. 

The  upper  segment  of  this  ring  is  formed  by  the  adenoid  tissue  of  the 
naso-pharynx,  or  "pharyngeal  tonsil,"  already  described  ;  the  lateral  segments 
are  formed  by  the  "  faucial  tonsils,"  and  the  lower  segment  by  the  lymphoid 
tissue  found  at  the  base  of  the  tongue,  "the  lingual  tonsil."  The  faucial 
tonsils  arc  small  oval  or  almond-shaped  masses  of  lymphoid  tissue,  placed 
within  the  somewhat  triangular  space  between  the  palato-pharyngeal  and  the 
palato-glossal  muscles.  In  the  normal  condition  they  are  about  three-quarters 
of  an  inch  in  vertical  length  by  one-third  of  an  inch  in  breadth.  Even 
within  normal  limits,  however,  there  is  great  variation  in  size.  The  free  sur- 
face of  each  faucial  tonsil  is  marked  by  numerous  round  or  slit-like  openings, 
arranged  in  two  or  more  parallel  columns,  or  more  irregularly,  which  lead 
down  into  invaginations  of  the  surface  called  crypts.  This  peculiar  structure 
i-  claimed  by  R-etterer  to  be  the  result  of  an  ingrowing  of  the  epiblastic  mem- 
brane into  the  hypoblast.  The  epithelial  elements  are  thus  forced  into  a 
lymphoid  mass,  and  the  latter  grows  around  the  invaginations  or  into  their 
wall-,  breaking  up  their  outline  into  small,  lateral  pockets.  The  diverticula, 
a-  Harrison  Allen  term-  the  lymph-follicles,  are  thus  in  the  faucial  tonsils 
arranged  in  groups  which  occasionally  sink  below  the  general  surface  of  the 
ma--,  thus  forming  the  crypt-. 

The  lingual  tonsil  occupies  the  ba-e  of  the  tongue,  1  > « ■  i 1 1  lt  placed  between 
tin-  and  the  epiglottis.  It  is  a  smooth,  soft,  even  mass  of  lymph-follicles, 
the  diverticula  of  which,  as  Allen  states,  are  single  and  not  in  groups. 

The  covering  of  both  the  faucial  and  lingual  tonsil-  consists  of  the 
pharyngeal  mucous  membrane.  In  many  instances,  however,  thi-  i-  under- 
laid by  band-  of  fibrous  tissue  which  more  or  less  fully  encapsulate  the 
lymphoid  masses. 

The  faucial  tonsil  is  in  rather  close  relation  with  the  internal  and  exter- 
nal carotid  arteries,  the  internal  jugular  vein,  and  the  pneumogastric  nerve. 
These  structure-,  however,  pass  through  the  posterior  portion  of  the  pharyngo 
maxillary  inter-pace,  while  the  faucial  tonsil  occupies  the  anterior  pan  of  this 
-pace:  thus  they  are  safely  beyond  the  reach  of  any  cutting  instruments 
which  are   used    with   -kill   and   care   in   operations  upon   the  tonsils. 

Thi'  blood-supply  of  the  faucial  tonsil  comes  from  the  facial  artery  by 
the  tonsillar  and  ascending  palatine;  from  the  lingual  artery  by  tie  dorsalis 
linguae;  from  the  external  carotid  by  the  ascending  pharyngeal;  and  from 
the  internal  maxillary  l>v  the  descending  palatine  branch.  The  most  impor- 
tant artery  is  the  tonsillar,  springing  from   the  facial  artery.      It    is  a  -mall 

vessel  in  children,  but    in  adult-  i-  of  more  iraj taut  size.      It    is  not  apt   t-» 

be  wounded  during  cutting  operation-  upon  the  tonsils,  mile--  such  procedures 
involve  the  ba-e  of  these  masses. 


81b'  ANA  TOM  1 '  OF  Til  E   UPPJE  ft   j.  1  /  ft- 1\  1 SS.  1  ( /  ES. 

The  veins  center  into  a  plexus,  named  the  tonsillar  plexus.  The  nerves 
are  from  the  fifth  nerve  and  the  glosso-pharyngeal   nerve. 

The  I^arynx. — The  larynx  forms  the  entrance  to  the  respiratory  tract 
and  i.-,  at  the  same  time,  the  organ  for  the  formation  of  the  voice,  [ts 
function  of  voice-production  depends  largely  upon  the  vocal  cords,  and  the 
general  structure  of  the  larynx  is  designed  to  protect  these  and  to  give 
attachment   to  the  muscles  controlling;  their  movements. 

The  Cartilages. — The  framework  of  the  larynx  (Fig.  537)  consists  of 
the  thyroid,  the  cricoid,  and  the  two  arytenoid  cart i luges,  composed  of  true 
cartilage  ;  and  of  the  two  corniculae  laryngis  (cartilages  of  Santorini),  the  two 
cuneiform  cartilages  (cartilages  of  Wrisberg),  and  the  epiglottis,  all  fibro- 
cartilaginous in  structure.  A.bove  the  larynx,  and  at  the  base  of  the  tongue, 
which  is  attached  to  it,  lies  the  hyoid  hone  (Figs.  537,  538).  The  hyoid 
bone  (from  the  Greek  y-shaped),  besides  its  important  relation  to  the  tongue 
and  its  function  in  serving;  to  stretch  the  pharynx  in  its  lateral  diameter, 
serves  also  to  give  a  point  of  fixation  above  to  the  larynx.  It  consists  of  a 
central  body  with  two  greater  and  two  lesser  cornua.  The  body  is  quad- 
rilateral in  form,  convex  on  its  anterior  surface,  concave  posteriorly.  It  sup- 
ports the  two  lesser  cornua  which  project  upward  and  backward  from  its 
superior  and  lateral  margins.  From  these  lateral  margins  beneath  the  lesser 
cornua  extend  backward  the  greater  cornua,  completing  the  half-circle.  From 
the  hyoid  bone  muscles  and  ligaments  pass  to  the  epiglottis  and  to  the  thyroid 
cartilages,  uniting  it  with  these  structures. 

The  thyroid  cartUa^e  (  Fig.  537)  (from  the  Greek,  a  shield)  consists  of 
two  curved  quadrilateral  plates,  converging  anteriorly  to  meet  in  the  median 
line,  and  forming  a  projecting  angle  somewhat  like  the  prow  of  a  ship.  This 
angle  is  a  prominent  feature  in  the  neck  (see  Fig.  534),  especially  in  the  adult 
male  (the  "Adam's  apple"),  standing  boldly  outward  beneath  the  integu- 
ment, from  which  occasionally  it  is  separated  by  a  bursa.  The  upper  mar- 
gin of  each  side,  or  a la,  of  the  thyroid  curves  downward  at  this  point  of 
junction,  forming  the  thyroid  notch,  resembling  the  spout  of  a  pitcher;  and 
backward  each  descends  .-lightly  to  rise  abruptly  at  the  posterior  limit  into  a 
long  process,  pointing  upward,  called  the  superior  cornu  (Fig.  538).  The 
prominent  anterior  angle  of  the  thyroid  is  slightly  concave  below  the  thyroid 
notch.  The  lower  border  of  each  ala  curves  backward  and  generally  down- 
ward and  forms  the  lesser  cornu.  The  posterior,  free  borders  of  the  thyroid, 
which  are  rounded  and  thick,  thus  terminate,  above  in  the  greater,  below  in 
the  lesser,  cornua.  An  oblique  ridge  passes  downward  and  forward  aero-.-  the 
outer  surface  of  each  ala  of  the  thyroid,  starting  from  a  tubercle  near  the  base 
<>f  the  superior  cornu.  and  gives  attachment  to  the  stcrno-t hyroid  and  thyro- 
hyoid muscles.  Back  of  this  ridge,  and  including  the  surfaceto  the  posterior 
margin  of  each  ala,  is  the  long  narrow  area  of  attachment  of  the  inferior 
constrictor  muscle  of  the  pharynx,  while  to  the  center  of  the  posterior  margin 
i-  attached  the  stylo-pharyngeus  muscle. 

The  inner  surface  of  each  ala  is  concave,  and  covered  in  the  upper  and 
posterior  portions  with  mucous  membrane.  In  the  receding  angle  anteriorly, 
where  the  two  al.e  unite  immediately  below  the  thyroid  notch,  the  thyro- 
epiglottic ligament  form- the  attachment  of  the  epiglottis,  and  ju-t  below  tin-, 
on  either  side,  are  the  anterior  points  of  attachment  for  the  ventricular  bands, 
or  false  vocal  cords  (Fig.  539).  The  true  vocal  cord-,  together  with  the 
thyro-arytenoid  muscles,  have  their  anterior  point-  of  attachment  immedi- 
ately beneath  these  in  the  lower  third  of  this  receding  angle.  The  lower 
margins    of   the    thyroid    cartilage,    in    their   anterior   ami    lateral    aspects, 


THE  CARTILAGES  OF   THE   LARYNX. 


SIT 


give   attachment  to  the  crico-thyroid    membrane   ami    in    the  crico-thyroid 
muscle. 

The  cricoid  <-<irtil<iti<  (from  the  Greek,  a  ring)  lies  immediately  below  the 


Fig.  537.— Larynx,  showing  the  thyroid  and  cri- 
coid cartilages,  with  the  trachea  below  and  the 
hyoid  bone  above,  with  the  connecting  mem- 
branes (Leidy  . 


Fig.  538.— Lateral  view  of  larynx  in  its  rela- 
tion to  the  hyoid  bone  and  trachea. 


thyroid  (Figs.  537,  538,  540).      Its  anterior  half  is  small,  narrow,  rounded. 
and  convex  in  shape.     Its  superior    margin   rises  as  it    extends  backward, 


8.— Inner  aspect  of  larynx  from 
behind,  showing 

true  and  false  cords,  and  of  the  intrin- 
sic muscles. 


:  arynx  dissected  to  sh  -  tl 
crico  thyroid  (9)  inserted  on  the  inner  aspei  i  of  the 
th.-  articulation   3) ;  tin'  posti  rior  ( 

l  at  the  base  of  the  arytenoid    i  .  behind  the  la< 
crico-arytenoid  (11);  thi    I 
the  position  of  the  voi 

and  aryteno-epiglottic  n  the  lain: 

the  aryepiglottic  fold:  and  tl  ••">'' 

arytenoid  cartilag  - 


causing  the  cartilage  to  broaden  toward   it-  posterior  portion,  which  is  almost 
thrice  as  broad,  in  a  vertical  direction,  as  is  theanterior;  while  it   is  at  the 


52 


818  ANATOMY  OF  THE   UPPER  AIR-PASSAGES. 

same  time  greatly  increased  in  thickness.  On  the  outer  lateral  surface  of  this 
posterior  "  seal  "  portion  of  the  ring  arc  facets,  one  on  cither  side,  for  articu- 
lation with  the  lesser  cornua  of  the  thyroid  cartilage.  On  its  upper  surface 
in  this  posterior  half  arc  two  facets,  their  long  diameters  transverse,  for 
articulation  with  the  arytenoid  cartilages,  [n  the  median  line  of  the  broad 
posterior  border  of  the  cricoid  is  a  vertical  ridge  for  the  attachment  of  the 
esophagus,  with  broad  points  of  attachment  on  cither  side  for  the  posterior 
crico-arytenoid  muscles.  The  outer  surface  of  the  cricoid  anteriorly  gives 
attachment  to  the  crico-thyroid  ligament  and  to  the  crico-thyroid  muscle  and 
to  the  lateral  crico-arytenoid  muscle. 

The  cricoid  forms  the  back  of  the  larynx,  as  well  as  its  lower  portion,  and 
is  the  base  upon  which  the  other  cartilages  of  the  larynx  rest. 

The  arytenoid  cartilages  (d,  a  pitcher)  (Fig.  539)  are  two  pyramidal  carti- 
lages which  articulate  with  the  upper  margin  of  the  thick  posterior  portion 
of  the  cricoid.  Theymighl  be  called  the  cartilages  of  the  vocal  cord-,  as 
the  vocal  cords,  together  with  all  the  muscles  controlling  their  movements 
(with  the  exception  of  the  crico-thyroid),  arc  attached  to  the  arytenoids. 
They  present  three  surface-,  a  base,  and  an  apex  for  study.  The  inner  surface 
of  each  cartilage,  covered  with  mucous  membrane,  is  smooth,  flat,  somewhat 
triangular  in  shape,  for  apposition  to  the  corresponding  side  of  its  fellow. 
The  anterior  surface  i-  convex  and  ffives  attachment  to  the  ventricular  hands 
and  the  thyro-arytcnoid  muscle.  The  posterior  surface  is  concave  and  tri- 
angular in  shape  and  gives  attachment  to  part  of  the  arytenoid  muscle.  The 
base  is  concave  for  articulation  with  the  corresponding  convex  facet  on  the 
cricoid,  and  is  marked  by  two  projections  or  processes  terminating  its  exter- 
nal and  anterior  angles.  The  longer  of  these  is  the  anterior,  called  the  vocal 
process,  as  to  it  the  vocal  cord  is  attached.  The  rounded  external  process  is 
named  the  muscular  process,  and  upon  it  are  inserted  the  posterior  and  the 
lateral  crico-arytenoid  muscles.  The  apices  of  the  arytenoids  are  pointed  and 
curve  backward  and  inward.  Each  apex  is  crowned  by  a  small  nodule  of 
cartilage,  serving  to  lengthen  it  slightly,  called  the  cornicula  laryngis,  or 
cartilage  of  Santorini.  To  these  nodules  are  attached  the  aryteno-epiglot- 
tidean  fold-,  in  which,  close  to  the  outer  side  of  each  cartilage,  are  embedded 
the  two  small  cartilages  of  Wrisberg,  the  cuneiform  cartilages.  They  are  sesa- 
moid 'm  character  and  vary  greatly  in  size  in  different  individuals.  Two  sets 
of  sesamoid  cartilages  are  also  found  occasionally,  the  posterior  and  ante- 
rior sesamoid  cart  i  la-  <■-.  When  present,  the  posterior  sesamoids  lie  between 
the  apices  of  the  arytenoids  and  the  cartilages  of  Santorini  ;  the  anterior  are 
found  in  the  extreme  anterior  end  of  the  vocal  cords,  being  attached  to  the 
receding  angle  of  the  thyroid  cartilage. 

The  epiglottis  (see  Figs.  538  and  539),  named  from  it-  position  above  the 
glottis,  is  the  cover  of  the  larynx.  It  is  an  oblong,  leaf-shaped  plate  of  fibro- 
cartilage,  its  upper  border  rounded,  it-  lower  somewhat  pointed  and  attached 
by  a  long  thyro-epiglottic  ligamenl  to  the  receding  angle  of  the  thyroid  carti- 
lage immediately  below  the  thyroid  notch.  The  mucous  membrane  covering 
the  anterior  surface  toward  the  base  of  the  tongue  is  reflected  to  the  side-  and 
base  of  the  cartilage  in  two  fold-,  the  glosso-epiglottic  ligaments.  The  anterior 
surface  curve-  forward  slight!)  toward  the  tongue,  but  the  position  varies 
greatly  in  differenl  subjects.  The  posterior  surface,  transversely  concave  but 
vertically  rather  convex,  faces  somewhat  downward  over  the  laryngeal 
entrance  and  is  covered  with  mucous  membrane,  which  at  its  base  is  thickened 
by  the  presence  of  adenoid  tissue  into  a  -month,  slightlj  prominenl  elevation 
termed  the  cushion  of  the  <j,i<//n//is.     It-  free  margin  i-  rounded,  or,  especially 


LIGAMENTS  OF  THE  LARYNX.  319 

in  children,  is  narrowed  into  a  curve,  with  the  concavity  downward,  rendering, 
when  in  this  form,  a  view  of  the  interior  of  the  larynx  somewhat  difficult,  as 
the  epiglottis  is  apt  then  to  lie  more  depressed  than  when  tin-  upper  margin 
is  broad  and  flattened.  The  epiglottis  is  also  connected  with  the  body  of  the 
hyoid  bone  on  the  posterior  surface  of  the  latter  by  a  ligamentous  or  elastic 
band,  the  hyo-epiglottic  ligament.  The  aryteno-epiglottic  folds  are  attached 
to  the  side-  of  the  epiglottis.  Numerous  pits,  or  depressions,  are  found  in 
the  body  of  the  cartilage  of  the  epiglottis,  in  which  lie  -mall  mucous  glands. 
The  epiglottis  being  freely  movable  varies  in  position  during  respiration  and 
deglutition.  During  respiration  it  maintains  a  somewhat  vertical  direction, 
it-  free  margin  being  curved  toward  the  base  of  the  tongue.  In  the  act  of 
deglutition,  however,  as  the  larynx  rises,  the  epiglottis  is  carried  upward 
against  the  base  of  the  tongue  and  it-  free  margin  is  greatly  depressed,  so  as 
to  serve  as  a  cover  to  the  entrance  of  the  larynx. 

Ligaments  of  the  Larynx. — The  thyroid  cartilage  is  bound  to  the  hyoid 
bone  by  three  ligaments,  the  two  lateral  thyro-hyoid  ligaments,  narrow, 
rounded  hand-  of  fibro-elastic  tissue,  attached  to  the  extremities  of  the 
superior  cornua  of  the  thyroid  cartilage  and  extending  upward  to  the  greater 
cornua  of  the  hyoid  bone;  also,  the  thyro-hyoid  membrane,  a  broad,  fibro- 
elastic  membrane,  attached  below  to  the  upper  border  of  the  thyroid  cartilage, 
and  above  to  the  posterior  face  of  the  body  of  the  hyoid  bone.  The  superior 
laryngeal  nerve  and  vessels  pass  through  the  median  line  of  this  membrane. 

The  thyroid  and  cricoid  cartilages  are  bound  together  by  three  ligaments, 
the  cricothyroid  membrane  and  two  capsular  ligaments  (see  Fig.  537).  '1  he 
crico-thyroid  membrane,  triangular  in  shape,  passes  from  the  superior  margin 
of  the  cricoid  cartilage  in  the  median  line  and  from  both  sides  anteriorly,  and 
i-  inserted  in  the  lower  border  of  the  anterior  part  of  the  thyroid  cartilage. 
Thick  in  the  center,  it  becomes  thinner  on  either  side,  and  these  lateral  portions 
are  joined  at  their  insertion  with  the  insertion  of  the  true  vocal  cords.  In  the 
median  line  the  crico-thyroid  membrane  lies  directly  beneath  the  -kin.  and  thus 
offer-  a  ready  means  for  effecting  an  artificial  opening  into  the  larynx.  At  this 
point  the  membrane  is  crossed  by  an  anastomosis  of  the  two  -mall  crico- 
thyroid arteries.  It  i-  covered  on  its  inner  surface  with  mucous  membrane. 
'I 'he  lateral  portion-  of  the  crico-thyroid  membrane  are  covered  by  the  crico- 
thyroid muscle  and  the  lateral  crico-arytenoid  muscles. 

The  capsular  ligament-  between  the  cricoid  and  thyroid  cartilages  bind 
the  inferior  or  short  processes  of  the  thyroid  to  the  cricoid  cartilage  at  their 
points  of  articulation^ 

The  arytenoid  cartilages  are  held  to  the  cricoid  cartilage  by  loose  citjisiilar 
ligaments,  also  posteriorly  by  the  -mall  posterior  crico-arytenoid  ligaments. 

The  epiglottis   is  bound    to   the   hyoid   bone  by  two  ligamentous  bands 

which  extend  fi i  the  sides  of  the  cartilage,  near  it-  apex,  the  hyo-epiglottic 

ligaments,  and  to  the  thyroid  cartilage  by  the  thyro-epiglottic  ligament  already 
described. 

The  median  glosso-epiglottic  fold-  of  mucous  membrane  unite  the  epiglottis 
to  the  base  of  the  tongue. 

Interior  of  tfo  Larynx  Fig.  541). — The  general  shape  of  the  laryngeal 
opening  is  triangular  with  the  base  posterior.  Looking  from  above  into  the 
larynx  the  free  margin  of  the  epiglottis  i-  first  -ecu.  a  curving  surface  which 
varies  in  the  degree  of  it-  curvature  in  different  subjects.  Beneath,  and  pos- 
terior to  the  inner  face  ,.1'  the  epiglottis,  appear  the  apices  of  the  arytenoid 
cartilages,  the  -mall  cartilages  of  Santorini  at  the  apex  of  each,  the  smooth 
rounded  swelling  on  tin ter  Bide  of  both  arytenoids,  paler  than  the  red  ol 


820 


AXATOMY   OF  THE    UPPER-   A  TR-PASSAd AX 


the  general  mucous  covering,  showing  the  location  of  Che  cartilages  of  Wris- 

hci'ir.  These  arc  seen  to  lie  each  in  the  body  of*  a  broad  prominent  fold, 
which  passes  in  a  half-circle  framing  the  sides  of  the  laryngeal  opening,  one 
on  each  side,  from  the  arytenoid  cartilages  upward  to  the  side  of  the  epi- 
glottis. These  are  the  aryteno-epiglottie  folds.  Below  the  level  of  the 
apices  of  the  arytenoid  cartilages,  two  bands,  covered,  like  the  tissue  already 
named,  with  mucous  membrane,  pass  from  the  arytenoids  forward  to  the 
receding  angle  of  the  thyroid  cartilage,  terminating  there  beneath  the  attach- 
ment of  the  epiglottis.  'These  are  the  ventricular  bands,  or  false  vocal  cords. 
They  are  also  named  the  superior  thyro-arytenoid  ligaments. 

Beneath  these  ventricular  hands,  and  appearing  to  v^v  their  free  border, 
although  in  reality  below  them,  are  seen  two  white  hands  which  pass  for- 
ward from  the  anterior  angles,  or  vocal  processes,  of  the  arytenoid  cartilages 
to  the  receding  angle  of*  the  thyroid  cartilage.  These  are  the  true  vocal  cords. 
Between  the  free  margins  of  the  vocal  cords  is  an  open  space  of  triangular 
shape  with  the  base  posterior,  which  varies  in  width  as  the  cords  approach  or 
recede  from  each  other.  This  is  the  glottis,  or  rvnrn  glottidis,  and  through 
this  space  can  be  seen  the  anterior  surface  of  the  trachea  ridged  by  its  rings 
perhaps  down  to  the  bifurcation  into  the  bronchi.  Between  the  arytenoids,  at 
about  the  level  of  the  vocal  cords,  is  a  point  of  considerable  clinical  impor- 
tance, the  space  between  the  arytenoids,  or  the  interarytenoid  space. 

A  free  space  exists  between  the  ventricular  bands  and  the  vocal  cords. 
This  space  is  found  to  follow  the  under  surface  of  the  ventricular  bands, 
extending  laterally  and  upward  between  the  ventricular  bands  and  the  alse  of 
the  thyroid  cartilage  on  either  side,  and  to  terminate  anteriorly  in  a  blind 
pouch.    The  space  is  called  the  ventricle  of  the  larynx,  and  the  pouch  named 


Fig.  541.— The  laryngoscopy  image  in  deep  inspiration  and  in  phonation. 

the  sacculus  laryngis  (Fig.  512).  This  entire  area  is  lined  with  mucous 
membrane  richly   supplied  with  mucous  glands. 

The  chink  of  the  glottis  varies  in  extent  according  to  age  and  sex.  In 
the  adult  male  it-  length  i-  about  -even-eighths  of  an  inch.  In  the  female  it 
i-  smaller.  When  fully  dilated  this  triangular-shaped  opening  at  its  base 
posteriorly  is  about  one-half  of  an  inch  in  width.  At  the  posterior  attach- 
ment of  the  vocal  cords  will  he  seen  usually  a  slighl  indentation  of  a  whiter 
color  than  that  of  the    main  body  of  the  cords.      This    point    is  the  extremity 

of  tin-  vocal   process  of  the  arytenoid-.     It   is  of  some  clinical  interest,  as 

these  point-  have  at  time-  been  mi-taken  for   ulceration-  or   cicatrice-  on  this 

pori  ion  of  i  he  vocal  cords. 

The  bee  margins  of  the  vocal  cord-  mark  the  mosl   narrow    portion  of  the 

larynx.  Below  these  the  subglottic  -pace  widen-,  assuming  the  general  form 
of  the  circle  formed  l.\  the  cricoid  cartilage,  a1  firs'  somewhal  oval  in  the 
lateral  diameter,  - changing  to  circular  as  the  trachea  is  approached.  Thus 

a  section  of  the  entire    larynx    would    roughly  iv-emble   an    hour-glass  form, 


wi  sc/.rs  or  tin:  i.ahysx. 


82] 


widening  above  and  below,  with  a  constriction  in  the  center  at  the  location 
of  the  vocal  cords  (see   Fig.  548). 

Muscles  of  the  Larynx. — The  muscles  of  the  larynx  are  the  posterior 
crico-arytenoidsj  the  lateral  cricoarytenoids,  the  interarytenoid  or  arytenoid, 
which  act  as  the  abducting  and  adducting  muscles  of  the  vocal  cords;  the 
thyro-arytenoids  and  crico-thyroid,  whose  function  it  is  to  regulate  the  tension 
of  the  vocal  cords;  the  thyroepiglottic, aryteno-epiglottic,  superior  and  infe- 
rior, supplying  some  power  of  movement  to  the  epiglottis;  the  thyro-hyoid 
and  sterno-hyoid,  which  serve  as  muscles  of  fixation   for  the  larynx. 

The  posterior  erico-arytenoid  arises  from  the  posterior  surface  of  the  cri- 
coid cartilage,  on  cither  side  of  the  median  line  (Fig.  539).     Its  fibers   pass 


EpujLottis 


Ibcaf  cord 
T?w  Ventricle 


Cartilago 
ofWri^barg  - 

Arytenoid  ^ 
Cartilay 


THYRO   EPI010TTIDEAN 

Fas  ic  at  us 


THYRO    ARYTENOID 

muscle 


T/rvroid 
Cartilage 


Cricoid  Cartilage 
in  section, 


CrvCO-  thjToLd. 
membrane 


1 


FlG.  542.— Interior  of  larynx,  showing  <>n  the  right  the  parts  in  median  section,  and  on  the  left  a  dis- 
section "f  this  half,  with  the  muscles  and  cartilages  ■  \i — l     U 


upward  and  outward  and  are  attached  to  the  muscular  process  of  the  aryte- 
noid cartilage  <  Fig.  540,  5).  With  point  of  fixation  on  the  cricoid,  this  mus- 
cle, by  contracting,  rotates  the  arytenoid  cartilage  outward  by  drawing  it- 
muscular  process  backward.  The  two  vocal  processes  of  the  arytenoid 
cartilages  are  thus  drawn  away  from  the  median  line  outward,  and  the  vocal 
cords  are  separated  (see   Fig.  665. 

The  lateral  crico-aryh  noid  muscles  (see  Fig.  540)  arise,  one  on  either  side, 
from  the  upper  margin  of  the  lateral  part  of  the  cricoid  cartilage.  The  fibers 
of  each  muscle  pass  upward  and  backward  and  are  inserted  in  the  muscular 
processes  of  the  arytenoid  cartilages  at  a  point  just  anterior  to  the  insertion 
of  the   posterior  crico-arytenoid   muscles.     The  action  of  the  lateral  crico- 


822  ANA10MY  OF  THE   (/>/>/■:/;   A  IB- PASSAGES. 

arytenoid  muscles,  being  fixed  at  their  cricoid  attachments,  i-;  to  adduct  the 
vocal  cords  by  drawing  forward  the  muscular  processes  of  the  arytenoid 
cartilages,  thus  approximating  the  vocal  processes  of  these  cartilages  (Fig. 
665. 

The  arytenoid  muscle  is  a  single,  square-shaped  muscle  with  two  sets 
of  fibers,  the  transverse  and  oblique.  The  transverse  fibers,  which  are 
the  deeper,  are  attached  to  the  posterior  surface  and  outer  margin  of  one 
arytenoid  muscle  and  pass  transversely  across  to  be  inserted  into  the  corre- 
sponding part  of  the  other  arytenoid  cartilage  (see  Fig.  540,  15).  The 
more  superficial  oblique  fibers  consist  of  two  thin  muscular  slips  which  pass 
from  the  base  of  one  arytenoid  cartilage  to  the  apex  of  the  other.  In  some 
instances  fibers  from  the  oblique  hands  pass  around  the  outer  sides  of  the  two 
cartilages  and  blend  with  the  fibers  of  the  thvro-arytenoid  or  the  aryteno- 
epiglottic  muscles.  The  action  of  the  arytenoid  muscle  is  to  bring  the  bases 
of  the  arytenoid  cartilages  together,  thus  completing  the  closure  of  the  chink 
of  the  glottis.  Contraction  of  the  lateral  crico-arytenoids  alone  Leaves  a 
small  triangular  opening  between  the  cords  at  the  interarytenoid  space.  This 
opening  is  closed  by  the  contraction  of  the  arytenoid  muscle  (Figs.  540  and 
541).  The  thyro-arytenoid  muscles  lie  parallel  to  and  slightly  below  the 
vocal  cords  along  either  side  of  the  larynx  (Fig.  540).  The  muscles  arise, 
one  from  either  side  of  the  receding  angle  of  the  thyroid  cartilage,  to  the  outer 
side  of  the  insertions  of  the  vocal  cords.  Passing  out  ward  and  backward  the 
fibers  arc  inserted  into  the  bases  and  anterior  surfaces  of  the  arytenoid  carti- 
lages and  into  the  external  surfaces  of  the  vocal  processes  (see  Fig.  o42». 
Each  thyro-arytenoid  muscle  is  divided  into  two  quite  distinct  portions,  inter- 
nal and  external.  The  internal  portion  follows  the  vocal  cord  closely,  some 
of  its  fibers,  indeed,  appearing  to  pass  into  the  structure  of  the  cord.  The 
external  portion  passes  backward  along  the  outer  side  of  the  saceulus  laryngis, 
and  has  a  broad  attachment  to  the  external  surface  and  outer  side  of  the 
arytenoid  cartilage.  With  point  of  fixation  at  the  receding  angle  of  the 
thyroid  cartilage,  the  thyro-arytenoid  muscles  draw  the  arytenoid  cartilages 
forward.  The  vocal  cords  arc  thus  shortened  and  relaxed.  The  internal 
portion  of  this  muscle,  however,  has  an  apparently  contradictory  action,  for,  by 
its  attachment  to  the  vocal  cords,  its  contractions  approximate  the  free  mar- 
gins of  the  cords  and  regulate  their  tension.  This  function  is  of  importance 
in  the  production  of  the  high  notes  in  the  singing  voice.  The  external  por- 
tion of  the  muscle,  besides  its  action  in  shortening  the  cord-,  has  also  the 
power  of  compressing  the  saceulus  laryngis.  A  superior  thyro-arytenoid  mus- 
cle i-  sometimes  described  (Santorini,  Luschka,  Schrotter),  which  is  viewed 
by  some  authorities  as  a  distinct  muscle,  [ts  origin  is  from  the  receding 
angle  of  the  thyroid  cartilage,  immediately  above  the  origin  of  the  thyro- 
arytenoid muscle,  ii  is  attached  to  the  muscular  process  of  the  arytenoid 
cartilage,  some  fibers  passing  downward  to  the  cricoid  cartilage  or  to  the 
crico-thyroid  membrane.  Ii  is  quite  probable  that  these  muscular  fibers, 
instead  of  forming  a  distinct  muscle,  constitute  a  series  of  oblique  fibers 
which   are,  in    reality,  a    part    of  the   complex    thyro-arytenoid   muscle. 

The  crico-thyroid  musch  arises  from  the  anterior  and  lateral  portions  of 
the  cricoid  cartilages  (see  Fig.  "d(i,  !i).  The  fibers  divide  into  two  bundle-, 
tin-  more  anterior  pass  directly  upward  and  slightly  backward  ami  are 
inserted    into  the  inner   portion  of  the  lower  margin  of  the  thyroid  cartilage. 

'I'he  more  posterior  fibers  pass  upward  and  backward  and  are  attached  to  the 
thyroid  cartilage  at  the  base  of  the  inferior  cornu.  The  action  of  this  mus- 
cle is  t<>  render  the  vocal  cords  tense  by  increasing  their  Length,  either  by 


THE  Ml  COUS  MEMBRANE  OF  THE  LARYNX.  823 

drawingthe  thyroid  cartilage  downward  toward  the  cricoid,  thus  stretching 
the  vocal  cords  and  increasing  their  tension,  or,  with  the  thyroid  cartilage 
as  the  fixed  point,  to  draw  the  cricoid  cartilage  upward  and  backward,  which 
movement,  it   is  claimed  by  the  advocates  of  this  method,  will  elongate  and 

increase  the  tension  of  the  vocal  cord-.  The  action  of  this  muscle  is  a  tpies- 
tion  which  is  still  in  dispute,  and  we  feel  that  it  has  not  yei  been  definitely 
dvr'u\vd. 

Blood-supply  of  the  Larynx. — The  arterial  supply  of  the  larynx  comes 
by  the  superior  and  inferior  thyroid  arteries. 

The  superior  fin/mid  is  a  branch  of  the  external  carotid.  It  divide- 
before  entering  the  larynx  into  two  branches,  the  superior  laryngeal  and  the 
inferior  laryngeal,  the  latter  called  also  the  crico-thyroid  artery. 

The  inferior  thyroid  artery,  one  of  the  branches  of  the  thyroid  axis,  sup- 
plies the  muscles  and  mucous  membrane  of  the  posterior  part  of  the  larynx 
by  means  of  its   laryngeal   branch,  or  posterior  laryngeal  artery. 

Veins. — The  laryngeal  veins  correspond  in  their  courses  to  those  of  the 
arteries.  They  unite  into  three  veins,  the  superior,  middle,  and  inferior 
thyroid   veins,  which   in  turn  enter  the  internal  jugular  vein. 

Lymphatics. — The  lymphatic  vessels  of  the  larynx  collect  from  a  thick 
network  of  vessels  in  the  laryngeal  mucous  membrane  into  two  trunks,  one 
above  the  ventricle  of  the  larynx  and  one  below  the  cricoid  cartilage.  These 
trunks  empty  into  the  deep  cervical  lymphatic  glands. 

Nerves  of  the  Larynx. — The  larynx  derives  its  nerve-supply  from  the 
pnenmogastric  nerve.  The  superior  laryngeal  branch  of  this  nerve  is  the 
general  nerve  of  sensation  for  the  mucous  membrane  of  the  larynx,  and  is 
the  motor  nerve  for  the  crico-thyroid  muscle  and  for  the  arytenoid  muscle, 
the  latter  being  supplied  also   by  the  recurrent   laryngeal   nerve. 

The  recurrent  laryngeal  nerve  is  the  general   motor  nerve  of  the  larynx. 

The  superior  laryngeal  nerve  arises  in  the  inferior  ganglion  of  the  pnen- 
mogastric. It  passes  downward  along  the  sides  of  the  pharynx  to  the  supe- 
rior margin  of  the  thyroid  cartilage.  Here  it  divides  into  an  external  and  an 
internal  branch.  The  external  branch  of  the  superior  laryngeal  nerve  passes 
downward  beneath  the  sterno-cleido  -mastoid  muscle  to  supply  the  crico-thyroid 
muscle.  The  internal  branch  pierces  the  thyro-hyoid  membrane  and  supplies 
all  the  mucous  membrane  of  the  interior  of  the  larynx,  as  well  as  the  base  of 
the  tongue,  with  sensory  filaments.  It  sends  filaments  to  the  arytenoid  inu- 
cle,  and  anastomoses  with  the  recurrent    laryngeal  nerve. 

The  recurrent  laryngeal  nerve,  sometimes  named  the  inferior  laryngeal 
nerve,  is  also  a  branch  of  the  pneumogastric.  On  the  right  side  of  the  body 
this  nerve  leave-  the  pneumogastric  at  about  the  level  and  in  front  of  the  righl 
subclavian  artery.  Passing  around  this  artery  from  before  backward  it 
a-cends  to  the  side  of  the  trachea,  posterior  to  the  common  carotid  and  inferior 
thyroid  arteries.  In  winding  about  the  subclavian  artery  the  recurrent  laryn- 
geal nerve  on  the  right  side  comes  in  very  near  relation  to  the  apex  ol  the 
right   lung. 

On  the  left  side  of  the  body  the  recurrent  laryngeal  nerve  leaves  the 
pneumogastric  in  front  of  the  arch  of  the  aorta.  It  passes  around  the  aortic 
arch  from  before  backward  at  the  side  of  the  ductus  arteriosus,  and  passes 
upward  to  the  side  of  the  trachea.  Both  right  and  left  recurrent  laryn- 
geal nerve-  pass  upward  in  the  groove  between  the  trachea  and  esophagus. 
They  pa--  beneath  the  lower  border  of  the  inferior  constrictor  muscles  of  the 
pharynx,  gaining  entrance  to  the  larynx  just  posterior  to  the  articulation 
between  the  inferior  cornua  of  the  thyroid  cartilage  and  the  cricoid  cartilage. 


$24  ANATOMY  OF  THE   UPPER   A  I R-PASSAd ES. 

They  supply  all  the  muscles  of  the  larynx  with  motor  filaments,  with  the 
exception  of  the  crico-thyroid  muscle.  There  is  anastomosis  between  the 
recurrent  laryngeal  and  superior  laryngeal   nerves. 

The  relations  of  the  recurrent  laryngeal  nerv< — on  the  right  side  with  the 
apes  of  the  lung  and  with  the  subclavian  artery;  on  the  left  side  with  the 
arch  of  the  aorta — are  of  great  clinical  importance,  as  paralyses  of  the  laryn- 
geal muscles  may  result  from  pressure  against  the  recurrent  laryngeal  nerve 
by  aneurysm  of  the  vessels  named,  at  the  point  of  passage  of  the  nerve  around 
them,  or,  on  the  right  side,  by  irritation  from  the  inflammatory  conditions  in 
the  apex  of  the  right  lung.  The  motor  fibers  of  the  recurrent  laryngeal  nerve 
arc  supposed  to  he  derived  from  the  spinal  accessory  nerve.  Russell  of  Lon- 
don '  has  investigated  the  nerve-supply  of  the  abducting  and  adducting  mus- 
cles  of  the  larynx  and  feels  warranted  in  "the  conclusion  that  the  muscles 
closing  and  opening  the  glottis  are  respectively  supplied  by  different  bundles 
of  nerve-fibers,  preserving  an  independent  course  from  center  to  periphery, 
the  abductors  being  situated  on  the  tracheal  side  and  the  adductors  on  the 
external  side  of  the  nerve."  This  theory  still  requires  more  general  observa- 
tion, as  does  also  that  of  Onodi,  quoted  by  Bosworth,  that  the  laryngeal  mus- 
cles  receive  a  supply  of  motor  fibers  from  the  spinal  cord,  by  way  of  the  spinal 
ganglia  of  the  sympathetic  system,  extending  as  low  as  the  lower  cervical  and 
first  dorsal  spinal  ganglia,  the  course  of  the  fibers  being  direct  from  the  spinal 
cord  to  the  first  thoracic  ganglion ;  then  through  the  communicating  branch 
between  this  ganglion  and  the  last  cervical  ganglion  ;  and  from  this  latter 
directly  to  the  recurrent  laryngeal  nerve.  The  advantage  of  having  a  double 
motor  nerve-supply  for  the  muscles  of  the  larynx  is  quite  obvious. 

The  Mucous  Membrane  of  the  Larynx. — The  laryngeal  mucous 
membrane  is  continuous  with  the  lining  membrane  of  the  pharynx  and 
trachea.  Its  epithelial  covering  is  generally  of  the  squamous  variety.  Over 
the  lower  or  posterior  surface  of  the  epiglottis  it  is  columnar  and  ciliated. 
This  is  also  true  of  the  mucous  membrane  extending  below  the  ventricular 
bands,  which  is  continuous  with  and  corresponds  to  that  of  the  trachea.  The 
vocal  cords,  however,  are  covered  with  squamous  epithelium.  The  mucous 
membrane  is  rather  loosely  attached  to  the  submucosa  over  the  anterior 
surface  of  the  epiglottis,  on  the  posterior  surface  of  the  arytenoids,  on  the 
aryteno-epiglottic  folds,  and  in  the  ventricle  of  the  larynx.  This  fact 
accounts  for  the  rapid  development  of  edema  of  these  parts  in  very  severe 
inflammatory   processes. 

The  larynx  contains  an  abundant  amount  of  lymphoid  tissue,  especially 
at  the  border  of  the  epiglottis  and  in  the  aryteno-epiglottic  folds,  the  aryte- 
noids, the  interarytenoid  -pace,  and  the  ventricles  of  the  larynx. 

The  Trachea. — The  trachea  extends  from  the  lower  margin  of  the  cri- 
coid cartilage  to  the  bronchial  tube-,  a  distance  in  the  adult  of  about  four 
and  "iie-half  inches.  It  is  a  cylindrical  tube  flattened  posteriorly  where  it 
lies  in  contacl  with  the  esophagus.  It  is  a  membranous  tube  partially  sur- 
rounded by  incomplete  rings  of  cartilage.  It  extends  from  the  fifth  cervical 
to  the  third  dorsal  vertebra,  where  it  divides  into  the  two  bronchi.  In  trans- 
verse diameter  varies  from  three-fourths  of  an  inch  to  an  inch.  Internally 
it  is  lined  with  mucous  membrane  covered  with  columnar  ciliated  epithelium 
and  richly  supplied  with  lymphoid  tissue  and  mucous  glands. 

The  trachea  is  surrounded  and  partly  covered  by  important  structures. 
The  common  carotid  and  inferior  thyroid  arteries  lie  on  either  side  of  it, 
together  with  the  recurrenl   laryngeal  nerve.     Crossing  it  on  a  level  with  the 

1  Brit,  Med,  Journ.,  .1 ■  18,  L892;   Annual  of  the  Univ.  Med,  Sciences,  vol.  xiv.  !•'.  3,  1893, 


THE  CLINICAL   ANATOMY  OF  THE  NASAL   CHAMBERS.      825 

second  and  third  tracheal  rings  lies  the  Isthmus  of  t li<-  thyroid  gland  in  a 
sheath  formed  by  two  layer-  of  the  deep  cervical  fascia.  The  lobes  <>t'  the 
thyroid  gland  lie  <>n  either  side  of  the  trachea  and  larynx  from  the  isthmus 
t<>  the  thyroid  cartilage.  Below  the  isthmus  and  immediately  over  the 
trachea    is  a    network   of  veins,   the   intrathyroid   plexus. 

On  either  side  of  the  trachea,  in  the  superficial  fascia  of  the  neck,  lie  the 
two  anterior  jugular  veins,  at  about  two-fifth-  of  an  inch  from  the  median 
line.  These  vein-  communicate  by  a  transverse  trunk  which  crosses  in  front 
of  the  trachea  immediately  above  the  sternum.  Of  the  arteries,  the  crico- 
thyroid must  be  recalled  crossing  the  crico-thyroid  membrane.  An  anom- 
alous  vessel,  the  arteria  thyroidea  ima,  is  found  in  rather  rare  instances  run- 
ning up  the  front  of  the  trachea  from  the  arch  of  the  aorta.  The  innominate 
artery,  crossing  the  trachea  at  the  level  of  the  episternal  notch,  sometimes 
crosses  higher  up  within  the  field  of  a  low  operation  for  tracheotomy.  In 
very  rare  instances  both  common  carotids  spring  from  the  innominate  artery. 
In  such  cases  the  left  common  carotid  crosses  in  front  of  the  trachea  to  reach 
the  left  side  of  the  neck.  In  all  operations  for  tracheotomy  the  relation 
of  the  trachea  to  these  important  structures  lying  about  it,  and  this  possible 
anomalies,  must  be  borne  in  mind. 


THE  CLINICAL  ANATOMY  OF  THE  NASAL  CHAMBERS.1 

By  Harrison  Allen,  M.  D. 

Correct  impressions  of  the  localities  in  which  morbid  processes  occur  in 
the  nasal  chambers,  as  well  as  the  means  resorted  to  for  their  relief,  demand, 
to  a  degree  perhaps  greater  than  in  other  parts  of  the  economy,  an  intimate 
acquaintance  with  the  structure  and  relations  of  the  component  parts. 

The  peripheral  olfactory  apparatus  must  be  conceived  as  a  special  mem- 
brane covering  the  nasal  aspects  of  the  lateral  masses  (Figs.  54.">,  o4oi,  the-e 
uniting  with  the  cribriform  plate  and  the  perpendicular  plate  to  form  the 
ethmoid  bone.  Kach  lateral  mass  is  comparable  to  the  eyeball  or  to  the 
petrous  portion  of  the  temporal  bone,  in  the  meaning  (,t  the  term  that 
it  is  devised  to  protect  an  organ  of  special  sense.  The  conditions  under 
which  the  act  of  smelling  i-  efficient  demand  the  act  of  breathing  to  be  also 
efficient:  hence,  each  lateral  mass  is  a  part  of  a  system  of  bone-  which  i- 
in  free  communication  with  the  outer  air.  The  bone-  are  named  as  follow-: 
the  vomer,  the  ethmoid  bone,  the  sphenoid  bone,  the  nasal  bone-,  the  superior 
maxilla-,  the  palatal,  the  inferior  turbinated,  and  the  lacrymal  bones. 

The  ethmoid    b >    the  vomer,  and  the    sphenoid    bone    belong    to   the 

brain  case,  since  they  are  developed  with  those  structures  which  enter  into 
the  composition  of  the  base  of  the  skull.  The  nasal  bones  and  the  incisorial 
intermaxillary  portion-  of  the  superior  maxilla'  are  developed  in  pair-  from 
the  fronto-nasal  process  of  the  embryo.  The  remaining  part-  al-o  arise  in 
pair-,  but  at  the  sides  of  the  skull,  and  (excepting  the  lacrymal)  extend 
inward  to  join  the  median  structures.  All  of  the-e.  with  the  exception 
of  the  ethmoid  and  inferior  turbinated  bones,  have  relation-  distinct  from 
those  pertaining  to  the  nasal  chamber.  The  communication  ol  the  nasal 
chamber  with  the  ethmoid  cells,  the  frontal,  the  maxillary,  and  the  sphenoid 

1  Through  the  untimely  death  of  the  anthor,  this  section  failed  I  Ins  final  revision 

and  personal  choice  of  illustrations  [Ed.]. 


m'i; 


AXATOMY   OF   THE    UPPER    A  I  R-PASSAa  ES. 


sinuses  add  greatly  to  the  intricacy  of  the  region.  The  os  planum  i>  often 
perforated  at  more  than  one  point  in  advanced  disease  of  the  ethmoid  cell-. 
as  is  the  floor  of  the  orbit  in  disease  of  the  maxillary  sinuses.  While  !>oth 
of  these  systems  are  accessory  to  the  nasal  chambers 
(Fig.  548),  their  clinical  relations  therewith  are  im- 
portant. 

The  nasal  chamber  is  conveniently  divided  into 
three  parts  by  planes,  the  initial  lines  of  which  are 
started  at  the  transverse  sutures  of  the  floor. 

The  anterior  part  lies  in  front  of  the  maxillo-pre- 
niaxillary  suture:  the  vertical  transverse  section  de- 
fining it  will  answer  to  the  interior  (vestibule)  of  the 
external  nose  (  nearly). 

The  middle  part  lies  between  the  maxillo-pre- 
maxillary  suture  and  the  maxillo-palatal  suture:  the 
plane  defining  it.  beginning  in  front  at  the  ductus  <i<l 
nasum,  will  embrace  the  lateral  mass  of  the  ethmoid 
bone  (nearly ). 

The    third    part    lies  back   of   the  maxillo-palatal 

suture  and  includes  the  vertical   plate  of  the   palatal 

bone  with  the   end   of  the  middle   turbinal  :   the  plane 

defining  it  is  sharply  limited  by  the  anterior  border 

of  the  vertical  plate  of  the   palatal   hone.     The  third 

part   is  continuous  with  the  internal   pterygoid  plate 
ceils,  tin-  closure  <>t   many      I       .1  .  ,    0  L       *  °  ' 

completed  by  the  frontal  and       in    the    meSO-pterygOlCl    tossa. 

theeethmo1dlndpJ0jegc^  Tt    may  ,,('  observed  that  the   inferior  turbinated 

fe^Sdmfddil^roFnaS     bone  has  no  morphological  value  and  is  ignored  in  the 
and  the  uncinate  process  (5)      definitions  oi    the  planes. 

The  variations  in  the  nasal  chamber  are  numerous, 
and  it  is  not  assumed  here  that  the  regions  above  named  are  uniform.  They 
are  available,  however,  since  they  are  based  on  function  and  are  true  in  the 
great  majority  of  examples  of  crania.  Among  the  exceptions  to  some  state- 
ment may  he  mentioned  the  following  :  the  floor  of  the  nose  in  advance  of 
the  maxillo-premaxillary  suture  is  sometimes  so  shortened  as  to  yield  a  plane 
which  would  not  contain  all  or  nearly  all  the  interior  of  the  external  nose. 
The  middle  turbinated  bone  sometimes  projects  forward  beyond  the  line  of 
thi'  dm -Ins  ad  nasum  into  the  anterior  third. 

The  anterior  third  is  in  reality  a  canal  of  entrance  to  the  olfactory  stir- 
face-,  and  the  posterior  third  is  in  a  less  exact  sense  a  canal-like  passage  of 
exit.  The  pint  lasl  named  is  the  same  at  different  periods  of  life  and  in  all 
animals;  while  thai  of  the  anterior  passage  is  exceedingly  variable,  both  in 
age-  of  the  individual  and  in  groups  of  animals. 

Each  nasal  chamber  is  bounded  by  the  roof,  the  floor,  the  outer,  and  the 
inner,  or  septal,  wall-. 

The  Roof. — The  roof  of  the  nasal  chamber  is  confined  to  the  under- 
surfaces  of  the  nasal  hone-  in  advance  of  the  frontal,  a  -mall,  unimportant, 
and  variable  surface  of  the  bone  last  named  ;  the  cribriform  plate  of  the  eth- 
moid hone  :  and,  at  the  extreme  posterior  part,  a  portion  of  the  body  of  the 
Bphenoid  hone.  The  cribriform  plate  i-  an  exceedingly  vulnerable  part  of 
the  roof.  Many  examples  are  on  record  of  wound-  penetrating  it  :  and  its 
position  at  the  top  of  the  cleft.  between  the  septum  and  the  middle  turbinated 
hone,  as  the  part-  are  -ecu  when  inspected  bv  the  anterior  rhinoscopy,  mn-t 
be  borne  in  mind  iii  all  intranasal  procedures. 


1 .'..-  Hack  and  side 
view  of  tin-  ethmoid  bone, 
showing  in  B  the  lateral 
masses  on  either  side  <»('  the 
vertical  septal  plate  (2),  with 
which  they  are  united  bj  1  he 
cribriform  plate  (3)  at  the 
base  "t  the  crista  1 1  .  Be- 
tween the  nasal  meatus  and 
the  orbital  plate  1 1 1  are  the 
cells,  the  closure  oJ 


THE  FLOOR. 


827 


The  Floor. — The  floor  of  the  nasal  chamber  on  either  side  of  the  incisor 
crest  is  elevated  in  proportion  a>  the  crest  itself  is  developed  (  Fig.  5  16) ;  \\  hen 


Fig.  544.— Metal  cast  of  the  upper  air-passages  and  oral  cavity,  showing  the  maxillary  sinus  on  the 
right,  asymmetrical  frontal  simtees  above,  with  the  delicate  infundibulum  and  the  anterioi'-ethmoid 
Randall). 

t!ie  crest  is  absent,  or  of  moderate  proportion,  the  floor  of  the  pestibule  is  on 
the  same  level  as  that  of  the  horizontal  plate  of  the  maxilla.  On  the  whole, 
it  is  disposed  to  incline  downward  slightly  from  before  backward.  An 
abrupt  fall  or  "  break  "  in  the  inclination  i^  sometimes  demonstrated  at   the 


Itf*  .  j?  -«k 


section  "f  the  nasal  chambers,  show  ing  marki  d 
middle  turbinated  bone  apparently  deflecting  the  septum  t>.  the  right  and   nai 
-inns    from  Zuckerkandl I. 

point  where  the  incisorial  portion  of  the  tl ■  ends  and  the  maxillary  portion 

begins  I  Pig.  546).     It  ia  of  importance  to  detect  the  chang  of  level,  for  Becre- 
tions  may  accumulate  in  the  angle  and  by  undergoing  d mposition   resist 


V_»S 


anatomy  or  Tin-:  cpper  air-passages. 


efforts  to  correct  the  causes  of  fetor.  The  mucous  membrane  in  the  recess 
may  be  ulcerated  and  the  lesion  escape  observation.     Straight   plugs,  tubes, 

<»r  cannula'  cannot  be  carried  conveniently  to  the  floor  of  the  passage  at 
a   level   below  that  of  the  incisorial   portion. 

The  Outer  Wall. — The  outer  wall  of  the  nasal  chamber  embraces  the 
superior, middle, and  interior  turbinated  hones  and  the  uncinate  process.  On 
the  lateral  mass  of  the  ethmoid  bone  is  defined  the  superior  meatus  ;  between 
the  middle  and  the  inferior  turbinated  hone  is  the  middle  meatus  ;  and  between 
the  interior  turbinated  hone  and  the  floor  of  the  nose  the  inferior  meatus. 

The  Middle  Turbinated  Bone. — 'Fhe  middle  turbinated  bone,  while 
understood  to  he  hut  a  process  of  the  ethmoid  hone,  is  clinically  defined  as 
though  it  were  a  separate  element.  It  presents  many  variations,  and  their 
study  becomes  a  matter  of  the  first  importance.  The  hone,  as  seen  foreshort- 
ened in  the  living  subject,  relates  less  to  the  outer  wall  of  the  nose  than  i3 
described  in  the  manuals  of  anatomy.     It  might  he  compared   to  a  stalactite 


■  •---// 


fittal  section  <>t"  tin-  skull,  showing  the  bony  miter  wait  of  the  nasal  chambers,  with  the 
turbinated  bones  and  the  rise  of  the  floor  in  front  at  the  incisorial  foramen. 


hanging  near  the  roof  of  an  irregular  cavern.  It  may  he  laminar,  without 
increased  width  of  the  five  lower  border,  which  is  variously  deflected;  it 
may  have  a  moderate  amount  of  inflation  ami  appear  in  sections  pyriform  in 
outline,  thus  constituting  perhaps  the  average  condition  ;  or,  as  i-  often  found 
in  females,  it  may  he  enormously  inflated  so  as  to  exhibit  in  sections  a  veri- 
table globose  contour  (Fig.  545).  Infrequently  the  inflation  is  not  confined 
to  the  pendant  portion,  hut  extend-  into  the  .interim-  portion  of  the  pedicle 
as  well,  where  it  may  even  involve  the  adjoining  ascending  process  of  the 
maxilla. 

The  size  of  the  middle  turbinate  varies,  quite  apart  from  its  shape.  A.s  a 
rule,  the  bone  answers  to  the  lower  limit  01  the  perpendicular  plate  of  the 
ethmoid  hone  where  it  joins  the  vomer;  while  it  rarely  extend-  below  this 
line,  it  often  falls  short  of  it.  One  of  the  most  interesting  variations  in  the 
ethmoid  bone  arises  from  the  arrest  of  development  after  an  attack  of  scarlet 
fever.  The  lateral  mass  remains  stunted  and  is  lodged  high  up  in  the  cham- 
ber.    When  ostitis  persists,  ae  i-  often  the  case,  the  proximity  of  these  masses 


THE  OCT  Kit    WALL. 

to  the  cribriform  plate  should  lead  the  practitioner  to  conduci  all  local  treat- 
ment with  <  1 1 n *  care.  It  is  quite  true  that  small  ethmoid  bones  arc  sometimes 
examples  of  arrest  of  development  from  fundamental  causes,  and  probably  in 
some  degree  correlated  with  defects  in  the  normal  rate  of  evolution  of  the 
brain.  For  we  must  not  overlook  the  harmony  known  to  exist  between  the 
size  of  the  olfactory  surfaces,  at  least  of  the  ethmoid  hone,  and  the  functions 
they  subserve  in  extending  the  distribution  of  the  special  nerve-  over  a 
peripheral   organ. 

The  middle  turbinate  is  composed  of  a  straight  or  globose  anterior  part 
and  a  deeply  concave  posterior  part,  the  concavity  being  directed  outward. 
The  concave  part  (conch)  can  be  explored  from  in  front  and  subjected  to 
treatment,  for  it  is  often  the  seat  of  retained  secretion  and  granulation-tissue. 
The  median  and  anterior  surfaces  of  the  bone  are  less  coarsely  marked  than 
is  the  inferior  turbinate,  although  it  maybe  provided  anteriorly  with  numbers 
of  small  spicules.  In  the  infant  the  anterior  end  is  always  thin,  compressed, 
and  parallel  to  the  perpendicular  plate,  although  the  free  lower  end  i-  de- 
flected either  inward  or  outward,  more  commonly  in  the  direction  first  named. 
En  all  ages  the  bone  inclines  downward  and  backward  to  a  degree  greater 
than    is  seen   in   the   inferior   turbinate   (see  Fig.  546). 

The  Inferior  Turbinated.  Bone. — The  inferior  turbinated  bone  is  attached 
to  the  maxilla  and  palate-bone  so  as  to  form  a  bond  of  union  between  these 
structures.  It  extends  the  length  of  the  nasal  chamber — the  extreme  front 
border  just  back  of  the  anterior  nasal  aperture  being  in  some  example-  free. 
The  bone  is  marked  by  numerous  coarse  depressions,  grooves,  and  rugosities. 
It  is  concave  on  its  outer  surface  and  convex  or  straight  on  its  inner.  Seen 
in  the  living  subject  the  anterior  end  presents  a  rounded,  almost  cherry- 
shaped  mass,  often  with  scarcely  a  suggestion  of  the  position  of  the  inferior 
meatus,  although  this  region  can  be  carefully  outlined  by  the  aid  of  the  probe  ; 
the  inner  (median)  surface  of  this  part  of  the  inferior  turbinated  bone  I-.  n- 
a  rule,  sharply  convex  and,  indeed,  is  the  most  rounded  of  any  part  of  the 
surface.  Not  infrequently  it  or  its  covering  forms  in  diseased  states  septal 
apposition,  if  not  actually  false  union  or  synechia.  In  my  opinion  the  dis- 
turbing factor  in  the  formation  of  this  union  is  not  septal  but  turbinal,  and 
the  reduction  of  the  turbinal  is  of  greater  use  than  the  disturbance  of  the 
septum.  Directly  back  of  the  point  of  septal  apposition  the  convexity  of 
the  bone  in  great  part  disappears.  The  inferior  turbinate  is  often  of  consider- 
able height — a  variation  never  seen  in  like  degree  in  cabinet  crania.  In 
cleft  palate  the  free  inferior  border  tends  to  grow  down  to  a  deeper  plane 
than   is  normal. 

The  Middle  Meatus  and  the  Uncinate  Process. — Above  the  middle 
turbinated  bone  lies  the  middle  meatus,  sharply  defined  both  from  in  front 
ami  behind.  The  most  conspicuous  structure  seen  in  the  skull  in  this  region 
is  the  uncinate  process  of  the  ethmoid  bone.  Usually  this  process  lie-  parallel 
to  the  anterior  part  of  the  lateral  ma—,  but  it  often  projects  at  right  angles 
to  the  plane  of  these  cells,  from  which  in  the  living  subject   it   is  often  difficult 

to  separate  it.     The  process  may  lie  mistaken  for  the  middle  turbinate.     In 

text-book-  the  usual  ac< nl  of  the  process  is  to  state  that   it   narrow-  the 

opening  from  the  maxillary  -inu-  into  the  middle  meatus.  This  it  certainly 
does;  but   it-  more  important  clinical   connection  is   '<•  the  ell-  with   winch 

indeed  it  i-  in   true  morphological    relation.      In  some  instances  the  pr ■-- 

is  deeply  concave  on  it-  anterior  surface,  and  it-  median  border  i-  turned 
sharply  forward.  When  the  lateral  masses  arc  moderately  developed  the 
process  makes  no  impression  upon  the  eye  in  the  living  3tibject,and  is  imper 


mo 


.  I  .Y.  1  7V  M/  >  •    o  /  ■■    77/  /.     /  7  7  'A/,'    .  I  /  ft-  / '.  I  X.v.  I  ( ;  ES. 


FlG.  547.— Horizontal  section 
passing  above  the  cribriform 
plates  and  showing  the  ethmoid, 
sphenoid,  and  frontal  sinuses 
with  their  openings  toward  the 
cares  (Zuckerkandl). 


fectly  discerned  even  in  the  skull  ;  but  when  the  procesf  is  at  right  angles  to 
the  outer  wall  the  anterior  ethmoid  cells  i  Fig.  547)  are  always  large, and  as  a 

rule,  constitute  a  single,  rounded,  cherry-like  mass 
(bulla  ethmoidalis).  Thus,  when  the  right-angled 
position  of  the  process  is  detected,  the  observer 
may  conclude  that  the  enlarged  cells  lie  directly 
behind  it.  It  is  the  relation  existing  between  the 
uncinate  process  and  the  anterior  ethmoidal  cells 
and  the  ascending  process  of  the  maxilla  that 
makes  this  part  of  the  nasal  chamber  of  impor- 
tance in  studying  the  relations  existing  between 
lacrymal  and  nasal  disease.  Directly  within  the 
middle  meatus  is  sometime-  seen  the  opening  into 
the  maxillary  sinus,  aim1  within  the  inferior  meatus 
that  of  the  lachrymal  canal. 

The  Inner,  or  Septal  Wall. — The  word  "sep- 
tum" implies  that  the  two  chambers  are  being 
studied  together  and  that  the  septum  is  a  partition. 
In  this  essay  the  septum  is  assumed  in  the  main  to 
yield  the  inner  wall  of  each  chamber  (Fig.  o44). 
The  septum  is  composed  of  a  bony  and  a  carti- 
laginous part.  The  anterior  third  (about)  of  the 
bony  septum  is  notched;  the  upper  border  of  the 
notch  is  defined  by  the  perpendicular  plate  of  the 
ethmoid  bone,  the  lower  border  of  the  vomer 
and  incisor  crest  of  the  maxilla.  The  notch  is  occupied  by  the  triangular 
cartilage,  which  appears  to  be  unfortunately  named — according  to  the 
-indies  of  Freeman,  it  is  of  a  quadrilateral  figure.  The  bony  inner  wall 
of  the  nasal  chamber  is  composed  of  the  perpendicular  plate  of  the  ethmoid 

bone,  the   v er   in    front    of    its  alse,   the  incisor  crest,   the  anterior   nasal 

spine,  and  that  much  of  the  horizontal  plate  of  the  superior  maxilla  which 
ascends  to  form  a  crest.  The  incisor  crest,  the  spine,  and  the  process 
lasl  named  differ  from  the  perpendicular  plate  and  the  vomer  in  being 
composed  of  symmetrica]  parts,  and,  in  common  with  all  such  structures, 
present  variations  according  to  the  manner  in  which  the  right  and  left  con- 
stituents unite.  This  statement  is  particularly  applicable  to  the  incisor  crest 
and  the  nasal  -pine,  which  present  innumerable  variations — no  two  specimens 
being  .dike.  The  nasal  -pine  is  developed  before  the  crest,  and  is  nol  simply 
tin'  anterior  end  of  this  elevation,  as  is  usually  stated.  The  cresl  is  always 
rudi mental  in  young  subjects,  and,  indeed,  is  often  absent,  although  the  -pine 
m:i\  be  prominent.  Although  divided  into  right  ami  left  pari-  in  adults,  not 
infrequently  the  cresl  remain-  in  its  juvenile  condition  throughout  life.  \- 
a  rule,  it  is  well  developed  and  ha-  ;i  disposition  not  to  extend  backward 
beyond  the  incisive  foramen.  The  vomer,  passing  forward  a-  a  single 
3traigh1  plate  deeply  grooved  I'm-  the  accommodation  of  the  triangular  carti- 
lage, will  have  ii-  relation  to  the  cresl  undisturbed  so  long  as  the  structure  lasf 
named  i-  of  moderate  developmenl  ;  bm  if  ii  be  more  than  usually  high  the 
union  i-  nol  harmonious.  I  lei  in  •  arises  the  thickening  of  t  he  septum  at  this 
place  and  the  disposition  to  deflection  either  to  the  right  or  left — in  mosl  cases 
the  latter.  The  heighl  of  the  incisor  cresl  is  often  so  greal  a-  to  cause  the 
septum  to  be  unyielding  in  the  region  answering  to  the  heighl  of  the  inferior 
turbinated  l>on<-.  If  ;i  high  cresl  i-  also  carried  well  to  the  outer  wall  of  the 
nose  n  creates  an  exceedingly  narrow  passage  within  the  vestibule. 


.  I S  YM  M  /•:  TB  ) '  OF  Til  E  \.  I  &  \L   (II A  MB  EBS. 


«:J1 


The  perpendicular  plate  of  the  ethmoid  bone  may  projecl  forward  beyond  the 
maxillae  and  downward  so  far  as  greatly  to  narrow  the  size  of  the  septal  notch. 
It  may  constitute,  when  nualplaced,  an  important  factor  in  nasal  obstruction. 
The  prognosis  should  always  be  guarded  when  the  plate  is  so  disposed. 

Sharply  defined  projections  from  the  septum  are  called  "  spurs."  Asa 
rule,  they  are  ledges  of  varying  degrees  of  development.  The  most  common 
of  the  "spurs"  is  on  the  upper  vomerine  border,  either  where  it  forms  the 
lower  boundary  of  the  triangular  notch,  or  where  it  is  joined  by  the  per- 
pendicular plate  of  the  ethmoid  hone.  But  a  spur  is  often  found  high  up  and 
hack  on  the  septum,  and  may  occupy  in  great  part  the  middle  meatus. 


'  D-aeiea] 

Fig.  548.— Scheme  of  upper  air  passages  based  upon  metal  corrosion  caste 

Asymmetry  of  the  nasal  chambers  is  generally  acquired  and  is  often  the 
result  of  injury.  Errors  in  growth  and  development  may  arise,  however,  in 
the  nasal  chambers  as  elsewhere  in  the  economy.  Asymmetries  of  the  group 
last  named  are  in  great  measure  products  of  civilization.  Ethnological  cabi- 
nets  furnish  material  for  study  less  valuable  than  that  obtained  from  the  dis- 
secting room  or  observed  in  our  patients.  Inflammatory  or  other  obstructive 
conditions,  even  when  temporary  in  character,  may  cause  narrowing  of  the 
passages.  Whatever  may  be  the  etiology  of  these  confessedly  obscure  varia- 
tions, the   fact    remains  that   one  chamber,  <• nonly  the  left,  is  the  smaller, 

and  that  the  septum  inclines  away  more  or  less  from  the  median  line.  A 
summary  of  the  above  statemenl  is  here  given  :  Deviation  of  the  septum  from 
a  straight  line  is  associated  with  a  high  incisor  crest  ;  and  when  this  is  well 
established,  the  vomer  tending  to  stow  forward  when  there  is  no  space  in 
front  to  permit  it  so  to  do,  it  is  deflected  from  the  straight  line;  or  it'  it 
enters  into  the  compass  of  the  triangular  notch,  it  is  itself  abruptly  turned 
to  the  left. 

Far  bach  in  the  nasal  chamber,  at  a  place  answering  to  the  union  between 
the  perpendicular  plate  of  the  ethmoid  and  the  vomer,  an  irregular  ridge  can 


832  ANATOMY  OF  THE   UPPKIi   MR-PASSAGES. 

often  be  fell  in  making  digital  examinations.  The  ridge  is  more  common  on 
the  left  than  on  the  right  side,  and  is  of  varying  degrees  of  hardness.  Often 
it  can  be  pressed  away  by  the  finger ;  l>ut  more  commonly  it  will  not  yield 
unless  sawed  or  drilled. 

The  degreeof  consistence  of  the  septum  and  turbinated  hones  is  subject 
to  variation.  The  former  may  be  thin  and  porous  or  thick  and  eburnated.  No 
sign  is  accepted  by  which  the  state  of  the  hone  can  be  determined  by  inspec- 
tion. Large  hones  projecting  well  into  the  chambers  may  yield  to  slight 
interference,  while  small  hone-  may  be  exceedingly  resistant.  The  applica- 
tion of  these  facts  to  practice  are  of  importance.  A  thin,  yielding  septum 
may  he  the  cause  of  failure  in  attempting  to  arrest  hemorrhage  by  plugging 
the  chambers.  A  marked  deviation  can  sometimes  be  corrected  by  the  finger 
to  almost  the  degree  desired ;  while  if  the  parts  be  thick  and  firm  nothing 
will  yield  until  they  are  attacked  vigorously  by  the  aid  of  instruments. 

The  Nasal  Apertures. — The  apertures  of  each  nasal  chamber  are  two 
in  number,  the  anterior  and  the  posterior.  The  anterior  is  the  nostril  and 
the  posterior  is  the  choana.  The  nasal  chamber  is  examined  by  reflected 
light  thrown  through  the  nostril,  or  by  a  mirror  carried  into  the  naso-pharynx, 
which  reflects  the  view  as  seen  at  the  choana1.  When  the  skull  is  examined, 
the  anterior  nasal  aperture  takes  the  place  of  both  the  nostrils  ;  and  the  mid- 
region  of  the  base  of  the  skull,  of  the  naso-pharynx.  If  it  is  accepted  that 
the  nostril  is  an  aperture,  the  term  cannot  be  used  as  a  synonym  for  "nasal 
chamber,'"  as  is  sometimes  done  by  clinical  writers.  The  term  "naris"  is 
discarded. 

The  anterior  nasal  aperture  is  defined  by  the  maxilla  and  the  nasal  bones, 
and  is  exceedingly  variable  when  a  series  of  all  races  of  men  is  examined. 
Hut  in  clinical  studies — excluding  those  conducted  on  the  negro — the  opening 
is  pyriform,  with  the  base  of  the  figure  downward,  and  presents  two  trench- 
ant asymmetrical  borders  which  are  raised  above  the  level  of  the  floor  of  the 
nose.  The  entire  figure  has  been  compared  to  the  heart  on  the  playing  card. 
Welcker  happily  likens  it  to  the  figure  of  the  European  elm  {Ulmus  mon- 
tanus),  from  the  fact  that  the  lower  border  of  one  of  the  chambers  (commonly 
the  left)  is  below  the  level  of  the  other.  The  conjoined  incisor  crests  of  the 
maxillae  often  appear  at  the  aperture.  The  perpendicular  plate  of  the  ethmoid 
bone,  infrequently  here  seen,  may  even  project  beyond  its  plane,  thus  in 
reality  converting  the  anterior  nasal  aperture  into  two  apertures. 

The  choana,  or  posterior  nasal  aperture,  is  bounded  inferiorly  by  the 
posterior  margin  of  the  palatal  bone.  The  lateral  margin  answers  to  the 
anterior  border  of  the  internal  pterygoid  plate.  It  would  be  difficult  to 
define  the  upper  margin  were  it  not  for  the  presence  of  a  group  of  minute 
bone-spicules    which    receive    no    name    in    anatomy,  SO    far    as    I    am    aware, 

which,  nevertheless,  are  exceedingly  useful  in  defining  the  plane  of  each 
choana.  The  inner  margin  is  the  septum,  but  this  is  not  a  reliable  guide  to 
the  base  of  the  choana.  since  the  posterior  margin  of  the  vomer  often  lies  well 
forward  on  the  crest  between  the  palate-bones.  I  have  called  this  phase  of 
the  nasal  septum  "recedent,"  to  distinguish  it  from  thai  form  where  the  base 
comes  sharply  up  to  the  base  of  the  posterior  nasal  spine.  In  subjects  that 
exhibit  the  recedent  form,  the  vomer  will  allow  the  posterior  ends  of  the 
inferior  turbinals  to  approach,  although  they  do  nol  touch-  the  mucous  mem- 
brane over  both  bone-  remaining  normal.  Care  should  betaken  in  such  con- 
ditions not  i  o  eon  Ibu  in  I  these  masses  with  hypertrophy  of  the  posterior  ends 
of  the  turbinal   bodies. 

The  region  of  the  choana?,  after  all    is  said,  is  not  of  importance.      In 


THE  NASAL   MUCOUS  MEMBRANE. 


833 


practice  the  choanae  in  reality  include  the  meso-pterygoid  fossa,  or.  ac  I  have 
ventured  to  call  it,  the posterula,  or  back  porch  to  the  nasal  chamber.  This 
is  a  single  region  into  which  the  choanae  del  touch.      It  contain-  the  alae  of  the 

vomer  and  all  of  the  inner  surface  of  the  internal  pterygoid  plate-.  The 
finger  introduced  into  the  naso-pharynx  is  received  inn,  the  posterula,  and 
the  pterygoid  surfaces  are  clearly  defined  at  the  sides.  In  rare  instances 
these  may  he  thickened,  retaining  the  infantile  form,  and  may  aid  other  con- 
ditions in  tending  to  reduce  beyond  normal  limits  the  posterior  aperture-  of 
the  chambers. 

The  Nasal  Mucous  Membrane  and  its  Blood-vessels. — The 
mucous  membrane  lining  the  nasal  chambers  is  of  three  kinds:  first,  the 
olfactory  membrane,  which  is  limited  (nearly)  to  the  ethmoid  hone  on  the 
inner  aspect  of  each  lateral  mass  and  the  opposed  surface-  of  the  perpen- 
dicular plate;  second,  the  highly  vascular  and  partially  erectile  -tinctures 
(tnrhinal  bodies)  covering  the  inferior  turbinated  bones  ;  third,  the  generalized 
membranes  which  line  the  other  bones  and  the  walls  of  the  accessory  sinuses. 

The  property  of  cocain  in  constricting  small  blood-vessels  is  \\<c(\  with 
advantage  in  studying  the  anatomy  of  the  nasal  chambers  in  the  living 
subject.  The  contrast  in  the  shapes  of  the  inferior  turbinal  body  before  and 
after  an  application  of  a  10  per  cent,  solution  of  cocain  is  such  as  to  give  the 
observer  an  accurate  impression  of  the  extent  of  the  erectile  mucous  mem- 
brane covering  it.  The  cushion  surfaces  of  the  bodies  with  contour  convex 
before  the  cocain  is  applied  disappear,  and  in  their  places  are  noted  a  mem- 
brane bound  down  to  the  bone,  to  whose  irregularity  it  conform.-.  We  speak 
of  a  turbinated  bone  and  a  turbinal   body — the   latter  phrase  to  express  the 

A  nl.  and  post,  ethmoidal  arteries 


Zuckerkandi's 

vein 


Naso-palatine  art. 


Spht  nopalatine 


Fig.  549.— Vessels  of  the  lateral  wall  of  the  nose,  >ln>«  ing  direct  cerebral  communication  through 
Zuckerkandi's  win  (Zarniko). 


fact  that  the  body  is  an  erectile  membrane  which  ha-  a  shape  in  a  measure 
distinct  from  the  skeletal  surfaces  with   which   it   is  closely  incorporated. 

As  a    rule,  incisions   into   the   turbinal    body  are  followed    by    i lerate 

bleeding,  which  ceases  spontaneously.  Occasionally  wounds  over  the  middle 
turbinal  bleed  more  freely,  which  in  order  to  stanch  require  interference  b) 
pre-- nre  or  use  of  astringents.  The  mucous  membrane  on  the  outer  wall 
and  in  the   sinuses   is  uniformly  indisposed  to  bleed  SO  a-  to  demand  inteiler 


834  ANATOMY  OF  THE   UPPER  AIM-PASSAGES. 

(Mice.  It  is  far  different  with  the  septum.  Here  the  cartilaginous  portion, 
where  it  joins  the  incisor  crest,  is  exceptionally  vascular.  A  caruncular 
swelling  is  often  found  at  this  point,  which  should  be  carefully  avoided  in 
making  incisions  for  minor  surgical  procedures.  A  second  point  from  which 
hemorrhage  is  apt  to  occur  i-  over  the  triangular  cartilage  itself.  This  is 
never  from  an  incision,  hut  i-  commonly  from  abrasions,  and  is  therefore  the 
region  front  which  blood  often  springs  in  non-surgical  epistaxis.  The  seat 
of  hemorrhage  is  found  at  a  point  just  beyond  the  tip  of  the  triangular 
notch.  Hemorrhage  occurring  from  wounds  reaching  the  submucous  tissues 
is  far  different  from  the  foregoing.  Two  distinct  locations  are  here  noted — 
namely,  the  septum  alone,  the  line  of  the  vomer  at  any  part,  which  answers 
to  the  positions  of  the  deep  septal  blood-vessels  ;  and  the  posterior  third  of 
the  outer  wall,  where  it  receives  the  arteries  and  veins  which  pass  through 
the  spheno-palatine   foramen  (Fig.  549). 

The  bones  of  the  nasal  chamber  are  remarkable  for  being  in  whole  or  in 
part  covered  with  mucous  membrane,  and  are  supplied  largely  with  its  blood- 
vessels. The  muco-periosteum  is  a  valuable  term  in  describing  such  a  mem- 
brane, for  it  fixes  the  mind  upon  the  analogy  between  such  a  membrane 
and  the  periosteum.  If  the  comparison  between  the  two  membranes  is  pre- 
cise, then  the  study  of  the  nasal  chambers  as  part  of  the  great  skeletal  group 
of  bones,  being  as  exact  in  pathology  as  in  anatomy,  relegates  many  of  the 
morbid   condition-   of  the  chamber  to  phases  of  periostei.tis  and   osteitis. 

The  Nerves. —  The  nerves  that  must  be  recalled  in  surgical  treatment 
of  the  nasal  chamber  are  unimportant.  The  operations  on  the  nasal  septum 
will  sometimes  cause  numbness  of  the  incisor  and  canine  teeth  to  be  com- 
plained  of  for  a   few   days  after  operation. 

Asymmetry  and  Narrowing  of  the  Nasal  Chambers. —  It    has 

been  stated  on  page  831  that  the  nasal  chambers  are  often  asymmetrical — -the 
asymmetry  being  caused  by  deviation  of  the  nasal  septum,  usually  to  the  left 
side,  and  that  such  deviation  is  acquired  either  as  a  direcl  result  of  trauma- 
tism or  of  disease.  The  chambers,  however,  may  be  unequal  in  size,  even 
when  the  septum  remain-  straight.  Such  a  relation  is  due  to  fundamental 
causes,  and  will  be  found,  like  all  these  condition-,  to  correlate  with  other 
peculiarities  in  the  economy.  An  important  element  in  prognosis  is  here  to 
be  considered,  for  a  congenitally  narrowed  or  occluded  chamber  can  never  be 
made  entirely  efficient.  Sometime-  the  posterior  portion  only  of  the  chamber 
exhibit-  asymmetry.  This  i-  due  to  a  delect  in  the  development  of  the 
sphenoid  bone,  the  body  of  which  does  not  normally  expand  ;  thus  the  ptery- 
goid  processes  are  kept  t slose  together,  the  palatal  bones,  as  well,  remain 

in  an  infantile  condition,  ami  in  time  the  choanal  are  even  inadequate  for  the 
accommodation  of  the  posterior  end- of  the  turbinals.  [fan  operation  be 
proposed  for  deviation  of  the  septum  or  other  causes  of  obstruction  in  the 
anterior  portion  of  a  chamber  of  a  subject  where  the  posterior  portion  remains 
undeveloped,  a  statement  of  the  results  to  be  expected  should  be  guarded, 
since  the  narrowing  at  the  choanse  and  posterula  may  in  it-elf  maintain 
obstruction.  In  these  cases  the  choanse  are  always  -mall  and  oval  ;  the  inter- 
nal pterygoid  processes  are  convex,  and  the  turbinals  are  thick  and  pressed 
together  against  the  septum.  Cases  have  been  observed  characterized  by 
retention  of  all  these  pari-  in  an  embryonic  condition,  with  resultanl  atresia. 
Even  w  hen  the  choanal  plane  i-  normal,  narrowing  may  occur  at  the  posterior 
third  of  the  chamber ;  thus  converting  each  posterior  portion  into  a  passage, 
which  might  be  compared  to  a  funnel  laid  on  it-  side  and  with  it-  neck 
directed   forward. 


PHYSIOLOGY  OF  THE  UPPER  AIR-PASSAGES. 

By    WALTEK  J.  FREEMAN,  M.  I), 

OF   PHILADELPHIA. 


The  study  of*  the  physiology  of  the  nose,  throat,  and  larynx  is  of  the 
greatest  practical  importance,  for  it  is  only  by  an  intimate  knowledge  of 
their  functions  in  health  that  we  are  able  correctly  to  appreciate  the  signifi- 
cance of  pathological  conditions.  At  times,  indeed,  when  insurmountable 
difficulties  prevent  thorough  physical  examination,  we  must  fall  hack  upon 
our  knowledge  of  the  normal  functions  of  the  parts,  such  as  breathing, 
swallowing,  phonation,  etc.,  to  obtain  a  correct  diagnosis. 

NOSE. 

The  old  idea  of  the  nose  as  simply  an  organ  of  olfaction  lias  given  place 
to  an  appreciation  of  the  influence  it  exerts  upon  the  whole  economy,  not 
only  by  its  vital  functions  of  warming,  moistening,  and  filtering  the  inspired 
air,  but  also  by  its  acting  as  a  protective  organ  to  prevent  the  admission  of 
harmful  substances   in   inhalation. 

Functions  of  the  Nose. —  Respiration. — (1)  Passage-way  for  air  in 
breathing;  (2)  warming,  moistening,  and  filtering  the   inspired   air. 

Olfaction. — (1)  Perception  of  odors  in  inspiration;  (2)  perception  of 
flavors  in  expiration. 

Phonation. — (1)   Resonance;  (2)  production  of  overtones. 

Protection. — (1)  By  sensation  ;  (2)  by  olfaction. 

Ventilation. — (1)  Of  thecals;  (2)  of  the  accessory  sinuses. 

Respiration. — (1)  We  notice  from  the  dryness  of  the  throat  in  mouth- 
breathing  that  this  is  not  the  passage-way  intended  by  nature  for  the  air  in 
inspiration,  and  we  realize  that  normal  respiration  should  take  place  through 
the  nose,  and  that  mouth-breathing  is  a  pathological  condition  giving  rise  to 
many  injurious  results. 

Paulsen  has  proved  that  the  air  in  respiration  takes  a  very  different 
course  from   that  formerly  supposed  to  be  the  case. 

Instead  of  Mowing  back  along  the  inferior  meatus,  the  air  passes  directly 
upward  from  the  nostril  to  the  superior  meatus,  whence  it  fill-  by  a  gentle 
curve  toward  the  choana.1  This  shows  the  old  arbitrary  division  of  the  nose 
into  a  lower  respiratory  ami  an  upper  olfactory  portion  to  be,  physiologically 
at  least,  incorrect.  It  seems  curious  that  the  inferior  meatus  should  thus  be 
avoided  by  the  inspiratory  current.-,  for  the  inferior  turbinals  contain  the 
largest  amount  of  vascular  tissue.  It  must  lie  remembered,  however,  that 
nowhere  in  the  nose  is  the  air  at   rest,  and  as  the  air   in  the  inferior  meatus  IS 

1  One  can  readily  be  convinced  thai  the  (stated  course  of  theair  is  the  true  one  by  exam  in 
Lug  the  nose  of  a  person  who  has  inhaled  finely  divided  magnesium      The  powder  will  l»- 
found   adhering  to  tin-   anterior  end   of  the   middle  turliinal  and  a-  far  up  tin-  olfactory  cl< 
one  can  see.  while  the  inferior  meatus  and  turbinal  remain  almo8i  entirely  t 
Hence  the  common  appearance  of  dust  and  crusts  <  n  the  anterior  ends  of  the  middle  turbii 

835 


836  PHYSIOLOGY  OF  THE   UPPER  A  1 B- PASSAGES. 

more  sluggish,  it    has   received    more   heat,  and  when  drawn   into  the  current 


Fig.  551.— Anterior  nares, 
s  1 1  <  i  w  ing  «  bite  deposit  of 
inspired  magnesium-pow- 
der upon  the  septum  and 
middle  turbinals  only. 


Fig.  550.— Diagram  showing  the  course  of  principal  and  auxiliary  currents  <>f  air  in  normal  respiration.1 

raises  its  temperature  more  quickly.2     The  main  currents  of  air  pass  into  the 
naso-pharynx  at  the  highesl  portion  of  the  choanal  arches,  and  an  enlarge- 
ment of  the  pharyngeal  tonsil,  encroaching  even  slightly 
upon    these    openings,    impedes    respiration    much    more 
W  than  does  swelling  of  the  ends  of  the  inferior  turbinals, 

.     '■•;'. ;;■•;>•''  blocking  to  a  marked  degree  the  lower  portion  of  the 

choanse  (compare  Fig.  560). 

The  course  of  the  air  in  expiration  is  nearly  the 
same  as  in  inspiration,  except  that  it  is  directed  higher 
up — i.  e.,  through  the  posterior  part  of  the  superior 
meatus,  a  point  that  we  shall  soon  see  is  of  importance 
in  detecting  flavors. 

(2)  Within  the  nose  the  shelf-like  arrangement 
of  the  turbinated  bones  gives  increased  extent  of 
surface  to  the  vascular  membrane  with  which  they 
are  covered.  The  interior  of  the  nose  is  completely  lined  with  mucous  mem- 
brane, that  covering  the  inferior  turbinals,  the  lower  portion  of  the  middle, 
and  the  posterior  ends  of  the  middle  and  superior  turbinals,  containing  vast 
systems  of  blood-vessels,  which  are  the  chief  source  of  the  heat  and  moisture 
supplied  to  the  air  in  inspiration.  These  blood-sinuses  are  surrounded  by 
involuntary  muscular  fibers,  and,  although  they  are  commonly  so  called,  they 
are  not.  correctly  speaking,  true  erectile  bodies,  which  consisl  of  large  irregu- 
lar spaces  lined  with  pavement  epithelium.  This  muscular  tissue  is  under 
the  control  of  the  sympathetic  system,  which  reaches  the  interior  of  the  nose 
by  way  of  the  spheno-palatine  ganglion,  and  derives  it-  influence  from  the 
cerebro-spinal  system.  It  is  known  that  there  are  vaso-dilators  us  well  as 
vaso-constrictors,  ami  their  centers  probably  lie  in  the  floor  of  the  fourth 
ventricle.'1  The  dilatation  and  contraction  of  the  sinuses  caused  by  these  nerves 
are  constantly  going  on.  and  are  physiological  actions  of  great  importance. 
The  object  i-  the  regulation  of  the  amount  of  blood  in  the  turbinals,  and 
he  nee  the  propel-  w ;  i  r  1 1 1  i  ii  L!  and  moistening  of  the  inspired  air.     The  mechanism 

i~.  indeed,  a  deli. -ate  which  i-  aide  to  supply  the  requisite  amount  of  heat 

.  *  Zarniko  :  THa   Krankheiten  da   Nase,  etc..  p.  38.      Later  observers  have  not  only  confirmed 
this,  Inn  have  found  thai  the  :iii  takec  n  -iill  highei  coursi 

'Zarniko,  p    10.  'Chapman:  Human  Physiology,  p  732. 


NOSE.  837 

and  moisture  under  ;dl  the  varying  changes  of  temperature  and  humidity  to 
which  animal  life  is  subjected.  Thus  we  notice  that  when  the  temperature  is 
cold,  the  turbinals  swell  and  the  passages  become  more  closed.  This  indi- 
cates that  the  vascular  tissue  has  become  tilled,  and  that  a  large  amount  of 
warm  blood  is  being  brought  into  contact  with  the  impeded  current  of  inspired 
air.  raising  its  temperature  to  a  higher  degree.  While  the  swelling  of  the 
turbinals  is  frequently  accompanied  by  increased  secretion,  tin-  i-  not  neces- 
sarily the  case,  for  we  may  have  the  one  independent  of  the  other.  Were  it 
otherwise,  in  cold  weather  we  should  normally  have  excessive  secretion,  a 
condition,  however,  which,  although  frequently  met  with,  is  due  to  abnormal 
sensitiveness  of  the  nasal  mucous  membrane  to  contact  with  cold  air.  We 
know  that  at  32°  F.  air,  to  be  saturated,  requires  but  2.1  gr.  of  water  to  the 
cubic  foot.  Thus  the  tissues  of  the  nose  would  be  called  upon  for  very  little 
moisture  in  cold  weather  did  they  not,  in  raising  the  temperature  of  the  in- 
spired air,  also  raise  its  saturation  point,  which  goes  to  illustrate  the  nice 
balance  which  must  normally  exist.  According  to  Aschenbrandt  and  Kayser, 
the  inspired  air  receives  from  20°  to  40°  of  heat,1  and  becomes  saturated,  or 
nearly  so,2  in  its  pas-age  through  the  nose.  This  renders  it  suitable  for  the 
interchange  of  oxygen  and  carbonic  acid  gas  in  the  lungs,  a  simple  action  of 
osmosis  which  takes  place  most  perfectly  when  with  warm  fluid  on  one  side 
of  a  membrane  there  is  warm,  moist  air  on  the  other. 

To  supply  the  large  amount  of  water  necessary  to  moisten  the  inspired 
air.  Bosworth  has  calculated  that  about  a  pint  should  be  secreted  by  the  aose, 
and  this  is  obtained  from  the  sinus-tissue  of  the  turbinals,  together  with  the 
tear-  and  the  secretion  of  the  muciparous  glands. 

The  function  of  the  nose  in  filtering  the  inspired  air  is  practically  per- 
fect, for  Tyndall  has  demonstrated  that  the  expired  air  is  free  from  germs. 
This  takes  place,  first  by  action  of  the  vibrissa?,  the  hairs  of  the  vestibules, 
which  hinder  the  entrance  of  large  particles,  and  next  by  the  adherence  of 
-mallei-  particles  to  the  moist  surfaces  of  the  intricate  passages  of  the  nose 
and  naso-pharynx.  When  in  large  amount,  or  when  the  nose  is  too  roomy, 
or  pathological  conditions  interfere  with  this  normal  filtering  process,  parti- 
cle- may  reach  the  lower  respiratory  tract.  While  the  mucus  i-  an  important 
agent  in  arresting  the  dust,  the  cilia1  are  in  no  less  degree  active  in  cleansing 
the  surfaces.  The  ciliary  wave  in  the  nose  is  toward  the  naso-pharynx,  that 
in  the  naso-pharynx  toward  the  mouth,  while  that  in  the  lower  respiratory 
tract  is  upward,  SO  that  foreign  particle-  are  carried  toward  the  mouth  and 
thus  removed,  either  bv  expectoration,  or,  more  physiologically,  by  swallowing. 
The  activity  of  the  cilia'  depends  very  much  upon  the  quality  of  the  mucus 
with  which  the  membranes  are  covered  ;  for  in  certain  state-,  when  there  i- 
iiiueh  viscidity,  it  is  known  that  their  action  is  much  hindered.  This  gives 
rise  to  a  feeling  of  stuffiness,  so  great  at  time-  that  patients  with  fossae  so 
open  that  one  is  able  to  see  the  vault  through  both  sides,  complain  thai  the 
uose  is  obstructed.  We  see,  therefore,  the  vital  function-  exercised  by  the 
intranasal  mucous  membrane;  and  a  correct  knowledge  of  it-  physiological 
functions  should  teach  us  as  far  as  possible  to  avoid  cauterization  or  destruc- 

1  'I'm  determine  tin-  amount  "t'  heal  thus  imparted  to  the  inspired  air,  Bloch  hns  formulated 
the  following  rule  :  The  .-1111(111111  of  heal  is  equal  t"  five-ninths  the  difference  between  the  bod) 
temperature  and  that  <>t'  the  external  air.  Taking,  for  example,  the  temperature  of  the  air  al 
32°  F.  and  thai  of  the  body  :ii  98.5  I  .  we  have  five-ninths  of  '•-  or  about  37  \  <  on- 
sequently  the  temperature  lei-  been  raised  from  32°  to  nearly  69  V  in  it  liorl  passage  through 
die  nose. 

2  Bloch  is  probablj  correct   in  the  experiment  Bhowing  thai  the  inspired  air  i*  onlj  two- 
thirds  saturated,  for  we  notice  .-in  uncomfortable  feeling  in  breathing  completely  saturated  air. 


838  PHYSIOLOGY  OF  THE   UPPER  AIR-PASSAGES. 

tion  of  this  tissue,  and  to  remove  instead  septal  ove%rowths  <>r  to  correct 
deformities  of  the  septum  which  interfere  with  respiration. 

Olfaction. — 1 1  )  As  a.function  tor  yielding  pleasure  and  for  serving  a-  a 
means  of  information  and  protection,  olfaction  has  been  held  in  far  too  low 
estimation.  In  man  this  sense  receives  very  little  attention,  partly  becauseof 
the  protected  position  which  the  organ  of  smell  occupies,  thus  greatly  dimin- 
ishing its  liability  to  injury,  and  the  consequent  infrequency  of  disorders 
of  olfaction,  but  more  especially  because  of  the  almost  universal  lack  of 
development  and  training.  It  i>  probable  that  in  the  course  of  evolution, 
devolution  of  this  sense  has  taken  place,  and  that  in  primitive  man  it  was 
much  more  highly  developed.  Indeed,  in  certain  cases  we  find  the  sense  so 
acute  that  its  possibilities  seem  almosl  incredible.1  The  increase  in  size  and 
number  of  the  turbinals  would  seem  to  have  an  important  bearing  on  the 
sense  of  olfaction,  as  furnishing  greater  extent  of  surface  for  distribution  of 
olfactory  nerves.  While  the  presence  of  a  fourth  or  even  a  fifth  turbinal 
i-  probably  due  to  a  persistence  of  the  sagittal  furrows  found  in  the  embryo, 
the  fact  that  a  fourth  turbinal  is  present  in  certain  negro  tribes  in  whom 
olfaction  is  very  acute  seems  to  point  toward  the  lessening  of  the  function  in 
civilized  man  as  due  to  lack  of  development  of  the  organ  of  olfaction.-  Not 
only  has  there  been  an  apparent  degeneration  of  the  sense,  but  directly  bear- 
ing upon  this,  also  a  decrease  in  size  of  the  olfactory  lobes  and  the  fields  of 
distribution  of  the  nerves."  Thus  while  most  writers  claim  that  the  terminal 
filaments  are  distributed  to  the  middle  as  well  as  the  superior  turbinal  and 
the  region  of  the  septum  opposite,  Schultze's  investigations,  confirmed  by  von 
Brunn's  careful  measurements,  have  proved  that  the  olfactory  epithelium  does 
not  reach  the  lower  edge  of  the  superior  turbinal  by  7},-  mm.,  and  that  the 
whole  olfactory  surface,  divided  nearly  equally  between  the  turbinal  and  the 
septum,  has  an  extent  of  but  257  sq.  mm.,  although  this  is  increased  slightly 
by  scattered  islands  of  olfactory  cells.  The  olfactory  organ,  then,  is  placed 
in  the  remotest  region  of  the  nose;  and  it  is,  therefore,  only  by  an  apprecia- 
tion of  the  direction  of  the  air-currents  in  respiration  that  we  are  able  to 
understand   how   it   can   be  acted    upon  at  all   by   odoriferous   particles. 

In  order  that  we  may  detect  odors,  certain  conditions  are  essential. 
The  perceptive  structures  must  be  normal,  nasal  respiration  must  be  un- 
hindered, ami  the  surface  must  be  moist.'  The  external  nose  and  the 
power  of  sniffing8  are  also  necessary  in  order  that  the  current  of  air  may  be 
properly  directed  into  the  superior  meatus.  Then  again,  that  the  odor  of 
substances  may  be  perceived,  they  must  be  either  in  a  gaseous  state  or  ill  a 
State  of  fine  subdivision  and  capable  of  absorption.  Whether  the  odoriferous 
substances  cause  olfaction  by  their  specific  weight,  by  their  power  to  absorb 
heat  (Tyndall)  by  their  chemical  properties,  or  by  their  specific  action  on  the 

1  TIk se  "i  smell   i-  far  more  acute  in  the  lower  races  of  man  than  in  the  higher,  to 

whatever  extent  in  the  latter  it  may  have  been  developed,  'thus  A. rabs  are  said  to  smell  lire 
thirty  mile-  away  (Chapman,  p.  764). 

!    <her  and  Penzold  have  found  that   in  man   .  mg.  of  sulphur-alcohol  (over  ten 

linn-  mi  lit-  powerful  than  musk  I  i"  one  liter  of  air  \\;i^  the  utmost  limit  in  which  odor  could  be 
detected.  The  ability,  however,  with  which  animals  are  able  to  follow  ;i  trail  shows  thai  their 
sense  of  olfaction  i-  much  more  acute  than  that  of  man  (Gaule:  Heymann'a  Handbuch  der 
haryngologie  und  Rhinologie,  vol.  iii.  p.  196  - 

'  Theolfactory  bulb  and  nerves  are  besl  developed  in  animals  in  which  the  Bense  of  smell 
i-  ijk  »— t  mimic     Theolfactory  region  i-  most  developed  in  the  dog    Chapman,  p  764 

1  Whether  moisture  is  necessary  because  ii  protects  the  epithelium,  or  whether  ii  has  a 
more  specific  action  in  transmitting  the  sensation,  we  do  not  know;  but  olfaction  is  markedly 
hindered  if  membranes  are  dry,  although  uot  interfered  with  even  if  Becretion  is  excessive. 

\ii"-ini:i  may  be  due  i"  facial  paralysis,  the  power  "i  sniffing  being  lost.     It  may  also  be 
caused  bj  '••     ■■>  the  external  nose,  being  restored  when  the  nose  is  replaced  by  operation. 


NOSE. 

pigmenl  cells  '  of  the  olfactory  region,  can  probably  never  be  stated  definitel) . 
It  is  a  matter  of  speculation  ami  theorizing  at  present,  and  many  ideas  as  to 
its  mode  of  action  have  been  advanced.  It  seems  probable  thai  the  theory 
that  olfaction  depends  upon  the  chemical  composition  (Haycraft)  and  molec- 
ular weighl  of  the  substance  will  finally  be  generally  accepted. 

( 2)  The  greater  pari  of  the  sensation  that  we  designate  as  taste  i-.  in  reality, 
olfaction- — that  is,  olfaction  during  expiration.  The  term  taste  -I  ion  Id.  strictly 
speaking,  be  limited  to  perception  of  sweet,  sour,  bitter,  ami  salt,  the  only 
sensations  detected  by  the  nerves  of  gustation  ;  but  so  narrow  an  interpreta- 
tion cannot  be  adhered  to  as  yet.  One  can  readily  lie  convinced  of  the  truth 
of  this  statement  by  holding  the  nose  while  drinking  or  eating,  for  thus  the 
current-  of  air  are  unable  to  pass  through  the  nose,  and  all  flavors  and  odors 
are  un perceived.  A.lso  in  cases  of  imperforate  choanse,  although  the  organs 
of  olfaction  are  normal  and  the  nasal  fossa?  otherwise  free,  the  senses  of  smell 
and  taste  are  both  in  abeyance  because  of  the  absence  of  both  inspiratory  and 
expiratory  currents  through  the  nose.  It  is  in  the  experience  of  everyone 
that  severe  coryza  will  likewise  rob  a  person  not  only  of  smell,  but  in  a  greal 
part  also  of  taste.  The  great  delicacy  of  the  sense  of  taste  seems  to  l>e  due 
to  the  course  of  the  air  in  expiration,  as  it  passes  higher  in  the  nose  and  thus 
more  powerfully  affects  the  olfactory  region. 

Phonation. — (1)  Resonance  being  an  increase  in  the  volume  of  sound, 
the  voice  gains  its  strength  and  character  by  the  reverberation  of  the  air  con- 
tained in  the  nasal  passages  and  accessory  sinuses.  The  hard  palate  must  In- 
looked  upon  as  a  sounding-board  and  as  a  decided  factor  in  transmitting  the 
vibrations  to  the  chambers  above.  We  can,  then,  understand  the  reason  why 
growths  that  obstruct  the  nasal  cavities  destroy  the  character  of  the  voice,  not 
only  by  preventing  the  passage  of'  air  through  the  nostrils,  hut  by  interfering 
with  vibration.  While  the  accessory  sinuses  have  been  variously  stated  to  be 
intended  to  lighten  the  skull,  to  act  as  sources  of  warm  air  and  a-  reservoirs  for 
mucus  to  moisten  the  nose,  and  for  use  in  olfaction,  these  functions  are  of  little 
or  no  weight  in  comparison  with  the  important  part  they  play  a-  resonating 
chambers.  Even  the  frontal  sinuses  seem  to  have  influence  in  this  direction  ; 
for  the  native  Australian  negroes,  who  have  no  frontal  cavities,  have  voices 
singularly  lacking  in  resonance,  a  peculiarity  said  to  he  due  to  tin-  malforma- 
tion. The  explanation  of  the  musical  voice  of  the  African  negro,  so  con- 
trasted with  the  unsympathetic  tones  of  the  American  Indian,  seems  to  lie  in 
the  greater  size  of  the  antra  in  the  former  race. 

i'l)  The  nose  and  naso-pharynx  are  also  necessary,  as  Elelmholtz  has  shown, 
for  the  production  of  overtones,  which  give  character  and  increased  richness 
and  volume  to  the  voire. 

Protection. — 1 1  |  We  have  already  spoken  of  the  protection  afforded  by 
the  nose  in  removing  from  the  inspired  air  foreign  particle-  which  would 
otherwise  penetrate  to  the  delicate  pulmonary  alveola.      Bui  the  nose  serves 

al-o  by  it-  sensitiveness  to  touch  to  prevenl  injurious  substances  fr gaining 

admittance,  of  by  calling  forth  reflex  action,  such  a-  sneezing,  t"  cause  their 

1  Darwin  -late-  thai  animals  with  darker  pigmenl  in  tin-  region  have  more  acute  sense  oi 
-null.     The  dark-complexioned  races  are  -- •  I — ■  •  known  to  have  the    Ifactory  sense  i •<■  highly 


.-i  1 1  v.  ii.  a   in       <  i  «i  i  r\  ~i   '  '  1 1 1  i  >  m    .\  ■  •  'i  m   <  i      ii<'   '   ■      "o      .11--     niivnii    vu    utix       '•■' 

developed.  Hutchinson  reports  the  case  of  a  negro  who  turned  white  and  subsequently  lost  the 
M-iisf  of  -mell.  <  >i.'le  iv | >orts  that  white  herbivorous  animals  arc  more  apl  to  be  poisoned  by 
eating  poisonous  plants  than  those  with  darker  pigment  >  Bosworth  l. 

-'  < >gle  reports  two  persons  both  of  whom  by  a  blow  on  the  head  lost  the  sense  of  olfaction, 
yet  the  o-nc  sen  e  was  preserved.     No  difference  could  I"  them  between 

boiled  onions  and  apples  or  port  and  Burgundy  wines ;  of  the  wines,  the  fii  I  *eemed  like  s* 
cii.d  water  and  the  other  like  dilute  vinegar  (Zwaardemaker     Die  1 


Sin  PHYSIOLOGY  OF  THE   UPPER  AIR-PASSAGES. 

expulsion.  For  these  purposes  we  have  an  abundant  supply  of  both  sympa- 
thetic and  sensory  nerves  distributed  to  the  interior  of  the  nose.  The  tri- 
geniinus  is  the  great  sensitive  nerve  of  the  nose,  and  transmits  the  impres- 
sions received  through  both  its  ophthalmic  and  superior  maxillary  branches. 
Thus  the  entrance  of  irritating  substances  tirst  gives  rise  to  a  cessation  of 
breathing,  followed  by  a  forcible  expiration  to  remove  the  offending  material. 
This  is  usually  accompanied  by  a  five  flow  of  mucus  due  to  the  irritation  of 
the  trigeminus  and  sympathetic,  the  former  exciting  an  abundance  of  clear, 
non-viscid  secretion,  and  the  latter  a  scanty,  but  very  viscid,  How. 

(2)  The  importance  of  olfaction  in  protecting  the  organism  against  injuri- 
ous air  and  food  is  seldom  appreciated,  although  its  function  in  enabling 
certain  animals,  such  as  the  carnivora,  to  track  their  prey  and  procure  food, 
and  others,  such  as  the  deer  or  rabbit,  ill-protected  by  nature  for  self- 
preservation,  to  avoid  danger,  is  universally  recognized. 

Ventilation. — (1)  The  pari  played  by  the  nose  in  the  function  of  ven- 
tilating the  middle  ears  can  best  be  understood  by  observing  the  interference 
which  takes  place  when  nasal  respiration  is  obstructed.  We  know  from  the 
Toynbee  experiment — that  of  swallowing  while  the  nostrils  are  closed — that 
the  air  within  the  tympani  is  rarefied  and  the  membranes  become  retracted. 
Grave  consequences  frequently  arise  from  the  persistence  of  the  malposition 
of'  the  tympanic  membranes  thus  taking  place  in  cases  of  hypertrophied  tur- 
binals,  deformities  of  the  nasal  septum,  etc.,  which  obstruct  the  free  passage 
of  the  air  through  the  nose,  and  therefore  interfere  with  ventilation  through 
the  Eustachian  tube-. 

(2)  A  somewhat  similar  action  takes  place  in  the  accessory  sinuses, 
although  the  effect-  cannot  be  directly  observed  and  do  not  usually  give 
rise  t<>  such  serious  results.  According  to  the  experiment  of  Braune  and 
Clausen,  while  the  pressure  in  the  nose  in  breathing  is  equal  to  from  7  to 
10  mm.  of  water,  in  the  act  of  sniffing  the  vacuum  formed  in  the  superior 
maxillary  -inns  is  equal  to  a  negative  pressure  of  780  mm.  of  water.  This 
explains  Randall's  observation,  that  by  sniffing  one  may  readily  produce 
hemorrhage  from  the  lining  membrane  of  these  cavities,  especially  when  they 
are  acutely  congested. 

NASOPHARYNX. 

Tin'  naso-pharynx  possesses  no  special  sense,  but  the  location  here  of  the 
pharyngeal  tonsil  and  numerous  muciparous  glands,  whose  functions  are  those 
of  protecting  and  lubricating  the  throat,  makes  it  of  great  importance.  It 
serves  also  a-  ;i  resonating  chamber  of  great  value  for  the  voice,  and  contains 
muscles  by  whose  action  the  tympanic  cavities  are  ventilated. 

While  the  pharyngeal  tonsil  perse  is  too  often  considered  an  abnormal 
growth, and  it-  function  as  a  germinating  center  for  leukocyte-  i-  o\  erlooked, 
its  enlargement  interferes  so  markedly  with  the  vital  processes  of  free  nasal 
breathing  and  normal  ventilation  of  the  ear-  that  its  physiological  functions 
-hould  not  weigh  against  such  important  considerations  when  damage  is 
threatened  by  it-  presence.  Ii  has  been  said  that  the  function  of  the  pharyn- 
geal tonsil  :i- ;i  source  of  lubricating  secretion  for  the  pharynx  is  of  no  im- 
portance, judging  from  the  atrophic  processes  which  alfeel  it  in  adult  life. 
Granting  that  this  pathological  condition  is  widespread,  so  that  the  mosl 
familiar  picture  is  that  of  absence  or  of  great  reduction  in  size,  it  is  never- 
theless niv  experience  that  only  those  throats  can  be  looked  upon  a-  normal 
in  which  all  the  tonsils,  although  small,  are  present  and  in  good  condition. 
So,  also,  in  the  nose,  the  sclerotic  condition  of  the  turbinals  in  late  adult  life, 


mo  urn—  run  o.\  r.  s4 1 

termed  senile  atrophy,  is  looked  upon  as  the  natural  accompanimenl  of  age 
because  of  the  frequency  of  its  occurrence,  in  apparent  forgetfulness  of  nor- 
mal though  rare  cases,  where  the  turbinals  are  as  large  ami  smooth  as  in  youth. 

Sensation  in  the  naso-pharvnx  is  supplied  not  only  by  the  trigeminus  and 
glosso-pharyngeal  nerves,  hut  also  by  the  superior  laryngeal.  From  this  lad 
arise  many  erroneous  impressions  in  patients,  who  refer  to  the  region  of  the 
larynx  sensations  arising  in  the  naso-pharvnx.1 

The  ventilation  of  the  ears  is  brought  about  by  the  action  of  the  palatal 
muscles.  While  the  velum  hangs  relaxed,  the  openings  of  the  Eustachian 
tubes  are  nearly  vertical  slits;  but  in  the  act  of  swallowing  they  open  and 
become  somewhat  triangular  in  shape,  allowing  the  free  entrance  of  air. 
During  "empty"  swallowing  this  is  even  more  pronounced,  for  the  sofl 
palate  then  ascends  to  its  utmost  limits,  and  in  this  manner  the  regular 
physiological  ventilation  is  constantly  provided  for. 

MOUTH. 

Among  the  many  functions  of  the  mouth,  want  of  space  will  permit  only 
a  brief  reference  to  certain  ones  bearing  directly  upon  our  subject.  Besides 
those  concerned  in  deglutition,  the  mouth  has  a  most  important  influence  on 
articulation,  the  consonants  and  many  of  the  vowels  being  formed  by  the 
movement  of  the  lips  and  tongue.  It  also  acts  as  a  speaking-trumpet  to 
throw  the  concentrated  and  amplified  sounds  in  definite  directions.  By 
means  of  the  special  sense  supplied  by  the  glosso-pharyngeal  and  lingual 
nerves  we  are  able  to  distinguish  only  the  sensations  of  salt,  sour,  bitter,  and 
sweet.  These  impressions  are  conveyed  to  the  centers  of  taste  in  the  brain 
through  the  fibers  of  the  chorda  tympani  from  the  anterior  two-thirds  of  the 
tongue,  and  through  the  glosso-pharyngeal  nerves  from  the  posterior  third. 

\\  Tile  the  nerves  of  special  sense  of  the  nose  and  mouth  contribute  much 
to  our  pleasure  in  eating  and  stimulate  the  powers  of  salivary  secretion  and 
digestion,  our  enjoyment  is  due  also  to  the  consistency  and  other  characteris- 
tics of  the  food  which  act  upon  the  nerves  of  general  sensibility.  The  glosso- 
pharyngeal and  lingual  are  also  nerves  of  general  sensation,  and  like  the 
trigeminus  in  the  nose  act  as  guards  against  injurious  substances.  The  inten- 
sity of  the  sensation  of  taste  depends  upon  the  "solubility  and  concentration 
of  the  substance  and  upon  the  degree  of  force  with  which  it  is  rubbed  in.  as 
in  tasting." 

THROAT. 

Limiting  the  term  throat  to  the  oro-pharynx,  we  find  its  physiology  of 
much  importance,  for  here  are  located  anatomical  structures  connected  with 
the  nose,  mouth,  ami  larynx,  making  their  functions  interdependent.  SO  that 
the  physiology  of  the  pharynx  is  really  that  of  the  related  pint-. 

Among  the  many  physiological  functions  which  find  their  expression  here 
are  the  voluntary  ones  of  articulation  and  sucking.  Deglutition  and  retching 
are  for  the  most  part  involuntary  and  occur  reflexlv.  The  pharynx  ha-  im- 
portant influence  in  articulation,  especially  in  modulation  of  the  voice,  as  in 
singing.  In  sucking,  the  base  of  the  tongue  is  drawn  downward  ami  out- 
ward, and  thus  creates  a  vacuum,  breathing  in  the  meanwhile  being  carried 
on  through  the  nose,  between  the  acts  of  sucking  and  swallowing.  The  vital 
importance  of  maintaining  i'ver  nasal   respiration  during  infancy  should  be 

too  well    recognized    to    need    further   c< lit. 

1 1  > i n -  must  lie  mm  his  guard  againsl  following  implicitly  the  assertions  of  the  patienj  :i~  to 
tin-  Beat  <>t'  sensation.  Many  :i  foreign  body  in  the  tonsil  has  been  sought  for  in  vain  in  the 
larynx  through  following  blindly  tin-  patient's  opinion  of  its  aup] 1  location. 


Ml'  PHYSIOLOGY  OF  THE   UPPER  AIR-PASSAGES. 

While  deglutition  i<  :it  the  beginning  a  voluntary  act,  when  once  started 
it  becomes  involuntary.  Ir  is  brought  about  reflexly  by  stimulation  of  the 
nerves  of  the  pharynx,  which  happens  normally  by  the  presence  of  food,  etc., 
or  pathologically  by  anysensation  of  foreign  substance  in  the  throat.  Thus, 
among  other  things,  any  abnormal  dryness  of  the  pharyngeal  mucous  mem- 
brane, or  enlargement  of  the  lingual  tonsil,  or  thickened  secretion  hanging  in 
the  throat  may  give  rise  to  the  ineffectual  or  ••empty*'  swallowing  which  so 
often  causes  great  distress.  In  swallowing  normally,  the  action  begins  at  the 
tij)  of  the  tongue,  which  is  pressed  against  the  root'  of  the  mouth,  the  other 
sections  following  in  order,  the  substance  to  be  swallowed  being  thus  forced 
backward  into  the  pharynx.  The  anterior  pillars  of  the  fauces  then  come 
together,  and,  with  the  arched  tongue,  shut  off  the  return  to  the  mouth.  Then 
the  superior  constrictors  contract,  forming  an  elevation  (Passavant's  cushion) 
across  the  posterior  pharyngeal  wall,  which,  meeting  the  elevated  soft  palate, 
shuts  off  the  entrance  to  the  naso-pharynx.  In  paralysis  of  the  velum,  as 
after  diphtheria,  or  in  destruction  or  cleavage  of  the  soft  palate,  the  closure 
is  incomplete,  so  that  fluids  and  even  solids  regurgitate  into  the  vault  and 
even  through  the  nose.  In  hypertrophy  of  the  pharyngeal  tonsil,  which 
hinders  the  full  elevation  of  the  velum,  and  in  adhesion  between  the  tonsils 
and  the  anterior  pillars,  which  prevents  the  soft  palate  from  ascending, 
the  same  insufficiency  occur-.  Following  the  contraction  of  the  superior 
constrictors,  the  middle  and  inferior  constrictors'  of  the  pharynx  act  in- 
voluntarily and  reflexly  and  force  the  object  downward.  At  the  moment  of 
swallowing,  the  larynx  is  drawn  upward  and  forward  under  the  tongue,  and 
the  epiglottis  is  thus  usually-  forced  over  the  laryngeal  opening. 

In  retching,  which  precedes  vomiting,  there  is  contraction  of  the  lateral 
Malls  of  the  pharynx  so  that  they  may  meet  in  the  median  line.  The  center 
for  vomiting3  being  near  that  of  respiration  in  the  medulla,  practical  use  may 
be  made  of  this  knowledge  in  preventing  vomiting  during  examination  of  the 
throat.  By  noticing  thi-  premonitory  contraction  of  the  fauces  and  directing 
the  patient  to  breathe  deeply  and  quickly,  the  tendency  to  retching  may  very 
frequently  he  stopped  and  the  examination  completed. 

TONSILS. 

While  the  physiology  of  these  structures  will  he  treated  more  fully  in  the 
section  allotted  to  them,  it  seems  desirable  to  emphasize  here  the  important 
pari  they  play  as  protective  organs.  It  is  now  recognized  that  all  the  lym- 
phatic tissue,  whether  in  the  form  of  simple  collections  of  lymphatic  cells 
scattered  throughout  the  nose,  Eustachian  tubes  or  pharynx,  or  collected 
into  prominent  groups,  ;i-  in  the  naso-pharynx,  fauces,  or  at  the  base  of  the 
tongue,  are  germinating  centers  lor  leukocytes.  That  absorption  is  :i  special 
function  of  the  tonsils,  as  asserted  by  some,  is  probably  a  mistake  :  lor  although 
made  up  of  lymphatic  tissue,  they  are  not  in  direct  connection  with  the  gen- 
eral lymphatic  system.  Their  peculiarly  irregular  surface  favors  the  catching 
and  retention  of  substances,  and  absorption  can  of  course  take  place  as  easily 
here  a-  through  any  mucous  membrane. 

1  Meltzer  lias  experimentally  Bhown  thai  tin-  middle  anil  inferior  constrictors  are  not  abso- 
lutely necessary  even  for  the  deglutition  of  solids  i  Einthoven  :  Heymann   vol.  ii.  p.  58 

It  has  been  Bhown  thai  the  epiglottis  does  a  t  even  normally  always  close  tin-  opening  of 
the  larynx    Schmidt:    /''■   Krankheilen  der  oberen  Luftwege,  p 

It  is  not  necessary  to  have  any  irritation  of  the  fauces  to  bring  aboul  the  action  of  retch- 
ing, :i-  there  are  fibers  connecting  tlu-  vomiting-center  with  the  convolutions.  The  simple 
thought,  by  translation,  may  acl  upon  the  center,  and,  as  we  often  Bee,  may  cause  gagging 
merely  al   the  Bight  of  the  examining  instrument   (Landois:   Physiologic  dee  Menschen, p.  295 


SOFT  PALATE  AND    UVULA— LARYNX.  843 

SOFT  PALATE  AND  UVULA. 

We  have  spoken  of  the  elevation  of  the  sofl  palate  in  deglutition.  As  its 
elevation  prevents  the  escape  of  food  into  the  naso-pharynx  in  swallowing,  so 
its  elevation  prevents,  and  its  relaxation  permits,  the  passage  of  waves  of 
sound  through  the  nose,  and  thus  it-  action  is  of  greal  importance  in  speak- 
ing. Particularly  is  this  action  of  importance  insinging,  for  the  naso-pharynx 
ami  nose  are  especially  concerned  in  the  production  of  overtones,  which  give 
fulness  and  character  to  the  voice. 

Too  little  attention  lias  been  given  to  the  physiological  functions  of  the 
uvula.  While  it  is  generally  recognized  that  it  assists  in  more  securely  stop- 
ping the  entrance  to  the  naso-pharynx  when  the  -oft  palate  i-  elevated.  I 
regard  its  most  important  function  as  that  of  acting  on  the  edge  of  the  velum 
like  a  weight  on  a  drop-curtain.  In  all  the  shades  of  tone  the  uvula  is  of 
great  influence  in  causing  the  edge  of  the  velum  to  fall  more  quickly,  over- 
ioming  the  tendency  tor  it-  moist  surface  to  adhere  to  that  of  the  posterior 
pharyngeal  wall.  The  rapidity  of  the  actions  of  the  soft  palate  in  singing 
or  speaking  car.  scarcely  be  appreciated  until  one  has  observed  it-  movemenl 
directly,  as  in  patients  after  the  removal  of  the  superior  maxilla.  That  this 
function  exists  and  is  of  practical  importance  can  he  readily  recognized  from 
the  change  in  voice  produced  by  too  long  or  too  heavy  an  uvula. 

LARYNX. 

The  two  important  physiological  functions  of  the  larynx  are  those  of  pro- 
tection of  the  delicate  structures  below  and  of  voice-formation.  In  addition. 
it  has  the  function  of  regulating  the  amount  of  air  in  breathing,  which  is 
done  reflexly,  the  glottis   widening  with  each  inspiration. 

Of  these,  by  far  the  most  important  to  the  whole  economy  is  the  function 
of  protection.  The  contact  of  anything  irritating  with  the  sensitive  structures 
guarding  the  larynx  immediately  causes  them  to  contract,  thus  pr<  venting  its 
entrance  ;  or,  if  it  has  gained  admission,  the  sudden  escape  of  air  through  the 
glottis  tends  to  carry  with  it  the  offending  substance,  and  the  action  i-  accom- 
panied by  a  harsh  sound  (cough),  due  to  the  rough  vibrations  of  the  vocal 
cords.  It  is  not  only  solid  particles  which  thus  call  into  action  the  protective 
function  of  the  larynx,  but  also  certain  gases,  such  as  ammonia  and  chlorin, 
called  irrespirable  gases;  and  even  strong  wind,  whether  warm  or  cold,  act 
in  a  somewhat   similar  manner. 

The  larynx  produces  sound  by  throwing  the  column  of  expiratory  and 
inspiratory  air  into  vibration  as  it  passes  over  the  approximated  edges  of  the 
vocal  cord-.  This  would  give  rise  to  sound  of  very  limited  nature,  hut  it  i- 
so  modified  by  the  force  of  the  current  (volume),  by  the  size  of  the  opening 
(pitch),  and  by  the  influence  of  the  surrounding  cavities  (quality  .  that  the 
voice  may  become  the  most  perfect  of  musical  instruments.  The  action  of 
the  larynx  i-  not  like  that  of  a  pipe  in  the  production  of  tone,  for  in  order  to 
give  the  low  note.  Do  (64  vibrations),  it  would  have  to  be  some  8  feel  long; 
neither  i-  it-  action  like  that  of  a  stringed  instrument,  tor  it  would  necessitate 
a  cord  many  feet  in  length  to  produce  this  low  note.1  It-  action  closely 
resembles  that  of  the  hautboy,  in  which  the  sound  i-  produced  by  a  combina- 
tion of  pipe  with  a  vibrating  reed.  The  knowledge  of  this  tact  i-  made 
use  of  after  laryngectomy  by  employing  a  reed  in  the  artificial  larynx  t" 
enable   the    patient    to    talk. 

'  i  hapman,  \>.  - 16, 


GENERAL    ETIOLOGY  AND  PATHOLOGY  OF  DIS- 
EASES OF  THE  UPPER  RESPIRATORY  TRACT. 


By  J.  H.  BRYAN,  M.  D., 

OF    WASHINGTON,   1).  C. 


Diseases  of  the  upper  respiratory  tract — that  term  for  the  purpose  of 
this  article  being  confined  to  the  naso-pharyngo-laryngeal   region — may  be 

either  local  conditions  or  local  manifestations  of  some  general  disease,  and 
they  are  as  varied  as  are  the  tissues  which  go  to  make  up  these  complex 
organs.  Thus  we  may  have  any  known  pathological  condition  of  the  mucous 
membrane,  cartilages,  bones,  blood-vessels,  or  glandular  tissue. 

In  an  article  devoted  to  the  consideration  of  the  general  etiology,  path- 
ology, and  symptomatology  of  diseases  of  the  upper  respiratory  tract,  it  will 
be  possible  to  give  only  a  general  idea  of  some  of  the  more  common  condi- 
tions met  with  in  this  region. 

Of  all  the  tissues  composing  this  tract,  the  mucous  membrane  is  the  one 
most  frequently  affected,  and  it  is  subject  to  three  forms  of  inflammation,  viz., 
tin'  catarrhal,  the  croupous,  and  the  diphtheritic. 

Catarrhal  inflammations  affect  adults  as  well  as  children,  and  they 
are  the  mosl  common  affections  we  have  to  deal  with.  They  have  been  recog- 
nized from  the  earliest  times  ;  early  writings  showing  the  familiarity  of 
the  ancients  with  these  affections  and  their  influence  on  the  general  health. 
These  inflammations  have  become  more  frequent  and  have  increased  in 
severity  during  the  presenl  century,  owing  to  the  complex  conditions  of  mod- 
em civilization,  which  has  no  doubt  developed  new  influences  which  operate 
to  produce  these  severe  conditions. 

They  have  a  widespread  distribution  over  the  earth's  surface,  and  are 
more  frequently  met  with  in  cold  than  in  warm  climates,  and  in  high  than  in 
low  latitudes.  In  the  temperate  zone,  according  to  Seitz,1  they  are  mos<  fre- 
quently observed  between  the  isotherms  of  18°  and  4°;  although  there  is  no 
region  absolutely  exempt.  In  a  study  of  the  etiology  of  these  affections  it 
i-  desirable  t<>  know  the  superficial  contour  as  well  as  the  geological  character 
of  the  region  before  the  full  influence  of  the  humidity  and  the  temperature 
and  barometric  changes  can  be  estimated.  Changeable  temperature  has  a 
gr<  .it  influence  in  the  production  of  these  affections  ;  therefore  they  are  more 
prevalent  in  the  spring,  when  the  temperature  and  winds  are  more  variable, 
than    in   the   fall. 

The  causes  of  catarrhal   inflammations  are  both  exciting  and   predispos- 
ing.    A.mong  the  exciting   causes  may  be  mentioned  a  sudden  exposure  to 
cold  when  the  body  i-  scantil}  clad,  thus  giving  rise  to  the  phenomenon  of 
"catching  cold."     There  are  aeveral  theories  as  i<>  the  process  of  catching 
1  Catarrh  "ml  Influenza,  1865,  p 

SI  I 


CATARRHAL   INFLAMMATIONS.  845 

cold.  The  theory  of  Rosenthal  is  that  the  cold  acting  upon  the  surface  of 
the  body  excites  the  arterioles  to  contraction,  by  which  the  blood  is  driven 
from  the  surface  to  the  interna]  organs  including  the  mucous  membranes,  and 
there  acts  as  an  irritant,  exciting  an  inflammation.  This  theory  is  based  upon 
the  faulty  assumption  that  a  part  is  inflamed  because  it  receives  more  blood, 
whereas  it  really  receives  more  blond  because  it  is  inflamed. 

The  theory  of  Seitz  is  that  inflammations  resulting  from  catching  cold 
are  the  resull  of  removing  heat  to  an  undue  extent  from  the  external  surface 
nt'  the  body,  this  sudden  removal  causing-  some  functional  disturbance  of  the 
body  by  which  a  morbid  process  is  set  up.  Neither  of  these  theories  explain 
satisfactorily  the  phenomena  that  take  place.  Bosworth1  is  more  uearly 
correct  when  he  states  that  the  action  of  cold  upon  the  body  is  probablyupon 
those  nutritive  changes  which  are  constantly  going  on  within  the  body,  and 
by  which  animal  heat  is  produced.  Any  interference  with  this  heat  produc- 
tion results  in  a  morbid  process  which,  in  a  mucous  membrane,  shows  itself  in 
the  form  of  an  inflammation. 

A  much  more  potent  factor  in  the  production  of  catarrhal  inflammations, 
than  simple  exposure  to  a  low  temperature  is  the  degree  of  the  relative 
humidity  of  the  atmosphere.  Probably  the  most  frequent  cause  of  this  form 
of  inflammation  to-day  is  the  influenza,  an  infectious  disease  which  appears 
in  epidemic  form,  rapidly  spreading  from  place  to  place.  It  is  of  microbic 
origin,  and  bacteriologists  have  succeeded  in  isolating  the  specific  germ  which 
causes  it.  The  local  conditions  of  this  affection  differ  in  no  wise  from  a 
simple  catarrhal  inflammation,  except  in  the  degree  of  the  inflammatory 
process. 

Aside  from  the  effects  of  the  changes  of  temperature,  the  inhalation  of 
irritating  vapors  and  finely  divided  mechanical  irritants  is  an  important  factor 
in  the  production  of  these  conditions.  Such  irritants  are  particularly  notice- 
able in  our  large  manufacturing  cities,  where  the  atmosphere  is  heavily  laden 
with  smoke  and  gases  produced  by  the  large  factories,  as  well  as  with  parti- 
cles of  dust  which  come  from  the  pulverizing  of  asphalt  in  our  modern  pave- 
ments. These  substances  being  constantly  inhaled  produce  more  or  less  irri- 
tation, which  eventually  results  in  a  low  form  of  inflammation.  A  more 
limited  number  of  cases  arise  from  some  systemic  or  organic  influence  or 
from  some  functional  disturbance;  and  a  few  cases  may  depend  upon  some 
structural  defects  in  the  parts  themselves.  Prominent  among  the  predispos- 
ing causes  from  within  the  organism  are  gastro-intestinal  disturbances  arising 
from  errors  in  diet  or  over-indulgence  of  the  appetite.  It  is  a  matter  of 
common  occurrence  that  a  defective  digestive  process  and  imperfect  assimila- 
tion exert  their  harmful  effects  in  the  production  of  reflected  irritation  in  the 
upper  air-passages.  This  frequency  is  noticed  in  children  under  the  third 
and  fourth  year,  in  whom  attack-  of  indigestion  so  readily  occur,  and  who 
show  a  greal  degree  of  reflex  sensitiveness.  Aside  from  the  so-called  reflex 
disturbances,  the  gastro-intestinal  disorders  are  frequently  the  direct  source 
of  inflammation  of  the  upper  respiratory  tract.  Chronic  pharyngitis,  one  of 
the  most  universally  distributed  diseases  of  this  region,  has  probably  for  it- 
mosl  common  origin  disturbances  of  the  stomach.  Dr.  T.  R.  French,2  who 
has  recently  made  a  very  interesting  contribution  to  the  study  of  this  subject, 
states  that  in  all  cases  of  chronic  pharyngitis  there  is  some  disorder  oi  the 
stomach.  In  conjunction  with  Dr.  C.  S.  Fisher  he  examined  the  throat- of" 
23  patients  whose  stomach-contents  had  been  examined  after  a  test-meal,  and 
in  all  of  these  patient-  there  was  found  some  form  of  stomach  disorder  asso- 

1  />;.<, ,!..,.< ,,/  ih.  \n,-.  ,i,ni  .\:i,'i-jii,,i,i/,ir,  j i.  58,  '  N.  )    Med.  J       ■■  Sept.  12,  I 


846         DISEASES  OF  THE   UPPER   RESPIRATORY  TRACT. 

ciated  with  a  pharyngeal  catarrh.  It  is  not  only  the  pharynx  and  naso- 
pharynx, but  also  the  nose  and  larynx  that  may  be  affected  by  such  condi- 
tions. Ariza,  cited  by  Moreau  Brown,1  mentions  three  forms  of  laryngeal 
disturbances  that  result  from  gastric  affections  : 

il)  Laryngeal  hyperesthesia,  where  the  patients  complain  of  a  burning 
sensation  and  pain  in  the  larynx,  hut  where  the  fauces  and  larynx  are  per- 
fectly normal. 

(2)  A  condition  in  which  the  vocal  cOrds  and  surrounding;  parts  are  both 
hyperemic  and  painful,  varying  in  intensity  according  to  the  severity  of  the 
gastric  disorder. 

(.'!)   A  reflex  paralysis  dependent  upon  gastro-intestinal  disturbance. 

Then  there  are  apt  to  he  acute  attacks  frequently  occurring  in  the  neuras- 
thenic, and  accompanied  by  more  than  ordinarily  profuse  serous  discharge. 

Aside  from  the  dyscrasia,  such  as  syphilitic  and  tuhereular  diatheses, 
which  render  the  raucous  membrane  peculiarly  liable  to  take  on  inflammatory 
action,  there  are  other  constitutional  affections  which  play  a  very  important 
role  in  the  production  of  diseases  of  the  upper  respiratory  tract,  such  as  gout 
and  rheumatism.  There  are  certain  conditions  of  the  throat  in  which  the  pain 
isoul  of  all  proportion  to  the  amount  of  local  disturbance  observed  ;  and  it  is 
in  such  cases  that  gout  or  rheumatism  will  in  the  majority  of  instances  he 
found  to  he  the  exciting  cause.  While  my  own  experience  leads  me  to 
believe  that  the  association  of  certain  forms  of  tonsillitis  and  rheumatism  is 
something  more  than  accidental,  I  consider  the  question  to  be  still  unsettled. 
If  the  researches  of  Henry  L.  Wagner2  and  others  who  claim  to  have  found 
the  same  microbe  in  tonsillitis  and  in  the  blood  in  rheumatism  are  confirmed, 
it  will  go  a  long  way  in  clearing  up  this  much-mooted  relationship  of  tonsil- 
litis to  rheumatism.  There  are  certain  forms  of  rhinitis,  especially  the 
hyperesthetic  variety,  either  associated  with  asthma  or  not,  which  are  fre- 
quently observed  in  overfed  and  plethoric  subjects,  and  which  have  for  their 
causation  a  surcharging  of  the  system  with  uric  acid. 

Prominent  among  the  causes  of  catarrhal  inflammations  of  the  pharynx, 
larynx,  and  trachea  may  he  mentioned  the  pernicious  habit  of  mouth-breath- 
ing resulting  from  some  morbid  condition  within  the  nose,  or  to  hypertrophy 
of  the  lymphoid  tissue  in  the  vault  of  the  naso-pharynx.  The  cold,  unfil- 
ti  red.  and  unmoistened  air  passing  over  the  pharynx  into  the  larynx  and 
trachea  affords  a  greal  disposition  to  catarrhal  inflammations  of  these  organ.-. 

The  strong  influence  of  many  modes  and  habits  of  life  in  the  production 
of  these  affections  is  obvious,  among  which  may  he  mentioned  a  sedentary 
life  in  a  close  vitiated  atmosphere,  and  the  custom  of  overheating  the  houses 
so  frequently  observed  in  this  country,  thereby  rendering  the  subject  sensi- 
tive t<>  the  changes  in  the  weather. 

Numerous  micro-organisms  find  an  excellent  culture-soil  in  the  oro- 
pharyngeal tract,  some  of  which  are  harmless,  while  other- are  pathogenic  in 
character  and  are  the  source  of  the  infections  and  contagions  affections,  such 
;i-  diphtheria.  -<:i  i  hi  fever,  whooping-cough,  and  phlegmonous  inflammations 
that  are  met  with  in  this  region.  Lennox  Browne3  further  subdivides  these 
micro-organisms  into  a  third  group,  which  are  innocuous  so  long  as  the  sub- 
ject enjoys  perfect  health,  hut  so  soon  as  this  is  depressed  or  there  i-  any 
abrasion  of  the  mucous  membrane  systemic  infection  takes  place,  with  some- 
times serious  results.  In  this  later  group  may  !>«■  classed  the  leptothnx 
buccalis,  the  pneumococcus,  and  the  diplococcus, all  of  which  arc  frequently 

1  A.    )'.  Med.  ./-'//■»..  Aug.  29,  I  Vra  is.  Amer.  Laryn.  Assoc.,  1894. 

■  hi  • "  i    oj  i>i<   Throaty  •!'!  I'M.,  p   l'il. 


PATHOLOGY  OF  CATARRHAL   INFLAMMATIONS.  847 

found  in  the  healthy  mouth  ami  throat.     To  these  may  be  added  the  staphy- 
lococcus albus  and  aureus  and  the  streptococcus  pyogenes. 

The  nose,  ou  the  other  hand,  docs  nol  offer  such  a  fertile  soil  for  the 
growth  of  these  micro-organisms  as  dues  the  oro-pharynx,  for  according  to  the 
researches  of  St,  Clair  Thomson1  and  Hewlett,  who  have  recently  investigated 
this  subject,  it  may  be  stated  thai  the  occurrence  of  micro-organisms  on  the 
Schneiderian  membrane  is  so  infrequent  thai  their  presence  musl  be  regarded 
as  quite  exceptional.  This  is  borne  ou1  by  our  clinical  experience,  for  infec- 
tious diseases  of  the  nose  are  much  less  frequent  than  in  any  other  part  of  the 
upper  respiratory  tract.  Paget2  has  confirmed  the  above  results,  and  finds  the 
nasal  cavities  in  the  normal  state  i'vw  from  microbes  except  at  the  anterior 
part  and  vestibule.  I  le  concludes  that  the  asepsis  of  the  nasal  cavities  i-  due 
to  the  structure  of  the  canal,  to  the  ciliated  epithelium,  and  to  the  germicidal 
quality  of  the  mucus,  which  he  finds  is  absolute  for  the  anthrax  bacillus,  very 
marked  for  the  Klebs-Lbffler  bacillus,  and  less  so  for  the  staphylococcus  and 
streptococcus  organisms.  This  explains  why  operations  in  this  region  show  a 
certain  degree  of  immunity  from  infection. 

Pathology. — While  the  pathology  of  ordinary  catarrhal  inflammations  is 
comparatively  simple,  there  are  certain  conditions  which  arc  much  more  ditli- 
■cult  to  understand.  Among  them  may  be  mentioned  hypertrophy  of  the 
lymphoid  tissue  in  the  vault  of  the  pharynx,  hypertrophy  of  the  turbinal 
bodies,  and  deformities  of  the  septum,  resulting  either  from  ecchondroses, 
exostoses,  or  deflections.  In  order  to  comprehend  fully  the  pathology  of 
inflammations  of  the  upper  respiratory  tract,  it  is  necessary  to  understand  the 
pathology  of  inflammations  in  general.  They  may  be  said  to  result  either 
from  the  action  of  micro-organisms,  or  from  an  irritant  of  which  cold  is  the 
most  common  example.  The  impression  produced  by  cold  upon  thevaso-con- 
strictor  nerves  stimulates  them  to  contract  the  capillaries  of  the  skin,  the 
result  of  which  is  a  diminution  of  the  blood-supply  to  the  periphery  and  a 
reflex  to  the  internal  organs  including  the  mucous  membranes,  ff  these 
•organs  are  in  a  state  of  health  no  harm  will  result.  In  those  cases,  however, 
where  there  is  a  deviation  from  the  normal  and  the  internal  resistance  i-  not 
sufficient  to  maintain  the  equilibrium,  the  capillaries  dilate  at  the  weakest 
point  from  overpressure.  This  is  the  condition  of  hyperemia  or  the  first 
stage  of  inflammation.  If  now  the  cause  is  removed  ami  the  paralyzing 
effect  on  the  vessels  overcome,  the  hyperemia  may  subside  and  recovery  occur. 
If,  however,  the  cause  should  continue  to  operate,  or  the  paralyzing  effect  on 
the  Mood-vessels  cannot  he  overcome,  the  case  passes  on  to  the  second  and 
third  stages  of  inflammation.  The  increased  rapidity  of  the  circulation, 
which  is  the  first  effect  of  the  dilatation,  is  soon  followed  by  a  slowing  of  the 
blood-current  ;  the  leucocytes  begin  to  seek  the  periphery  of  the  stream,  which 
adds  to  its  stagnation  ;  while  the  pressure  from  behind  continuing,  a  transu- 
dation of  the  llui'l  constituents  of  the  blood  through  the  walls  of  the  vessels 
takes  place,  and  is  thrown  out  on  the  surface  of  the  membrane.  This  exudate 
varies  in  quality,  according  to  the  intensity  of  the  inflammation,  from  a  thin 
serous  to  a  thick  mucous  discharge — this  constituting  the  second  stage  "I 
inflammation.  II'  the  inflammatory  action  increases  and  the  leucocytes  form 
a  part  of  the  exudate,  we  have  the  third,  or  suppurative,  stage. 

In  acute  inflammations  the  quantity  of  mucus  is  largely  increased  over 
that  of  the  normal  flow ;  hut  in  the  chronic  processes  the  apparent  increase 
may  be,  a-  Bosworth  ;  suggests,  a  diminution,  owing  to  the  fact  that  the  normal 

1  Medico-ckir.  Trans.,  vol.  Ixzviii.  '  Journal  of  Laryngulog  .  So>  .  1896. 

■  Op,  cit.,  p.  101. 


M>         DISEASES  OF  Till-:    UPPER  RESPIRATORY  TRACT. 

secretion  of  serum  which  serves  to  dilute  the  mucus  in  health,  and  which  dis- 
appears by  evaporation  without  being  noticed  by  the  patient,  is  diminished 
when  the  membrane  is  inflamed,  leaving  behind  a  thick  mucous  discharge 
which  soon  makes  itself  evident. 

Croupous  and  Diphtheritic  Inflammation. — The  other  forms  of 
inflammation  met  with  in  mucous  membranes  are  the  diphtheritic  and  croup- 
ous. In  both  of  these  affections,  the  exudate.  Instead  of  being  fluid  as  in  the 
catarrhal  variety,  is  characterized  by  a  membranous  deposit.  Occasionally 
we  meet  with  conditions  characterized  by  pseudo-membranous  deposits  caused 
by  irritants,  non-microbic  in  character,  such  as  steam,  ammonia,  and  chlorine. 

Until  within  recent  years  the  two  diseases  known  as  croup  and  diphtheria 
have  been  considered  a-  separate  and  distinct  affections;  but  since  the  ad- 
vances made  iii  bacteriological  research  there  is  a  tendency  to  consider  them 
as  one  and  the  same  affection.  Clinically,  they  are  similar  only  in  the  sense 
thai  both  are  characterized  by  the  formation  of  a  membranous  deposit.  True 
croup  lacks  many  of  the  constitutional  symptoms  of  diphtheria,  such  as  the 
high  temperature,  septic  infection,  and  the  frequent  serious  sequelae  of  the 
latter  affection.  The  confusion  of  these  two  affections  has  been  caused  by 
finding  the  Klebs-Loffler  bacillus,  the  cause  of  diphtheria,  in  the  croupous 
deposit.  When  we  consider  that  this  bacillus  is  frequently  found  in  the  throats 
of  patients  who  are  not  suffering  from  diphtheria,  we  are  forced  to  the  con- 
clusion that  their  presence  in  the  croupous  deposit  is  either  accidental,  or,  ;i- 
Moritz  Schmidt'  suggests,  these  two  affections  may  hear  the  same  relation  to 
each  other  as  do  tuberculosis  and  lupus  of  the  skin. 

Nasal  Obstruction. — Thus  far  we  have  considered  the  pathology  of 
simple  inflammations  of  the  mucous  lining  of  the  upper  respiratory  tract. 
There  are  other  conditions,  however,  whose  pathology  is  not  so  readily  ex- 
plained. In  order  to  understand  the  so-called  obstructive  affections  of  this 
region,  it  will  be  necessary  to  make  some  reference  to  the  physics  of  the  nose 
and  its  relation  to  the  resl  of  the  respiratory  tract.  Without  encroaching  too 
much  upon  the  domain  of  physiology,  it  will  only  he  necessary  to  refer  to  the 
nose  a-  a  respiratory  organ,  the  significance  of  which  has  only  within  recent 
years  been  fully  appreciated  ;  one  of  its  principal  and  most  important  func- 
tion- being  to  heal  ami  moisten  the  external  air  on  its  way  to  the  lungs. 
When  from  any  cause  this  function  is  interfered  with,  mouth-breathing  results 
with  all  its  accompanying  evils.  The  disturbances  which  mouth-breathing 
produce  are  the  more  serious  the  younger  the  subject  and  the  longer  the 
existence  of  the  interference  with  the  free  passage  of  air  through  the  nose. 
The  conditions  which  give  rise  to  interference  with  free  nasal  respiration  are 
obstructive  in  character,  and  they  may  result  from  congenital  or  acquired 
closure  of  the  nostrils  ;  from  paralysis  of  the  alee  nasi  ;  from  hypertrophy  of 
the  inferior  turhinal  bodies,  or  of  the  lymphoid  tissue  in  the  vault  of  the 
pharynx;  from  ecchondrosis,  exostosis,  or  deflections  of  the  septum;  from 
polypi  and  granulation  tissue,  resulting  from  suppurative  inflammations  of  the 
accessory  sinuses;  or  from  foreign  bodies.  The  effecl  of'  these  nasal  obstruc- 
tions on  the  rest  of  the  respiratory  tract  is  to  render  the  subject  prone  to 
attack-  of  pharyngitis,  laryngitis, and  tracheitis,  which  when  once  established 
are  liable  to  become  chronic. 

In  obstructions  resulting  from  hypertrophy  of  the  inferior  turbinal 
bodies  there  i-  generally  an  antecedent  chronic  rhinitis,  producing  a  conges- 
tion and  swelling  of  the  erectile  tissue  sufficient  to  produce  a  temporary 
stenosis  of  the  nasal  chamber.     Anion-  other  causes  for  nasal  stenosis  may 

1  hn   Krankheiten  deroberen  Luftwege,  \>.  369. 


XASAL   OHSTnCCTlON.  849 

be  mentioned  the  constanl  inhaling  of  irritating  vapors,  which  causes  :i 
chronic  congestion  and  swelling  of  the  parts.  Bosworth,1  on  the  other  hand, 
believes  that  these  eases  in  the  majority  of  instance-  are  dependent  upon 
septal  deformity,  either  as  a  deflection  or  projecting  spurs,  tracing  the  origin 
of  these  etiological  factors  back  to  infancy,  when  the  child  received  a  blow 
on  the  nest'  sufficient  to  produce  the  deformity.  There  is  no  doubt  that  se]  tal 
deformities,  either  in  the  shape  of  deflections  or  projecting  spurs,  are  in  a 
large  number  of  eases  associated  with  hypertrophy  of  the  inferior  turbinals, 
although  they  are  not  always  present.  Wherever  these  stenoses  are  situated, 
the  atmospheric  pressure  behind  the  obstruction  has  become  diminished,  and 
in  consequence  a  chronic  congestion  is  produced.2  Tin-,  of  course,  mean-  an 
increased  nutrition  of  the  body  with  a  resulting  hypertrophy,  in  which  there 
is  an  increase  of  all  the  tissues  which  go  to  make  tip  these  bodies,  viz.,  the 
epithelial  and  tibro-elastie  layer,  and  the  submucous  tissue  containing  the 
racemose  glands  and  venous  sinuses.  The  degree  of  hypertrophy  varies,  in 
some  cases  being  very  slight,  not  eausing  sufficient  obstruction  to  the  respira- 
tion to  attract  the  attention  of  the  patient;  while  in  other  instances 
the  increase  in  size  is  sufficient  to  block  up  the  nasal  chambers  and  occa- 
sionally to  project  backward,  presenting  tumefied  masses  in  the  nasopharyn- 
geal space. 

Septal  deformities  maybe  either  deflections  or  in  the  form  of  ecchondroses 
or  exostoses.  They  may  originate  either  as  a  result  of  traumatism  or  from 
an  inflammation  of  the  mucous  membrane.  Traumatism  in  early  youth  or 
infancy  plays  no  doubt  a  most  important  part  in  the  production  of  these  de- 
formities, but  I  believe  it  is  by  no  means  the  frequent  cause  that  is  so  gen- 
erally assumed.  It  may  happen  that  these  injuries  in  infancy  are  readily 
overlooked  or  forgotten  ;  but  when  they  do  not  occur  until  later  in  life,  an 
injury  sufficient  to  produce  a  marked  bending  of  the  septum  is  not  apt  to 
pass  entirely  out  of  the  memory.  These  conditions  have  their  beginning  in 
the  infancy  or  early  life  of  the  subject.  When  such  a  person  is  exposed  to 
cold  a  catarrhal  inflammation  of  the  lining  membrane  of  the  nose  sets  in,  with 
a  resulting  nasal  stenosis.  This,  of  course,  acts  in  the  same  manner  as  in 
hypertrophic  rhinitis  by  producing  a  rarefaction  of  the  air  posterior  to  the 
stenosis,  with  a  resulting  hyperemia  which  eventually  becomes  chronic.  The 
consequence  is  an  increased  nutrition  of  the  parts  with,  in  the  case  of  the 
cartilaginous  portion  of  the  septum,  a  production  of  cartilage-cells  beneath 
the  mucous  membrane.  This  production  of  cells  continues  as  long  as  the 
irritation  lasts,  and  there  is  a  distinct  projection  from  the  septum  into  the 
nasal  chamber  known  as  an  ecchondrosis.  The  same  process  holds  true  for 
the  vomer,  when  the  projecting  process  or  tumor  is  composed  of  bone,  and  is 
known  as  an  exostosis.  They  may  exist  either  alone  or  the  one  may  be  con- 
tinuous with  the  other,  and  they  generally  have  their  starting  at  the  sutural 
junction  between  the  triangular  cartilage  and  the  vomer.  Occasionally  we 
find  them  without  any  deflection  of  the  septum,  but  in  the  majority  of  cases 
there  is  some  decided  bending  to  the  side  corresponding  t<>  the  ecchondrosis 
or  the  exostosis.  Syphilis  is  also,  in  my  experience,  :i  common  cause  in  the 
production  of  these  conditions. 

'fhe  deformities  resulting  from  deflection  of  the  septum  are  not  so  readily 
explained.     It   is  occasionally  congenital,  and   in   many  cases  if   results  from 

traumatism,  but   thi-  i-  not   go  common  an  etiological    factor  a-   to  explain  thi- 

verj  frequently  occurring  deformity.     Inflammations  explain  the  process  01 

1  Op.  r,l..  p.  [25. 

2  [Despite  the  authorities  supporting  this  view,  it  -.■•  ms  overdrawn       Ed.] 

o4 


850         DISEASES  OF  THE   UPPER   RESPIRATORY  TRAIT. 

bending  in  a  few  cases  by  the  weakening  of  the  septum,  the  atmospheric 
pressure  being  greater  on  one  side  than  on  the  other  at  some  period  of  the 
process  causes  it  to  bend  in  the  direction  of  the  least  resistance.  In  most 
instances  it  is  the  result  of  a  physiological  process — the  septum  being  fixed 
between  two  unyielding  planes,  bends  to  one  side  or  the  other  in  order  to 
make  room  t'<>r  its  increased  growth. 

Adenoid  Hypertrophy.  Situated  in  the  naso-pharynx,  pharynx-wall, 
and  at  the  base  of  the  tongue  there  is  a  certain  ring  of  tissue,  similar  in  struct- 
ure but  differing  from  the  neighboring  tissues  of  the  upper  respiratory  tract, 
which  plays  a  very  important  part  in  the  pathology  of  the  diseases  of  this 
region.  While  all  the  lymphoid  tissue  forming  this  ring  has  a  striking  simi- 
larity in  structure,  there  is  a  decided  difference  as  regards  its  life-history 
when  diseased,  in  that  the  tissue  in  the  naso-pharynx  shows  a  tendency  to 
atrophy  at  puberty,  while  that  in  the  lances  and  lingual  region  may  continue 
into  adult  life  ;  indeed,  the  lymphoid  tissue  at  the  base  of  the  tongue  is  rarely 
diseased  until  after  puberty.  This  brings  us  to  the  consideration  of  the  next 
and  probably  the  mosl  important  form  of  obstructive  disturbance  met  within 
the  upper  respiratory  tract,  and  that  is  hypertrophy  of  the  lymphoid  tissue 
in  the  vault  of  the  pharynx.  This  affection  has  been  variously  described  as 
enlargement  of  the  third  tonsil  and  adenoid  vegetations.  It  has  been  recog- 
nized for  many  year.-,  hut  it  was  left  to  the  laic  Prof.  Wilhelm  Meyer1  to 
point  out  the  frequency  of  it;-  occurrence  and  its  clinical  importance.  It  is 
essentially  a  disease  of  childhood,  occurring  occasionally  at  the  earliest  periods 
of  life.  While  it  -how-  a  tendency'to  disappear  at  puberty,  it  is  frequently 
observed  in  adults.  Although  this  affection  cannot  properly  he  said  to  he 
due  to  heredity,  it  i-  nevertheless  observed  as  occurring  very  frequently  in 
families  with  the  so-called  lymphatic  temperament.  Several  members  of  the 
-Mine  family  may  be  afflicted  in  the  same  manner,  all  showing  a  tendency  to 
hypertrophy  also  of  the  faucial  and  the  lingual  tonsils. 

Climate  has  a  very  decided  influence  in  the  production  of  this  condition, 
it  being  much  more  frequently  observed  in  cold,  damp  countries  than  in  those 
where  the  atmosphere  i-  warm  and  dry. 

Probably  the  most  frequent  cause  of  the  hypertrophy  of  this  tissue  i> 
frequent  and  neglected  attack-  of  catarrhal  inflammations  of  the  nose  and 
naso-pharynx.  The  lymphoid  tissue  becoming  once  inflamed,  -hows  a  ten- 
dency t<>  continue  and  become  chronic  through  the  same  agencies  that  produce 
hypertrophy  of  the  inferior  turbinal  bodies,  with  which  it  is  very  frequently 
associated.  Among  the  other  exciting  cause-  may  he  mentioned  diphtheria 
and    the   exanthemata. 

The  stenosis  resulting  from  an  acute  catarrhal  rhinitis,  or  from  that  due 
to  one  of  the  previously  mentioned  obstructive  nasal  disorders,  may  lie  suffi- 
cient to  excite  a  hyperemia  and  -welling  of  the  post-nasal  lymphoid  tissue  by 
rarefying  the  air  in  the  naso-pharyngeal  space.     This  congestion  resulting 

from  lessening  of  the  ;;t sph<  ric  pressure  in  this  region  causes  an  increased 

nutrition   of  the    tissue  with   .1   consequent    hypertrophy   of   its  constituent 
elements. 

In  the  faucial  lymphoid  tissue  there  are  several  distinct  pathologi- 
cal conditions  recognized,  \  i/..  the  acute  inflammations,  which  may  involve 
only  the  mucous  covering  of  the  gland  or  extend  into  1  he  follicles,  giving  rise 
to  the  croupous  or  follicular  variety  ;  or  the  whole  gland  may  he  involved, 
and,  going  on  to  the  suppurative  stage,  result  in  abscess  of  the  tonsil  or  peri- 
tonsillar tissue.  In  the  chronic  form  we  recognize  the  hypertrophic  variety, 
1  //  /    !e7w/e,  Copenhagen,  Nov.,]-''- 


SYMPTOMA  TOLOG  >'.  851 

and,  according  to  the  classification  <>f  Bosworth,  the  hyperplastic,  which  i.->  in 
reality  an  advanced  stage  of  the  hypertrophic  form. 

The  croupous  variety  is  a  simple  inflammation  of  the  follicles  thai  go  t<» 
make  uj>  the  gland,  infectious  in  character,  and  manifested  l>\  a  thick  deposit 
making  its  appearance  at  the  mouths  of  the  crypts,  and  occasionally  spreading 
out  as  a  membrane  on  the  surface  of  the  gland.  This  exudate  is  sofl  and 
easily  wiped  away  from  the  tonsil,  when  it  can  be  seen  exuding  from  the 
mouths  of  the  follicles.  In  the  hypertrophic  variety  of  tonsillitis  there  i-  an 
increase  in  all  the  tissues  that  constitute  this  eland.  The  follicles  occasionally 
become  overdistended  with  secretion,  giving  rise  to  a  constant  fetid  discharge 
from  the  gland.  In  the  hyperplastic  variety  there  is  an  increase  in  the 
connective-tissue  elements,  with  a  gradual  destruction  of  the  lymphoid  tissue 
proper.      In  these  cases  the  gland  becomes  hard  and  fibrous  in  character. 

The  lingual  tonsil  situated  at  the  base  of  the  tongue  is  liable  to  be  affected 
by  any  of  the  pathological  conditions  mentioned  as  affecting  the  other 
lymphoid  glands  ;  but  it  is  much  more  rarely  affected.  It  is  essentially  a 
disease  of  adult  life,  and  may  have  for  its  origin  any  of  the  infectious  dis- 
eases ;  but  it  is  more  frequently  associated  with  some  form  of  gastric  dis- 
turbance. 

SYMPTOMATOLOGY. 

Many  of  the  diseases  affecting  the  naso-pharyngo-laryngeal  tract  have 
symptoms  which  are  common  to  one  or  more  of  them,  and  in  a  general  way 
they  may  be  either  subjective  or  objective — the  former  relating  to  the  dis- 
turbance of  functions  of  the  organs  affected,  while  the  latter  are  such  as  can 
be  seen  by  the  observer  only. 

Obstruction  to  nasal  respiration,  resulting  in  mouth-breathing,  i- 
one  of  the  most  prominent  symptoms  among  nasal  disturbances,  as  pre- 
viously  set   forth. 

Occasionally  the  patient  will  be  found  to  insist  that  he  has  perfect  nasal 
respiration,  especially  when  the  intranasal  obstruction  is  not  sufficienl  to 
make  a  very  decided  impression  on  him,  but  careful  questioning  will  generally 
elicit  the  further  information  that  he  awakens  in  the  morning  with  the  mouth 
open  and  dry,  and  that  there  is  snoring  during  sleep.  This  symptom  is 
probably  more  frequently  noticed  in  children  who  arc  also  very  restless 
during  sleep,  frequently  awakening  and  calling  for  water  to  moisten  their 
parched  throats.  When  the  mouth-breathing  has  existed  for  some  time  mosl 
decided  changes  .ire  noticed,  m »t  only  in  the  soft  parts,  but  also  in  the  bony 
frame-work  of  the  mouth  and  chest,  which  are  more  severe  the  younger  the 
individual.  The  features  are  relaxed  and  assume  a  well-recognized  indolent 
and  stupid  expression. 

Disturbances  of  speech,  such  as  stuttering  and  imperfect  articulation,  are 
also  frequently  observed. 

Headache  is  a  common  symptom  noticed  in  many  forms  of  intranasal  dis- 
turbances, especially  when  resulting  from  the  pressure  on  the  soft  parts  of 
bony  or  cartilaginous  projections  from  the  septum,  from  pressure  due  in 
-welling  of  the  middle  turbinals,  and  in  inflammator)  conditions  of  the 
accessory  sinuses. 

Loss  of  memory  and  lack  of  mental  application  to  the  extent  of  being 
unable  to  concentrate  the  attention  upon  any  one  subject  are  symptoms  fre- 
quently observed  in  these  nasal  and  post-nasal  disturbances.  It  is  especially 
noticeable  in  children  suffering  from  hypertrophy  "f  the  post-nasal  lymphoid 
tissue.     These  little  subjects  irequentl)  gel  the  reputation  unjustly  of  being 


852        Z>7N/;.|,s7>   of  THE   UPPER   RESPIRATORY  TRACT. 

stupid,  when  their  mental  inactivity  is  entirely  due  t<>  some  form  of  nasal 
obstruction.  This  is  the  condition  described  by  Guye  of  Ajmsterdam  as 
aprosexia. 

Nocturnal  enuresis  is  a  symptom  so  frequently  associated  with  nasal 
obstruction  in  children,  especially  that  resulting  from  lymphoid  hypertrophy, 
that  it-  concurrence  can  scarcely  be  ••ailed  accidental.  Groubech,1  cited  by 
Schech,  out  of  192  eases  of  hypertrophy,  of  the  post-nasal  lymphoid  tissue, 
found  enuresis  24  times.     Twelve  of  these  cases  were  cured  alter  operation. 

The  Palate  and  Teeth. — A  brief  reference  in  this  place  may  he  made 
in  connection  with  mouth-breathing  to  the  changes  in  the  arch  of  the  hard 
palate,  which  in  the  very  young  becomes  altered,  assuming  an  acute  how  or 
V-shape.  This  deformity  results  from  a  combined  pressure  of  the  buccal 
muscles  exerted  on  both  sides  and  a  column  of  air  constantly  striking-  the 
hard  palate.  Corner  distinguishes  between  the  alterations  of  the  upper  jaw 
of  children  who  have  suffered  from  nasal  stenosis  before  the  shedding  of  the 
deciduous  teeth,  and  those  which  result  from  nasal  stenosis  during  the  change 
<>f  teeth.  In  the  firsl  instance  there  occurs  generally  the  cupola-shaped 
elevation  of  the  palate;  the  alveolar  border  which  naturally  forms  a  semi- 
circle assumes  the  form  of  an  ellipse;  but  there  is  no  change  in  the  position 
of  the  teeth.  If  the  nasal  stenosis  exists  at  the  time  of  the  change  of  the 
teeth,  then  the  lateral  alveolar  borders  are  approximated  while  the  anterior 
border  is  pushed  forward,  and  the  high  arch  of  the  palate  increases  until  it 
encroaches  upon  the  cavities  above.  The  teeth  in  these  cases  assume  a  very 
irregular  shape. 

Diseases  of  the  ear  frequently  accompany  nasal  and  post-nasal  disorders, 
and  vary  from  a  simple  occlusion  of  the  Eustachian  tube,  resulting  from  an 
acute  rhinitis,  to  a  severe  suppuration  of  the  middle  ear,  with  all  its  danger- 
ous sequelae.  Children  suffering  from  hypertrophy  of  the  post-nasal  lym- 
phoid tissue  frequently  exhibit  various  degrees  of  deafness,  varying  according 
to  the  size  of  the  growth  from  a  slight  diminution  of  the  hearing  to  almosl 
complete  deafness. 

I/OSS  of  smell,  varying  from  a  slight  impairment  to  a  complete  loss 
of  the  function,  known  as  anosmia,  may  accompany  almost  any  form  of 
intranasal  disturbance  involving  the  upper  part  of  the  nose;  but  it  is  most 
frequently  associated  with  development  of  polypi  and  other  inflammatory  con- 
dition- of  the  ethmoid  bone.  In  many  cases  where  there  is  a  loss  of  smell 
there  will  also  be  observed  seme  disturbance  in  the  function  of  taste.  While 
the  taste  may  not  lie  absolutely  lost,  it  will  often  be  found  very  much  dimin- 
ished for  the  perception  of  flavors. 

Voice. — The  influence  of  nasal  diseases  is  frequently  observed  on  the 
voice,  the  obstructive  affections  of  the  nose  and  naso-pharynx  modifying  its 
tone  and  rendering  articulate  speech  thick  <>r  muffled  and  difficull  to  under- 
stand.     Thc-e  defects   arc  occasionally  observed    in    paretic   conditions  of  the 

soft  palate  which  so  often  accompany  disorders  of  the  nose  and  naso-pharynx, 
giving  the  voice  a  nasal  character,  bo  that  it  is  difficull  at  times  to  distinguish 
it  from  that  due  to  nasal  stenosis.  The  pronunciation  of  certain  consonants 
under  these  condition-  i-  considerably  modified  ;  for  example,  d  sounds  like 
n.  and  A  i-  similar  to  ///.  while  the  -(.iind  of  g  i-  very  difficull  to  make.  It 
frequently  becomes  a  nice  poinl  to  decide  whether  the  cause  of  these  speech- 
defects    lie-    within    the   nose,    na-o-phar\  n\.   or   i-   of  central   origin. 

In  laryngeal    affections  the  voice    may  be  natural    in   -peaking  and  altered 

only  in  singing,  breaking   in  the  passage  from  the  lower  to  the  higher  regis- 
1  Sit:<iiiq.ln ,nli.'i  ih    Aerztlichen  Pereiiw,  Munich. 


DEGLUTITION.  853 

fcers.  It  may  be  hoarse  or  uncertain,  being  natural  at  times  and  husky  at 
others,  or  it  may  be  entirely  absent  as  in  aphonia.  The  respiration  may  be 
seriously  embarrassed  both  in  nasal  and  laryngeal  affections.  In  the  former 
it  may  be  obstructed  by  either  acute  swelling  or  hypertrophy  of  the  turbinal 
bodies,  hypertrophy  of  the  post-nasal  lymphoid  tissue,  deformities  of  the 
septum,   or  by   new   formations   within   the   nasal   cavities,   such   as   polypi. 

Respiration. — In  laryngeal  affections  the  respiration  may  be  more  or 
less  embarrassed,  hurried,  or  retarded,  according  to  the  nature  of  the  affec- 
tion. It  is  often  accompanied  by  a  loud  noise  which  may  be  either  stridul- 
ous  or  stertorous  in  character — the  former  generally  accompanying  inspira- 
tion, when  it  indicates  some  laryngeal  obstruction  resulting  from  new  forma- 
tions or  foreign  bodies,  spasm  of  the  laryngeal  muscles,  false  membranous 
deposits,  or  paralysis  of  the  abductor  muscles  of  the  vocal  cords;  while 
stertorous  breathing  more  frequently  accompanies  expiration  and  is  associated 
with  general  paralytic  conditions. 

Cough  is  a  common  symptom  of  diseases  of  the  larynx,  varying  in 
character  according  to  the  location  and  intensity  of  the  inflammation  from 
a  simple  hacking  cough  or  clearing  of  the  throat  to  one  that  i>  hoarse,  bark- 
ing, or  metallic  in  sound.  It  may  occur  in  paroxysms  and  is  frequently 
suffocative.  Cough  is  also  a  not  infrequent  symptom  of  diseases  of  the  nose 
and  naso-pharynx,  when  it  is  said  to  be  reflex  in  character,  and  due  to  some 
pressure  on  the  sensitive  nerve  filaments  in  these  regions  or  to  an  undue 
irritability  of  certain  sensitive  areas,  as  in  the  auditory  canal,  which  when 
irritated  give  rise  to  an   annoying  form  of  paroxysmal   cough. 

Deglutition  in  diseases  of  the  upper  respiratory  tract  may  he  either 
difficult,  a  condition  known  as  dysphagia;  painful,  odonphagia;  or  at  times 
impossible,  aphagia. 

While  dysphagia  is  not  a  symptom  very  common  to  nasal  affections,  it 
nevertheless  occurs  occasionally  in  those  cases  where  there  is  a  decided 
enfeeblement  of  the  soft  palate  resulting  from  nasal  and  post-nasal  inflamma- 
tions. It  is  much  more  frequently  observed  in  those  cases  in  which  the 
pharynx  and  larynx  are  involved,  especially  where  there  i-  obstruction  in  the 
fauces,  pharynx,  or  esophagus,  or  where  there  is  any  ulceration  or  destruction 
of  the  velum,  either  with  or  without  an  enfeeblement  of  the  nervo-muscular 
control  of  the  constrictor  muscles  of  the  pharynx.  It  frequently  happens  in 
such  cases  that  the  food  passes  into  the  nares.  Occasionally  also,  when  the 
epiglottis  is  either  ulcerated  or  destroyed  through  the  action  of  syphilis  or 
tuberculosis,  the  food  has  a  tendency  to  pass  into  the  larynx  until  the  part  - 
so  adapt  themselves  a-  to  enable  it  to  follow  the  natural  channel  into  the 
es<  tphagus. 

Odonphagia  is  associated  with  nearly  all  (he  acute  inflammatory  affections 
of  the  pharynx,  particularly  tonsillar  inflammations,  and  also  with  many  ol 
the  chronic  condition--  of  the  larynx,  such  as  tubercular  laryngitis,  especially 
when  the  epiglottis  is  involved  ;  or  when  this  organ   is  the  seat  of  malignaul 
disease. 

Aphagia   is  generally  presenl  when  the  larynx  or  the  pharyngo-laryngeal 
tract  are  the  seat  of  malignant   disease,  and   results  either  from   the  acl  "l 
swallowing  being     so  painful    that    the   patient    refuses  to  swallow,  or  the 
obstruction    is    SO    marked    that    it    cannot    lie   overcome. 

Under  the  heading  of  objective  symptoms  or  those  revealed  to  the  phy? 
cian  by  the  various  methods  of  examination,  may  he  mentioned  a  change  in 
the  color,  form,  position,  and  secretion  of  the  parts  studied. 

The  color  mav  he  increased  or  diminished  according  to  the  nature  ol  the 


854        DISEASES  OF  THE   UPPER   RESPIRATORY  TRACT. 

disease,  being  increased  in  all  affections  of  an  inflammatory  nature,  the 
intensity  varying  in  degree  according  to  whether  the  parts  are  the  seat  of 
an  acute,  subacute,  or  chronic  inflammation.  Jt  is  frequently  diminished  in 
those  eases  where  there  is  general  anemia  or  a  marked  depression  of  the 
heart's  action. 

It  may  l»c  altered  when  the  patient  is  suffering  from  such  general  condi- 
tions as  jaundice,  when  the  membrane  assumes  a  decidedly  yellow  hue,  or 
from  tuberculosis  in  its  early  stages,  when  the  membrane  frequently  presents 
a   grayish   appearance. 

The  form  may  he  changed  by  an  increase  of  tissue,  as  in  the  hypertrophic 
form  of  inflammation  so  often  noticed  in  the  nasal  and  naso-pharyngeal  cavities, 
or  by  a  decrease  of  tissue,  such  as  is  observed  in  atrophic  rhinitis.  In  the 
larynx  the  lining  membrane  may  he  the  seat  of  a  serous,  purulent,  tubercular, 
syphilitic,  or  malignant  infiltration,  sufficient  at  times  to  encroach  upon  and 
diminish  the  caliber  of  the  glottis  to  a  marked  degree.  The  size  and  shape  of 
the  glottis  may  be  changed  by  the  several  positions  assumed  by  the  vocal 
cords  in  the  various  paralyses  of  the  intrinsic  muscles  of  the  larynx.  The 
position  of  the  nose  may  be  altered  by  any  morbid  growth  springing  from 
within  the  nasal  cavity,  but  otherwise  it  is  rarely  changed.  The  larynx, 
however,  is  very  frequently  displaced  from  its  normal  position  by  such  extra- 
laryngeal  affections  as  bronchocele,  cancer,  or  enlarged  glands  of  the  neck  ; 
while  contraction  of  the  cicatricial  tissue  resulting  from  syphilitic  ulceration 
in  many  instances  disturbs  the  normal  relation  of  the  parts  within  the 
cavity. 


METHODS  OF  EXAMINATION    AND    DIAGNOSIS    IN 
AFFECTIONS  OF  THE  NOSE  AND  THROAT. 


\\\    JOHN   \V.   FARLOW,    M.  I».. 

OF    BOSTON,    MASS. 


Before  proceeding  to  the  examination  of  the  interior  of  the  aose  and 

throat,  it  is  always  of  importance  to  look  critically  at  the  face  and  neck  of 
the  patient  and  also  to  try  to  gel  as  much  preliminary  information  as  possible 
by  external  palpation.  This  often  furnishes  valuable  clues  and  hints  which 
arc  quite  likely  to  be  overlooked  it'  they  are  left  until  after  the  internal 
examination.  Look  at  the  region  of  the  frontal  sinuses  and  see  if  there  is 
any  prominence  or  tenderness  on  either  side;  look  at  the  conjunctiva? ;  feel 
of  the  nasal  hones  with  reference  to  depression  or  abnormalities  of  any  kind. 
The  decree  of  mobility  of  the  cartilaginous  septum  and  the  presence  ol 
deviations  and  large  perforations  can  be  felt  by  the  fingers  on  the  outside. 

The  ahv  nasi  should  also  be  tested  as  to  their  strength  or  flaccidity.  The 
folds  and  creases  about  the  nose  are  often  indications  of  muscular  action 
which  has  for  its  object  the  opening  of  the  nostril  by  drawing  the  ala  away 
from  the  obstructing  septum.  Notice  whether  the  mouth  is  habitually 
closed,  the  shape  of  its  aperture,  the  dryness  of  the  lips,  whether  the  teeth 
or  jaws  overlap.  Always  feel  for  enlarged  glands  of  the  neck  both  in  front 
of  and  behind  the  sterno-mastoid  muscle.  The  neck  should  he  thoroughly 
relaxed,  otherwise  the  glands  are  not  easily  reached. 

Inform  yourself  as  to  the  condition  of  the  ear-,  especially  as  regards  the  ex- 
istence of  suppuration.  The  hyoid  bone  and  the  thyroid  and  cricoid  cartili 
are  to  he  examined  and  any  enlargement  of  the  thyroid  gland  noted.  Move 
the  larynx  from  side  to  side  to  tesl  it-  mobility  and  the  amount  of  creaking 
on  the  prevertebral  structures  and  also  to  see  if  there  is  any  tenderness. 
The  finger  placed  lightly  on  the  crico-thyroid  membrane  detects  the  narrow- 
ing of  the  crico-thyroid  space  when  the  pitch  of  an  emitted   note  is  raised. 

\< rding  to  Gerhardt,1  very  important  deduction-  can   he  drawn  a-  to 

paralysis  of  the  larynx  by  external  palpation  alone;  hut  it  i-  not  my  purpose 
here  to  do  more  than  point  out  the  advantages  of  n  thorough  external  exam- 
ination as  a  matter  of  routine  practice  before  beginning  internal  exam- 
ination. 

,\s  regards  the  latter,  the  nose  should  always  he  examined  first,  then  the 
mouth  ami   post-nasal   space,  and  lastly   the  larynx. 

EXAMINATION  OF  THE  NARES. 

For  illuminating  the  nose  and  throat  we  have  at   our  disposal  diffused 

daylight,  sunlight,  candle,  oil-lamp,  gas,  the   Welsbach  burner,  electric  light, 

oxyhdrogen    light,  and    perhaps   acetylene  gas.     Ordinary   daylight    i-    not 

strong   enough    for    the    nose    or    post-nasal    space,   and    i-    too  uncertain    and 

Archivfur  Laryngol.,  vol.  ii.  p 


METHODS  OF  EXAMINATION  AND   DIAGNOSIS. 


variable.  Sunlight  lias  the  merit  of  bringing  out  in  their  natural  colors 
the  various  structures  examined,  but  it  also  has  many  drawbacks.  Its 
change  of  position,  intervening  clouds,  and  various  obstructions  on  the  earth 
render  it  very  unreliable.  With  the  concave  head-mirror  the  rays  are 
easily  brought  to  a  focus,  and  a  burn  may  result  unless  we  are  careful 
to  keep  the  illuminated  area  beyond  the  local  distance.  In  order  to  change 
the  direction  of  the  rays  and  make  them  more  horizontal  and  thus  better 
adapted  for  reflection  by  the  head-mirror  it  is  well  to  have  them  caughl 
by  a  plane  mirror  at  the  window,  which  will  reflect  them  at  any  re- 
quired angle  to  the  head-mirror.  The  power  of  the  sun's  rays  is  so  great 
that,  in  spite  of  many  draw  hacks,  it  certainly  illuminates  and  brings  out 
most   vividly  the  various  tissues  under  examination. 

The  electric  light  is  used  either  as  a  .-mall  lamp  attached  to  the  head  or 
as  a  lamp  fastened  to  the  wall  or  table,  and  the  rays  are  reflected  by  the 
head-mirror.  The  head-lamps  have  always  seeemed  to  me  to  he  heavy  and 
cumbersome  and  to  have  no  special  advantage.  In  the  other  form  of  lamp 
the   light  is  often  not  bright   enough  and  the  film   casts  a  disturbing  shadow. 

1  have  seen  the  oxyhydrogen  light  is  some  European  clinics,  hut  it  is  bulky, 
expensive,  and  not  easily  managed.  It  is  u>n\  as  a  direct  illuminant  and 
not  reflected  by  a  head-mirror,  and  we  shall  see  particularly  as  we  examine 
the  nose,  that  it  is  very  essential  to  focus  the  light  quickly  at  varying  depths, 
and  that  in  so  small  a  space  the  axis  of  vision  and  of  illumination  should  he 
the  same  and  a   head-mirror  is  indispensable. 


i  olding  Lamp  foi  laryngoscopy,  ophthalmoscopy,  and  other  uses 

An  oil-lamp  with  a  bright  flame,  such  as  the  Rochester  burner,  or  even 
the  ordinary  student's  lamp,  is  to  he  recommended  where  there  is  no  gas,  the 
principal  objection  being  the  heat  ;  but  for  everyday  work  nothing  has 
proved  itself  bo  well  suited  for  our  purpose  as  gas  with  the  Argand  burner. 
Gas  ha-  also  an  advantage  over  the  electric  light  in  that  with  it  we  can  warm 
oiii'  mirrors  and  instruments,  fuse  medicines  upon  probes,  etc.  Ike  Welsbach 
burner  gives  a  very  brilliant  light,  ami  it  i-  unfortunate  that  it  is  so  fragile, 
especially  when  used  with  adjustable  fixtures.  The  lighl  from  acetylene  gas 
i-  \c\-\  powerful,  and  objects  illuminated  hv  it  look  more  as  they  do  by  day 
lighl  than  when  ordinary  gas  is  used,  but  it  is  hardly  yet  available. 

One  of  ik''  besl  fixtures  for  gas  is  the  adjustable  arm-brackel  attacked 


EXAMINATION  OF  THE  NAR1  -  857 

firmly  to  the  wall.     This  can  be  raised  or  lowered  and  moved  iii  any  direc- 
tion.    Where  the   lighl    is  to  be  od  a  table  at  a  distance  from    the   wall  a 

movable  gas-lamp  with  an  adjustable  arm  is  excellent.     A  very  g I   little 

portable  lamp,  verv  compact,  easily  carried,  and  well  adapted  for  use  ;it  the 
bedside  is  the  one  figured  (Fig.  -~> ~> ^ ) . 

It  is  advisable  to  have  a  dark  chimney  with  a  bull's-eye  condenser  to 
concentrate  the  lighl  ami  make  it  more  powerful,  and  I  have  found  the 
Mackenzie  condenser  very  satisfactory  (see  Fig.  553).     The  room  need  not  be 


Fig.  o.Jo.— Shade  and  condenser. 

dark,  but  no  strong  light  should  shine  on  the  patient's  face.  He  should  -it 
in  a  wooden  chair  with  a  fairly  straight  high  hack  without  arms.  For 
operation,  a  head-rest  can  be  attached  to  the  baek,  against  which  the  head 
can  be  pressed.  Women  sometimes  like  to  have  a  small  cushion  behind  the 
shoulders  or  back  of  the  head,  especially  if  the  examination  is  at  all  pro- 
longed. The  clothing  about  the  neck  should  he  loose,  and  there  should 
always  he  a  handkerchief  in  the  hand  and  nothing  else.  The  use  of  instru- 
ment- i-  so  likely  to  cause  a  flow  of  mucus,  sneezing,  gagging,  etc.,  that  a 
handkerchief  may  be  needed  suddenly  at  any  moment.  The  hands  should 
he  in  the  lap.  and  the  arm  should  not  rest  on  the  table,  because  this  force- 
up  one  shoulder  and  make-  the  examination  harder.  The  position  should 
he  an   easy,  natural   one  and    without    any  tendency  to    rigidity  of  the   neck. 

The  light  should  he  on  the  right  of  the  patient,  on  a  level  and  about  on 
a  line  with  his  mouth,  and  far  enough  away  from  the  head  so  that  the  heat 
is   not    annoying — about    nine    inches — and    when    not    actually    in    use   had 

better  he  turned  down.     On   the  left    hand,  at  a  < venient   height,  should 

he  some  form  of  spittoon.  The  doctor  sits  directly  opposite  the  patienl  on 
a   light,  hut   linn   -tool,  with   his  knees  outside  those  of  the  patient. 

I  have  already  spoken  briefly  of  what  we  should  look  for  externally. 
.Notice  the  -i/e  and  shape  of  the  nostrils,  see  if  the  fleshy  septum  is  directly 
under  the  cartilaginous  septum,  or  if  the  latter  projects  anteriorly  into  one 
or  the  other  nostril.  Look  for  dilated  capillaries  where  the  septum  pre* 
against  the  -kin.  for  crack-,  fissures,  -kin  eruptions.  fry  the  strength  of 
the  ahe  and  see  if  there  is  a  tendency  for  them  to  collapse  or  fill  iii  and 
block  the  nose  by  a  valve-like  action. 

In  testing  the  patencj  of  the  nostrils  place  the  finger  under  the  opening 
in  such  a  way  as  not  to  displace  the  parts.      The  sound  made  by  the  expelled 

air  shows  more  or  less  accurately   the  ; mm   of  obstruction   in   the  nose. 

[f  an  oily  liquid  is  blown  into  one  nostril  by  a  vaseline  atomizer  it  should 
come  out  of  the  other  in  nearly  equal  volume  if  both  nostrils  and  the  post- 
nasal -pace  are  five,  bm  obstructions  in  or  behind  i  he  nose  diminish  the  ai ml 

of  the  escaping  vapor  in  proportion  to  the  degree  of  obstruction.     It  a  piece 


858  METHODS  OF  EXAMINATION  AM)    DIAC XOSfS. 

of  finely  frayed-out  absorbent  cotton  is  beld  lightly  in  front  of  each  nostril 
the  amount  "t   motion   imparted  to  the  cotton  by  the  air  as  it  comes  out  of 

the  nose  will  show  to  a  certain  extent  the  perviousness  of  the  nose.  This 
met  hod  is  often  of  use  to  demonstrate  that,  for  instance,  in  the  ease  of  a 
child  asleep  with  month  wide  open,  most  of  the  air  goes  through  the  nose 
and  very  little  through  the  month.  Hold  the  cotton  in  front  of  the  month 
and  then  near  the  nostrils,  and  the  movement  of  the  cotton  may  he  much 
less  by  the  air  from  the  mouth  than  from  the  nose,  even  when  the  post-nasal 
space  is  much  blocked  and  the  mouth  is  wide  open.  This  is  a  very  forcible 
way  of  showing  to  parents  that  the  mouth  is  not  doing  the  work  of  the 
nose. 

A  graphic  idea  of  the  perviousness  of  the  nostrils  can  be  obtained  by 
holding  a  cold  glass  mirror  horizontally  under  the  nostrils  on  a  level  with  the 
upper  lip  and  noting  the  size  and  shape  of  the  moisture  which  condense-  on 
the  glass  on  exhaling  through  the  nose.  The  length  of  time  that  it  requires 
for  the  moisture  to  disappear  is  also  a  factor  in  determining  the  degree  of 
obstruction,  the  vapor  from  the  narrow  side  disappearing  first. 

The  sense  of  smell  is  toted  in  a  general  way  by  holding  to  the  nostrils 
various  volatile  substances  of  different  strengths  as  regards  their  odor  and 
noting  how  they  are  perceived  by  the  patient.  For  more  accurate  measure- 
ment, an  instrument  devised  by  Zwaardemaker  and  called  an  olfactometer 
can  he  used.     This  consists  of  a  glass  tube  ( '  (see  Fig.  554),  whose  bent  end 


i — i — i — i 1 — i — r 


b 

Fig.  554.— Zwaardemaker's  olfactometer. 


fits  into  the  nostril.  This  slides  in  a  cylinder  T,  which  is  made  of  the 
odorous  substance  or  is  impregnated  with  it.  When  the  tube  Cis  pushed  to 
the  end  of  the  tube  /',  the  inspired  air  contains  no  vapor,  but  the  more  the 
tube  < '  is  drawn  out  of  the  tube  T,  the  more  the  inspired  air  will  be  exposed 
to  the  inner  side  of  T,  which  is  odorous.  The  distance  to  which  ('  has  to  he 
drawn  out  before  the  odor  is  perceived,  and  which  is  indicated  by  the  scale 
marked  on  the  glass,  gives  the  measure  of  the  acuteness  of  smell.  Tubes 
impregnated  with  differenl  volatile  substances  are  used,  and  the  temperature 
of  the  air  should  be  borne  in  mind,  as  the  warmer  the  air  the  more  volatile 
the  substance.  The  perception  of  an  irritation  of  the  oasal  mucous  mem- 
brane by  vapors,  such  as  ammonia,  or  powders,  should  not  be  confounded  with 
i  he  sense  of  smell. 

For  illuminating  the  interior  of  the  nose  it  is  necessary  to  have  a  concave 
mirror  to  concentrate  the  light  and  project  it  in  any  required  direction.  The 
early  mirrors  were  larger  than  many  of  those  now  in  use,  hut  possessed  no 
advantages  from  their  size.  One  with  a  diameter  of  .').',  inches  is  large 
enough,  and  the  lighter  it  is  the  better.  Thin  idass  and  an  aluminum  back 
diminish  the  weight.  A  large  open  eye-hole  gives  a  much  bettter  view  than 
a  small  one.  The  head-hand  should  lie  firm  hut  not  elastic.  The  Schrotter 
band  with  the  two  knobs  to  resl  on  the  nose  causes  an  unpleasant  feeling  of 
weighl  and  pressure,  ami  to  tny  mind  i-  much  inferior  to  the  simpler  ones 
which  have  a  padded   piece  to  resl   on  the  forehead  over  the  eye.     One  that 

gives  a  linn  BUpport,  is  light,  ami  can  he  folded  together  and  over  the  mirror, 

making  ii  safely  portable,  is  to  !><■  preferred.     An  open  wire  hand  to  go  over 


EXAMINATION  OF  THE  NARES. 


the  vertex  and  take  support  under  the  occiput  is  thought  by  some  to  cause 
less  heat  and  fatigue  than  the  -olid  bands.  The  perforated  hard-rubber  band, 
shaped  to  the  head,  made  by  Pfau  of  Berlin,  has  the  advantage  of  being 
clean,  and  the  weight  of  the  mirror  is  distributed  over  the  whole  circumfer- 
ence of  the  head.  The  ordinary  hand  absorbs  the  perspiration  and  in  warm 
weather  can  become  foul  and  irritate  the  skin. 

The  mirror  is  usually  worn  over  the  right  eve,  although  some  prefer  it 
over  the  left,  claiming  that  it  thus  protects  the  examiner's  eves  better  from 
the  glare  of  the  lamp.  It  can  be  attached  to  a  rod  fastened  to  the  lamp,  and 
it-  weight  is  then  entirely  removed  from  the  head  (see  Fig.  553).  This  is  not 
a  good  arrangement  for  examining  the  nose,  because  it  is  necessary  to  move 
the  patient's  head  up  and  down  and  in  various  directions,  and  the  opening  of 
the  nose  is  so  small  that  a  slight  movement  of  the  head  throws  the  light  away 
from  the  nose  and  the  position  of  the  mirror  has  to  he  changed  constantly  by 
the  hand.  For  the  tonsils  and  pharynx  and  also  for  the  larynx,  when  the 
latter  is  easy  to  see,  it  is  more  useful,  because  slight  movements  of  the 
patient's   head  do   not   remove  the   light  from  the  throat. 

The  nasal  specula  most  commonly  used  are  those  of  the  bivalve,  duck-bill, 
and  the  open  wire  type,  with  their  various  modifications.  The  open  wire 
specula  have  certain  disadvantages;   they  do  not  hold  the  hairs  out   of  the 


Fig.  555.— Hartmann's  bivalve  speculum  I   -  the  study  of  the  inferior  turbinal  and  n 

i  tin-  opened  nasal  chai 

way,  they  have  almost  no  reflecting  surfaces,  and  they  cut  into  the  nose 
Some  of  them,  Bosworth's,  for  example  (one  of  the  best  .  are  self-retaining 
in  eertain  ease-,  and  are  useful  as  retractor-  in  operating  in  the  front  of  the 
nose,  but  are  not  so  well  adapted  for  examining  the  middle  and  posterior 
parts. 

The  duck-bill  specula,  of  which  Duplay's  i-  one  of  the  most  generally 
used,  are  light,  have  good  reflecting  surfaces,  thus  lighting  up  well  the  deeper 
portions  of  the  nostrils,  hold  the  alae  and  the  hairs  well  out  of  the  way,  and 
do  not  cut  into  the  nose.    They  do  not  allow  the  passage  of  large  instruments 


860 


Mirnions  of  lxam/xatiox  axi>  diauxosis. 


through  them,  and  in  some  cases  are  not  well  adapted  for  operations,  but  for 
examinations  they  are  excellent. 

Of  bivalve  specula  there  are  many  varieties.  I  have  always  considered 
that  Hartmann's  (Fig.  555)  answered  its  purpose  very  well.  A  firm  even 
expansion  of  the  nasal  orifice  can  he  made  with  it,  and  it  has  good  reflecting 
surfaces  and  allows  the  passage  and  manipulation  of  good-sized  instruments. 
The  blades  are  sometimes  made  too  thick. 

As  a  simple  retractor  of  the  ala  a  bent  hairpin  can  be  u^cd  and  can  be 
held  in  place  by  a  tape  fastened  to  it  and  then  tied  around  the  head.  A  nasal 
probe  is  indispensable  for  exploring  tiie  cavities  and  estimating  the  density 
and  mobility  of  the  various  -tinctures.  It  should  be  long  enough  to  reach 
the  posterior  pharyngeal  wall  easily  through  the  nose  and  fairly  stiff.  I  have 
used  with  satisfaction  one   like    Fig.  550.      It  is  live  inches  long  from  the  tip 


I  [i     •  56.— Nasal  probe  inserted  into  semilunar  hiatus  an<1  infundibulum  of  a  cast  of  the  <lis 

nasal  chambers. 


•ctcd 


to  where  it  bends  downward  at  the  handle.  All  instruments  should  be  warm 
and  used  very  gently. 

In  order  to  gel  better  access  to  the  interior  of  the  nose  its  tip  should  be 
lifted  up  by  the  linger  so  a-  to  get  a  view  over  the  anterior  projection  of  the 
floor  of  the  nose.  The  speculum  i<  introduced  closed,  one  blade  resting 
againsl  the  septum  and  the  other  against  the  ala,  and  gradually  opened.  'I 'he 
anterior  septum  should  be  looked  at  while  the  speculum  is  being  put  in, 
otherwise  the  blade  may  cover  -mall  cracks,  vessels,  or  ulcers.  Students 
often  overlook  -mall  perforations  lor  this  very  reason.  The  thin  mucous 
membrane  of  the  septum  can  be  made  to  bleed  very  easily  by  pressure  of  the 
end  of  the  speculum,  a  thing  to  he  carefully  avoided. 

When  the  patient's  head  i-  -traight  (see  Fig.  555)  the  most  prominent 
object  on  the  outer  wall  of  the  nostril  is  the  red  rounded  end  of  the  inferior 
tiiil>iii;il   body,  underneath  which  i-  the   inferior  meatus.      'flic  opening  of  the 

tear-passage  into  this  meatus  is  not  -ecu.  being  concealed  by  the  turbinal. 
\\  e  should  be  able  to  follow  thi<  body  along  to  near  its  middle  and  sometimes 
even  to  it-  posterior  end,  and  may  even  see  a  portion  of  the  posterior  pharyn- 
geal wall.     I'>\  getting  tin'  patient  to  say  A,  we  not  infrequently  see  the  -oft 


EX.  I  MIN.  1  TION  0  /•'  Til  E  A.  I  R  ES.  861 

palate  Lifted,  and  if  the  turbinal  is  very  small,  \\c  may  see  the   Eustachian 
eminence  :  and  the  acl  of  swallowing  shows  the  mouth  of  the  tube  brought 

nearer  the  median   line  and   more  into  view. 

The  turbinal  is  subject  to  great  variations  in  size  from  vaso-motor  influ- 
ences, as  well  as  from  hypertrophy  and  atrophy  of  its  tissues.  Sometimes  il  is 
so  large  as  to  till  the  whole  anterior  part  of  the  nostril,  and  a  mere  touching 
with  the  probe  may  cause  it  to  diminish  perceptibly.  Spraying  also  may 
have  the  same  effect.  We  must  distinguish  between  a  true  and  an  apparent 
hypertrophy.  The  former  is  quite  firm  to  the  probe  and  does  not  diminish 
appreciably  in  size  under  the  influence  of  cocain.  The  turbinal  may  also  be 
very  small,  in  which  ease  the  inferior  meatus  is  usually  large  and  the  posterior 
pharyngeal  wall  may  be  plainly  seen.  It  is  important  to  determine  whether 
this  smallness  is  natural  or  due  to  an  atrophy.  W  normal,  the  mem- 
brane over  it  will  have  the  normal  color  and  moisture,  and  the  rest  of  the 
nose  will  lie  found  in  good  condition.  If  atrophic,  the  membrane  will  be  a 
dull,  lusterless  red,  perhaps  rather  dry,  and  there  may  be  crusts  or 
muco-purulent  secretions  over  it  or  in  the  rest  of  the  nose.  The  posterior  end 
of  the  turbinal  is  liable  to  great  swelling,  which  can  be  determined  by 
the  probe  from  the  front,  or  often  better  by  posterior  rhinoscopy,  as  we 
shall  see. 

The  head  should  now  be  tipped  farther  back,  which  brings  into  view  the 
middle  meatus,  the  usual  seat  of  polypi  and  the  place  where  the  openings  of 
the  antrum,  frontal  sinus,  and  ethmoid  cells  are  found.  Above  this  is  the 
middle  turbinal  body,  which  begins  farther  back  than  the  inferior,  is  less 
rounded  in  shape,  and  with  its  mucous  membrane  more  closely  adherent  to 
the  bone.  It  is  not  seen  to  such  an  extent  as  the  inferior,  as  a  general  rule, 
and  great  hypertrophy  of  the  latter  or  deviations  of  the  septum  may  conceal 
it  altogether.  If  the  head  is  tipped  still  farther  back,  we  can  see  the  root'  of 
the  nose  and  the  olfactory  fissure;  but  the  superior  turbinal  is  not  visible. 
The  upper  regions  of  the  nose  are  narrow  and  sensitive,  and  the  probe  should 
be  carefully  used.  As  the  olfactory  nerve  is  distributed  on  the  upper  part 
of  the  septum  and  over  the  superior  and  middle  turbinates  we  should  notice 
whether  there  are  any  obstructions  which  would  prevent  the  air  from  having 
free  access  to  these  important  regions  and  also  whether  the  membrane  in 
which  the  nerve  is  distributed  is  normal  or  atrophic  or  covered  with  crusts 
or  abnormal  secretions. 

Foreign  bodies  are  usually  in  the  inferior  meatus  and  cause  a  purulent  or 
even  bloody  discharge.  A  unilateral  discharge,  especially  in  a  child,  should 
always  awaken  a  suspicion  of  a  foreign  body,  and  with  the  probe  we  are  able 
to  feel  and  locate  it.  Necrosis  may  also  cause  a  bloody,  purulent  discharge 
with  the  characteristic  odor,  and  should  be  carefully  hunted  for  with  the 
probe,  in    the   upper  part   of  the  nose  particularly. 

On  the  inner  side  of  the  nostril  is  the  septum,  made  up  of  the  anterior  or 
cartilaginous  septum,  the  perpendicular  plate  of  the  ethmoid  and  the  vomer. 
It  is  very  uncommon  to  find  the  septum  straight,  dividing  the  nose  into  two 
equal  nostrils.  The  cartilage  is  very  frequently  bent  so  as  to  encroach  upon 
one  nostril,  or  it  may  have  a  sigmoid  deviation  which  occludes  both  nares. 
Thickenings  in  the  shape  of  ridges  and  Bpurs  are  common.  These  may  press 
against  the  turbinal-  in  such  a  way  as  to  make  it  very  difficull  or  even  impos- 
sible to  see  far  into  the  oose. 

To  determine  the  thickness  of  the  septum  we  can  introduce  the  little 
finger  into  each  nostril  and  estimate  the  amount  of  intervening  cartilage ;  or 
we  can  make  use  of  the  septometer,  such  as  Seiler's,   whose  scale  gives  an 


sii-j  METHODS  OF  EXAMINATION  AND  DIAGNOSIS. 

accurate  measure  of  the  thickness  of  the  structures  between  the  ends  of  the 
blades. 

If  tlu'  light  is  thrown  into  one  nostril,  especially  if  it  is  sunlight,  the 
color  <>t'  the  septum  when  viewed  through  the  other  nostril  is  much  lighter 
where  the  septum  is  thin  than  in  its  thickened  portions.  A  probe  bent  at 
the  end  when  slid  along  a  ridge  or  spur  will  show- when  the  posterior  edge 
has  been  reached. 

The  anterior  vulnerable  septal  cartilage  is  the  usual  seat  of  epistaxis,  and 
here  we  should  look  for  dilated  vessels,  ulcers,  and  perforations. 

The  normal  secretion  of  the  nose  is  clear  mucus,  more  copious  in  cold 
weather  than  in  summer.  The  character  and  seat  of  the  secretions  of  the 
oose  should  be  carefully  noted  before  they  are  removed  by  spray,  swab,  or 
forceps.  Occasionally  we  meet  a  case  where  there  is  a  very  profuse  and 
annoying  How  of  clear  mucus  which  hinders  our  examination.  A  small  dose 
of  atropin  about  four  hours  before  the  visit  serves  to  check  this.  Our  great 
resource  for  obtaining  a  better  view  of  the  interior  of  the  nose  is  cocain. 
This  causes  the  turbinals  to  diminish  in  size;  the  amount  of  blood  in  the 
mucous  membrane  is  lessened.  This  is  of  special  value  in  hypertrophic  con- 
ditions where,  without  it,  we  could  see  only  the  anterior  part  of  the  inferior 
turbinal.  The  nose  should  be  carefully  dried  with  cotton  and  a  small  quan- 
tity of  a  weak  solution,  say  4  per  cent.,  placed  against  the  tissues  which  it  is 
desired  to  diminish  in  size.  This  is  much  wiser  than  spraying  the  solution 
indiscriminately  into  the  nose.  When  the  anterior  obstruction  is  diminished, 
another  application  can  be  made  farther  in.  The  nose  should  be  first  exam- 
ined as  thoroughly  as  possible  without  the  cocain  ;  for  this,  while  rendering 
the  deeper  structures  visible,  blanches  the  tissues  and  so  changes  their  aspect 
that  we  might  be  entirely  misled  unless  we  knew  the  condition  before  the 
cocain  was  applied. 

Yet,  even  with  the  help  of  cocain.  we  shall  find  some  nostrils  so  narrow 
and  tortuous  and  the  external  orifice  so  small  and  even  pointing  downward 
that    we  can  get  but  a  very  imperfect  view  of  the  interior. 

ACCESSORY  CAVITIES. 

Within  the  last  few  year-  the  accessory  cavities  have  begun  to  attract  the 
attention  they  deserve.  The  antrum,  frontal  sinus,  and  anterior  ethmoidal 
(•ell-  open  into  the  middle  meatus  (see  Fig.  556);  the  posterior  ethmoidal 
cells  and  the  sphenoidal  sinus  open  into  the  superior  meatus.  If  a  discharge  of 
pus  i-  seen  in  the  upper  part  of  the  nasal  chamber,  when  not  due  to  necrosis 
or  a  foreign  body,  it  probably  conic-  from  one  of  these  cavities.  In  early  life 
they  are  very  imperfectly  developed  ;  but  in  later  life,  especially  since  the 
epidemics  of  influenza,  their  diseases  are  seen  to  be  not   uncommon. 

The  largest  and  most  frequently  affected  cavity  is  the  maxillary  antrum, 
which  has  ii-  outlet  at  the  top  and  empties  into  the  middle  meatus  by  an 
opening  which  i-  usually  concealed  by  the  middle  turbinal,  under  which  pus 
from  the  antrum  make-  its  appearance,  [f  this  pus  is  thoroughly  removed 
and  the  head  bent  forward  and  downward,  with  the  side  of  the  face  corre- 
sponding t"  the  Buspected  antrum  uppermost,  pus  will  thus  more  readily  run 
out  of  tin'  natural  opening  and  can  be  -ecu  under  the  middle  turbinal  when 
ili''  patient  again  sits  upright. 

Transillumination  often  gives  ;i  certain  amount  of  information  a-  to 
whether  the  pus  is  located  in  the  antrum,  and  should  always  be  tried  before 
making  an  exploratory  puncture.     Unless  the  room  can  be  made  absolutely 


.  U  7  v/.v.s-o /.•  r  VA  VITIES. 


863 


dark,  it  is  well  to  use  a  piece  of  black  cloth,  such  as  photographers  use  in 
focussing,  or  a  Mack  rubber  sheet  which  can  cover  the  heads  of  examiner 
and  patient,  and  when  tightly  held  under  the  chin  shuts  oul  effectually  every 
ray  of  light.  A  small  electric  light  (Heryng's  is  good,  bill  there  are  a  num- 
ber of  others)  is  placed  in  the  mouth  above  the  tongue  and  the  lip-  are  tightly 
closed.  All  tooth-plates  should  be  removed.  When  the  electric  lignl  is 
turned  on,  the  healthy  antrum  should  allow  the  lighl  to  pass  through  it 
and  show  a  crescentic  bright  area  under  the  eye.  and  sometimes  the  pupil 
is  lighted  up  (see  Plate  14).  The  patient  should  also  have  the  subjective 
sensation  of  light  in  the  eye  with  the  eye-  closed.  In  case  the  antrum  i- 
filled  with  pus  or  any  opaque  substance,  this  area  and  sensation  of  light  are 
entirely  wanting.  This  method  is  often  of  great  value  as  corroborative  evi- 
dence ;  but  too  much  reliance  should  not  be  placed  on  it,  because  there  are 
cases  in  which  the  face  fails  to  be  lighted  up  when  the  antrum  i-  empty,  even 
when  the  bony  walls  are  not  abnormally  thick.  But  I  think  we  may  safely 
say  that  where  there  is  a  discharge  of  pus  under  the  middle  turbinal  and  that 
side  of  the  face  remains  absolutely  dark  without  sensation  of  light  in  the  eye, 
while  the  other  side  is  brightly  illuminated  with  sensation  of  light,  the 
chances  are  very  greatly  in  favor  of  our  having  to  deal  with  empyema  of  the 
antrum  (see  page  970). 

To  make  sure  that  the  antrum  is  the  part  affected  we  can  wash  it  out  in 
various  ways.  A  hollow  cannula,  such  as  Hartmann's,  can  be  passed  along 
under  the  middle  turbinal  till  it  comes  to  the   neighborhood  of  the  natural 


& 


Fig.  557.— Hajek's  straight  cannula  inserted  for  puncture  of  the  antrum-wall  in  the  inferior  meatus  (in 
a  cast  of  the  nasal  chamber,  dissected  to  snow  the  lachrymal  duct,  the  infundibulum,  i 


opening  and  then  turned  outward,  and  it  can  sometimes  be  fell  to  enter  the 
opening.  A  syringe  attached  to  the  cannula  may  be  used  to  suck  the  pus 
out,  or  warm  water  may  be  forced  in,  and  the  stringj  flocculenl  pus  which 
appears  -how-  it-  antral  origin. 

In  case  the  opening  is  nol  found,  it  i-  possible  to  perforate  the  outer  wall 
of  the  middle  meatus  with  a  trocar  and  wash  out  through  this  artificial 
opening,   the   pus  escaping  through   the    natural   opening  or  one  or   more 

accessory  openings  which  may  exist.     Care  -1 Id  be  taken   nol  to  puncture 

too  deep   for  fear  of  entering  the  orbit.     Cocain   should   be  ^-<<\  for  these 
manipulations,  both   to  produce  anesthesia  and  also  to  cause  a   shrinking  ol 
the  tissues  and  gain   room.      It  ma}  be  necessary  to  remove  the  anterior  end 


864  METHODS  OF  EXAMINATION  AND   DIAGNOSIS. 

of  the  middle  turbinate  to  gain  greater  freedom  for  the  cannula.     Pieees  of 
polypi  and  granulations,   il*  present,  should  also  be  removed. 

I  have  preferred  to  make  the  exploratory  puncture  in  the  outer  wall  of 
the  inferior  meatus,  about  the  middle  third,  where  the  bone  is  usually  thin. 
For  this  the  curved  trocar,  such  as  Krause's  or  Myles's  can  be  used,  or  the 
straight  hollow  needle  of  Hajek  (see  Fig.  557).  'This  is  passed  along  under 
the  interior  turbinate  to  the  proper  spot,  and  is  then  pointed  outward  and 
pushed  through  the  hone  into  the  antrum,  when  the  washing  out  follows,  as 
above  described.  Ii*  a  tooth  has  recently  been  extracted,  the  alveolar  socket 
may  be  so  thin  that  a  cannula  can  be  passed  easily  through  it  into  the 
antrum.  The  alveolar  process  can  be  perforated  through  the  socket  of  the 
bicuspids  or  molars  or  between  the  roots  of  the  teeth.  These  latter  places, 
as  well  as  the  canine  fossa,  are  generally  chosen  in  carrying  out  treatment 
rather  than   for  simple  diagnostic  purpose. 

In  case  we  find  that  the  pus  in  the  middle  meatus  does  not  conic  from 
the  antrum,  we  should  look  to  the  frontal  sinus  and  the  anterior  ethmoidal 
cells.  The  former  is  reached  through  the  infundibulum  by  a  small  hollow 
sound  or  cannula  (see  Fig.  556).  This  is  often  difficult,  and  it  may  be 
necessary  to  remove  the  anterior  end  of  the  middle  turbinate.  If  pus  is 
brought  away  on  the  sound  when  it  enters  the  infundibulum.  or  if  washing 
out  the  cavity  through  the  cannula  shows  pus,  the  frontal  sinus  is  presumably 
the  seat  of  disease,  as  it  may  be  when  the  antrum  is  filled  by  its  discharge. 

We  can  also  make  use  of  transillumination  by  covering  the  electric  lamp 
with  a  thick  piece  of  rubber  open  at  the  end  so  as  to  throw  the  light  in  one 
direction  only.  The  rubber  is  placed  against  the  roof  of  the  orbit,  not  too 
near  the  thick  orbital  ridge  (see  Plate  14),  and  pressed  upward,  inward,  and 
backward.  The  healthy  sinus  may  thus  be  lighted  up  and  show  an  illumin- 
ation over  (piite  an  area.  In  case  one  side  is  light  and  the  other  not.  it  will 
give  us  an  intimation  that  the  dark  sinus  may  contain  pus.  But  the  frontal 
sinus  is  so  irregular  in  contour  and  size  that  we  must  not  lay  too  much  stress 
on  this   mode  of  examination. 

The  anterior  ethmoidal  cells  are  entered  by  passing  the  probe  upward 
between  the  middle  turbinal  and  the  outer  wall  into  the  hiatus  semilunaris 
(see  Fig.  556).  The  opening  is  near  that  of  the  frontal  sinus,  and  the  end  of 
the  probe  should  be  bent  at  a  right  angle. 

The  opening  of  the  sphenoidal  sinus  can  sometimes  be  seen  when  the 
turbinals  are  very  much  atrophied.  The  anterior  wall  is  usually  about  seven 
centimeters  from  the  anterior  nasal  spine.  A  probe  passed  along  the  anterior 
part  of  the  floor  of  the  nose  upward  and  backward  between  the  septum  and 
the  middle  turbinal.  crossing  the  latter  a  little  posterior  to  its  center,  should 
reach    the  anterior   wall   of  the  sinus  (see    Fig.  555). 

EXAMINATION  OF  THE  PHARYNX. 

The  lips,  cheeks,  teeth,  palate,  tongue,  and  floor  of  the  mouth  should  he 
carefully  examined  for  ulcers,  cicatrices,  fissures,  swellings,  ranula,  tongue- 
tie,  etc. 

For  the  tonsils,  pharynx,  and  post-nasal  space  a  tongue-depressor  i-  neces- 
sary, it  i-  possible  to  gel  something  of  a  look  at  the  fauces  by  pressing 
down  the  tongue  with  a  Bpoon,  pencil,  paper-cutter,  the  patient's  finger,  or 
even   without   any   instrument,   the    patient    saying  "Ah!"  during  a   deep 

inspiration,  bul   no  thorough  examination    can   be  thus    made.      The  depress  or 

of  Turck  i-  one  of  the  oldesl  and  ha-  the  advantage  of  resting  at  the  corner 


EXAMINATION  OF  THE  PHARYNX. 


865 


of  the  mouth  and  is  easily  held  by  tlif  patient  when  the  examiner  desires  to 
use  both   hands  in   examining  or  operating. 

The  narrow-bladed  depressor  of  Frankel  is  much  used  and  holds  down 
the  center  of  the  tongue  well  and  takes  up  but  little  room  in  the  mouth. 
But  I  have  found  the  sides  of  the  tongue  likely  to  be  raised  on  either  side 
of  the  instrument,  shutting  off  the  sides  of  the  throat  and  the  base  of  the 


Fig.  558.— The  author's  tongue-depressor. 


tonsils  from  view.  It  has  not  seemed  to  me  to  take  a  sufficiently  strong 
hold  on  enough  of  the  tongue  to  keep  it  steady  and  out  of  the  way.  I  pre- 
fer a  broader,  thin  blade  with  a  fenestrum,  somewhat  concave  from  side  to 
side  and  also  from  front  to  back.  About  an  inch  in  width  at  its  widest  part 
and  from  3— 3|  inches  in  length  gives  a  blade  which  keeps  the  sides  a-  well 
as  the  center  of  the  tongue  out  of  the  way  (Fig.  558). 

In  open  wire  depressors  the  tongue  is  very  apt  to  protrude  between  the 
wires  and  obstruct  the  view  ;  and  folding  depressors,  although  portable  and 
convenient,  are  not  always  stiff  enough. 

The  proper  use  of  the  tongue-depressor  is  of  great  importance  and  is  the 
key  to  a  correct  examination  of  the  throat  and  post-nasal  space.  The  patient 
should  be  told  to  open  the  mouth,  but  not  too  wide,  and  to  keep  the  tongue 
inside  the  mouth,  its  tip  against  the 
lower  front  teeth.  He  should  then  say 
"  Ah!"  in  a  natural  voice  without  con- 
tracting the  throat.  When  he  has  said 
this  several  times  the  tongue-depressor 
is  taken  in  the  hand  and  carried  over 
the  tongue  till  the  end  of  the  blade  is 
well  over  the  dorsum  where  the  tongue 
begins  to  curve  downward,  and  while 
"  Ah!"  is  being  spoken  the  instrument 
presses  downward  and  pulls  forward  the 
base  of  the  tongue.  It'  the  handle  is 
held  between  the  thumb  and  forefinger, 
the  middle  finger  placed  under  the  chin 
acts  as  a  fulcrum  and  the  third  and  little 
fingers  pull  the  handle  upward  and  con- 
sequently help  to  depress  the  tongue  still 
more.  With  the  tongue,  chin,  and  depressor  thus  firmly  held,  the  patient's 
head  can  be  moved  up  or  dowD  or  sideways,  and  is  well  under  the  control  oi 
the  examiner  (  Fie;.  559). 

There  are,  however,  many  eases  where  this  is  :i  very  difficult  undertak- 
ing. A  short,  thick,  muscular  tongue  requires  considerable  force  to  make 
it  lie  down;  a  strong  but  steady  pressure  should  l>e  used.  Some  patients 
have  such   Irritable  throat-  that  they  gag  even   before  the  tongue-depressor 

55 


Fig.  559.    Tongue-depressor  in  position  i 
amining  the  fauces,  with  finger  under  the 
chin. 


866  M/r/'HODS  OF  KXAMIN AT/ON  AND  DIAGNOSIS. 

touches  the  toDgue.  Greal  patience  is  Deeded  and  many  trials.  It  is  some- 
times well  to  endeavor  to  turn  the  patient's  attention  from  what  you  are 
trying  to  do  by  getting  him  to  say  ".1A/"  several  times  in  a  loud  tone 
while  you  try  the  depressor,  [mmediately  after  a  meal  there  is  a  greater 
tendency  to  gagging  than  when  the  stomach  is  nearly  empty,  and  the  visil 
should  he  timed  accordingly.  It'  there  is  secretion  on  the  posterior  pharyn- 
geal wall,  it  should  he  removed,  because  it  tends  to  cause  gagging  when  the 
tongue  is  held.  The  nose  anil  post-nasal  space  should  he  i'vcvd  from  secre- 
tions,  a-  free  nasal  respiration  makes  it  easier  to  have  the  tongue  held.  The 
gagging  of  the  alcoholic  may  he  almosl  impossible  to  overcome,  and  in  such 
cases  it  is  well  to  try  a  few  doses  of  bromid.  Pieces  of  ice  held  in  the 
mouth  diminish  the  irritability. 

In  case  we  find  our  patient  still  unable  to  allow  a  satisfactory  view  of  the 
throat  we  can  generally  succeed  by  painting  the  posterior  pharyngeal  wall 
with  a  5  per  cent,  solution  of  cocain.  The  unpleasant  sensation  of  suffoca- 
tion and  of  a  foreign  bod}  impossible  to  dislodge  soon  disappears,  and  the 
patient  should  he  told  of  this.  A  fairly  still'  probe  is  of  greal  use  in  exam- 
ining the  tonsils.  If  passed  between  the  anterior  pillar  and  the  tonsil.it 
-hows  the  presence  or  absence  of  adhesions.  It  should  he  passed  into  the 
crypt-  to  determine  whether  they  contain  cheesy  secretions  or  tonsilliths.  A 
dull  wire  curette  is  valuable  for  searching  under  the  anterior  pillar  and  in 
any  deep  depressions  in  or  about  the  tonsil.  The  probe  can  also  pull  the 
tonsil  from  its  bed  and  render  it  more  visible  and  bring  out  more  clearly  the 
size  of  its  attachment  to  the  side  of  the  throat.  During  gagging  the  tonsils 
ale  everted,  approach  the  median  line,  and  appear  much  larger  than  they 
really  are,  consequently  they  should  he  examined  while  at  rest  and  in  their 
natural  position.  If  one  forefinger  is  placed  under  the  angle  of  the  jaw  and 
the  other  in  the  mouth  against  the  tonsil  or  soft  palate,  we  can  determine  the 
density  of  the  tonsil,  whether  it  contains  a  hard  concretion  or  a  cyst,  and  also 
the  presence  of  fluctuation. 

POST-NASAL  SPACE. 

For  the  post-nasal  -pace  we  make  use  of  the  rhinoscopic  mirror,  which 
should  have  a  size  corresponding  to  the  distance  between  the  -oft  palate  and 
the  pharynx-wall  and  also  between  the  uvula  and  the  tonsil.  The  common 
size  i-  ahout  half-an-inch  in  diameter,  hut  for  children,  especially  where  the 
tonsils  are  large,  one-half  the  size  is  lame  enough.  In  some  cases  where 
there  is  plenty  of  room  and  the  part-  not  sensitive,  we  are  able  to  use  a 
laryngoscopic  mirror.  The  usual  angle  of  the  mirror  to  the  shank  is  about 
|o:.  ,  hni  mirrors  are  also  made  with  a  joint  by  means  of  which  any  desired 
angle  can  be  obtained.  The  head  should  he  held  a  little  forward.  After 
warming  the  mirror,  to  avoid  condensation  of  moisture,  it  should  he  held  like 
;i  pencil,  the  reflecting  surface  upward  and  passed  parallel  to  the  surface  of 
the  tongue  until  the  uvula  is  reached.  It  should  then  he  turned  diagonally 
and  passed  between  the  uvula  and  the  tonsil,  usually  to  the  right  of  the  uvula 
and  then  behind  and  below  the  sofl  palate,  with  the  reflecting  surface  facing 
upward  and  forward.  Tin1  patient  should  he  directed  to  breathe  through  the 
nose  and  tn  to  -my  " en"  with  :i  strong  nasal  tone. 

The  view  obtained  i-  of  a  part  onl}  of  the  post-nasal  -pace  at  a  time,  ami 
the  mirror  has  to  he  turned  in  order  to  see  the  differenl  part-  in  succession. 
It  i-  very  important  t"  have  the  base  of  the  tongue  well  pulled  forward  bo  as 
to  have  plenty  of  room  for  this  manipulation  "l   the  mirror.     The  landmark 


I'ost-xasal  si •.[<■!■:. 


867 


for  which  we  look  is  the  back  of  the  vomer,  which  is  of  a  yellowish  gray 
color,  broader  at  the  top  than  lower  down.  The  middle  turbinal  is  generally 
more  prominent  than  the  inferior,  whose  lower  half  and  the  inferior  meatus 
arc  often  not  visible.  These  -tinctures  are  lighter  colored,  more  gray,  than 
their  anterior  ends.  High  up  we  may  see  on  one  or  both  sides  the  -mall 
superior  turbinals  which  are  not  visible  through  the  anterior  nares.  The 
mirror  has  to  be  turned  considerably  toward  the  -ides  in  order  to  see  the 
Eustachian  prominences  with  their  yellowish,  crater-like  openings,  over  the 
edge  of  which  a  small  red  vessel   is  often  seen.     Behind  the  prominences  are 


Fig.  560.— Adenoid  hypertrophy  as 

seen  from  the  front,  showing  its  true 
relation. 


Fig.  "til.— The  same  growth  apparently  far 
less  dependent,  as  seen  by  posterior  rhinos- 
copy (Zarniko). 


the  fossae  of  Rosenmiiller,  perhaps  irregular  at  the  bottom,  or  there  may  be 
bands  of  adhesion  stretching  across  to  the  prominences.  The  pharyngeal 
vault  should  be  dome-shaped  and  is  often  irregular.  In  the  center  we  may 
find  a  cleft,  the  median  recess,  whose  depth  can  be  told  by  passing  into  it 
behind  the  palate  a  suitably  curved  probe,  which  can  also  give  information  as 
to  the  density  and  extent  of  any  thickened  tissues  at  the  vault.     The  mirror 


Fig.  562.— Post-rhinoscopic  view  of  the  septum,  choanse,  Eustachian  tube-i  ■   ■"  '""' 

!ix  \ .i 1 1 1 1  (after  Hej  mane 

alone  sometimes  gives  an  inadequate  idea  of  the  : inl  of  hypertrophy  at 

the  vault,  as  will   be   readily  seen   by   looking  at    Figs.   560  and   561. 

We  will  suppose  thai  there  is  a  growth  which  reaches  down  to  the  lower 
border  of  the  inferior  turbinal.  When  looked  at  through  the  anterior  nares 
we  see  the  growth  hanging  down  as  far  as  the  inferior  meatus,  represented  bj 
the  dotted  line.     The  rhinoscopic  mirror,  however,  seems  to  indicate  thai  its 


868  METHODS  OF  EXAMINATION  AM)   DIAdXOSI.s. 

lower  margin  i>  od  a  level  with  the  superior  meatus,  and  is  consequently  of 
much  less  extent  than  it  really  is.  In  such  a  case  it  is  well  to  hold  the 
mirror  more  horizontal  and  look  a1  the  posterior  end  of  the  growth,  if  that  is 
possible,  when  we  may  find  that  it  hangs  (town  farther  than  we  had  first 
supposed.  But  a  much  better  way  is  to  make  use  of  digital  exploration,  as 
we  often  have  to  do  when  no  post-nasal  examination  is  possible.  The 
examiner  stands  at  the  side  of  the  sitting  patient  with  his  arm  around  the 
patient's  head,  and  in  the  case  of  a  child  it  is  well  to  press  the  cheek  in 
between  the  teeth,  which  serves  to  keep  the  mouth  open  and  also  prevents 
the  biting  of  the  examiner's  finger.  A  metal  finger  is  often  used  as  protec- 
tion against  the  sharp  lower  teeth,  or  a  mouth-gag  may  he  employed. 

Tin-  forefinger  of  the  doctor'.-  hand,  the  palmar  side  up,  is  then  passed 
along  the  side  of  the  mouth  to  the  tonsillar  region  and  then  behind  the  soft 
palate,  being  very  careful  not  to  carry  the  uvula  or  palate  with  it.  The  elbow 
i-  well  depressed  and  carried  in  front  of  the  patient  and  the  finger  feels  for 
the  septum,  turbinates,  Eustachian  eminences,  the  vault,  and  can  thus  esti- 
mate very  accurately  the  amount  and  character  of  any  obstructions,  whether 
central,  near  the  choanae,  how  much  of  each  posterior  naris  is  covered,  and 
whether  the  growths  are  on  the  posterior  wall.  The  examination  should  he 
short  hut  thorough,  and  may  he  unsatisfactory  unless  the  child  is  firmly  held. 
It  should  follow  and  not  precede  other  methods  of  examination,  because  the 
child  has  usually  had  all  the  examination  he  will  submit  to  when  the  finger 
has  once  been  behind  the  palate. 

Still  another  way  of  seeing  the  post-nasal  space  is  advocated  by  Katzen- 
stein  of  Berlin,1  who  calls  it  autoscopie.  The  patient  lies  on  his  back  with 
the  head  hanging  down  as  far  as  possible.  The  mouth  is  then  opened  and 
the  tongue  drawn  forward,  as  in  laryngoscopy.  A  palate-retractor,  resem- 
bling an  eyelid-retractor,  is  then  placed  behind  the  uvula,  and  by  slowly 
and  gradually  increasing  the  force  used  the  palate  is  drawn  so  far  forward 
and  downward  that  we  are  able  to  see  the  posterior  pharyngeal  wall,  the 
vault,  the  Eustachian  eminences  and  openings,  the  plica  salpingo-palatina, 
the  plica  salpingo-pharyngea,  and  the  fossa  of  Rosenmuller.  The  septum, 
turbinates,  and  choanse  are  not  visible.  Post-nasal  tumors  and  adenoid 
hypertrophy  can  be  seen  and  operated  on  in  this  way  without  a  mirror,  and 
the  catheter  can  be  placed  directly  in  the  Eustachian  tube  without  having  to 
pass  it  through  the  nose.  Strong  illumination  is  necessary  here,  as  in  all 
examinations  of  the  post-nasal  space. 

The  obstacles  to  rhinoscopic  examination  are  many.  The  tonsils  may  be 
bo  large  a-  to  prevent  the  introduction  of  even  the  smallesl  mirror.  A  very 
broad  uvula  may  interfere  in  which  <-a~c  we  can  hold  it  to  one  side  or  lift 
it  by  a  palate-retractor.  The  distance  between  the  -oft  palate  ami  the 
pharynx  may  1m-  so  -mall  that  there  is  no  room  for  the  mirror.  By  using  a 
little  cocain  on  the  back  of  tlie  palate  we  may  be  able  to  pull  it  forward  by 
the    palate-hook    and    gain    -pace   enough    for  a    small   glass. 

Where  the  fauces  are  of  sufficient  size  the  attempt  to  pass  the  mirror 
behind    the    palate    often    causes    the    latter    to    be    drawn    back     against     the 

pharynx-wall,  even  when  the  mirror  has  not  touched  the  tongue,  uvula,  or 
pharynx.  The  mere  presence  of  the  mirror,  whether  by  interfering  with 
the  passage  of  the  air  or  by  acting  on  the  mind,  i-  enough  to  excite  move- 
ments of  the  palate.  A  very  -mall  mirror  may  be  tolerated  when  a  large 
"tie  i-  not.  1  have  sometimes  succeeded  by  passing  the  tongue-depressor  on 
the  aide  of  the  tongue  instead  of  in  the  center  ami  pushing  the  tongue  over 

1  Arch,  f.  Laryngol.,  Band  v.  p,  283. 


LARYNX. 

to  the  other  side.  Thus  room  enough  is  gained  near  the  tonsil  for  a  small 
glass,  and  the  patient  does  not  have  so  much  the  feeling  that  the  tongue  is 
being   held   down. 

1  have  already  spoken  of  the  need  and  value  of  a  weak  solution  of 
cocain  in  the  pharynx,  and  it  is  also  well  to  paint  a  little  mi  the  hark  of  the 
palate. 

A  good  many  self-retaining  palate-retractors  have  been  devised  to  hold 
refractory  palates  out  of  the  way,  and  that  of  White  is  probably  as  good  as 
any.  One  end  goes  behind  the  soft  palate  and  the  anterior  branches  are 
placed  on  the  outer  side  of  the  lip,  one  on  either  side  of  tin-  uose.  I  have 
found,  however,  that  cases  that  needed  them  generally  did  not  tolerate  tin m  ; 
and  when  they  were  well  home  that  they  were  not  necessary.  The  palate 
may  he  held  forward  by  tapes  or  rubber-bands  passed  through  the  nose, 
drawn  down  behind  the  palate  and  out  of  the  mouth,  and  tied  over  the  upper 
lip.     This  method  is  more  commonly  used  in  operating  than  in  examining. 

LARYNX. 

The  lingual  tonsil  and  the  glosso-epiglottic  fossa  are  not  well  -ecu  by 
using  the  tongue-depressor,  although  it  is  occasionally  possible  to  pull  the 
tongue  sufficiently  away  from  the  epiglottis  to  get  a  view  of  part  of  the 
region.  But  we  succeed  so  much  better  with  the  laryngoscopic  mirror  that 
this  examination  is  generally  combined  with  that  of  the  larynx.  The  fore- 
finger passed  all  around  the  base  of  the  tongue  gives  a  very  good  idea  of  the 
amount  of  tissue  present,  its  character,  whether  inflammation  or  suppuration 
are  present,  and  can  often  detect  foreign  bodies  which  find  here  a  convenient 
lodging  place. 

For  looking  at  the  larynx  the  usual  method  is  to  have  the  patient's  head 
held  well  hack  and  the  extended  tongue  held  between  the  thumb  and  fore- 
finger of  the  examiner.  This  lifts  the  whole  larynx.  Care  must  be  taken 
not  to  pull  the  tongue  too  hard,  especially  when  it  is  sore  or  the  teeth  sharp 
and  rough.  For  a  mirror  we  use  a  glass  about  an  inch  in  diameter,  although 
if  the  fauces  are  small  or  the  tonsils  large,  and  usually  in  children,  we  have 
to  choose  a  smaller  -ize.  On  the  other  hand,  in  adults  we  can  sometime-  use 
one  much  larger,  and  with  one  the  size  of  a  silver  dollar  I  have  obtained  a 
very  satisfactory  view.  The  shank  should  be  quite  stiff,  and  I  have  been 
surprised  to  find  so  many  -lender  and  flexible  one-  in  the  market.  Those 
sold  in  students'  sets  are  often  too  flimsy  for  actual  use.  A  stiff,  firm  handle, 
shank,  and  mirror  are  much  more  easily  borne  by  the  patient.  The  mirror 
figured   (Fig.  563)   is   one   that    I    have   found   excellent. 

The  glass  should  be  warmed  over  the  lamp  and  the  metal  back  tested 
against  the  ball  of  the  thumb  to  insure  its  not  being  too  hot.  The  handle  i- 
then  taken  between  the  extended  fingers  and  thumb.  The  mirror  is  intro- 
duced with  the  glass  side  down,  above  and  parallel  to  the  dorsum  of  the 
tongue,  hut  without  touching  the  latter.  The  patient  i-  directed  n>  say 
".l//.'',  and  as  he  does  so  the  base  of  the  tongue  is  lowered  and  the  soil 
palate  is  raised.  The  mirror  is  placed  under  the  uvula,  which  it  carries 
backward  and  upward,  and  the  glass  i-  pointed  downward  at  an  angle  <>l 
about  15°.  This  is  the  position  for  looking  into  the  larynx;  bul  it  is  well 
before  this  to  look  at  the  base  of  the  tongue.  For  this  purpose  we  hold  the 
mirror  nearly  horizontal  and  near  the  posterior  edge  of  the  hard  palate.  \\  . 
can  thus  look  directly  down  on  the  base  of  the  tongue,  or  if  we  carry  the 
mirror  back  to  the  uvula  we  must  -hint  it  farther  forward  than  as  if  I     look 


870 


METHODS  OF  EXAMINATION  AND  DIAGNOSIS. 


into  the  larynx.  We  should  note  the  region  of  the  circumvallate  papillae 
and  the  glosso-epiglottic  fossa,  which  should  normally  he  free  and  rather 
smooth,  [f  hypertrophy  of  the  lingual  tonsil  is  present,  we  see  red,  rounded, 
raised  masses  tilling  the  whole  or  a  part  of  the  space  or  even  crowding  upon 
the  epiglottis,  or  we  may  find  it  acutely  swollen,  with  yellow  or  white  spots 
on  the  surface,  or  false  membrane  or  ulceration.  A  smooth  atrophy  in  this 
region  is  thought  by  some  to  be  characteristic  of  syphilis. 

Coursing  over  the  base  of  the  tongue  in  adults  we  may  see  large,  dilated, 
or  varicose  vessels,  looking  not  unlike  rivers  in  the  atlas: 

After  having  examined  the  region  anterior  to  the  epiglottis,  we  place  our 
mirror  to  look  into  the  larynx,  as  spoken  of  above.     The  epiglottis  is  now 


I  ic  '>»?,.— Schematic  view  of  tongue-base,  epiglottis,  arytenoids,  and  ary -epiglottic  folds,  ventricular 
bands  and  vocal  cords,  with  the  laryngoscopic  reflection.  A  polyp  shows  below  the  left  cord  (after 
Schrotter) 

the  great  obstacle  and  the  patient  should  be  told  to  say  "Ah!"  or  what  is 
-till  better,  to  take  a  number  of  deep  breaths  and  say  "eh!"  during  the 
inspiration.  This  serves  to  lift  the  epiglottis.  If  not  successful  at  first,,  we 
an-  generally  rewarded  after  a  number  of  trials  by  seeing  it  gradually  lift. 
We  may  at  need  spray  a  little  cocain  into  the  larynx  or  paint  the  posterior 
surface  of  the  epiglottis  and  hook  it  forward  with  a  bent  probe,  the  patient 
holding  the  tongue. 

The  epiglottis  varies  greatly  in  shape  and  position.  It  is  usually  of  a 
reddish-yellow  color,  and  its  free  edge  is  thin.  It  may  be  erect  or  pendulous, 
hanging  completely  over  the  larynx,  or  in  any  position  between  these 
ixtremes.  In  children  it  i<  generally  benl  more  backward  than  in  adults. 
It  may  be  rounded,  incurved  in  the  center  of  its  free  edge,  omega-shaped, 
its  edge  turned  over,  etc.  It  is  sometimes  not  symmetrical,  and  may  not  be 
in  the  median  line.  The  mucous  membrane  is  much  more  closely  adherent 
to  the  posterior  surface  than  to  the  anterior,  so  thai  swellings,  edema,  or 
cysts  are  more  often  Pound  on  the  latter.  Low  d<>wu  on  the  posterior  sur- 
face we  see  the  projection  called  the  cushion  see  Fig.  541),  which  is  al  times 
quite   marked.       Extending  downward    from    either  side  of   the  epiglottis 


/..I  R  )'.V.V. 


871 


toward  the  median  line  and  the  posterior  |>art  of  the  larynx  we  see  whal  are 
called  the  ary-epiglottic  folds,  which  arc  narrow  near  the  epiglottis  and 
become  wider  a>  they  descend.  The  two  rounded  projections  on  either  side 
of  the  median  line  are  the  small  cartilages  of  Santorini  and  Wrisberg,  and 
below  them  are  the  arytenoid  cartilages,  whose  form  is  qoI  definitely  seen. 
These  structures  are  covered  with  a  reddish  membrane  in  health.  Between 
the  arytenoids  is  the  intefarytenoid  space,  where  hypertrophies  of  various 
kinds  are   likely  to  occur. 

The  vocal  cords  are  the  pearly-white  bands  which  stretch  across  from 
their  anterior  commissure  at  the  inner  angle  of  the  thyroid  cartilage  to  the 
vocal  processes  of  the  arytenoids  posteriorly.  In  respiration  the  posterior 
ends  separate,  leaving  a  V-shaped  aperture,  but  in  phonation  they  lie  parallel 
to  and  nearly  or  (juite  in  contact  with  each  other.  Jus!  above  the  cords  is  a 
dark  space,  the  opening  of  the  ventricle,  more  plainly  seen  when  the  larynx 
is  thin  and  relaxed.  Just  above  and  outside  the  mouths  of  ventricle-  are 
the  ventricular  bands  or  false  cords,   which   are  of  a  red  color. 

Below  the  true  cords  we  see  a  little  of  the  inner  side  of  the  cricoid  carti- 
lage, and  farther  down  a  number  of  transverse  white  bands,  the  rings  of  the 
trachea,  and  consequently  the  anterior  wall  ;  and  occasionally  we  can  even 


Fig.  564. — Larynx  opened  from  the  front  and  partially  dissected  on  the  lefl  showing  the  anatomical 
relations  of  tin-  cords,  < ./.  ventricles, '/.  coruiculae  •  ttis  (Scnrotl 

see  the  bifurcation  of  the  trachea  and  the  opening  of  the  bronchi.  Outside 
of  the  ary-epiglottic  folds  are  the  pyriform  sinuses;  and  the  cornua  of  the 
thyroid  cartilage  may  sometimes  be  seen  as  whitish  elevations  in  their 
floor. 

In  the  mirror  these  laryngeal  structures  look  a-  if  spread  out  in  one 
plane;  bul  study  of  the  exsected  larynx  (Fig.  564)  Bhows  very  forcibly  what 
should  he  borne  in  mind  while  using  the  mirror — that  tiny  are  on  very 
different  planes,  and  that  from  the  top  of  the  middle  of  the  ary-epiglottic  fold 
down  to  the  top  of  the  vocal  cord  is  about  an  inch.  It  is  of  greal  service 
to  study  a  model  or  a  larynx  removed  from  the  body  a-  a  preliminary  t" 
using   the   mirror. 


872  METHODS  OF  EXAMINATION  AX  I)   1>IA<;  XOSIS. 

The  objects  looked  at  in  the  mirror  arc  seen  as  if  inverted  ;  that  is,  the 
anterior  commissure  of  the  cords  is  at  the  top  of  the  mirror  and  apparently 
points  backward,  whereas  the  arytenoids  are  on  the  lower  side  of  the  mirror 
and  seem  to  he  anterior.  The  figure  (Fig.  563)  will  illustrate  my  meaning. 
In  using  the  probe  to  touch  the  different  parts  of  the  larynx  it  is  necessary  to 
hear  this  inversion  in  mind,  and  it  is  well  to  practise  on  a  model.  It  has 
seemed  t e  that  students  have  more  difficulty  in  passing  the  probe  hack- 
ward  against  the  anterior  face  of  the  interarytenoid  space  than  forward 
toward    the  anterior  commissure  when   trying  on   the  exsected   larynx. 

There  are  many  difficulties  in  the  way  of  obtaining  a  good  view  of  the 
larynx.  A  short,  thick  tongue,  perhaps  even  tongue-tied,  may  he  almost  im- 
possible to  hold  with  the  fingers  or  may  till  up  so  much  of  the  mouth  as  to 
leave  very  little  room  for  the  mirror  and  the  light.  We  may  then  find  it 
better  to  use  tin-  tongue-depressor  and  draw  the  tongue  forward  with  it  so  as 
to  make  room  at  its  base  for  the  mirror.  If  the  throat  is  very  irritable 
we  can  spray  coca  in  into  the  larynx  or  paint  the  pharynx  or  use  pieces  of 
ice. 

In  children  the  epiglottis  is  often  bent  over  the  larynx  in  respiration,  and 
the  glottis  i>  difficull  to  see.  To  overcome  this  the  long,  curved  tongue- 
depressor  of  Mount  Bleyer  can  he  used,  which  <m>cs  behind  the  tip  of  the  epi- 
glottis, lifts  it  and  also  the  whole  larynx  to  some  extent,  or  the  tongue- 
depressor  of  Escal  may  he  tried.  Its  branched  ends  arc  placed  behind  the 
sides  of  the  epiglottis  in  the  pyriform  fossa,  and  so  pull  forward  and  upward 
the  epiglottis  a>  to  open  up  the  entrance  to  the  larynx,  and  a  view  can  he 
obtained    with   the   mirror.      A    uth-gag  may   he   necessary. 

In  the  ordinary  examination  with  the  head  thrown  well  back  the  face  of 
the  mirror  is  so  turned  as  to  show  the  anterior  wall  of  the  trachea.  W  the 
head  is  bent  well  forward  while  the  patient  is  standing  and  the  examiner, 
kneeling  in  front  of  the  patient,  holds  the  mirror  well  up  against  the  uvula, 
:i  very  different  view  is  obtained.  Instead  of  the  anterior  part  of  the  larynx 
and  trachea  we  see  the  posterior  wall,  sometimes  even  as  far  as  the  bifurca- 
tion. This  is  the  method  <>t  Killian,  and  is  valuable  for  looking  at  the  pos- 
terior part  of  the  larynx,  the  posterior  ends  of  the  cords  and  underneath 
their  surface.  It  i-  not  always  easy  to  carry  out,  as  the  position  of  the 
examiner  i-  not  a  comfortable  one.  The  saliva  runs  out  of  the  mouth  into 
the  doctor'.-  hand  and  up  his  sleeve,  SO  that  it  is  well  to  have  the  patient 
expectorate  before  we  use  the  mirror.  The  light  does  not  come  in  a  suitable 
direction,  and  the  head-mirror  i-  usually  beyond  its  focal  distance  from  the 
throat-mirror.      If  the  examiner  wears  glasses  they  may  also  he  an  obstacle 

from   the  i sua!   positi f  the  head,     lint   in   spite  of  these  difficulties 

the  view  of  the  posterior  part  of  the  larynx  and  trachea  i-  often  very 
striking    and    gives    information     not     to    he    obtained    hv    the    ordinary 

method. 

The  laryns  can  also  he  viewed  by  transillumination  inn  dark  room.  The 
electric  lamp,  such  a-  i-  used  for  the  frontal  sinus,  is  placed  against  the  from 
of  the  necfe  iii  the  neighborhood  of  the  cricoid  cartilage.  The  tongue  is  held 
and  the  mirror  passed  as  in  ordinary  examinations,  only  no  lighl  is  thrown 
in  through  the  month.  The  lar\  nx  is  seen  iii  the  mirror  to  he  illuminated 
by  :i  lighl  which  traverses  the  tissues  of  the  neck  and  gives  a  yellowish-red 
look  to  the  parts  quite  different  from  the  usual  examination.  It  was  hoped 
that  this  method  would  he  ol  greal  9ervice  in  determining  abnormal  densities 
of  the  differenl  tissues  traversed  by  the  rays  of  light,  hut  it  is  not  much  \i^vi\ 
for  that  purpose  at  present. 


Plate  i$. 


Fig.   L— Larynx  of  a  child  in  quiel  breathing,  uearly  covered  by  the  epiglottis. 

Fi<;.  2.— Tin-  same  during  phonation,  with  the  epiglottis  raised  and  the  cords  in  apposition. 

Fig.  3. — Adult   larynx  and  trachea  to  the  bifurcation  in  deep  inspirati showing  tin 

wall  by  (Lillian's  method,  with  tin-  chin  low  and  tin'  head  inclined  forward. 

Fig.   1.     Usual  view  of  tin'  normal   larynx  and   front  wall  of  the  trachea  to  the  bifm 
from  Krieg's  Atlas,  with  -dijilit  modification). 


AUTOSCOPY. 


B73 


AUTOSCOPY. 

Under  this  name  Kirstein  has  reverted  to  the  oldesl  method  of  exam- 
ining the  larynx.  No  throat-mirror  is  used,  bul  the  base  of  the  tongue 
and  the  epiglottis  are  drawn  very  much  forward  by  a  specially-constructed 
tongue-depressor,  and  the  examiner  looks  directly  down  into  the  throal  illu- 
minated by  an  electric  lamp  or  by  light  reflected  from  a  head-mirror  and  sees 
the  posterior  part  of  the  larynx,  the  arytenoid-,  perhaps  the  posterior  half 
of  the  cords,  and  the  posterior  part  of  the  trachea.  The  patienl  should  have 
a  yielding  tongue  and  neck  to  give  good  results.  lie  should  be  seated,  the 
upper  part  of  the  body  thrown  forward  and  the  head  tilted  slightly  hack- 
ward.  The  physician  stands  in  front,  and  place-  the  depressor  as  far  back 
as  possible  on  the  tongue  with  firm  pressure  downward  and  forward  on  it- 
root,  whereby  a  deep  groove  is  formed,  allowing  the  ray-  of  light  to  fall  in 
line  with  the  laryngotracheal  axis. 

According  to  Kirstein,  in  about  one-fourth  of  all  adults  the  whole  larynx 


Fig.  565. — Kirstein's  laryngoscope  with  electric  light  at- 
tachment ami  interchangeable  depressor    i  borner). 


Fig.  566.  Position  of  neck  ami 
bead  during  examination  with  the 
elect  ri' 


and  trachea  can  he  thus  conveniently  examined,  except  that  the  extreme  apex 
of  the  anterior  commissure  can  he  seen  in  hut  one-tenth  of  nil  cases.  About 
one-half  of  all  people  can  be  fairly  well  examined,  so  thai  the  posterior  region 
of  the  larynx,  including  sometimes  ;i  more  or  less  extensive  portion  "f  the 
trachea,  i-  exposed  to  view.  This  method,  he  claims,  is  applicable  t"  children 
under  anesthesia,  and  sometimes  withoul  anesthesia.  This  needs  corrobora- 
tion, and  the  method  is  in  no  sense  a  substitute  for  ordinary  examination  with 
the  mirror,  which  gives  us  in  mosl  cases  all  needed  information. 


THE   RONTGEN  RAYS. 


The  A'-rav  has  served   to   locate   foreign   bodies  in   the  air-passages  ami 
esophagus.    The  nose  and  upper  throal  are  so  accessible  by ■  presenl  means 

of  illumination  that  it  i-  ool  of  the  -nine  help  to  the  laryngologisl  as  t"  the 

general  -ur<_reon. 


THERAPEUSIS  AND  PROGNOSIS. 

By  GEO.    A.    LELAND,  A.M.,  M.  I>., 

OP    HUSTON.    MASS. 


General  Therapeusis. — Treatment  in  the  diseases  of  the  upper  air- 
pa-sages  may  be  divided  into  general  and  local,  the  former  of  which  may  first 
be  considered.  And  it  may  be  premised  that  these  regions  are  not  to  be  con- 
sidered as  separate  from  the  rest  of  the  body,  but  as  a  part  of  it,  and  not 
only  influencing  it  but  being  influenced  by  it — the  corollary  of  which  is  that 
they  are  not  always  to  be  subjected  to  local  treatment  alone,  but  that  the 
general  diseases  and  conditions  of  the  body  are  to  be  taken  into  account.  For 
it  will  frequently  be  found  that  general  treatment  is  far  more  efficacious  in 
the  removal  of  some  of  the  manifestations  of  disease  in  the  upper  air-pas- 
sages than  local  treatment,  which  is  so  often,  in  these  days  of  enthusiastic 
specialism,  given  the  most  prominent,  if  not  the  only,  place  in  the  thoughts 
of  some  so-called  laryngologists.  An  early  recognition  of  these  conditions 
may  often  save  the  patient  from  much  discomfort  and  expense,  and  the 
physician  from  no  little  anxiety  and  apprehension.  For  many  local  mani- 
festations of  general  disease  are  only  aggravated  by  local  treatment — e.  g.,  an 
acute  gouty  pharyngitis,  late  syphilitic  tumefactions  of  the  tonsils,  the  first 
swelling  of  late  syphilis  in  the  nose,  the  laryngeal  papillomata  which  precede 
malignant  disease,  and  so  on. 

Aside  from  the  exanthemata  (including  typhoid  fever)  with  their  char- 
acteristic throat  manifestations,  which  will  doubtless  be  discussed  in  their 
proper  articles,  there  are  some  common,  every-day  conditions  which  cause 
much  discomfort  and  no  little  alarm.  One  of  the  most  common  of  these  is 
rheumatism,  where  there  is  very  little  to  be  seen.  The  faucial  and  pharyn- 
geal mucosa  shows  bul  slight  redness,  often  in  small  areas,  variable  in  their 
locations,  more  or  less  early  in  the  day.  The  history,  not  only  of  the  individ- 
ual, lint  of  the  family  near  and  remote,  assists  in  the  diagnosis.  The  lithemic 
diathesis  perhaps  -how-  frequent  manifestations  not  only  in  him,  but  in  various 
members  of  his  family,  even  in  several  generation-.  In  such  a  throat  it  i- 
not  rational  to  suppose  that  the  local  exhibition  of  the  usual  sprays  or  pig- 
ments will  produce  more  than  a  very  transient  amelioration,  and  may, 
especially  the  latter,  produce  only  discomfort  ;  this,  however,  may  yet  serve  a 
purpose  by  making  the  throat  seem  80  much  worse  that  when  the  irritation 
subsides  the  patient  considers  himself  better.  It  is  here  that  general  remedies 
directed  to  the  diathesis  are  to  be  employed.  The  correction  of  ailments  of 
the  prima  via,  such  as  gastro-intestinal  catarrh,  and  regulation  of  the  bowels; 
the  exhibition  of  the  lithic  solvents,  such  as  the  various  salts  of  potash  and 
lithia,  the  salicylates  and  salicylic  acid  (always,  however,  using  these  last 
either  not  at  all  or  with  greal  caution  where  there  is  a  tendency  to  deafness 
(Vol  1 1  middle-ear  or  labyrinthine  lesions),  piperazin,  etc.  ;  the  regulation  of  diet. 
especially  as  to  the  ingesti if  foods  containing  uric  acid,  and  the  xanthin 


GENERAL    THERAPEl  sis. 

group,  notablv  red  meats  and  tea  and  coffee  according  to  Haig ,'  urging  the 
importance  of  drinking  large  quantities  of  pure  water  (the  English  rule  being 
:;  to  5  pints  daily) — these  among  other  measures  may  be  mentioned.  The 
solvent  action  of  some  of*  the  alkaline  tablet-,  dissolved  -lowly  in  the  mouth 
and  followed  by  a  copious  draughi  of  water,  is  often  of  local  service,  notably 
those  prepared  from  the  Ems  Springs  by  evaporation,  and  known  as  the  Ems 
pastilles. 

It  is  notable  that  in  his  discussion  of  general  therapy  for  disease  of  the 
upper  air-passages.  Dr.  Phillip  Schech  devotes  a  page  and  a  half  to  the  men- 
tion and  recommendation  of  mineral  waters.2 

A  peculiar  manifestation  of  the  lithemic  diathesis,  and  a  very  distressing 
one,  is  the  dry  mouth  and  throat  rarely  complained  of  by  the  aged.  The 
salivary  and  mucous  secretions  are  nearly  if  not  quite  absenl  ;  the  tongue  is 
dry  and  parched  and  at  times  painfully  cracked  ;  deglutition  is  almosl 
impossible.  The  urine  will  show  almost  no  color,  very  light  specific  gravity, 
and  very  small  amounts  of  uric  acid  and  especially  of  urea.  Here  some  oi 
the  measures  above  noted,  assisted  at  the  onset  and  perhaps  longer  by  minute 
doses  of  pilocarpin  muriate  or  nitrate,  will  produce  wonderfully  satisfactory 
results,  while  the  whole  gamut  of  local  applications  may  be  tried  in  vain. 

Another  form,  perhaps,  of  lithemic  diathesis,  or  at  any  rate  of  mal- 
assimilation,  is  the  thick  throat  associated  with  obesity.  The  faucial  appear- 
ances here  are  those  of  a  very  narrow  space  behind  the  velum,  the  surface  of 
which  is  thrown  into  ruga?  by  gagging  and  phonation,  thus  almost  entirely 
closing  the  passage.  This  thickening  can  most  probably  not  be  gotten  rid  of 
by  local  applications  without  danger  of  producing  too  great  reaction,  and 
later  even  cicatrices,  which  may  leave  the  throat  in  a  worse  condition  than 
before.  Treatment  should  be  directed  to  the  general  condition  ;  to  the  diges- 
tion, both  gastric  and  intestinal ;  to  the  action  of  the  liver  and  the  kidneys. 
And  it  is  possible  that  we  may  hope  from  the  study  of  glandular  therapy  to 
find  that  some  of  these  cases  are  due  to  a  greater  or  less  degree  of  Basedow's 
disease,  as  was  well  shown  in  the  report  of  a  case  of "  myxedema  of  the  throat  " 
by  Dr.  Farlow,  in  the  last  "Transactions  of  the  American  Laryngological 
Association." 

In  the  writer's  experience  some  eases  of  submucous  thickening  of  the 
throat  have  apparently  been  much  benefitted  by  the  exhibition  of  thyroid 
extract.  Of  course,  in  cases  of  thickened  hypertrophic  pharyngitis  a  local 
cause  may  be  found  in  improper  nasal  respiration,  which,  as  will  be  referred 
to  in  its  proper  place,  can  lie  corrected. 

Closely  allied  with  these  rheumatic  diatheses  is  the  gouty  ;  and  it  will  be 
found  of  greal  value  to  recognize  it-  acute  or  chronic  manifestations,  hi  its 
acute  form  we  find  a  crimson-red,  thick,  shiny  mucous  membrane  ol  the 
pharynx  and  fauces,  where  the  characteristic  feature  is  the  extremely  acute 
pain," much  aggravated  by  swallowing,  which  seems  much  more  than  the 
manifestations  call  for.  It  would  be  hopeless  to  use  sprays  except  for  slighl 
and  transient  benefit,  and  the  usual  pigments  would  only  produce  extreme 
discomforl  for  a  longer  or  shorter  time.  It  will  be  found  in  the  history  of 
BUCh  ;1  patienl  thai  he  has  perhaps  had  some  -out  before  in  other  and  more 
usual  locations,  and  thai  he  has  remedies  which  he  i-  accustomed  to  use  ;  and 
these  will  doubtless  produce  a  much  more  satisfactory  cure  of  hi-  throat  than 
other  means.  And  so  also  in  the  chronic  gouty  throal  or  in  the  throal  con- 
valescing from  the  licit,,  stage,  which  ha-  h.-t   it-  shiny  reddened  appearance 


:  /        Add  in  tin  '  I  •  \    1 1 

-  /,..   Krankheitend     Kehlkopfa und  der   Lvftrohre,   189  nd  51 


876  THERAPEUSIS  AND  PROGNOSIS. 

and  has  become  flabby  and  pale  with  a  mucopurulent  viscid,  sticky  secre- 
tion, remedies  directed  to  the  diathesis  are  much  more  efficacious  than  those 
for  local  application,  excepl  so  far  as  they  arc  beneficial  as  cleansing  agents. 
In  all  these  conditions  allied  to  the  lithemic  diathesis  it  is  necessary  to  pay  a 
great  deal  of  attention  to  the  diet j  and  here  a  general  physician  who  has  a 
thorough  mastery  of  the  physiology  and  pathology  of  digestion,  or  the  throat 
specialisl  who  add-  this  also  to  his  specialty,  will  have  greater  success  than  lie 
w ho  simply  treat-  locally. 

There  is  another  condition  described  as  neuralgia  of  the  throat  where  there 
is  a  greal  complainl  of  painful  sensations  both  at  rest  and  upon  movement, 
especially  probably  in  the  latter  part  of  the  day,  and  the  pain  is  of  a  sharp 
and  lancinating  quality  ;  here  local  applications  are  absolutely  contra- 
indicated,  since  they  generally  produce  an  aggravation  of  the  discomfort.  It 
will  be  found  that  the  patient  is  anemic  or  neurasthenic  and  that  general 
treatment  i-  much  more  serviceable  than  local.  Mere,  however,  it  may  be 
-aid  as  applying  to  this  condition,  as  well  as  to  those  which  have  been  before 
mentioned,  that  where  the  symptoms  are  especially  referred  to  any  one  part, 
the  patient  feels  much  better  to  be  doing  something;  and  while  not  much  is 
to  be  expected  from  local  treatment  per  se,  some  simple  gargle  may  be  pre- 
scribed as  a  placebo. 

Another  painful  condition  of  the  throat  is  to  be  found  in  hardworked 
individuals,  especially  professional  men.  It  is  not  infrequent  that  over- 
worked physicians,  clergymen,  teachers,  and  even  lawyers  have  a  painful 
condition  of  the  throat  come  on  at  the  end  of  the  day  :  this  is  simply  a  con- 
dition of  muscular  and  nervous  fatigue,  in  which  local  applications  are  of 
little  benefit,  but  where  rest,  and  tonics  like  mix  vomica,  arc  very  efficacious. 
It  i-  not  infrequent  to  have  an  overworked  physician  drop  into  the  office  late 
in  the  day  complaining  of  just  this  fatigue  of  the  throat,  and  it  is  with  great 
satisfaction  that  we  can  assure  him  that  there  is  no  alarming  malady  threat- 
ening. Public  speakers  doubtless  have  this  trouble  much  aggravated  by  an 
improper  use  of  the  voice,  and  the  so-called  4l  ministers'  sore-throat"  is  often 
but  the  result  of  the  American  method  of  talking  back  in  the  throat  with 
indistinct  articulation — wallowing  of  the  words,  as  the  Germans  call  it. 
Correction  of  bad  habits,  with  attention  to  the  general  condition  of  the 
patient,  will  here  give  the  best  results.  Some  of  the  lozenges  may  be  of 
assistance  t . .  reduce  hyperemia  or  to  induce  moisture  when  there  is  a  sense  of 
dryness,  bin  they  are  merely  palliative;  the  underlying  cause  must  he  sought 
out  and  abolished. 

In  this  place  may  he  mentioned  a  peculiar  condition  of  the  pharyngeal 
mucosa  characterized  by  thickening,  pale  pinkish  color,  sluggish  scanty  secre- 
tion, and  obstinacy  under  treatment,  which,  on  the  exhibition  of  iodids  and 
perhaps  mercurials,  will  seem  to  he  due  to  ,-i  latenl  taint  of  specific  disease, 
although  the  history  is  doubtful  or  absolutely  negative  and  there  are  no  other 
lesions  to  be  discovered  in  ordinary  examination.  This  i-  not  very  common, 
but  should  always  I'e  l.orne  in  mind;  and  it  will  he  found  that  thi-  treat- 
men!  does  not  always  have  to  he  used  as  a  last  resort.  The  pathology  of  this 
condition  has  probably  not  been  throughly  worked  up;  hut  it  may  he  said  in 
general, judging  from  clinical  observation,  to  he  a  submucous  infiltration  with 
more  or  leas  involvement  of  the  superficial  lymphatic  structures  which  have 
a  rather  pale  mid  asthenic  appearance.  These  may  easily  break  down  in  a 
superficial  loss  of  substance  with  a  grayish  base;  not  the  usual  appearance 
of  a  mucous  patch,  hut  more  nearly  that  of  a  superficial  abrasion  from  rough 
treatment,  a  scraping  oil'  of  the  surface,  a-  it  were.     It  may  not  be  true  that 


(iEXKIiAL    TIIERAPEISIS.  877 

these  appearances  are  always  due  to  specific  disease  ;  Imt  it  has  happened  to 
the  writer  to  have  them  clear  up  so  kindly  under  the  iodid  of  potash  or 
syrup  of  hydriodic  acid,  perhaps  assisted  by  biniodid  of  mercury,  and  after- 
ward to  find  an  obscure  history  of  infection,  that  it  does  not  seem  to  be  a 
condition  of  great  rarity.  Of  course,  where  there  are  the  characteristic 
lesions  of  secondary  or  later  stages,  the  ordinary  remedies,  both  general  and 
local,  will  be  exhibited  without  question. 

There  is  one  other  condition  which  seems  to  claim  a  place  here,  and  that 
is  an  affection  of  the  throat  where  there  is  an  even  blush  diffused  over  the 
fauces  and  pharynx  and  even  the  mouth,  of  more  or  less  intense  redness; 
sometimes  the  tongue  will  be  fiery  red,  with  none  of  the  usual  coating,  an 
appearance  which  is  shared  by  the  interior  of  the  mouth  and  throat  to  a  less 
degree.  Arsenical  poisoning  must  here  be  borne  in  mind,  especially  if  it  is 
found  that  the  patient  is  better  away  from  his  ordinary  dwelling,  as  in  vaca- 
tion time,  or  that  he  has  the  usually  ravenous  appetite,  with  perhaps  the 
malaise  of  this  condition.  Perhaps  he  is  given  to  the  deleterious  habit  of 
putting  things  into  the  mouth,  as  in  one  case  which  came  under  the  writer's 
observation,  where  in  reading  a  book  the  patient  tore  off  the  corner  of  each 
page  after  finishing  it  and  put  it  into  his  mouth.  With  this  throat  it  is  well 
to  institute  the  usual  investigation  to  find  out  the  source  of  the  poison, 
including  the  examination  of  the  urine,  to  see  if  it  is  present  in  the  system,  or 
to  clear  up  at  least  that  possibility.  General  treatment  only  can  here  be 
indicated. 

The  various  forms  of  paralysis  come  under  this  general  head,  among 
which  may  be  mentioned  paresis  of  the  palate  in  greater  or  less  degree  in 
post-diphtheritic  paralysis,  or  in  the  early  stages  of  tabes  dorsalis ;  the  laryn- 
geal crises  in  later  stages  of  this  last  distressing  disease  ;  or  vagus  paralysis 
on  one  side  in  aneurysm  of  the  arch,  or  of  the  innominate,  or  from  pressure 
of  mediastinal  glands,  etc. 

There  are  doubtless  other  states  of  the  system  which  have  their  manifes- 
tations prominently  in  the  throat,  but  those  mentioned  are  the  most  prom- 
inent which  have  come  under  the  writer's  observation.  Figures  are  not  at 
hand  and  probably  have  not  been  collected  to  enable  us  to  judge  of  the  pro- 
portion of  such  cases  ;  but  it  is  doubtless  true  that  a  very  large  percentage 
are  much  better  treated  by  general  measures  than  by  local  treatment  alone, 
and  it  is  also  obvious  that  general  treatment  is  only  assisted  by  the  local  in 
their  management. 

Before  leaving  the  general  part  of  the  subject,  it  may  be  well  in  this  place 
to  note  certain  hygienic  measures  which  may  offer  suggestions  in  preventive 
therapeutics  or  preventive  medicine,  in  which  such  vast  strides  have  been 
made  toward  the  comfort  of  humanity  in  our  modern  times.  An  ounce  of 
prophylaxis  may  be  worth  a  pound  of  surgical  or  pharmaceutical  interfer- 
ence. 

In  general,  it  may  be  asserted  that  nothing  is  more  conducive  to  the 
maintenance  of  a  proper  condition  of  the  mucous  membranes  of  the  upper 
air-passages  than  the  avoidance  of  colds;  for  to  colds  may  be  attributed  the 
beginning  of  most  of  the  common  inflammatory  states  of  these  membranes. 
Their  initial  congestions  are  due  principally  to  three  causes:  I,  a  sluggish 
skin  ;  2,  a  state  of  the  blood  best  called  litheinia  in  our  present  knowledge 
of  the  subject ;  and  3,  to  the  action  of  atmospheric  micro-organisms  and 
dust. 

1.  If  the  skin  is  active — i.  e.,  if,  after  being  chilled,  it  will  again  take  up 
its  quantum  of  blood   on  returning  to  warm  surroundings — the  internal  con- 


-7-  THERAPEUSIS  AND  PROGNOSIS. 

ion,  called  ••"Id,  will  nol  remain.  To  keep  the  skin  active  is  one  of  the 
problems  in  the  prophylaxis  of  catarrh.  This  raises  the  question  of  clothing, 
bathing,  \  entilation,  and  heating. 

The  clothing  should  be  adapted  to  the  weather ;  and  in  a  changeable 
climate  like  that  of  New  England  and  the  Atlantic  coast,  also  of  the 
Southern  shore  of  the  Greal  Lakes,  should  be  of  such  material  that  sudden 
chill-  may  be  avoided.  The  layer  next  the  .-kin  should  he  such  that  it  will 
conduct  the  perspiration,  both  sensible  and  insensible,  into  the  next  layer,  so 
that  the  -kin  may  ii"i  be  in  a  damp  envelope.  To  this  end  cotton  should  be 
avoided  because  it  dee-  not  hold  the  body-heat  if  dry,  and  when  wet  with 
perspiration  allow-  rapid  evaporation  and  so  chilling  of  the  surface.  Wool 
is  almosl  universally  recommended  because  it  retains  heat:  it  is,  however, 
irritating  t.»  sensitive  skins,  and,  having  the  property  of  absorbing  moisture 
slowly,  also  gives  it  off  slowly.  Hence  the  skin  is  damp  before  the  moisture 
i-  absorbed  and  enclosed  in  a  damp  envelope  afterward,  which  may  keep 
up  evaporation  and  abstraction  of  body-heat  for  a  long  time,  until  the  gar- 
ment ha-  become  dry  again.  This  would  be  an  advantage  to  the  laboring 
man  who  i-  constantly  manufacturing  heat;  but  i-  a  disadvantage  to  those 
who  have  long  periods  of  rest  between  those  of  exercise.  The  material, 
however,  which  seems  theoretically  to  answer  the  purpose  best  is  a  new  one 
now  bidding  for  public  favor,  viz.,  a  linen  mesh.  This  is  smooth,  unirrita- 
ting  and  absorbent  :  it  carries  the  moisture  from  the  skin,  and  quickly  dry- 
in-,  maintains  a  layer  of  warm  air  next  the  surface  of  the  body.  It  remains 
to  be  -en  whether  it-  advantages  will  enable  it  to  win  recognition  against 
the  |m .pillar  prejudice  in   favor  of  wool. 

In  general  it  may  be  said  that  clothing  for  the  house  should  not  be 
to.,  heavy,  but  that  sufficient  addition  should  be  made  on  going  out  in 
wintry  weather.  The  fashion  of  wearing  furs,  except  in  the  most  rigorous 
weather,    i-    doubtless    conducive   to   dampness   of    the    skin    and    should    be 

avoided.      Woollei ter  garments  are  much  more  to  lie  recommended  than 

tin'  heavy  impervious  pelt-  through  which  there  can  be  no  ventilation  ;  like 
the  rubber  boot,  the  latter  tend  to  keep  the  skin  in  a  bath  of  perspiration, 
which  i-  destructive  of  it-  activity  and  allows  the  rapid  loss  of  heat  on  their 
removal. 

Bathing,  both  for  it-  stimulating  and  cleansing  purposes,  is  rightly  con- 
sidered nol  only  a  prophylactic  but  a  therapeutic  measure  of  great  service 
in  tin-  treat  men!  of  catarrh  of  the  upper  air-passages.  Rosenberg1  recom- 
mends daily  cool  bath-,  and  it  is  well  known  that  they  who  take  the  cool 
morning  dip  are  less  troubled  with  colds;  doubtless  because  the  vaso-motor 
system    i-  toned   up  to  better  control   of  the  vascular  supply  of  the  nose. 

Little    liced    be     -.lid    oil    tlli-     -llbject    except     to   c;|l|tio||    that     tile     -kill    should 

never  be  left  in  :i  slightly  moisl  -i:it «•  after  a  bath.  Hence,  the  cold  <>r  hot 
bath  i-  much  better  than  the  tepid  one  which  i<  not  stimulating  enough  to 
produce  a  reaction.  A-  a  therapeutic  measure  the  very  hot  bath  (103  to 
108  V .  .  ii-  d  w  ithin  the  first  fort)  -eight  hour-  of  a  cohi,  followed  by  a  cold 
dash    60    to  80    !•'.].  and  this  followed  by  vigorous  friction  till  the  .-kin   is 

perfectly   <\y\    and    of  a    pink    color,  i-   one  of  the    be-t    means    which    can   be 

suggested  to  break  up  i  eld.  The  hoi  soak  should  be  continued  fifteen  to 
twenty  minutes  ;  the  cooling  "if  from  two  to  ten  minutes  ;  and  after  the  dry- 
ing of  the  -kin  the  bed-clothing  should  nol  be  heavier  than  usual. 

In  thi-  connection  may  be  mentioned  that  hyperidrosis  pedis  with  its 
accompanying  cold  feet  is  a  prolific  cause  of  catarrh,  not  only  of  the  hyper- 

YtundhohU,  d  dea  Kehlkopfes,  Berlin,  1893,  p.  84. 


STATE  OF  Till:   BLOOD.  879 

trophic,  l>ut  of  the  atrophic  variety — as  mentioned  by  Kretschmann,  quoted 
by  Jacobson.1  This  author  recommends  very  stimulating  treatment  for  the 
feet,  and  states  that  cure  maybe  brought  about  even  in  atrophic  rhinitis 
without  local  treatment. 

The  necessity,  therefore,  of  keeping  the  feel  warm  and  dry  is  obvious. 
Foot-wear  in  eases  of  catarrh  should  be  as  carefully  attended  to  as  possible: 
in  the  damp  winter  and  spring  weather  the  ordinary  leather  sole,  especially 
of  ladies'  shoes,  is  probably  never  thick  enough  to  keep  dampness  from  i In- 
sole of  the  toot,  and  should  always  be  supplemented  by  rubber. 

Shampooing  the  head  is  also  sometimes  a  cause  of  obstinate  inflammatory 
conditions,  most  often,  perhaps,  because  of  insufficient  drying,  which  allows 
of  chilling  of  the  surface  by  evaporation  and  hence  congesting  of  the  interior. 
This  may  take  place  even  in  some  cases  where  drying  is  properly  done.  It 
is  a  question  whether  the  long  hair  of  our  lady  patients  can  he  dried  so  as 
not  to  work  evil  in  some  catarrhal  cases.  At  all  events,  the  evil  is  sufficient 
to  make  the  practice  always  a  subject  of  inquiry. 

Ventilation. — This  is  a  matter  of  no  small  importance,  especially  as  regards 
that  of  the  chamber  at  night  in  the  winter  season.  The  popular  craze  for 
fresh  air  during  sleep  is  often  carried  too  far.  To  live  in  a  room  arti- 
ficially heated  to  70°  to  80°  F.  during  the  day,  and  then  to  retire  with  the 
windows  open,  so  as  to  be  practically  out  of  doors  with  uncovered  head  when 
the  body-resistance  is  reduced  in  sleep,  would  seem  to  be  wholly  irrational. 
The  sunless,  chill  night-air,  blowing  in  steady  draughts  or  only  in  gentle 
gusts  upon  the  unprotected  head,  must  do  much  injury  in  catarrhal  eases, 
and  should  be  strenuously  avoided.  The  night-caps  of  our  grandparents, 
relegated  to  the  past  with  their  unheated  chambers  situated  remote  from  the 
warm  living-rooms,  would  still  be  useful  articles  of  night-clothing  for  those 
who  must  sleep  with  open  windows. 

Heating. — In  our  northern  climates  this  should  receive  careful  atten- 
tion from  the  throat  specialist.  The  physiological  functions  of  the  nose  in 
respect  of  the  supplying  of  moisture  to  the  inspired  air  should  point  out  to 
us  the  cause  of  much  of  the  engorgement  and  hypertrophy  of  the  interior 
of  the  nose  and  throat  which  manifest  themselves  in  winter  colds.  The  air 
below  the  freezing-point  is  deprived  of  much  of  its  moisture  :  brought  into 
our  houses  and  raised  to  70°  or  80°  F.,  or  drawn  in  as  breath  and  raised  to 
98°  F.,  it  must  take  up  its  quota  of  moisture.  Hence,  a  more  or  less  in- 
creased function  of  the  mucous  coverings  of  the  turbinals — and  in  mouth- 
breathers,  of  the  throat — which  results  in  an  obstructive  engorgement  or  in 
chronic  inflammatory  thickening.  These  evils  may  be  avoided  by  proper 
saturation  of  the  indoor  atmosphere  with  moisture — much  more  important 
when  the  heating  i-  by  steam  or  hot  water.  It  is  obvious  then  that  cauteri- 
zation of  such  engorged  noses  may  be  productive  of  evil,  and  painting  of 
such  hypereinic  throat-  with  astringents  only  a  source  of  discomfort  and  not 
of  cure  ;  and  thai  both  may  be  more  rationally  treated  by  proper  attention 
to  indoor  atmospheric  conditions.  Here  the  hygrometer  come-  to  be  a  much 
more  important  in.-t rumeiit  of  observation  than  the  thermometer.  Ami  it 
may  be  said  that  house-  are  much  more  comfortably  heated  when  this  instru- 
ment registers  65    to  so    than  when  below  50°  F. 

2.  State  of  the  Blood. —  It  often  happens  that  patient-  complain  of 
colds  which  they  say  come  on  without  cause — i.  e.,  without  known  exposure 
or  carelessness  in  dress,  etc.  This  may  often  be  due  to  a  lithemic  condition, 
as  lately  pointed  out   by  Dr.   L.  Duncan   Buckley.     A  cold  may  thus  be,  as 

i  Lehrbwh  <!■  r  Ohrenheilkunde,  L893,  p.  135. 


xvi,  THEBAPEl  SIS  AND   PROGNOSIS. 

it  w.  iv.  a  urio-acid  explosion.  On  investigation  ii  flttay  be  found  to  follow 
the  ingestion  of  a  beavy  meal,  or  of  a  quantity  of  malt  liquors,  or  of  tea  or 
coffee— which  Eaig1  has  shown  to  contain  large  quantities  of  the  xanthin 
group— or  to  neglecl  of  proper  exercise  or  bathing. 

Buckley's  method  of  cure  has  been  found  in  certain  cases  to  be  very 
efficacious,  and  is  as  follows:  Twenty  grains  of  bicarbonate  of  soda  are  given 
every  one-quarter  hour  for  four  doses;  if  there  is  not  sufficient  relief  after 
waiting  two  hours,  the  same  Beries  is  repeated.  The  live-grain  soda-mint 
tablets  are  a  convenient   means  of  administration. 

:'».  Atmospheric  Micro-organisms  and  Dust. — Probably  the  presence  of 
colds  in  a  large  part  of  the  community  at  any  one  time,  so  as  to  seem  like 
an  epidemic,  is  due  to  this  cause.  The  prevalence  of  epidemics  of  influenza, 
of  hay-fever,  of  diphtheria,  or  tonsillitis  is  often  accompanied  by  great  fre- 
quency  of  colds,  or  at  least  of  irritable  states  of  the  upper  mucous  raem- 
branes.  At  other  times,  when  the  graver  forms  are  not  so  pronounced  as  to 
show  evidence  of  the  above-named  diseases,  colds  may  be  the  lesser  expres- 
sion of  their  influence. 

The  mechanically  and  chemically  irritant  effects  of  atmospheric  dust  are 
a  prolific  cause  of  inflamed  mucous  membranes.  Hence  during  the  windy 
months  in  our  cities  it  is  often  almost  universal  to  see  cases  of  inflamed 
noses  and  throat-  due  solely  to  surface  irritation.  Certain  classes  of  the 
community  also  are  frequent  sufferers  from  this  state  of  the  mucous  lining 
lit'  their  upper  air-passages— among  which  may  be  mentioned  gentlemen  who 
assume  personal  '-are  of  their  furnaces,  teachers  who  make  much  use  of  the 
blackboard,  workers  in  dusty  shops,  and  tinsmiths  and  plumbers  who  inhale 
the  acid  fumes  inseparable  from  soldering.  For  these  people  some  of  the 
various  nasal  respirators  are  of  service  to  clear  the  inhaled  air  (or  even  a 
-mall  1 1 1 1 "t  of  absorbent  cotton  introduced  into  the  orifice  of  each  nostril), 
and  bland  or  protective  -prays  may  be  frequently  used  with  advantage  to 
cleanse  the  irritated  surface.  Schech  and  others  recommend  that  sufferers 
fro  ii  bacteria-laden  or  dust-laden  atmospheres  in  larynx;  or  nose  be  removed 
from  the  city  into  the  cleaner  air  of  the  country  or  the  woods. 

Mouth-breathing. — This  is  a  habit  which  should  be  interdicted  in  foto 
from  the  very  earliest  moment  of  life;  and  it  is  the  duty  of  every  physician 
to  impress  upon  the  young  (or  old)  mother  that  nasal  respiration  must  be 
insisted  upon  at  the  Outset  with  every  infant.  The  part-  are  so  small  that  if 
the  nose  is  deprived  of  its  proper  air-currents,  the  engorgement  of  the  parts 

Boon  closes  it.     The  a mcheur  attend-  to  the  funis,  the  bowels,  and  even  the 

of  the  infant,  but  habitually  omits  to  call  attention  to  the  importance  of 
nasal    respiration.      It    is   ool    improbable   that    this  may  be  one   factor  in    the 

early  occurren f  obstructive  nasal    engorgement  which   results  in  adenoid 

vegetations. 

Diet. — This  must  usually  be  left  to  the  family  physician  ;  but  at  times 
even  the  throat  specialist  may  find  it  convenient  to  interfere.  When  the 
trouble  is  due  to  the  lithemic  state  and  it-  congeners,  as  mentioned  above,  it 
may  he  necessary  to  proscribe  sweets  and  starches  in  some  cases,  or  nitro- 
genous foods  in  others  :  highly  spiced  food-  may  keep  up  a  congestion  of  the 
tauces  and  pharynx.  Alcoholic  beverages  probably  act  in  two  ways,  as  local 
irritants  and  a-  vaso-motor  dilator-.  '1'.,  avoid  the  first  effect,  the  stronger 
liquors  should  be  diluted  ;  to  obviate  the  Becond,  excessive  use  should  be  pro- 
hibited. In  the  writer'-  experience  the  most  uniformly  reddened  and 
thickened  mucous  membrane-  of  all  visible  parts  of  the  upper  air-tract  above 

1  /.■> 


L  O  CA  L    THE  A  TM  i:.\  T.  88 1 

the  bifurcation  of  the  trachea  was  in  a  man  who  complained  not  of  pain  but 
only  of  sonic  discomfort,  who  confessed  to  habitually  having  taken  about 
fifty  drinks  of  whiskey  per  diem  for  several  years  ;  miscellaneous  libations  of 
the  vinous  and  malt  liquors  were  not  counted. 

Tobacco  undoubtedly  exercises  more  or  less  of  an  irritating  oiled  on  the 
mucous  membranes,  especially  when,  as  Rosenberg1  even  finds  it  well  to  say, 
the  smoke  is  blown  through  the  nose.  The  inhalation  of  cigarette-  probably 
is  the  worst  form  of  the  use  of  tobacco;  but  there  is  a  vast  difference  in  the 
irritating  effect  of  tobaccos.  Those  which  contain  saltpeter  in  appreciable 
amounts,  whether  natural  to  the  leaf  or  introduced  in  the  curing,  should  be 
avoided  by  patients  whose  throats  are  irritable,  or  by  those  whose  tongues  or 
lips  show  a  tendency  to  Leukoplakia.  The  presence  of  the  nitrate  of  potash  is 
easily  seen  when  the  fire  causes  a  flashing  as  it  progresses  down  the  leaf  and 
leaves  minute  white  dots  of  the  hydrated  carbonate  of  potash  on  the  ash. 
This  drug  is  probably  introduced  to  carry  the  fire  in  moist  tobaccos — such  as 
plug  and  cigarettes,  as  well  as  in  some  cigars  designed  to  be  used  "  green,"  and 
is  chosen  because  it  has  no  objectionable  flavor,  but  only  adds  a  pungency  to 
the  smoke.  But  in  the  decomposition  by  combustion,  nitric  acid  is  given  off 
to  be  added  to  the  smoke,  which  can  but  be  irritating  to  the  mucous  surfaces 
with  which  it  comes  in  contact. 

Rest. — Schech  lays  great  stress  on  the  importance  of  rest  in  inflammatory 
and  ulcerative  conditions,  especially  when,  in  the  vocation  of  the  patient,  use 
of  the  voice  is  necessary.  He  even  goes  so  far  as  to  send  the  patient  away 
to  a  quiet  place  or  resort,  according  to  the  severity  of  his  condition. 

Use  of  the  voice  should  be  interdicted  in  inflammatory  states  of  pharynx 
and  fauces,  and  especially  of  the  larynx  ;  and  in  the  former  the  use  of  some 
drug,  as  belladonna  or  atropia,  to  diminish  the  secretion  and  so  diminish 
the  necessity  of  swallowing,  may  be  of  service.  In  cases  of  singers'  nodes 
(pachydermia  tuberosa),  both  acute  and  chronic,  absolute  rest  of  the  voice  is 
the  most  efficient  method  of  treatment,  and  should  be  insisted  upon  also  with 
any  other  mode.  Per  contra,  in  paralytic  affections,  especially  those  depend- 
ing on  the  hysteric  or  neurotic  state,  diphtheritic  paralysis,  etc.,  exercise 
should  be  employed  rather  than  rest — according  to  the  same  author.1 

After  this  somewhat  lengthy  but,  it  is  to  be  hoped,  useful  consideration 
of  the  general  therapeutics  and  hygiene  of  the  subject,  we  come  to  that  of  the 
local  manipulative  treatment,  which  too  often  assumes  a  greater  importance 
than  it  really  deserves.  And  at  the  outset  it  is  well  to  lay  down  a  principle 
that  whatever  is  to  be  done  should  be  done  with  strict  attention  to  the 
physiological  function  of  the  parts — that  their  efficiency  should  be  by  no 
means  impaired,  but   facilitated. 

I/OCal  Treatment. — in  local  treatment  there  arc  employed  various 
means  and  procedures,  as  follows: 

Gargles. — it  is  a  universal  custom  to  prescribe  gargles  for  almosl  every 
affection  of  the  throat,  but  it  is  obvious  that  in  laryngeal  and  naso-pharyn- 
geal  affections  they  are,  as  a  rule,  wholly  useless  unless  a  method  is  employed 
which  requires  a  greai  <l«:il  of  practice  for  its  proper  performance.  It  is 
possible  by  hall'  swallowing  the  fluid  to  reach  the  top  of  the  larynx,  and  by 
suddenly  throwing  the  head  forward  in  its  ejection  to  wash  the  naso-pharynx, 
as  elucidated  by  Swain  and  others;  but  in  the  most  common  use  of  the  gar- 
gle it  probably  does  not  reach  back  of  the  posterior  pillars  of  the  lances. 
"Made-up"  gargles  have  deservedly  fallen  into  disrepute,  and,  although 
tannin  and   some  other  astringents  are  sometimes    used   in    acute  congestions, 

1  /.<»■.  dt. 
56 


THERAPEUSIS  AND   PROGNOSIS. 

they  are  of  doubtful  value.  Astringent  and  stimulating  remedies  must 
necessarily  be  irritating,  and,  therefore,  in  painful  and  inflammatory  states 
an-  :i|»t   to  aggravate  rather  than  cure. 

( iargles  are  of  more  value,  probably,  because  of  their  temperature  than  of 
their  composition.  The  most  useful  gargle  is,  in  the  writer's  opinion,  hot  water, 
to  which  may  be  added  simple  substances  such  a>  bicarbonate  of  soda  <>r  borax, 
or  even  -alt,  which  have  cleansing  and  stimulating  or  soothing  properties  and 
are  easy  of  access.  In  the  inflammatory  states  the  extremes  of  heal  and  cold 
are  of  greatest  value,  and  in  such  atl'ections  as  acute  inflammation  of  the 
fauces  or  tonsils,  probably  extreme  heat  as  a  gargle,  or  better,  as  advocated  by 
Smith  of  Cleveland,  pressed  upon  the  inflamed  area  in  the  form  of  a  large 
tampon  soaked  in  hoi  water,  has  much  antiphlogistic  power.  The  universal 
use  of  chlorate  of  potash  a-  a  gargle  is  probably  of  most  value  as  a  placebo. 

Sprays. — The  forcible  and  voluminous  spray  recommended  by  Mackenzie 
i<  doubtless  of  great  value  as  a  cleansing  agent  and  should  be  used  warm  in 
the  nose  :  the  solution  should  l»e  of  the  strength  of  two-thirds  of  one  per 
cent,  of  alkali  (as  Dobell's  or  Seiler's  solution)  to  give  a  bland,  unirritating 
wash  for  the  nasal  mucous  membranes.  It  should  be  a  rule  that  no  liquids 
which  cause  smarting  should  be  used  in  the  nose;  and  that  liquids  should  be 
used  principally  when  there  is  secretion  to  be  washed  away.  The  nose  is 
made  for  air  ami  not  for  water;  ami  it  is  probable  that  much  evil  is  pro- 
duced by  the  routine  employment  of  -pray- and  washes  on  the  Schneiderian 
membrane.  In  inflammatory  states  soothing  sprays  may  be  used,  such  as  those 
exhibited  iu  an  oily  menstruum ;  but  even  these  are  suspected  of  doing  evil 
after  long-continued  use,  since  they  tend  to  cause  a  feeling  of  dryness  and 
discomfort,  probably  affecting  the  secreting  power  of  the  mucous  membrane 
unfavorably.  In  sluggish  -late-  of  the  secretion,  or  in  atrophic  states,  stimu- 
lating sprays  may  be  employed,  such  as  those  containing  iodin  or  alcohol 
in  various  proportions.  Rectified  spirit  is  used  by  Miller  of  Edinburgh  in 
cases  of  polypi,  and  by  ('re-well  Baber  in  hypertrophic  rhinitis  (McBride).1 

<  'old  -pray-  should  not  be  used,  lest  by  producing  a  hyperemia  they  may 
produce  a  chronic  engorgement.  The  spray-apparatus  most  highly  to  be 
recommended  is  that  which  has  a  nasal  tip  in  the  shape  of  an  acorn  or  cone, 
which  should  be  introduced  only  into  the  orifice  of  the  naris,  pointing  back- 
ward parallel  with  the  septum,  the  fluid  being  propelled  by  a  force  of  not 
more  than  ten  to  fifteen  pounds  pressure,  lest  the  mucosa  of  the  turbinates 
and  septum  be  abraded.  The  straight-pointed  tips  often  sold  for  nasal  use 
an-  to  be  avoided,  except  in  the  hand  of  the  physician,  since  the  tender  mucous 
Burface  of  the  septum  anteriorly  near  the  colunina  may  be  SO  wounded  by 
contact  that  an  eroding  ulcer  may  be  started  ami  kept  up.  It  is  not  infrequent 
to  see  an  area  a  centimeter  in  diameter,  with  a  eru-t  more  or  less  bloody, 
under  which  i-  i Icrr  of  the  septum  which  will  produce  a  perfora- 
tion if  allowed  to  continue.  This  may  also  be  brought  about  by  improper 
use  of  the  handkerchief  or  finger-nail,  a-  well  as  by  the  end  of  the  spray- 
tube  :  hence,  the  acorn-  or  cone-shaped  tip  is  tin'  one  which  should  be  used  by 

the  patient  himself  in  hi-  own  nostril,  the  -haft  being  held  parallel  to  the 
median    line. 

An  atomizer  which  force-  considerable  fluid  should  be  -elected,  since  the 
use  of  the  finest  sprays  i-  usually  mosl  inefficacious  and  tedious.  Sprays 
may  !>.•  used  with  greater  force  in  the  fauces;  but  the  turned-up  tip  for  the 
naso-pharynx  i-  of  doubtful  value,  since  it-  contact  with  the  i sous  mem- 
brane of  the  throal  may  often  produce  irritation.  Sprays  used  in  the  larynx 
/'                /            '■        and  Ea\ ,  I  - 


DOUCHES.  883 

for  cleansing  or  soothing  purposes  are  of  great  value  in  the  hands  of  the 
physician,  and  if  used  during  phonation  probably  can  be  made  to  reach  all 
supraglottic  parts  of  the  larynx  ;  and  with  a  forcible  stream,  perhaps  under 
pressure  of  twenty  pounds  or  more,  with  a  spray-tube  capable  of  delivering 
a  large  volume,  the  interior  of  the  trachea  can  sometimes  be  cleansed,  during 
deep  inspiration,  of  the  inspissated  secretion  of  a  dry  inflammation  of  its 
membrane.  In  the  larynx  at  first  but  a  small  amount  of  the  Quid  should  be 
sprayed  in  quickly,  lest  the  patient  be  embarrassed  by  unpleasant  spasm  and 
cough.  Vapors  formed  by  very  line  comminution  of  fluids  are  of  doubtful 
value  in  the  upper  air-passages,  since  only  an  exceedingly  small  amount  of 
the  medicament  can  come  into  contact  with  the  membranes,  especially  if 
coated  with  secretion  ;  and  it  is  hardly  possible  that  such  mild  applications 
can  be  of  much  service,  since  it  is  the  function  of  mucous  membranes  to 
throw  off  all  foreign  substances.  Thus,  in  all  these  uses  of  sprays  it  i>  well 
to  bear  in  mind  that  the  solution  should  be  of  sufficient  strength  to  accom- 
plish its  object  before  the  mucous  secretion  can  wash  it  away,  except  where 
cleansing  only  is  desired,  when  this  eliminating  property  of  the  membrane  is 
more  or  less  in  abeyance. 

The  use  of  the  nascent  chlorid-of-ammonium  vapor  caused  by  the  union 
of  the  fumes  of  strong  hydrochloric  acid  and  ammonia  water  by  means  of 
an  apparatus  devised  by  Yereker,  Lewin,  or  Kerr  is  doubtless  of  considerable 
value:  the  way  in  which  it  acts  is  probably  not  yet  determined,  but  the 
membranes  assume  a  more  normal  condition  after  being  well  bathed  with  its 
white  dense  cloud. 

Douches. — Douches  are  of  great  value  when  properly  used,  but  are 
liable  to  be  exceedingly  dangerous.  The  introduction  of  a  solid  stream  of 
water  by  whatever  means  is  antagonized  perhaps  overmuch  by  aurists,  because 
of  the  liability  to  force  the  fluid  into  the  middle  ear.  There  is  no  doubt, 
however,  that  intelligent  patients  may  be  able,  under  explicit  directions  and 
by  experience,  to  so  use  the  douche  that  it  may  be  of  greatest  value,  especially 
in  cases  of  atrophic  rhinitis  or  other  less  offensive  purulent  conditions.  The 
very  hot  douche  may  be  of  use  in  its  poultice  action  to  reduce  inflammations 
in  the  nose  which  cause  such  inflammatory  states  of  the  accessory  sinuses,  as 
recommended  by  Bosworth  ;  but  the  rule  should  be  laid  down  that  the 
douche  should  always  be  introduced  through  the  narrower  nostril  and  that 
the  act  of  swallowing  should  not  be  performed  during  the  passage  of  the 
stream  ;  and  after  its  use  that  the  fluid  should  be  hawked  away  from  the 
na-o-pharynx  before  blowing  the  nose;  and,  of  course,  that  the  Politzer 
air-douche  should  not  be  used  until  a  considerable  time  has  elapsed.  It  is 
probable,  however,  that  after  the  membranes  have  been  soaked  by  the  use  of  the 
•  louche,  the  patient  may  be  more  susceptible  to  cold  in  going  out  into  the  open 
air  in  the  colder  weather.  The  solutions  to  be  used  in  the  douche  are  usually 
those,  such  as  Dobell's  and  Seder's,  which  have  alkaline  and  antiseptic 
properties.  They  should  be  of  such  strength  as  not  to  produce  smarting  or 
tingling  of  the  membranes  and  should  be  at  the  body  temperature  or  higher ; 
about  two-thirds  of  one  percent,  is  the  proper  strength.  The  small  elevation 
of  the  reservoir  i~  important  :  the  bottom  of  the  reservoir  should  not  !><•  over 
six  or  eight  inches  above  the  orifice  of  tin-  nose.  The  patient  should  also  be 
cautioned  never  to  use  the  douche  carelessly  or  in  haste  :  for  one  lapse  mighl 
destroy  the  middle  ear  for  life. 

The  external  application  of  cold  and  heat  is  often  serviceable  in  inflam- 
matory states  <if  the  nose  or  of  the  throat.  After  injury  an  extreme  cellulitis 
may  be  kept    under  by  cold  compresses  on   the  nose.     Acute  tonsillitis  may 


884  THERAPEUSIS  AND   PROGNOSIS. 

be  aborted  by  holding  an  ice-bag  behind  and  under  the  angle  of  the  jaw. 
Acute  laryngitis,  even  to  the  extent  of  inflammatory  edema,  may  also  ho 
aborted  or  kept  under  by  the  ice-bag  or  by  Leber's  coil  (cold)  around  the 
front  of  the  neck.  The  application  of  heal  to  the  tonsils  and  throat,  in  the 
form  of  the  poultice  or  coil,  is  often  very  grateful  to  the  patient,  and  requires 
do  comment. 

Powders. — The  use  of  these  agents  in  the  nose  is  not  physiological,  be- 
cause of  its  function  to  gel  rid  of  foreign  bodies  by  sneezing,  hypersecretion, 
and  the  action  of  the  ciliated  epithelia.  Hence,  the  general  use  of  snuffs 
because  they  "  clear  the  head  "  is  calculated  to  entail  congestion  and  hyper- 
nutrition,  especially  in  the  common  form  of  catarrh  of  which  patients  com- 
plain, which  is  generally  that  of  a  slight  hypertrophy  or  engorgement;  they 
should  be  forbidden,  since  they  tend  to  increase  the  evil.  Bland  antiseptic 
powders,  however,  can  often  be  used  to  advantage  after  operations  or  in  cases 
where  there  i<  superficial  loss  of  substance  in  the  nose,  or  even  where  only 
the  cilia  -rr\w  to  be  absent.  Such  substances  as  iodoform,  dermatol,  aristol, 
and  their  congeners,  which  have  become  so  numerous  of  late,  may  be  of  value 
in  these  cases,  either  pure  or  diluted  with  starch  or  bismuth  or  even  compound 
stearate  of  zinc.  It  musl  be  home  in  mind,  however,  that,  as  in  the  ear,  an 
insoluble  powder  sometimes  hinder-  the  proliferation  of  the  mucous  mera- 
brane  to  cover  a  defect.  In  these  cases,  therefore,  insoluble  powders  should 
not  l>e  used  ;  but  they  should  be  of  such  material  that  by  the  heat  and 
moisture  of  the  uose  they  will  he  melted  into  an  oil  or  syrup. 

The  use  of  powders  in  the  larynx  probably  does  not  in  most  cases  com- 
pensate for  the  dis< iforl  which  they  cause;  but   the  antiseptic  powders  and 

those  having  a  specific  action,  such  as  iodoform  and  its  congeners,  are  valuable 
in  ulcerative  condition-  of  this  organ. 

The  best  powder-blower  for  the  nose  is  one  manufactured  by  the  David- 
son (  "..  known  as  No.  192. 

Pigments. —  The  name  of  these  substances  is  legion — and  is  continually 
being  added  to — but  the  one  substance  which  has  lasted  through  many 
periods  of  antagonism,  and  which  is  now  probably  the  most  universally  used, 
especially  in  <  rermany,  is  the  solution  of  nitrate  of  silver  in  various  strengths  ; 
this  has  a  slightly  astringent,  strongly  antiseptic,  and  somewhat  stimulating 
action.  It  can  be  applied — except  in  the  nos< — to  all  the  parts  of  the  upper 
mucous  membranes.  It  i-  best  applied  to  the  naso-pharynx  and  larynx  in 
strength  from  '_'  to  8  per  cent.  ;  and  may  be  used  even  to  12  per  cent,  in  the 
larynx  and  on  the  tonsils.  It  is  best,  of  course,  to  begin  with  mild  solutions 
and  work  up.  It  is  to  be  borne  in  mind  that  the  nitrate  of  silver  some- 
times produces  cerulean  ism  ;  and   the  writer  has  ^rrn  at   least  one  case  where 

ep-brown  pigmentation  of  the  membranes  and  a  dull  coloration  of  the 
.-kin  was  attributed  to  the  use  of  nitrate  of  silver  in  the  throat  ;  fortunately 
these  cases  are  of  extreme  rarity. 

Where  an  astringent  effect  is  sought  for,  as  in  pharyngitis,  solutions  of 
tannin,  60  grs.  to  the  oz.  of  glycerin  ;  of  the  subsulphate  of  iron.  In  grs.  to 
the  oz.  of  water ;  of  sulphate  of  zinc,  l<>  to  30  grs.  to  the  oz.  of  water  (also 
used  ae  a  spray),  may  be  mentioned  anion-  others  as  of  considerable  value. 
h  i-  probable  that  the  use  of  astringents  in  the  nose,  such  as  tannin  or  iron, 
even  in  their  -ti-on-  solutions,  are  productive  of  more  discomfort  to  the 
patient  than  of  benefit  to  his  condition  ;  much  better  results  may  be  obtained 
bv  the  use  of  caustics. 

\-  stimulating  pigments  may  be  mentioned  tincture  of  iodin  from  10  to 
50  per  cent,   in  glycerin,  which   may  be  of  value  in   various  states  of  the 


LOZENGES  AND   TROCHES.  885 

pharynx  characterized  by  sluggish  secretion.  Sonic  have  recommended  a 
saturated  solution  of  iodoform  in  ether  in  such  conditions.  The  pigment 
selected  should  he  applied  by  a  brush;  various  kinds  are  recommended,  but 
probably  the  most  efficacious  is  that  made  by  twisting  a  pledgel  of  cottoo  on 
the  roughened  end  of  a  metallic  applicator.  In  all  manufactured  brushes 
there  is  the  element  of  uncleanliness,  and  the  shoulder  of  the  part  containing 
the  hair  is  apt  to  injure  the  membrane  with  which  if  comes  in  contact.  In 
Germany  a  form  of  forceps,  such  as  Baginsky's,  is  frequently  used  to  hold  the 
saturated  pledget  of  cotton  ;  but  they  are  unwieldy  and  have  no  advantages 
over  the  cotton  firmly  wound  upon  a  roughened  stilct.  One  of  the  great  dis- 
advantages of  the  brush  is  that  the  hairs,  one  or  all,  may  be  left  in  the  throat 
of  the  patient.    This  can  never  occur  with  a  cotton  applicator  properly  made. 

Tampons. — In  atrophic  rhinitis  the  Gottstein  tampon,  cither  dry  or  sat- 
urated with  a  stimulating  solution,  has  been  very  much  advocated.  It  pro- 
duces its  effect  by  extreme  irritation,  which  brings  on  a  hyperemia  and,  there- 
fore, greater  nourishment  of  the  parts.  The  principle  is  doubtless  correct. 
The  small  pledget  of  cotton  or  tampon  soaked  with  a  4  to  10  per  cent,  solu- 
tion of  cocain  (to  which  has  been  added  4  or  5  grs.  of  resorcin  to  the  oz. — 
which  not  only  preserves  the  fluid  but  seems  to  prevent  constitutional  effects) 
and  accurately  applied  to  the  atrophied  turbinals  is  also  of  great  value  in 
these  states.  The  first  effect  of  the  cocain  is  to  exsanguinate  the  parts ;  the 
second  is  to  paralyze  the  vessels  and  so  to  induce  a  passive  hyperemia  which 
lasts  a  considerable  length  of  time  and  increases  the  nourishment  of  the  parts 
without  the  disagreeable  effect  of  the  Gottstein  tampon. 

Cocain. — To  this  drug  the  rhinologist  is  indebted  for  the  opening  of  his 
whole  field;  but  on  account  of  its  secondary  action  and  its  constitutional 
effects  its  use  should  be  restricted  to  diagnostic  purposes.  It  should  not  be 
prescribed  for  the  patient's  personal  use,  and  may  be  said  to  have  no  thera- 
peutic value  except  in  cases  of  atrophic  rhinitis,  as  mentioned  above.  When, 
however,  in  the  later  stages  of  tuberculosis,  or  of  malignant  disease  of  the 
larynx,  deglutition  becomes  excruciatingly  painful,  it  may  be  used  to  enable 
the  patient  to  eat  with  more  comfort  and  so  keep  up  his  nourishment.  The 
formation  of  the  cocain  habit,  which  is  doubtless  one  of  the  worst  of  the 
drug-habits,  must  always  be  borne  in  mind,  although  fortunately  it  does  not 
seem  to  be  very  common  among  patients. 

In  the  first  congestion  of  a  cold  it  may  be  of  use  to  establish  nasal  respi- 
ration; but  if  the  result  is  not  permanent  after  one  or  two  trials  its  use 
should  not  be  continued.  It  is  without  doubt  true  that  the  continued  use  of 
cocain  produces  a  state  of  engorgement  and  hypertrophy  which  is  most 
intractable.  The  great  advantage  of  cocain  in  producing  anemia  and  shrink- 
ing of  the  nasal  structures — a-  well  as  anesthesia — does  not  seem  to  be  shared 
by  the  new  drug  lately  brought  to  notice,  eucain.  The  fad  thai  the  latter 
produces  engorgement  and  hyperemia  will  probably  prevent  its  coming  into 
general  use  in  the  nose.  Menthol  has  a  mildly  anesthetic  action — e.g.,  in  5 
to  10  per  cent,  solutions  in  oily  menstrua,  and  may  be  useful  in  some  cases 
of   painful   deglutition,   but    cannot    take   the   place  of  cocain. 

Lozenges  and  Troches. — Certain  substances  are  with  advantage  put  into 
this  form  :  the  drug  makes  a  solution  or  mixture  with  the  saliva  and  accom- 
plishes the  object  desired.  For  stimulating  purposes,  when  the  throat  feels 
rough  and  uncomfortable,  the  various  combination-  of  chlorid  ol  ammonium 
are  very  useful ;  among  these  may  be  commended  those  made  after  the  formula 
of  the  London  Throal  Hospital  Pharmacopeia,  with  black-currant  paste; 
and  those  compounded  with  cubebs  and   licorice  or  with  guaiacum,  made  !>\ 


THEBAPEUSIS  AND   PROGNOSIS. 

various  pharmaceutical  chemists,  may  be  mentioned.  Antisepsis  is  by  this 
method  often  carried  oul  most  efficiently  in  cases  of  Foul  mouth  or  lacunar 
tonsillitis,  or  even  in  mild  cases  of  streptococcus  or  diphtheritic  throats  by 
use  of  tablets  of  the  bichlorid  of  mercury  l„,0„  to  .,,',,,  gr.,  as  made  by 
Fraser,  Wyeth,  and  other-.  Tablets  of  these  strengths  are  not  disagreeable 
to  tli«'  taste,  and  should  be  dissolved  in  the  mouth  every  one  to  four  hours, 
thus  converting  the  saliva  into  an  antiseptic  solution  of  more  or  less  strength. 
In  acute  tonsillitis  may  l>e  recommended  here  the  small  tablet,  made  by 
Fraser  and  other-,  called  "tonsillitis  tablets,"  containing  aconite  and  bella- 
donna to  influence  the  circulation,  and  the  red  iodid  of  mercury  as  an  anti- 
septic; probably  this  iodid  of  mercury  is  more  powerfully  antiseptic  than 
the  bichlorid,  and  ,,',,,  gr.  in  each  tablet  is  not  too  much  to  be  given  even- 
two  to  four  hours.  In  mild  inflammatory  conditions  where  there  is  consider- 
able annoying  irritation  of  the  fauces,  the  tablets  of  "red  gum"  or  other 
astringeni  drugs  may  be  used  with  advantage.  After  the  irritation  produced 
bv  smoking,  chlorid  of  ammonium  and  red  gum  have  been  often  given  to 
advantage. 

The  almosl  universal  remedy  in  this  form  is  chlorate  of  potash,  which, 
given  in  all  states  of  the  throat,  is  almost  as  often  given  erroneously.  This 
drug  i-  supposed  to  he  taken  into  the  circulation  and  eliminated  by  the 
salivary  glands  and  mucous  glands  of  the  fauces  and  pharynx  ;  it  therefore 

increases  the  activity  of  the  hi l-supply  of  these  regions,  and   hence  should 

not  be  given  in  acute  inflammatory  states.  In  cases,  however,  of  dry  pharyn- 
gitis, where  there  i-  nioi'e  or  less  lack  of  secretion — the  chronic  inflammatory 
thickening  producing  an  engorgement  and,  therefore,  sluggish  action — this 
drug  generally  finds   its  rational   therapeutic  use. 

It  may  here  be  mentioned  that  some  drugs  seem  to  have  a  specific  action 
on  the  membranes  of  the  upper  air-passages:  for  example,  the  iodid-  in- 
crease their  circulation  and  glandular  action  ;  belladonna  diminishes  their 
secretion,  and  may  be  used  when,  a-  in  an  early  coryza,  it  is  desirable  to  stop 
the  mucous  flow.  Quinin,  arsenic,  mix  vomica,  and  other  tonic-;  are  of 
value  in  those  cases  of  engorgement  of  the  nasal  mucous  membranes  where 
the  vaso-motor  system  seems  to  have  lost  its  tone.  Iodids  seem  also  to 
increase  the  secretion  of  the  larynx  and  trachea,  so  that  they  may  be  given 
where  an  expectorant   effect   is  desirable. 

Massage  is  recommended,  notably  by  some  German  author-.  I  n  atrophic 
rhinitis  a  stroking  or  vibratory  massage  has  been  recommended  (by  M. 
Braum)  and   much  claimed   for  it;  but    Rosenberg1  considers  it  of  doubtful 

value,  although    some   g I  effects    have    been  observed.     A    probe-tipped 

applicator  i- wound  with  cotton  which  is  saturated  with  a  solution  of  tincture 
of  iodin  in  glycerin,  I  part  to  I  or  8,  or  in  an  ointment  containing  iodin, 
and  applied  to  the  membrane  in  this  manner.     Theobjecl  here  is  an  increased 

U l-supply,  as    in    the   case  of  the    tampon.       Laker    r inmends  a   similar 

procedure  in  dry  laryngitis.  In  paralysis,  muscle-weakness,  and  neuralgia, 
massage  is  recommended   bj   M.  Schmidl  and  other-. 

Electricity  i-  doubtless  of  greater  value  in  these  conditions,  either  used 
a-  the  faradic,  induced  vibratory  current,  or  as  the  interrupted  con-taut  gal- 
vanic current.  Electricity  may  he  used,  by  means  of  the  double  electrode  of 
v.  Ziemssen,  on  the  muscles  of  the  velum  palati,  fauces,  or  in  the  larynx  ;  or 

more  comfortably   by  tl 'dinary  single  electrode,  the  kathode  (N)  being 

placed  ou  the  area  to  he  treated,  ami  the  anode  (P)  by  a  sponge  electrode  at 
the  outside  of  the  throat  or  back  of  the  neck.     In  diphtheritic  paralysis,  in 

'  /.•"■.  til.,  p   "7 


CAUSTICS.  887 

the  weak  muscular  action  of  the  late  persisting  puerile  voice,  in  the  fatigued 
larynx  of  singers,  especially  after  a  cold,  these  procedures  arc  of  greal  value, 
the  strength  of  the  current  being  regulated  by  the  sensations  of  tin-  patient. 
Faradization  of  the  whole  larynx  may  also  !><■  accomplished  by  pressing  a 
-mall  electrode  deep  at  each  side  of  the  larynx,  or  by  placing  the  negative 
pole  in  front  of  it  and  the  positive  pole  at  the  hack  of  the  neck.  This  pro- 
cedure is  of  much  service  in  atonic  states  characterized  by  weak  voice,  caua  d 
by  cold,  overuse,  or  vocal  strain,  and  similar  condition-. 

The  combination  of  massage  and  electricity  to  the  outside  of  the  larynx 
is  often  very  useful.  This  is  accomplished  by  clamping  the  negative  pole 
to  the  right  hand  or  wrist  of  the  operator,  so  that  the  current  will  flow 
through  the  fingers,  and  placing  the  positive  pole  at  the  hack  of  the  neck, 
as  before   mentioned. 

Caustics. — In  the  use  of  these  destructive  agents  the  greatest  caution  is 
to  be  advocated,  since  they  are  to  lie  used  principally  in  the  nose  and  larynx. 
It  is  very  easy  to  remove  by  their  means  redundant  tissue;  it  i-  not  so  eas) 
to  remove  just  enough  and  still  preserve  the  functions  of  the  part-.  It 
should  be  the  rule  to  do  a  little  less  than  enough  rather  than  a  little  more, 
since  it  is  easy  to  burn  more,  but  not  to  restore  that  which  has  been  too 
zealously  destroyed. 

In  the  nose  first  was  used  glacial  acetic  and  fuming  nitric  acids,  but  being 
liquid,  their  action  was  difficult  to  control  and  they  have  deservedly  been 
relegated  to  the  past.  Next  comes  chromic  acid,  which  could  be  fused  on  a 
metallic  applicator  and  drawn  in  lines  along  the  turbinal  bodies.  Its  dis- 
agreeable  odor,  its  active  deliquescence  and  too  powerful  action,  causing  a  deep 
wound  and  a  troublesome  slough  and  slow  healing,  have  been  disadvantages 
which  have  led  to  its  disuse.  It  is,  however,  the  best  agent  to  close  the  little 
bleeding  vessels  in  the  septal  ulcers  before  mentioned,  which  are  the  frequent 
cause  of  epistaxis. 

The  best  acids  for  caustic  action  are  without  doubt  the  monochloracetic  and 
the  trichloracetic  acids.  These  act  practically  in  the  same  way  to  produce 
condensation  (Bosworth)  of  the  tissues  subjacent  to  the  area  of  their  applica- 
tion, the  former  having  a  little  more  powerful  effect  than  the  latter.  These 
acids  come  in  crystals  and  can  be  readily  fused  on  the  applicator  ;  or,  being 
-lowly  deliquescent,  the  thick  liquid  can  be  taken  up  on  a  probe  very  finely 
wound  with  cotton  (the  exec—  being  shaken  off),  and  this  will  have  almost 
the  same  caustic  value  ;i-  the  former  method  and  i-  easier  of  preparation. 
These  acids  have  the  great  advantage  that  the  slough  become-  hygroscopic 
and  remains  on  the  site  of  the  application  as  a  protective  covering,  like  ;i 
piece  of  wet  chamois  -kin,  leaving  a  smooth  surface  on  removal.  After  the 
effect  of  the  cocain  ha-  subsided,  there  is  apt  to  be  some  pain  ;  but  it  is  not 
lasting,  and  is  far  less  than  after  the  use  of  chromic  and  glacial  acetic  acid-. 

flic  most  efficient  and  most  accurately  controllable  agent  in  this  class  is 
the  galvano-cautery  ;  and  now  it  is  the  most  reliable,  since  the  rheostat  has 
been  perfected  and  the  Edison  street  current  can  be  brought  to  our  hand, 
enabling  us  to  discard  the  ever  troublesome  and  expensive  battery. 

This  powerful  agent  should  not  be  used  on  turbinals  presenting  a  tran- 
sient engorgemenl  from  atmospheric  irritation  or  vaso-motor  relaxation,  but 
only  upon  those  showing  true  hypertrophy  :  the  distinction  i-  made  manifest 
by  cocain.  II'  the  whole  turbinal  shrinks  down  to  a  minimum,  it  i-  not 
hypertrophy;  but  if  some  remains,  especially  if  it  i-  pale,  flabby,  and  less 
easily  compressible,  then  it  i-  a  true  hypertrophy  and  will  permit  the  use  of 
these  agents.      The  galvano-cautery  tip  can   be  used   in  two  way-  in  these 


888 


THEBAPEUSIS  AND  PROGNOSIS. 


cases  :  the  point  being  heated  to  a  cherry-red  color,  a  line  can  be  drawn  on 
the  Lower  eage,  and  on  one  or  two  parts  of  the  face  of  the  third  turbinals  or 
along  the  middle,  or  one  or  both  sides  of  the  second  or  middle  turbinals;  or 
one  or  more  lines  may  be  drawn  along  that  swelling  of  the  septum  so  often 
occurring  over  the  suture  between  the  ethmoid  plate  and  the  triangular  carti- 


^^ 


''     J  :     iC 


-'  '?:»■„  TO  flllC"^ |!|  Will1, 


Fig.  567  — Rheostat  or  commutor  for  adapting  the  street  current  to  cautery  use. 

lage.  Some  have  decried  the  cauterization  of  the  second  turbinal,  fearing 
meningitis  by  extension  of  inflammation  or  other  evils.  But  this  fear  is 
probably  not  well  grounded  unless  the  operation  were  done  where  there  was 
so  much  swelling  in  the  lower  parts  of  the  nose  as  to  make  drainage  poor  or 
nil.  For  this  reason  the  lower  parts  of  the  nose  should  he  treated  first,  and 
after  healing  has  taken  place  it  will  be  safe  to  treat  the  upper  parts. 

This  '•  lining"  of  the  surface  of  the  intranasal  swellings,  however,  causes 
much  destruction  of  the  ciliated  epithelium  and  of  the  glandular  layer  under 
this;  healing  is  then  sometimes  rather  tedious,  and  there  is  danger  of  synechias 
it'  the  lumen  i-  narrow.  Hence,  it  is  at  times  better  to  puncture  the  anterior 
part  of  the  -welling  and  to  carry  the  heated  point  backward  as  far  as  is  neces- 
sary in  the  cavernous  layer  parallel  to  the  outer  surface.  For  this  purpose 
the  platinum  pari  of  the  point  may  be  made  longer  than  usual,  say  three-fourths 
of  an  inch  in  length.     In  this  way  only  a  small  round  point  of  the  surface  is 

mwh=^ — — > 

Fig.  568.    <  tautery  point. 

destroyed  and  healing  is  more  rapid.  A  flow  of  blood  is  apt  to  follow  the 
extraction  of  the  point,  but  can  be  controlled  by  withdrawing  it  slowly  and 
then  sealing  the  aperture  with  the  still  glowing  point.  A  white  heat  is  not 
hemostatic. 

The  besl  handle  is  that  of  Schech,  and  he  has  also  probably  brought  the 
points  to  the  greatesl  perfection  as  to  their  form.  If  the  copper  part  of  the 
electrode  is  too  small,  it  will  get  disagreeably  hoi  before  the  operation  is 
finished  ;  this  adds  much  to  the  nervous  apprehension  of  the  patient  it"  it  is 
felt.  The  copper  pari  should,  therefore,  be  large  enough  to  keep  the  plat- 
inum heated  without  itself  getting  hot.  This  principle  is  carried  oul  in 
point-  made  by  the   Edison  Company. 

The  use  of  the  ealvano-cautery  on  hypertrophied  tonsils  is  advocated  by 
many.  In  th<-  opinion  of  the  writer,  however,  it  is  irrational  and  dangerous. 
The  inflamed  tonsil  (especially  in   the  lacuna!   variety)  is  large  because  of 


PROGNOSIS.  889 

morbid  processes  and  products  in  the  crypts.  Unless  the  electric  point  is 
carried  to  the  bottom  of  these  crypts  and  the  whole  of  the  interior  treated, 
some  of  the  materies  morbi  is  left  after  the  adhesive  inflammation  has  sealed 
the  outer  part  of  the  lumen  (there  is  the  same  objection  to  the  ordinary 
amputation  with  the  guillotine);  and  if  it  is  carried  to  the  bottom  it  comes 
too  near  the  capsule  and  the  large  vessels  lying  just  to  the  outside.  Enuclea- 
tion or  discission  (as  first  advocated  by  Hoffman  and  elucidated  by  the 
writer,  Boston  Medical  and  Sv/rgieal  Journal,  Oct.  12  and  19,1893)  seems 
much  more  rational.  Moreover,  the  galvano-caustic  method  of  reduction 
requires  several  sittings,  and  thus  keeps  the  throats  of  most  patients  in  a 
state  of  painful  inflammation  longer  than  does  discission,  which  may  need 
but  one  or  two  sittings. 

The  use  of  the  galvano-cautery  or  of  other  caustics  is  fortunately  not 
often  required  in  the  larynx,  but  may  be  indicated  in  some  cases  el*  tumefac- 
tions. For  example,  lactic  acid  (40  per  cent,  to  100  per  cent.)  has  been  very 
highly  praised  in  tubercular  nodules  and  ulcers;  and  nitrate  of  silver,  fused 
on  Shrotter's  concealed  applicator,  in  papillomata  or  pachydermia  among 
others.  But  the  use  of  the  galvano-cautery  for  singers'  nodes  (pachydermia 
tuberosa)  as  advocated  is,  in  most  cases,  entirely  uncalled  for,  since  absolute 
rest  will  cause  their  disappearance  in  a  very  few  weeks,  with  much  less 
danger  to  the  delicate  edges  of  the  vocal  cords. 

PROGNOSIS. 

The  question  is  often  asked  of  the  specialist,  "Can  my  catarrh  be 
cured?"  or  "Can  it  be  cured  permanently?"  The  first  of  these  ques- 
tions can  generally  be  answered  in  the  affirmative,  except  in  some  very 
bad  cases  of  atrophic  nasal  catarrh  or  of  destructive  specific  ozena  ;  and  the 
second  also  in  the  affirmative,  as  truly  as  in  any  other  affections  of  the 
mucous  membranes.  Recurrences  are  to  be  expected  or  to  be  guarded 
against  in  most  ills  to  which  human  flesh  is  heir,  except  perhaps  death  or 
those  which  can  be  permanently  shut  out  by  surgical  measures,  such  as  enu- 
cleation of  an  eye,  or  amputation  of  a  limb,  or  removal  of  the  appendix 
vermiformis :  then  why  not  a  recurrence  of  catarrhal  conditions  to  be 
brought  on  by  the  same  means  as  previous  attacks?  But  it  is  altogether 
probable  that  if  all  contacts  are  abolished  in  the  nose  by  removal  of  extrane- 
ous growths  and  by  reduction  of  abnormal  swellings  of  normal  structures 
without  destroying  the  functions  of  the  parts,  so  as  to  establish  the  habit  of 
nose-breathing;  if  purulent  cavities  are  drained  and  allowed  to  heal,  whether 
of  the  accessory  sinuses  or  other  sources  of  pus  emptying  into  the  nose:  if 
caries  or  necrosis  of  hard  or  soft  parts  can  be  stopped  and  their  products 
removed  so  as  to  be  no  longer  the  source  of  irritation  as  foreign  bodies;  it 
bad  habits  are  corrected  and  the  daily  life  brought  into  rational  physiological 
channels;  if  troublesome  or  deleterious  dyscrasia  and  diatheses  can  be  elim- 
inated or  held  in  abeyance — then  probably  the  symptoms  of  catarrh  can  be 
abolished.  So  that  in  most  eases  the  patient  may  be  promised  thai  lie  can 
be  cured  or,  if  not  cured,  made  so  much  better  that  he  will  consider  himself 
cured,  till  by  his  own  carelessness  or  misfortune  causes  operate  to  induce  a 
new    manifestation  of  his  trouble. 

These  same  questions  are  almosl  always  asked  by  anxious  parents  when 
hyperplasia  of  the  pharyngeal  tonsil  has  been  discovered  in  their  children. 
It  seem-  to  the  writer  that  an  affirmative  answer  can  always  be  given,  pro- 
vided the  nares  are  unobstructed  and  the  habit  of  nasal  respiration  i-  imme- 


890  THERAPEUSIS  AND   PROGNOSIS. 

diately  established.  No  statistics  are  at  hand;  but  it  i-  probably  true  th.it 
habit  and  hypertrophic  nasal  obstruction  are  the  great  factors  operative  in 
cases  of  recurrence.  Per  contra,  given  an  obstructed  nose  and  adenoid 
vegetations,  it  is  often  safe  to  iri\  «•  the  prognosis  that  the  latter  may  wholly 
disappear  or  cease  from  troubling,  provided  they  arc  not  too  old  and  hard,  if 
the  former  is  restored  to  normal  caliber  and  mouth-breathing  -topped.  This 
desirable  result  has  been  attained  in  the  practice  of  the  writer  more  than 
once  :  and  the  cases  of  recurrence  which  have  formerly  come  under  his 
observation  were  in  children  with  obstructed  noses  or  whose  parents  did  not 
insist  on  nasal  respiration. 

In  closing  this  article,  a  word  as  to  the  danger  of  too  much  or  too  radical 
surgical  interference  in  the  upper  air-passages  deserves  a  place.  Destruction 
of  tissue  in  the  nose  should  be  limited  to  the  hard  parts  as  much  as  possible. 
It  is  a  great  mi-take  to  remove  the  lower  turbinate  except  for  necrosis, 
although  much  of  their  covering  may  he  redundant.  The  posterior  ends  may 
hi'  amputated,  the  middle  and  anterior  ends  may  be  prodded  and  scored 
with  the  cautery  and  any  excrescences  removed,  but  not  enough  to 
shrivel  them  into  cicatricial  masses  without  function.  The  whole 
body  even  may  be  bent  downward  and  outward  on  its  attachment  like 
a  hinge,  but  it  is  protested  that  it  should  not  be  destroyed  nor  removed. 
Atrophic  rhinitis,  dry,  crusty,  malodorous  catarrh,  pharyngitis  sicca,  and 
chronic  inflammation  of  the  surface-  lower  down  threaten  the  victim  of  such 
mistaken  zeal,  if  not  immediately,  surely  in  the  near  future.  The  middle 
turbinal  i-  functionally  less  important  and  may  even  be  removed  with  less 
danger  of  future  evil  when  it  suffers  edematous  mucous  degeneration  (so- 
called)  or  caries,  or  becomes  cystic  ami  enlarged,  causing  painful  disturbance 
of  the  fifth  nerve  by  pressure.  'Twere  better  to  reduce  its  size  by  the  vari- 
ous means  suggested,  but  even  then  its  ability  to  keep  its  surface  clean 
should    not    be    impaired. 

It  i-  significant,  a-  (  !hapell  and  others  have  shown,  that  even  by  ordinary 
operations  in  tin-  nose  in  certain  individuals  reflex  neurosis  may  be  set  up, 
producing  exaggerated  nervous  symptoms  especially  as  to  the  nose  itself, 
inability  to  apply  the  mind,  and  even  melancholic  depression.  Perhaps  in 
no  branch  of  surgery,  then,  is  there  more  nerd  of  caution  than  in  this  region. 

It  i-  obvious  al-o  that  the  mucous  membrane  of  the  naso-pharynx  should 
not  he  removed  with  the  pharyngeal  tonsil,  nor  the  pillar-  of  the  fauces 
with  the  faucial  tonsil,  nor  in  the  larynx  should  the  delicate  edges  of  the 
vocal  cords  be  injured,  nor  other  pari  wounded  so  that  cicatricial  band-  may 
impair  it-  Bhape  or  movement--.  In  fin.',  in  all  this  region  of  the  upper  air- 
passages,  the  operator  should  have  ever  in  mind  the  inflexible  rule  that  if 
he  cannot  reach  the  perfection  of  hi-  ideals,  he  certainly  must  make  the 
patient    no   worse    in   any    particular. 


ACUTE  AFFECTIONS  OF  THE  NOSE. 

By  WILLIAM    E.  CASSELBERRY,  M.  I)., 

OF    CHICAGO,    ILL. 


Acute  Rhinitis. — Acute  rhinitis,  or  eoryza,  colloquially  termed  '-cold 
in  the  head,"  is  an  acute  inflammation  of  the  mucous  membrane  and  sub- 
mucous  tissues  of  the  nasal  cavities,  the  naso-pharynx  being  usually  likewise 
involved,  at  least  to  some  degree.  It  not  infrequently  affects  the  ears,  via 
the  Eustachian  tubes,  and  is  prone  to  extend  to  the  pharynx,  larynx,  and 
bronchioles.  This  sequence  may  on  occasion  be  reversed,  the  rhinitis  follow- 
ing an  initial  inflammation  in  the  lower  respiratory  tract;  or  tin;  whole  sur- 
face may  become  inflamed  at  one  time.  Also,  the  maxillary,  frontal,  and 
sphenoid  sinuses  and  the  ethmoid  cells,  being  cavities  immediately  contigu- 
ous to  the  nasal  chambers  proper,  can  rarely  wholly  escape ;  and  at  times 
one  or  more  of  them  may  present,  as  a  complication,  an  acute  sinusitis  far 
more  grave  than  the  original   rhinitis. 

Etiology. — While  local  inflammation  is  the  salient  feature  of  an  acute 
"cold  in  the  head,"  there  is  reason  to  believe  that  a  fundamental  disorder  of 
the  nerve-centers  leading  to  vaso-motor  paresis  is  associated  therewith. 
Reasoning  from  analogy  and  from  pathology  and  clinical  history,  one  musl 
regard  acute  suppurative  rhinitis  as  an  infection  by  pathogenic  micro-organ- 
isms, although  germs  specific  to  this  particular  form  of  suppuration  have  not 
as  yet  been  identified.  However,  certain  local  and  constitutional  conditions 
seem  to  favor  infection,  and  the  latter  ensues  finally  under  the  influence  of 
vascular  disturbance  which  has  "been  excited  by  some  sort  of  exposure. 

1.  Chronic  hypertrophic  rhinitis,  obstructive  deformities  of  the  septum, 
and  adenoid  vegetations  probably,  by  maintaining  local  congestion  and  steno- 
sis, favor  recurrent  attacks  of  acute  rhinitis. 

2.  Extreme  bodily  fatigue  or  nervous  exhaustion,  the  physical  lassitude 
engendered  by  excesses,  and  the  tuberculous  and  syphilitic  dyscrasise  render 
the  individual  more  vulnerable  upon  exposure.  'The  habit  of  hoi  bathing, 
especially  previous  to  going  out  in  cold  weather,  is  a  prolific  underlying 
source  of  rhinitis.  These,  as  well  as  the  custom  by  many  of  wearing  too 
heavy  apparel  and  living  in  overheated  apartments,  seem  to  exerl  ;i  softening 
influence  upon  the  bodily  suffice,  lessening  its  resistance  to  draughts  and 
climatic  inequalities. 

3.  In  the  presence  of  such  local  or  constitutional  predisposing  conditions, 
acute  rhinitis  follows  certain  exposures  with  such  regularity  and  precision 
that  one  must  infer  a  causal  relation-hip  to  exist  between  chilling  of  the  body 
and  rhinitis.  A  draught  between  the  shoulders,  permitting  the  feet  or  other 
parts  of  the  body  to  become  cold  and  damp,  exposure  to  bleak  winds,  m-  in 
driving  in  an  open  vehicle,  or  too  rapid  checking  of  the  perspiration,  causes 
through  the  intervention  of  tin1  vaso-motor  nervous  system  a  sudden  turges 
cence  of  the  nasal  vessels,  especially  of  the  turbinal  bodies.     Jn  the  majority 

891 


892  ACUTE  AFFECTIONS  OF  THE  NOSE. 

of  instances  this  congestion  is  hut  transitory,  passing  off  in  a  few  hours  and 
followed  merely  by  increased  secretion;  but  in  other  instances  it  does  not 
subside,  bul  augments  in  violence,  and  is  followed  in  twelve  to  twenty-four 
hours  by  a  muco-purulent  and  then  almost  a  purulent  discharge.  This  con- 
gests  f   the  nasal   vessels  occasioned   by   thus  "taking  cold"  seemingly 

favors  a  microbic  invasion  <>f  the  mucous  membrane  by  impairing  in  some 
manner  its  power  ot'  resistance. 

Extreme  heat  of  weather,  especially  when  accompanied  by  enervating 
dust-laden  wind-  and  acting  upon  individuals  in  a  state  of  fatigue,  is  capable 
<»t'  exciting  a  form  of  acute  rhinitis  colloquially  termed  "heat-cold."  In  like 
manner  a  much  overheated  sitting  apartment  or  assembly  hall,  or  a  journey 
in  a  superheated  railroad  car  can  have  a  similar  result.  In  fact,  a  "cold" 
results  quite  as  frequently  from  getting  too  hot  as  from  being  too  cold. 

Again,  the  subjects  of  supersensitive  nasal  mucous  membranes  may  suffer 
from  pronounced  nasal  irritation  when  exposed  to  the  inhalations  of  various 
atmospheric  impurities — e.  g.  the  dust  of  railroad  travel,  the  smoke  and  fumes 
of  large  cities,  particularly  when  combined  with  fog.  as  is  often  the  case  in 
Loudon  and  Chicago,  different  kinds  of  pollen,  and  even  the  aroma  from 
horses.  Asthmatic  symptoms  occasionally  supervene  upon  this  variety  of 
nasal  irritation,  and  the  whole  picture  differs  somewhat  from  that  of  an 
ordinary  acute  rhinitis,  partaking  more  of  the  condition  which  in  its  typical 
form  is  known  as  "hay-fever"  or  vaso-motor  rhinitis. 

Instances  are  not  wanting  of  direct  infection  of  one  person  by  the  dis- 
charges of  another — an  accident  which  is  apt  to  happen  among  children  by 
the  use  of  handkerchiefs  in  common.  Suppurative  rhinitis  in  infants  is  also 
attributable  to  direct  infection  from  the  vaginal  discharge  during  birth,  and 
this  infection  may  be  of  a  gonorrheal  nature.  Acute  blennorrhea  is  another 
term  applied  to  suppurative  rhinitis  with  profuse  secretion.  The  infecting 
agenl    may   be   the   gonococcus  or  other  pyogenic  micro-organisms. 

Rhinitis  is  one  of  the  salient  manifestations  of  genuine  influenza  ;  it  is  an 
initial  symptom  of  measles;  and  quasi-rhinitis  is  a  prominent  characteristic 
of  iodism,  and  to  a  less  extent  of  cinchonism.  It  is  apt  to  occur  during  preg- 
nancy and  i-  then  aggravated  by  the  passive  venous  congestion  which  is  inci- 
dental to  that  state. 

Symptoms. — A  sense  of  stuffiness  in  the  nostrils,  with  sneezing,  burning, 
and  dryness,  together  with  malaise  and  a  slight  febrile  reaction,  is  succeeded 
in  a  few  hour-  by  an  acrid  watery  discharge,  which  later  leads  to  a  free  muco- 
purulent secretion.  A  simultaneous  congestion  of  the  frontal  sinuses  will 
occasion  headache:  bul  this  does  nol  argue  pressure  by  accumulated  muco- 
purulent secretion  within  these  cavities,  for  actual  empyema  of  the  frontal 
sinuses  b  rare.  Much  discomfort  results  from  the  partial  or  complete  occlu- 
sion  of  the   nares,  especially  at    night,  the   patient    necessarily  breathing  in 

part    through  the  o th,  which  occasions  dryness  of  the  throat  and  a  sense 

of  dyspnea  :  -mall  children  will  actually  struggle  for  breath  and  even  suffer 

attacks  of  hr\  ngis -  stridulus  excited  in  consequence.     The  sense  of  smell 

is  obtunded  or  for  the  time  suspended,  and  that  part  of  taste  which  is  depen- 
dent on  the  olfactory  sense  i-  impaired.  A  symptom  which  becomes  a  serious 
inconvenience  to  public  speakers  ami  singers  b  alteration  in  the  quality  of 
the  voice,  which  acquires  a  guttural  and  so-called  "nasal  tone"  because  of 
limitation  of  the  resonance-space  by  intranasal  swelling.  The  anterior  nares 
become  red,  sensitive,  and  excoriated. 

<  )u    inspection    by    mean-  of  a    nasal    speculum  and    reflected    light    the 

miic n-  membrane  appear-    of  a    darker  red  color  than  usual  and  the  turhinal 


ACfTK  RHINITIS.  893 

bodies  swollen.  At  times,  however,  especially  at  the  second  stag* — that  of 
profuse  serous  discharg* — the  turbinal  bodies  of  now  one  and  then  the  other 
side  may  appear  collapsed.  At  the  third  stage  quantities  of  muco-purulenl 
secretion  will  be  observed.    Posteriorly  the  condition-  and  aspects  are  similar. 

Diagnosis. — From  erysipelas,  acute  rhinitis  is  distinguished  by  the 
gravity  of  the  former  affection  and  the  erysipelatous  hue  which  will  gradually 
extend  over  the  lip  and  nose  externally.  The  nasal  irritation  from  a  foreign 
body  is  unilateral  ;  that  of  measles  is  indistinguishable  from  simple  acute 
rhinitis  until  the  cutaneous  eruption  appears  ;  that  of  iodism  will  be  asso- 
ciated with  cutaneous  papules  and  will  promptly  cease  on  withdrawal  of  the 
drug.  Hay-fever  occurs  in  August  and  September;  the  patient  will  perhaps 
have  a  history  of  previous  attacks,  and  in  any  event  the  sneezing,  burning, 
post-nasal  and  lachrymal  irritation  endure  without  diminution  or  change  for 
a  period  much  in  excess  of  simple  acute  rhinitis. 

Prognosis. — Simple  acute  rhinitis,  uncomplicated  by  serious  implication 
of  the  collateral  sinuses  or  of  the  ear,  will  spontaneously  terminate  in  recovery 
in  from  five  to  fourteen  days.  Nevertheless  treatment  should  not  be  neglected, 
for  it  will  certainly  lessen  the  severity  and  duration  of  the  disease  and  tend 
to  prevent  complications  or  a  transition  into  chronic  nasal  catarrh. 

Treatment. — Sufferers  should  receive  the  benefit  both  of  immediate  treat- 
ment and  of  wise  prophylaxis.  At  the  time  of  an  attack  many  remedies  are 
of  real  service  ;  but  a  multiplicity  of  recommendations  is  confusing  and  tends 
to  lessen  confidence  in  any  one  line  of  treatment.  I  will  therefore  describe 
simply  my  own  methods  of  dealing  with  these  cases. 

If  it  is  sought  to  abort  the  disorder,  a  single  average-sized  dose  of 
Dover's  powder  or  of  morphin  or  codein  is  given  at  bedtime,  also  a  laxative 
if  needed.  The  morphin  may  be  combined  with  atropin  to  advantage,  as  in 
the  customary  hypodermic  tablet — e.  g.,  morphin  sulphate,  gr.  i,  and  atro- 
pin sulphate,  gr.  T.\(T.  The  patient  is  especially  well  covered  in  bed,  outside 
air  is  excluded,  and  the  temperature  of  the  apartment  maintained  during  the 
night  at  60°  to  70°  F.  This  will  usually  result  in  a  slight  excess  of  secre- 
tion from  the  skin,  but  no  effort  is  made  to  produce  profuse  perspiration.  If 
a  decided  sudorific  effect  be  desired,  a  sort  of  "  Turkish  bath  "  may  be  extem- 
porized previous  to  retiring  by  seating  the  patient,  enveloped  in  a  blanket, 
upon  a  chair  beneath  which  a  small  lamp  is  caused  to  burn.  In  the  morning 
on  rising  three  ounces  of  Rubinat  saline  water  should  be  taken,  provided  a 
laxative  has  not  been  administered  the  night  before.  If  convenient,  a-  in  the 
case  of  many  ladies,  confinement  to  the  house  for  a  day  or  two  will  insure  a 
prompt  recovery. 

Quinin  has  acquired  notoriety  among  laymen  as  an  abortifacienl  agent  ; 
but  it  is  unreliable,  and  seems  even  at  times  to  aggravate  the  condition. 
Cocain,  in  the  form  of  a  spray,  only  exceptionally  succeeds  in  actually  aborting 
the  disease,  although  it  affords  temporary  relief;  and  one  i-  also  disappointed 
in  the  alleged  effects  of  antipyrin  similarly  used  for  the  same  purpose. 

During  the  course  of  the  affection  I  have  raosf  frequently  prescribed  pre- 
pared "rhinitis-tablets"  (Dr.  Lincoln's  formula,  one-half  strength),  one  every 
two  hours,  which  are  composed  as  follows: 

1^.     Ext.  belladonna?  fid.,  gr.  \    .008; 

(  iimphone,  gr.   J     .016  ; 

Quininse  sulph.,  gr.  ',    ."It;. — M. 

although  other  remedies — e.  g.,  aconite,  potassium  bromid,  Btrychnin,  or 
codein — may   be    indicated    at    particular    stages;    aconite   and    potassium 


894  ACUTE  AFFECTIONS  OF  THE  NOSE. 

broraid  early  when  there  is  fever,  and  strychnin  later  to  stimulate  the  pare- 
tic vaso-motor  system.  Codein  or  morphin  conjoined  with  atropin  in 
small  doses  is  serviceable  when  there  is  a  harassing  cough;  and  even  for  the 
rhinitis  itself  during  the  firsl  few  days  it  would  be  an  excellent  remedy  if  it 
were  noi  for  well-known  objections  to  its  continuous  or  general  use. 

Local  treatment  is  of  the  utmost  importance,  and  the  following  mixtures 
render  satisfactory  service  by  atomization  : 

Ny;/1'///    No.    I. 

\{.     Menthol,  grj  .065; 

01.  eucalypti,  Nliij  •-  : 

01.  gaultherise,  Ttliij  .2; 

Sodii  bicarbonatis,  gr.  xv  1. ; 

Sodii  boratis,  gr.  xv  1.  ; 

Glycerini,  .~iij  12.; 

A.|ii;e.  (|.s.  ad.,  5J  32. — M. 

Sjgf — Dilute,  adding  one  teaspoonful  of  medicine  to  one  ounce  of  warm 
water  for  use  as  a  spray. 

Spray  No.  .'. 
U.     Menthol, 

( )1.  pini  pumilionis, 
( )1.  gaultherise, 
Ol.  eucalypti, 
••  Benzoinol," 

"Oil  vaselin,"1  q.  s.  ad.,  §j 

Sig. — Use  with  a  double-bulb  (  Davidson)  atomizer,  either  alone  or  follow- 
ing the  use  of  Spray  No.  1. 

In  office  practice  it  is  quite  customary  to  spray  first  with  a  \  percent. 
solution  of  cocain,  followed  in  five  minutes  by  Spray  No.  1,  and  this  in  turn 
by  the  emollient  Spray  No.  2. 

At  home  either  Spray  No.  1  or  Spray  No.  2  or  both  may  be  used  every 
three  hour.-  or  according  to  convenience. 

To  Spray  No.  1  can  be  added  a  minute  quantity  of  cocain  hydrochlorate 
equal  to  \  per  cent,  when  diluted  ;  but  then  care  must  he  observed  not  to  use 
the  spray  with  greater  frequency  than  every  two  or  three  hours,  as  the  too 
frequent  use  of  even  diluted  solutions  of  cocain  in  the  nose  results  in  a  re- 
actionary turgescence  of  the  concha'  and,  in  susceptible  individuals,  in  sys- 
temic disorder  of  the  nervous  system  and  irregularity  of  the  heart's  action. 
In  fact,  one  should  avoid  a>  far  as  possible  prescribing  or  placing  cocain  in 
the  hand-  of  patients ;  for  the  sensations  engendered  by  its  nasal  use,  together 
with  the  cerebral  stimulation  by  absorption  through  the  nasal  mucous  mem- 
brane, arc  -i.  enticing  as  to  tempt  the  patienl  not  only  to  too  frequent  and 
profuse  use  of  the  substance  for  the  time  being,  but  also  to  the  formation  of 

a  chronic  cocain   habit. 

For  young  children,  who  are  often  terrified  by  spraying,  may  be  substi- 
tuted a  small  syringe  or  an  ordinary  medicine-dropper  used  as  a  syringe,  with 
which  to  project  gentl)  either  of  these  spray  solutions  through  the  nostrils. 
All  solutions  for  nasal  use  should  be  somewhal  warm. 

Of  the  many  vapor  inhalations   I  would  mention  camphorated  .-team  as  a 

d -tie   remed)    oi  power.      It   i-  conveniently  used   by  placing  a   pint   oi 

1  Bj  "  "il  vaselin"  in  meant  the  yellow  opalescent  oil  free  from  kerosene  odor. 


gr-  j 

.065  : 

111  V 

.35; 

TTliij 

2  • 

miij 

2  . 

§ss 

15.; 

ai 

32.-M 

ACUTE  RHINITIS.  895 

steaming  hot  water  in  a  glass  fruit-jar  and  adding  two  drachms  of  spirit  of 
camphor:  a  funnel,  preferably  of  glass,  is  then  inverted  to  cover  the  mouth 
<>t"  the  jar,  and  the  rising  steam  is  inhaled  through  the  nostrils  as  it  escapes 
from  the  small  end  of  the  funnel.  So  used,  especially  during  the  evening  for 
a  half  hour,  it  conduces  to  a  comfortable  night's  rest  and  facilitate-  recovery. 
The  inhalation  of  -team  through  a  sponge  wrung  out  of  hot  water  is  another 
domestic  expedient.  The  vapor  from  a  tew  drop-  of  a  mixture  of  equal 
parts  of  spirit  of  ammonia,  carbolic  acid,  and  cologne,  inhaled  from  cotton 
stuffed  into  a  paper  cornucopia,  conduces  to  the  comfort  of  the  sufferer,  a-  do 
pocket-inhalers  which  contain  menthol  or  its  combinations. 

When  intumescence  of  the  turbinal  bodies  continue-  to  be  annoying 
beyond  the  usual  period  of  actual  acute  inflammation,  immediate  relief  will 
be  afforded  by  two  skilfully-made  electro-cauterization-  after  the  manner 
much  in  vogue  for  chronic   hypertrophic   rhinitis. 

Prophylaxis. — Tho-e  who  are  exposed  to  climatic  inequalities,  and  who 
would  at  the  same  time  escape  recurrent  attacks  of  acute  rhinitis,  should 
seek  in  their  mode  of  life  to  conserve  and  increase  a  natural  resistance.  To 
this  end.  no  hygienic  detail  is  of  greater  importance  than  the  habit  of  cold 
bathing  immediately  on  rising  in  the  morning.  The  bath  may  be  of  the 
plunge,  shower,  or  wet-towel  variety,  with  the  water  at  a  temperature  of  50° 
to  56°  F.,  taken  in  a  reasonably  warm  room  and  followed  by  friction  with  a 
linen  crash  towel,  and  this  by  brief  calisthenic  exercises.  Patients  who  have 
a  fancied  repugnance  to  cold  water  are  directed  to  commence  by  simply  rub- 
bing the  whole  surface  of  the  body  quickly  with  a  wet  crash  towel.  The 
cold  bath  invigorates  the  vaso-motor  nervous  system,  accustom-  the  cutaneous 
surface  to  changes  of  temperature,  and  generally  augments  the  bodily  tone. 
This  "hardening  process,"  to  get  the  best  effect,  should  be  supplemented  by 
regular  and  persistent  open-air  exercise  in  all  kinds  of  weather.  When 
properly  clad  even  delicate  patients  may  safely  be  discouraged  from  omit- 
ting their  outings  simply  because  it  rains,  snows,  or  blows.  To  remain 
indoors  because  of  trifling  inclemency  in  the  weather  means  at  certain 
seasons  an  uninterrupted  confinement  to  hot  and  ill-ventilated  rooms  for 
days  at  a  time,  with  all  the  softening  effects  that  such  a  mode  of  life 
invoke-. 

As  to  clothing,  it  is  a  golden  ride  to  keep  comfortable,  avoiding  an  excess 
of  raiment  even  more  assiduously  than  a  deficiency;  and  changing  even  to 
the  underwear  as  frequently  as  required  by  variations  of  temperature.  For 
instance,  on  a  sultry  late  November  day  it  is  certainly  Less  hazardous  to 
rechange  to  lighter  wear  than  to  endure  the  general  relaxation  incidental  to 
being  overclad.  Even  in  winter,  extra-thick  underwear  is  undesirable  for 
tho-e  who  live  chiefly  indoors,  a  light  grade  of  good  woollen  material,  supple- 
mented by  varying  grades  of  outer  clothing  and  overcoat-,  being  best,  for 
spring  and  fall  a  still  lighter  article  either  of  good  merino  or  wool,  and  for 
midsummer  balbriggan  or  even  gauze,  is  suitable  for  the  ordinarily  robust 
individual.  Chest-protectors  are  abominations,  and  neck-mufflers  arc  per- 
missible only  on  extreme  exposure.  Ordinarily  leather  will  not  keep  out 
moisture;  and  wet  or  even  damp  feet  in  cold  weather,  endured  for  hours 
without  opportunity  to  change,  is  a  prolific  cause  of  ••••"Id-."  \  protective 
overshoe,  a-  low-  a-  will  answer  the  purpose  and  removed  on  passing  indoors, 
is  therefore  a  necessity. 

Living  apartment-  and  offices  should  not  be  heated  beyond  70  to  72  I-'., 
and  means  should  be  provided  for  reasonable  ventilation  and  for  imparting  t<> 
hot  air  a  degree  of  humidity  ;   however,   when  the  other  conditions  above 


ACUTE  AFFECTIONS  OF   THE  NOSE. 

mentioned  arc  complied  with,  the  baneful  effects  of  oftentimes  uncontrollable 
superheating  become  much  less  manifest. 

Finally  those  individuals  who  are  predisposed  to  acute  rhinitis  by  reason 
of  adenoid  vegetations,  chronic  hypertrophy  of  the  turbinal  bodies,  obstruc- 
tive deformities  of  the  septum,  or  aasal  polypi,  should  have  such  affections 
remedied  by  accepted  methods,  supplementing  this  treatment  by  observance 
of  the  laws  <>f  hygiene. 

Membranous  Rhinitis. — Membranous  rhinitis,  also  termed  croupous 
rhinitis  ami  rhinitis  fibrinosa,  is  an  acute  inflammation  of  the  nasal  passages 
accompanied  by  a  whitish  membranous  exudate  which  covers  the  whole  or 
parts  of  the  inflamed  mucosa.  A  membranous  exudate  frequently  forms  in 
consequence  of  chemical  or  electro-cauterization  of  the  turbinal  bodies;  but 
this  condition  differs  essentially  from  genuine  membranous  rhinitis.  The 
exudate  is  thick,  gray-white  in  color,  confined  to  the  immediate  vicinity  of 
the  cauterized  site,  which  it  overlaps  somewhat,  shading  off'  to  a  thin  edge  a 
little  distance  from  the  center  of  the  mosl  intense  inflammatory  action.  If 
this  pseudo-membrane  be  forcibly  detached  on  the  second  day,  it  redevelops; 
if  allowed  to  remain  it  becomes  incorporated  with  the  eschar  produced  by  the 
cautery,  and  the  whole  will  separate  spontaneously  like  an  eschar  about  the 
fifth  day.  There  is  no  evidence  that  such  a  membranous  exudate  results 
otherwise  than  from  a  regenerative  type  of  inflammation  following  the  appli- 
cation of  an  intense  and  destructive  irritant,    Contaminating  micro-organisms 

are  found  ;  but  to  them  cai t   be  attributed  the  initial  pathogenic  role.     It 

is  of  importance  chiefly  as  an  object  lesson,  serving  to  remind  one  that  all 
membranous  exudates  arc  not  to  be  ascribed  to  a  single  cause,  and  that,  how- 
ever ubiquitous  the  Klebs-Lofller  bacillus  may  be,  there  are  yet  other 
agencies  capable  of  producing  an   inflammation  of  the  membranous  type. 

A.S  in  the  throat,  so  also  in  the  nose,  an  exudate  like  that  of  membranous 
rhinitis  proper  can  doubtless  ensue  from  infection  by  any  one  of  several 
specie-  of  pathogenic  micro-organisms;  in  many  of  the  cases  only  staphylo- 
cocci and  streptococci  have  been  found;  while  in  others  of  identical  clinical 
course  Klebs-Lofller  diphtheria  bacilli  have  been  demonstrated — albeit  often- 
times sparse  in  numbers,  of  questionable  virulence,  or  mixed  with  other 
microbes.  Of  twenty-two  cases  which  were  subjected  by  Edmund  Meyer1  to 
both  microscopic  and  bacteriologic  investigation  with  animal  experiments,  in 
thirteen  virulent  diphtheria  bacilli  were  present,  and  in  nine  there  were 
streptococci  of  little  virulence  and  the  staphylococcus  pyogenes  albus  and 
aureus.     The  clinical  course  in  both  -eric-  of  eases  was  essentially  the  same. 

It  i-  true  tli.it  tin  disease  which  has  acquired  the  name  of  membranous 
rhinitis,  even  when  the  diphtheria  bacillus  is  associated  therewith,  differs 
radically  in  symptomatology  from  typical  nasal  diphtheria.  Its  manifesta- 
tions are  chiefly  local,  it  i-  not  accompanied  by  constitutional  symptoms  other 
than  those  of  a  "cold  in  the  head."  and  it  shows  bul  little  disposition  to  extend 

to  the  throat.       Hence  in  those   cases    in   which  the    Klebs-Lbffler  bacillus  has 

been  reported,  it  ha-  sometimes  been  suggested  that  this  in  reality  mighl  be 
the  pseudo-diphtheria  bacillus  of  Hoffmann,  which  is  little  virulent,  but 
which  morphologically,  studied  only  by  the  microscope,  is  quite  similar  to 

the  diphtheria  bacillus.     A.8  i-  now    well-known,  the  pseudo-bacillus  IS  viewed 

by  Escherich  a-  an   independenl   organism,  bul   by  Rous   and    Yersin  as  an 

attenuated  form  of  the  K  leb—  Loffler  bacillus.      A  train,  since  diphtheria  bacilli 

are  occasionally  present  in  health)  throats',  and  as  their  detection  alone,  unac- 
companied by  the  usual  symptoms,  hardly  suffices  for  a  diagnosis  of  diph- 
1  Arckin   i   Laryngologit,  etc.,  Viert<  i    Band,  Heft  '-',  8.  253. 


MEMBRANOUS  RHINITIS.  897 

theria,  so  also  in  the  nose  the  presence  of  a  leu  such  bacilli  does  not  render 
it  certain  that  they  constitute  the  responsible  cause  of  the  membranous  rhin- 
itis. In  this  connection,  \h-.  W.  EL  Gross,1  of  the  Children's  Hospital  of 
Boston,  presents  valuable  corroborative  evidence.  Weekly  culture  examina- 
tions were  made  from  the  normal  throats  and  noses  of  300  children,  the 
Klebs-Loffler  bacillus  being  found  in  8  per  cent,  of  the  cases.  Of  this 
number  the  nose  was  the  habitat  in  65  per  cent,  and  the  throal  in  35  per 
cent.      In    none  of  these  did   clinical   diphtheria   develop. 

However,  since  in  Edmund  Meyer's  thirteen  cases  all  the  Klebs-Loffler 
bacilli  were  found  to  be  virulent,  it  is  impossible  to  escape  the  conclusion 
that  these  cases  at  least  were  of  diphtheritic  origin,  and  that  there  are  con- 
ditions not  yet  definitely  known,  pertaining  to  the  resistance  of  the  individual 
or  to  the  degree  of  virulence  and  number  of  the  micro-organisms,  which 
determine  a  wide  variation  from  the  usual  clinical  picture  of  nasal  diphtheria. 
Until  these  conditions  are  better  understood  such  cases  will  be  found  classed 
under  the  designation  "  membranous  rhinitis;"  although  it  is  expected  that 
in  the  immediate  future  the  general  term  "diphtheria"  will  have  appropri- 
ated most  of  them   for  its  own. 

Etiology. — From  an  etiologic  point  of  view  one  may  therefore  divide  Hi- 
called  membranous  rhinitis  into  two  types:  diphtheritic  and  non-diphtheritic. 
Corroborative  evidence  of  the  identity  of  the  diphtheritic  type  of  mem- 
branous rhinitis  with  true  diphtheria  is  occasionally  obtainable  in  a  definite 
history  of  exposure  to  infection  while  in  attendance  upon  diphtheria  patients. 

Case  I. — Miss ,  a  trained  nurse,  applied  for  treatment  at  St.  Luke's  Hospital, 

complaining  of  obstruction  of  the  left  nostril,  which  she  had  at  tirst  attributed  to  a 
"cold."  The  inflammation  had  commenced  while  she  was  nursing  a  diphtheria  patient, 
and  she  had  been  under  the  treatment  of  her  patient's  physician  for  about  eight  days. 
During  that  time  the  passage  was  occluded  by  a  white  membranous  exudate,  pieces  of 
which  were  detached  by  forceps  and  subjected  to  bacteriological  examination,  disclosing 
Klebs-Loffler  bacilli.  On  personal  examination  at  the  end  of  the  eighth  day  the  vesti- 
bule of  the  nose  and  the  upper  lip  were  found  tumefied  and  incrusted  by  an  excoriating 
discharge,  while  the  septum  and  anterior  part  of  the  inferior  turbinal  body  were  still 
covered  by  a  thin  whitish  exudate.  On  account  of  the  swelling  it  was  impossible  to  de- 
termine the  exact  extent  of  the  exudate;  but  none  was  visible  by  posterior  rhinoscopic 
examination.  A  culture  taken  at  this  time  again  disclosed  Klebs-Loffler  bacilli  mingled 
with  cocci.  The  right  nostril,  while  somewhat  inflamed,  presented  no  exudate.  The 
patient  had  not  complained  of  any  constitutional  symptoms  whatever,  but  appeared 
worn-out  and  anemic:  she  had  continued  her  nursing  duties  to  the  end  and  left  the 
hospital   the  same  day   to  rest   at   her  own    home. 

Case  II.  —Dr.  S ,  a  young  physician,  was  interne  at  the  Children's  Free  Hos- 
pital of  Detroit  during  an  epidemic  of  diphtheria.  A  few  days  alter  the  cessation  of 
this  continuous  exposure  he  noticed  an  inflammation  in  the  left  nostril,  which  pro- 
gressed to  the  point  of  total  occlusion  by  swelling  and  a  white  exudate,  witli  an  excori- 
ating discharge,  lb'  Stated  that  this  exudate  had  been  SO  plentiful  thai  -hied-  could 
readily  be  detached.  He  was  examined  about  the  seventh  day,  at  which  time  the  mem- 
brane consisted  of  a  mere  film  covering  an  excoriated  surface  which  embraced  the  vesti- 
bule, the  cartilaginous  septum,  and  the  anterior  part  of  the  external  nasal  wall,  extend- 
ing backward  not  exceeding  three  centimeters.  A  culture  was  taken  and  examined  by 
Dr.  Gehrman,  of  the  Chicago  Health  Department,  in  conjunction  with  his  assistanl  and 
the  patient  himself,  who  reported  the  presence  of  Klebs-Loffler  bacilli.  There  were  no 
constitutional  symptoms,  and  convalescence  was  complete  in  three  week-. 

It  is  thus  -een  that  a  liability  to  the  dissemination  of  diphtheria  lurk-  in 
the  diphtheritic  type  of  membranous  rhinitis;  it  doubtless  escapes  medical 
observation  and  treatment  many  times,  being  regarded  by  the  parents  of  the 
affected  children  -imply  a-  a  "cold,"  while  in  reality,  from  etiologic  and 
pathologic   standpoints,   it   is  veritable  diphtheria,  differing  only   in  degree 

1  University  Medical  Magazine,  Oct.,  1896;  Medicine,  Nov.,  1896. 

57 


ACUTE  AFFECTIONS  OF  THE  NOSE. 

rather  than  in  kind.     Nevertheless,  •  is  not  justified  in  assuming  all  cases 

of  membranous  rhinitis  to  be  diphtheritic,  for  in  many  the  most  careful  search 
has  disclosed  only  cocci.  The  crucial  tesl  lies  in  the  microscopic  examination 
of  a  culture,  which  should  be  deemed  imperative  in  every  case. 

Pathology.—  The  structure  "I"  the  pseudo-membrane  is  similar  to  that 
which  occurs  elsewhere  in  diphtheria.  .Microscopically,  it  is  composed  of 
proliferated  epithelial  cells  in  a  fibrinous  network. 

Symptoms. — The  symptoms  are  much  the  same  for  both  types  of  the 
disease,  and  are  ushered  in  by  dryness  and  fulness  of  the  nostrils  with  per- 
sistent tickling;  later  there  is  a  free  discharge,  watery  at  first,  but  becoming 
thick  and  tenacious.  By  the  third  day  an  exudate  will  have  formed,  which, 
if  torn  away  l>y  forceps,  leaves  bleeding  points  and  soon  re-forms.  The  fibrin- 
ous deposit  may  occur  in  one  or  both  nostrils  and  may  embrace  any  or  all 
part-  of  the  passages,  extending  a  variable  distance  backward.  Jt  rarely 
embrace-  the  throat,  although  it  may  do  so;  or  rather  in  these  instances  it 
seems  to  originate  in  conjunction  with  acute  infectious  pseudo-membranous 
inflammation  of  the  faucial  and  post-nasal  tonsils.  Much  discomfort  ensues 
from  the  total  occlusion  of  one  or  both  nostrils  and  from  the  excoriation  and 
tumefaction  of  the  anterior  nares,  the  external  nose  and  upper  lip  being;  at 
time-  SO  Vid  and  swollen  a-  to  suggest  erysipelas.  In  fact,  it  is  likely  that 
the  micro-organism  of  erysipelas  may  be  one  of  those  capable  of  producing 
membranous  rhinitis.     These  conditions  are  well  exemplified  in 

///.     Dr.  I) had  been  exposed  by  attendance  upon  a  case  of  scarlet  fever 

with  membranous  deposil  in  the  pharynx,  lie  was  taken  ill  with  the  characteristic 
Bymptoms  of  acute  infectious  pseudo-membranous  tonsillitis.  Within  the  right  nostril 
was  observed  a  distinct  exudate  covering  the  vestibule,  cartilaginous  septum,  inferior 
turbinal  body,  and  other  parts  as  tar  a-  one  could  see.  It  differed  from  the  ideal  diph- 
theritic deposit,  being  thinner  ami  semi-translucent,  and  had  more  the  aspect  of  epithe- 
lial debris;  bul  was  evidently  not  merely  such.  The  nose  externally  was  swollen  and 
nt'  ;i  decidedly  erysipelatous  lute,  the  refine—  being  confined,  however,  and  not  extend- 
ing above  the  bridge  of  the  nose. 

Diagnosis.- — This  will  depend  upon  attention  to  the  salient  features 
already  described  ;  if  -ecu  late,  after  the  characteristic  appearances  have  sub- 
sided,  it  mighl  be  mistaken  for  simple  rhinitis  which  had  led  to  excoriation 
of  the  vestibule  or  for  secondary  syphilis.     Erysipelas  should  be  kept  in  mind. 

Prognosis. — The  disease  ha-  endured  usually  for  about  three  weeks;  nor 
ha-  this  period  varied  in  consequence  of  treatment,  although  the  comfort  of 
the  patient  i-  conserved  by  remedial  measures. 

Treatment. —  For  the  diphtheritic  type  of  membranous  rhinitis  antitoxin 
-hoiihl  be  injected,  provided  the  condition  assumes  a  degree  of  gravity.  One 
would  expect  this  to  ameliorate  the  condition  and  shorten  the  duration  of  the 
disease. 

For  the  non-diphtheritic  type  the  tincture  of  the  chlorid  of  iron  inter- 
nally be-t  meets  the  indications.  Locally  a  variety  of  medicaments  have 
been  used;  often,  however,  with  disappointing  results.  Cocain  in  "2  per 
cent,  t"  1  per  cent,  solution  fails  to  exert  it-  ciTstomary  degree  of  retraction  ; 
but  wisely  employed,  especially  l>\  mean-  of  cotton  tampons,  it  affords  relief 
and  i-  serviceable  preceding  the  application  of  other  remedies.  In  my  own 
cases,  following  the  cocain  I  have  applied  satisfactorily  by  tampons  this 
lotion  ; 

EL.      Re*  -leiii, 

<  >l.  amygdalae, 

<  1 1\  cerinse, 
Alcohol. 


gr.  xv 

1.; 

•"'ii 

1  li.  ; 

•"i.i 

S.   ; 

§»j 

10.— M. 

ABSCESS  OF  THE  NASAL  SEPTUM. 


899 


For  its  destructive  effects  upon  the  membrane  a  weak  solution  of  one 
of  the  iron  preparations  has  been  commended.  Loffler's  solution,  appropri- 
ately diluted  for  nasal  use,  might  be  substituted.  It  is  composed  as  follow-  : 
Menthol,  10  gm. ;  toluene,  q.  s.  ad.,  36  c.c.  ;  creolin,  2  c.e. ;  iron  chlorid 
solution,  4  c.c;  alcohol,  q.  s.  ad.,  100  c.c.  Medicaments  which  smart  and 
irritate  the  nostrils  for  any  length  of  time  had  better  be  avoided  or  their 
strength  reduced.  For  his  own  use  an  alkaline  and  antiseptic  spray  con- 
duces to  the  comfort  of  the  patient — e.  g. : 

fy.     Menthol, 

Ol.  eucalypti, 
Ol.  gaultheriae, 
Sodii  bicarbonatis, 
Sodii  boratis, 
Glycerini, 

Aquas,  q.  s.  : 

Sig. — To  be  diluted  by  adding  one  to  three  teaspoon  fuls  of  medicine  to 
an  ounce  of  water  for  a  spray. 

Abscess  of  the  Nasal  Septum. — The  condition  which  for  the  sake  of 
simplicity  in  nomenclature  is  designated  "abscess  of  the  septum"  only  occa- 
sionally presents  the  typical  characteristics  of  acute  circumscribed  suppura- 
tion. When  caused  by  traumatism,  the  first  stage  may  be  an  effusion  of 
blood  beneath  the  muco-perichondrium  of  the  cartilaginous  septum,  which  is 
termed  "  hematoma  of  the  septum."  In  time  the  blood  degenerates,  perhaps 
becomes  infected  by  pyogenic  micro-organisms,  and  changes  to  a  brownish- 


gr-  i 

.22; 

gr.  xv 

1.; 

gr.  xv 
3j 

f  iiss 

1-J 

4.; 
4.; 

4->.  ; 

f.siv 

120.— M. 

Fig.  569.— Abscess  of  the  septum,  protrurtins  bilaterally. 

yellow  fluid,  which  when  evacuated  appears  neither  like  bl 1   nor  typical 

pus.  In  this  State  it  has  been  called  "cold  abscess."  Ae/ain,  when  it  origi- 
nates without  traumatism  and  runs  an  acute  course,  with  pain,  fever,  and 
obstructive  swelling,  terminating  in  ideal  suppuration,  it  has  been  spoken  of 
as  "acute  perichondritis."  Jurasz1  has  described  a  form  in  which  the  con- 
tained fluid  is  at  first  serous,  termed  serous  perichondritis.  Some  sort  of 
abscess  is  the  culminating  stage  of  all  these  conditions  (see  page  1117). 

1  Journal  of  Laryngology,  etc.,  Nov.,  Is-'."'..  \>.  'JtiO. 


900  ACUTE  AFFECTIONS  OF  THE  NOSE. 

Although  it  might  be  possible  for  the  bony  portions  to  be  affected,  the 
usual  seal  of  the  disease  is  the  cartilaginous  pari  of  the  septum,  and  it  may  be 
cither  unilateral  <>r  bilateral. 

Etiology.— Tlir  mo-i  frequenl  cause  is  believed  to  be  traumatism — e.g. 
blows  or  falls  upon  the  uosej  yel  in  many  cases  it  is  impossible  to  establish 
this  relationship.  Slight  contusions,  readily  forgotten,  can  determine  a  hema- 
toma of  the  septum.  This  may  run  an  insidious  course,  endure  for  day-  or 
weeks,  and  undergo  spontaneous  absorption,  having  been  little  noticed  ;  but 
in  other  instances  the  blood  changes  to  sanguinolent  pus  and  the  cartilage 
itself  disintegrates,  the  absci — contents  being  retained  by  the  bulging  muco- 
perichondrium.  Pyogenic  micro-organisms  could  excite  suppuration  in  these 
and  also  in  so-called  idiopathic  cases  by  gaining  an  entrance  through  the 
excoriations  which  are  frequenl  on  these  surfaces.  The  disease  may  occur 
also  during  thr  course  of  typhoid  fever  or  small-pox  ;  and  Schech  '  calls 
attention  to  the  frequency  with  which  facial  erysipelas  proceeds  iron  1  abra- 
sions upon  the  septum,  and  infers  that  abscess  of  the  septum  can  be  caused  by 
infection  by  the  streptococcus  erysipelatus.  In  many  cases  still  it  is  quite 
impossible  to  assign  any  definite  cause.  This  was  true  in  the  following  case, 
which  is  a  typical  example  of  the  variety  termed  cold  abscess  : 

/.    -Master  (J ,  aged  sixteen  years,  while  away  from  home  at  school,  began 

to  suffer  from  nasal  obstruction,  which  he  attributed  to  an  acute  exacerbation  of  his  cus- 
tomary "  catarrh."  No  history  of  traumatism  could  be  elicited,  the  disease  having 
ingly  commenced  as  a  cold  and  continued  several  weeks  before  it  received  serious 
consideration.  Bui  nasal  obstruction  and  swelling  within  and  without  the  nose  gradu- 
ally grew  so  serious  that  he  was  sent  home,  where  he  was  confined  to  bed,  supposed  to 
be  suffering  from  asthma.  On  examination  the  diagnosis  was  at  once  apparent,  for  from 
each  Bide  of  the  septum  bulged  a  fluctuating  tumor  which  completely  blocked  both  nos- 
trils. The  enveloping  mucosa  was  unbroken,  somewhat  inflamed,  and  the  nose  generally 
reddened  and  edematous.  A  brownish-yellow  liquid  was  withdrawn  by  a  hypodermic 
Byringe,  and  this  was  followed  by  a  tree  incision  toward  the  base  of  one  side  and  gentle 
curetting  of  the  cavity.  The  central  portion  of  cartilage  had  liquefied;  but  it  redevel- 
oped from  the  muco-perichondrium  and  perfect  recovery  ensued. 

Symptoms. —  In  case  of  the  transition  of  a  hematoma  into  an  abscess,  the 
disease  may  manifest  itself  either  quite  insidiously  or  the  suppurative  change 
may  ensue  quickly  and  be  associated  with  sneezing,  general  nasal  irritation, 
and  slight  fever,  [n  either  evenl  the  salient  symptom  ultimately  complained 
of  will  be  obstruction  to  nasal  respiration,  together  with  the  discomforts  of 
i ith-breathing. 

When  the  abscess  arises  in  the  form  and  in  consequence  of  acute  peri- 
chondritis, it  is  ushered  in  during  a  i\-\v  days  l>v  symptoms  indicating  a  high 
degree  of  inflammation — e.  g.  chill,  pronounced  fever,  swelling  and  redness  of 
the  whole  organ.  Spontaneous  rupture  is  more  apt  t<>  occur  quickly  in  this 
than  in  the  former  type,  although  it  may  be  much  delayed  after  the  subsidence 
of  the  inflammatory  Bymptoms,  leaving  again  nasal  obstruction  as  the  salient 
-vmptoin. 

//.  exemplifies  the  latter  type.     Mr. ,  aged  twenty-six  years,  thought  he 

had  contracted  a  Bevere  "  cold  in  the  head.'  the  condition  commencing  with  chilly  sen- 
sations, followed  by  headache,  fever,  local  sensitiveness,  and  redness  extending  to  the 
bridge  of  the  nose.  These  symptoms  gradually  subsided,  bu1  were  replaced  by  nasal 
obstruction  and  whal  he  now  supposed  was  chronic  nasal  catarrh.  The  examination  was 
m.t  made  till  the  third  week,  when  a  fluctuating  tumor  was  observed  to  bulge  from  each 
of  the  Beptum.  Tj  pical  pus  was  evacuated  by  an  incision  and  the  cavity  curetted. 
The  destroyed  central  part  of  the  cartilage  ultimately  redeveloped  without  deformity. 
•  !>  positively  denied  the  leasl  probability  of  traumatism  as  a  cause. 

/'•   K  ■'  lU.it. a  .I.,  Mundhohle,  det  Rachena  und  der  Na  ■,  5  \utl.,  1896,  8.  298, 


ERYSIPELAS  OF  THE  NOSE.  901 

Diagnosis. — By  simple  inspection  with  the  bead  tilted  backward  the 
semicircular  tumor  may  be  seen  bulging  from  one  or  both  sides  of  the  septum 
(Fig.  569).  Palpation  by  a  probe  will  cause  deep  pitting  or  even  fluctuation, 
and  aspiration  by  a  hypodermic  needle  will  provide  a  sample  of  the  content-. 
It  may  thus  be  readily  distinguished  from  polypus,  for  which  it  is  mosl  com- 
monly mistaken  by  novices,  which  occurs  but  rarely  in  this  situation  ;  and 
also  from  syphilitic  gumma,  which  commonly  develops  at  just  this  spot.  I 
have  seen  one  case  of  gumma,  in  which  the  central  part  had  liquefied  before 
the  occurrence  of  superficial  ulceration,  in  which  the  diagnosis  would  have 
been   impossible  had  not  other   syphilitic  signs  been   present. 

Prognosis. — If  recognized  reasonably  early  and  the  abscess  evacuated, 
the  prognosis  is  very  good.  Notwithstanding  complete  liquefaction  of  the 
cartilage  itself,  if  the  muco-periehondrium  be  preserved  another  cartilaginous 
septum  will  develop,  and  this  usually  without  deformity.  However,  if  the 
disease  be  unrecognized  or  if  the  inflammatory  action  extend  to  the  antero- 
superior  border  of  the  septum,  the  line  of  junction  of  the  septum  with  the 
lateral  cartilages  and  nasal  bones,  softening  and  depression  of  these,  which 
constitute  the  dorsum  of  the  nose,  will  result.  Apart  from  this  "  saddle- 
back" deformity  or  in  conjunction  with  it,  perforation  of  the  septum  can 
also  ensue. 

Treatment. — When  the  initial  stage  is  a  hematoma,  cold  applications 
would  be  suitable.  In  any  event,  as  soon  as  pus  is  present  a  rather  free 
incision  should  be  made  low  down  on  one  side  and  the  contents  expressed. 
This  should  be  reopened  daily  with  a  probe  until  the  cavity  has  been  effaced. 
It  is  probably  not  necessary  to  curette,  wash  out,  or  pack  the  cavity  with 
gauze,  although  one  or  all  of  these  may  seem  desirable  at  times. 

Abscess  and  Furuncle  of  the  Nasal  Wing. — Furunculosis  of  the 
wing  of  the  nose  is  of  frequent  occurrence  and  results  commonly  from  infec- 
tion or  irritation  in  or  about  the  hair-follicles,  as  from  pulling  out  hairs. 
The  boil  is  usually  quite  small,  scarcely  more  than  a  "  pimple,"  but  is  accom- 
panied by  an  amount  of  tenderness,  swelling,  and  redness  of  the  nasal  ap- 
pendage quite  disproportionate  to- its  size.  It  points  inside  the  wing  of  the 
uose  in  a  position  difficult  of  observation  even  with  a  nasal  speculum,  but  it 
can  be  exposed  to  view  in  a  small  rhinoscopic  mirror  held  just  within  the 
vestibule.  Tt  should  be  punctured  as  soon  as  suppuration  is  evident.  a<  this 
will  abbreviate  materially. the  incidental  discomfort. 

Genuine  abscess  occurs,  but  much  more  rarely,  in  the  same  situation,  and 
may  lie  ascribed  to  similar  causes.  I  have  observed  but  few  cases  ;  in  one  of 
them,  however,  the  abscess  had  attained  the  size  of  a  hickory-nut.  with  large 
swelling  and  total  occlusion  of  the  nostril.  Laudable  pus  was  evacuated  by 
an   incision   made   from    within. 

L.  Wroblewski  '  mentions  having  seen  and  operated  upon  several  casesof 
abscess  of  the  wing  of  the  nose  occasioned  by  the  bacillus  anthrax  benignus. 

Erysipelas  Of  the  Nose. — Too  little  attention  has  been  drawn  to  the 
fact  that  so-called  idiopathic  facial  erysipelas  quite  commonly  originate- 
within   the   nose. 

Etiology. — The  cause  here,  as  elsewhere,  is  an  infection  by  the  strepto- 
coccus erysipelatus,  a  micro-organism  specific  to  erysipelas,  which  gains 
entrance  through  fissures  and  excoriations  which  frequently  affect  the  anterior 
nares  and  the  cartilaginous  septum  as  well  as  more  rarely  the  deeper  surfaces 
of  the  nasal  fossae.  Otherwise  trifling  intranasal  operation-  may  furnish  the 
responsible  gap,  and   it  is  even  possible,  although  not  proven,  that  infection 

1  Archivfur  Laryngologu  wad  Rhinologie,  ii  [orZweiter],  Band,  L895,  S.  "J'.'T. 


At  l  Ti:  AFFECTIONS  OF  THE  NOSE. 

may  occur  through  an  unbrokeu  surface.  <  tertain  persons  are  predisposed  to 
infection  on  the  slightesl  provocation. 

Symptoms. — The  affection  commences  like  an  acute  rhinitis  of  unusual 
severity.  The  temperature  runs  high,  there  is  total  occlusion  of  the  nostrils, 
a  profuse  excoriating  muco-purulenl  secretion,  swelling  with  erysipelatous 
redness  of  the  nasal  appendage,  and  later  an  extension  of  the  erysipelatous 
dermatitis  to  a  variable  distance  over  the  face.  In  like  manner  it  may  ex- 
tend posteriorly  to  the  naso-pharynx  and  pharynx  or  involve  the  collateral 
sinuses  of  the  nos< — a  combination  which  may  present  the  gravesl  aspect-. 
On  in-pecti.m  the  nasal  mucosa  appears  of  a  dusky-red  color,  or  it  maybe 
covered   by  a  thin   milky  exudate. 

Treatment. —  By  way  of  prophylaxis,  especially  with  those  who  have  a 
history  of  previous  attacks,  excoriations  and  fissures  should  receive  adequate 
attention  to  secure  prompt  healing  ;  all  operative  measures  not  strictly  neces- 
sary should  be  avoided  and  others  made  with  thorough  antiseptic  precautions. 

During  the  attack,  tor  internal  administration,  the  classical  remedy  for 
erysipelas,  tincture  of  the  chlorid  of  iron  in  doses  of  ten  minims  and  upward, 
has  not  been  successfully  superseded.  Locally,  for  intranasal  use,  sprays 
Nos.  1  and  2,  formulas  for  which  are  given  in  the  section  on  acute  rhinitis, 
servea  useful  purpose  ;  and  as  a  topical  application  for  the  excoriated  anterior 
Dares  and  inflamed  skin  surfaces,  the  resorcin  mixture  detailed  in  the  section 
on  membranous  rhinitis  can  he  commended. 

Bpistaxis — Nose-bleed. — Epistaxis  (epi  staxo,  to  flow  drop  by  drop) 
i-  a  hemorrhage  from  the  nose,  and  varies  in  degree  from  a  trifling  incon- 
venience to  an  occurrence  which  involves  grave  danger  to  life. 

Etiology,  Pathology,  and  Varieties. — 1.  Idiopathic. — Even  when  ap- 
parently spontaneous,  a  slight  traumatism  as  in  picking  the  nose  or  using  a 
handkerchief  roughly  may  he  the  exciting  cause.  The  bleeding  point  can  he 
anywhere  in  the  nasal  fossse  ;  hut  in  90  per  cent,  of  the  cases  by  actual  count l 
it  i-  found  just  within  the  nostril  on  the  cartilaginous  septum.  This  structure 
i-  richly  supplied  with  blood  by  the  anterior  artery  of  the  septum,  a  branch 
of  the  superior  maxillary,  and  in  copious  hemorrhages  it  may  be  the  artery  of 
the  septum  itself  or  some  of  it-  twigs  which  have  been  opened.     The  vessels 

are  | rly  protected  by  a  thin  mucosa,  ami  the  spot  is  much  subject  to  erosion, 

ulceration,  and  incrustation.  With  vessels  thus  ready  to  break  at  any  mo- 
ment, a  variety  of  local  and  constitutional  condition-  serve  to  excite  bleeding. 

It  i-  a  well-known  symptom  of  typhoid,  malarial,  and  pneumonic  fevers. 
It  i-  liable  to  ensue  upon  violent  exercise  or  to  accompany  "  rush  of  blood  t<> 
the  head,"  from  whatever  cause,  especially  in  plethoric  individuals  and  in 
per-. ,n-  affected  with  passive  congestion  of  the  venous  system  from  organic 
disease  of  the  heart,  liver,  or  kidneys,  and  during  pregnancy.  It  follows 
large  doses  of  quinin.  It  i-  of  course  a  symptom  in  ulcerative  syphilitic 
disease,  in  angioma  or  "  bleeding  polypus  of  the  septum/'  in  sarcoma,  carci- 
noma, ami  other  nasal  neoplasms.  I  n  elderly  persons,  if  recurrent  and  with- 
out other  cause,  it  indicates  an  ominous  degeneration  of  the  vessels.  This  I 
have  observed  in  the  case  of  an  aged  gentleman  who  had  hied  profusely  in 
■pile.,)'  remedies  and  through  the  packings  for  three  days,  when  careful 
examination   by  reflected   light  and  with  rapid  swabbing  disclosed  a  spurting 

alters    of   the  septum,   which   «:i-    in-taut  ly  sealed    by  electro-cauterization. 

Vicarious  epistaxis  is  a  substitution  of  nasal   hemorrhage  for  the  natural 
menstrua]   flow,  and  occurs  at   time-  of  acute  suppression  of  the  menstrual 
function  or  of  it-  difficult  establishment  about  the  age  of  puberty  and  during 
1  i  hiari  and  Baomgarten,  i  ited  by  Boeworth  i  Dueaset  <•/  the  Nm  <""/  Throat,  vol.  i.  p.  312. 


r.ris  r.  i  xts—nose-bl  /■:/:/).  903 

the  menopause.  Doubtless  in  these  cases,  also,  there  is  a  weakness  or  erosion 
of  the  vessels  of  the  septum,  which  are  unable  to  withstand  the  hyperemia  of 
the  head  which  results  during  perversion  of  menstruation.  The  menstrual 
molimen,  including  the  congestive  headache,  is  relieved  by  the  vicarious 
epistaxis,  which  within  reasonable  limits  may  be  regarded  as  beneficial  rather 
than  detrimental.  In  one  case  cited  by  Frankel,1  however,  the  recurrent 
nasal   flow  was  so  profuse  that  a  fatal   termination  endued. 

2.  TraumaMc. — Hemorrhage  following  fractures  and  other  intranasal  ac- 
cidents,  while  profuse  for  a  short  time,  commonly  ceases  spontaneously.  If 
persistent  in  spite  of  packing,  it  indicates  an  injury  to  neighboring  parts. 
Serious  bleeding  has  occasionally  resulted  from  otherwise  trifling  intranasal 
operations — e.  f/.  removal  of  spurs  from  the  septum,  cauterization  of  the 
conchas,  etc.,  so  that  means  to  cope  with  this  contingency  should  be  provided 
and  operations  possibly  declined  on  persons  from  whom  a  bleeding  history  is 
elicited. 

Symptoms. — Only  the  premonitory  symptoms  of  those  subject  to  habitual 
epistaxis  require  special  mention.  Patients  complain  of  vertigo,  tinnitus, 
temporal  throbbing,  a  sense  of  cerebral  pressure  and  headache,  while  the 
cheeks  are  flushed  and  the  conjunctivae  injected.  They  are  gratified  at  the 
bleeding  for  the  relief  which  it  brings. 

Diagnosis. — In  the  absence  of  actual  hemorrhage  only  a  careful  search 
and  palpation  with  a  probe,  at  the  risk  of  exciting  bleeding,  will  disclose  the 
responsible  vessels. 

Treatment. — Most  attacks  cease  spontaneously  inside  of  half  an  hour. 
Simple  expedients  are:  the  superficial  plugging  of  the  nostril  with  cotton, 
pressure  of  the  nasal  wing  against  the  septum,  the  insertion  of  a  finger  into 
the  bleeding  nostril,  ice  applied  to  the  side  of  the  nose  and  held  in  the  mouth, 
the  application  of  ice  in  small  pieces  within  the  nostrils,  ice  to  the  back  of 
the  neck  and  along  the  spine  for  its  reflex  action,  the  injection  of  hot  water, 
120°  F.,  or  spraying  of  hot  vaselin  into  the  nose,2  damming  of  the  blood 
into  the  general  venous  system  by  constriction  of  the  extremities  near  the 
trunk  by  straps  or  handkerchiefs,  and  the  administration  internally  of  a 
mixture  of  gallic  acid,  antipyrin,  and  fluid  extract  of  ergot. 

Spraying  the  nostril  by  strong  astringent  solutions  of  tannic  acid.  iron,  or 
alum  is  seldom  effective  and  is  objectionable  on  account  of  the  irritation  pro- 
duced, although  the  insufflation  of  powdered  matico  is  generally  commended. 
A  better  and  really  effective  spray  is  composed  of  4  per  cent,  solution  of 
cocain  in  2  per  cent,  solution  of  antipyrin,  materials  which  act  as  powerful 
vessel-constrictors.  After  spraying,  a  pledget  of  cotton  soaked  in  peroxid 
of  hydrogen  may  be  introduced  well  into  the  nostril,  the  pressure  from  the 
liberated  gas  in  all  directions  assisting  in  the  formation  of  a  clot. 

Really  serious  cases  are  prone  to  resist  all  of  these  measures,  and  then  one 
musi  either  locate  the  bleeding  vessel  by  rapid  swabbing  and  cauterize  it  by 
electricity,  chromic  acid,  or  nitrate  of  silver,  named  in  the  order  of  desirabil- 
ity, or,  in  case  the  hemorrhage  is  too  profuse  to  permit  of  this  procedure,  or  it' 
for  other  reasons  it  cannot  be  accomplished,  one  should  pack  the  nasal  fossa 
from  front  to  back  with  H>  percent,  moisl  iodoform  gauze.  This  is  besi 
done  by  a  slight  modification  of  the  plan  firsl  proposed  by  Dr.  E.  Fletcher 
Ingals.'  Two  strips  of  double-thickness  gauze,  each  two  feet  in  length  and  a 
full  inch  in  width,  are  prepared,  and  near  t  he  distal  end  of  each  (the  end  lir-t 

1  '/.i  Cyclopedia,  vol.  iv.  p.  152. 

*Frank  M.  Rnmbold:    The  Laryngoscope,  L896. 

3  !■'..  Fletcher  [ngals:   hi, >,,.<,-  ,,f  il„-  (just,  Throat,  ■  ml  Sa  al  Cavitu  .  | 


904  ACUTE  AFFECTIONS  <)E  THE  NOSE. 

to  be  inserted)  a  strong  thread  is  tied.  The  first  strip  is  passed  through  the 
inferior  meatus  to  the  naso-pharynx,  fold  after  fold  being-  pushed  in  until  the 
Lower  channel  is  full.  The  second  -nip  is  passed  in  like  manner  well  into  the 
middle  meatus,  and  traction  is  then  made  on  the  threads  in  order  firmly  to  pack 
the  gauze  at  the  rear  end,  the  surplus  of  gauze  in  front  is  cut  oil*  and  the 
threads  anchored  to  a  padded  stick  across  the  nostril.  In  narrow  nostrils 
there  may  be  room  to  manipulate  but  one  strip  of  gauze,  and  this  will  then 
suffice.  The  point  is  thai  the  gauze  shall  be  placed  as  far  backward  as  the 
naso-pharynx   and   nol    merely   -tuck   in   front. 

Plugging  the  posterior  nares  is  a  common  resort  for  obstinate  epistaxis  \ 
but  it  is  liable  to  provoke  inflammation  of  the  middle  ear,  mastoiditis,  and 
brain  complications.  I  have  seen  a  patient's  life  placed  in  jeopardy  thereby, 
and  am  firmly  of  the  opinion  that  posterior  plugging  should  be  avoided 
whenever  possible.  A  substitute  is  found  in  the  above-described  method  of 
packing  the  nose  from  in  front,  which  will  suffice  for  all  cases  of  strictly 
nasal   hemorrhage. 

When,  however,  the  bleeding  i-  from  the  naso-pharynx  itself,  as  from  the 
removal  of  "adenoids"  or  tumors  or  from  operations  on  the  posterior  ends 
of  the  turbinated  bodies,  it   may  he  necessary  to  plug  posteriorly. 

A  wad  of  iodoform  gauze,  adapted  in  size  either  to  lit  well  into  the 
choana  or  to  fill  in  part  the  naso-pharynx,  according  to  the  location  of  the 
bleeding  point,  is  tied  across  the  middle  by  strong  double  silk  thread.  A  soft 
catheter  i-  passed  through  the  nose,  and  to  its  end,  picked  from  the  pharynx 
h\  forceps,  one  double  thread  is  tied,  and  the  plug,  assisted  by  a  linger  around 
the  velum,  i-  thus  drawn  into  the  naso-pharynx.  These  threads  are  best 
anchored  to  a  -mall  padded  stick  across  the  anterior  nares.  The  other  string 
end-,  or  niie  of  them,  is  maintained  through  the  mouth  as  "a  leader"  by 
which  to  detach  the  plug.  The  posterior  packing  should  not  remain  longer 
than  twenty-four  to  thirty-six  hours  without  removal.  A  still  less  septic 
plug  and  one  perfectly  -oft  and  globular  can  be  prepared,  a-  suggested  to  me 
1>\  Dr.  Ethan  A.  Gray,  by  making  it  double,  as  it  were,  one  layer  inside  the 
other,  the  strings  being  secured  around  the  inner  kernel  and  both  layers  being 
covered  by  thin  rubber  cloth.  Thus  I  have  saved  the  life  of  one  patient  who 
required  packing  for  :i  period  of  five  weeks. 

Note.  Other  acute  diseases  of  the  nose,  primary  and  secondary  syphilis,  nasal 
diphtheria,  acute  sinusitis  of  the  maxillary,  frontal,  ethmoid,  or  sphenoid  cavities,  and 
traumatism  will  be  considered  in  tin-  respective  chapters  devoted  to  these  conditions 
as  a  w  hole. 


CHRONIC  AFFECTIONS  OF  THE  NOSE. 

By   MORRIS  J.  ASCH,   M.  D., 

OF    NEW    YORK    CITY. 


Chronic  hypertrophic  rhinitis  is  a  condition  of  the  nasal  passages  char- 
acterized by  hypertrophy  of  the  mucous  membrane  covering  the  turbinal 

bodies,  by  enlargement  of  the  bodies  themselves,  and  by  outgrowths  from 
the  septum  or  floor  of  the  nose,  which  may  result  from  local  or  constitutional 
causes. 

Etiology. — Chronic  hypertrophic  rhinitis  may  follow  repealed  attacks 
of  acute  rhinitis,  whether  they  result  from  exposure,  unhygienic  surround- 
ings, or  from  unhealthy  occupations.  Printers  and  workers  in  chemical-  or 
in  trades  where  dust  abounds  are  particularly  liable  to  the  affection,  as  the 
particles  thus  inhaled  aggravate,  if  they  do  not  cause,  it  ;  while,  in  addition, 
there  is  the  class  of  workmen  exposed  to  both  climatic  changes  and  dust — 
such  as  dock-laborers  and  workers  in  saw-mills — who  are  frequent  sufferers 
from  the  disease. 

The  condition  is  not  of  rapid  development,  but  come-  on  gradually,  atten- 
tion being  called  to  it  by  the  resulting  inconvenience.  Some  are  peculiarly 
liable  by  reason  of  temperament,  especially  neurotic  individuals.  Constitu- 
tional causes  are  gout  and  defective  nutrition.  Lithemic  patients  are  prone 
to  this  affection  along  with  other  diseases  of  the  throat  and  nose  met  with  in 
gouty  subjects.  Broken-down  constitutions,  whether  resulting  from  syphilis, 
or  from  defective  nutrition  following  acute  disease,  or  anv  depressing  cans*  — 
such  as  insufficient  nourishment  and  poor  surroundings — are  easy  victims  of 
chronic  rhinitis.  Leukemia,  malaria,  and  scrofula  are  all  factors  in  its  causa- 
tion, but  although  chronic  hypertrophic  rhinitis  occurs  mainly  in  those  of 
poor  constitution,  yet  in  persons  otherwise  healthy  an  acute  catarrh  may, 
under  external  influences,  become  chronic  and  give  rise  to  the  pathological 
changes  peculiar  to  this  disease.  It  has  been  observed  as  the  resull  of  grip, 
and  i-  said  to  occur  sometimes  after  medication  with  iodin  and  mercury. 
Irritation  caused  by  obstruction  of  the  nasal  passage,  deviation,  spurs,  or  by 
the  '"narrow  nose"  of  Storck,  may  produce  chronic  hypertrophic  rhinitis,  or 
by  causing  a  passive  hyperemia  aggravate  it  when  resulting  from  any  consti- 
tutional cause. 

Pathology. — The  prominent  condition  in  chronic  hypertrophic  rhinitis 
is  hypertrophy  of  the  turbinal  bodies  and  of  the  mucous  membrane  covering 

them.     This  membrane  is  richly  supplied  with  bl l-vessels,  and  especially 

veins.  It  is  elastic,  and  therefore  erectile,  and  forms  with  the  submucous 
layer  true  corpora  cavernosa,  which  fill  or  collapse  according  as  they  are  sup- 
plied with  or  emptied  of  blood.  When  the  walls  of  the  venous  canal-  become 
thickened  through  hypertrophy  and  lose  their  elasticity,  the  enlargement  he- 
come-  permanent.     Wingrave1  -ays  that  the  condition  is  noi  a  mere  hyper- 

1  ./mini.  <;/'  laryngoL,  1  39  I 

905 


(  HRONIC  AFFECTIONS  OF  THE  NOSE. 

trophy  of  the  structure,  bul  consists  of  a  true  degeneration  and  infiltration  of 
the  walls  of  these  vascular  spaces;  the  walls  gradually  losing  their  power  of 
active  recoil,  the  vessels  become  more  and  more  distended  and  a  permanent 
enlargement,  which  is  in  fact  a  varix,  ensue.-. 

In  the  firsl  stage  of  the  disease  the  turbinal  borders  are  greatly  enlarged 
and  the  mucous  covering  sofl  and  sodden,  yielding  without  elasticity  to  the 
pressure  of  a  probe.  There  is  a  decided  cellular  infiltration  of  the  epithelium 
and  subepithelial  tissue,  especially  about  the  glands  and  vessels. 

The  epithelial  cells  are  increased  in  Dumber,  the  upper  layers  becoming 
flattened  or  cuboidal,  while  the  ciliated  cells  are  preserved  only  to  a  slighl 
extent.  The  venous  channels  are  distended  in  the  deeper  portions.  After  a 
time  the  swelling  of  the  mucous  membrane  becomes  more  marked  and  there 
i-  a  change  from  diffuse  infiltration  to  a  circumscribed  thickening.  The  ap- 
pearance of  the  parts  now  indicates  a  fibrous  change,  and  the  surface  of  the 
turbinals  may  become  irregular  from  want  of  uniformity  in  the  swelling. 

The  inferior  turbinal  is  the  part  usually  enlarged,  especially  in  its  posterior 
extremity.  The  anterior  extremity  is  also  frequently  affected,  while  it  is  very 
rare  to  find  enlargemenl  only  of  the  middle  portions.  These  circumscribed 
infiltrations  sometimes  appear  as  true  growths  of  varying  color — sometimes 
purple,  indicating  great  vascularity — sometimes  whitish  because  of  prepon- 
derating connective  tissue  and  thickening  of  the  epithelium. 

The  surface  is  frequently  s >th,  as  in  ordinary  nasal  mucous  membrane; 

at  other  time-  papillary  hyperplasia  is  so  strongly  developed  as  to  give  rise  to 
a  mulbeny-like  appearance.  Not  infrequently  myxomatous  changes  occur, 
especially  a1  the  anterior  extremity  of  the  inferior  turbinals,  while  papillary 
degeneration  is  mosl  frequently  observed  in  the  posterior  hypertrophies. 
Lmcr  on  we  find  cartilaginous  and  bony  outgrowth  from  the  septum  and 
floor  of  the  nose,  which  ly  obstruction  to  respiration  and  by  pressure  act 
injuriously. 

Posteriorly  the  ends  of  the  inferior  turbinals,  when  enlarged,  are  usually 
dark  red,  although  sometimes  white  in  color,  with  a  surface  varying  in  ap- 
pearance, sometimes  smooth  and  rounded,  but  often  rough,  irregular,  and 
mulberry-like,  and  occasionally  they  protrude  into  the  naso-pharynx  so  as  to 
interfere  with  the  functions  of  the  Eustachian  tubes.  The  middle  turbinals 
are  also  the  seal  of  these  hypertrophies,  as  is  also  the  floor  of  the  nose  and 
the  sides  of  the  septum.  The  pharyngeal  tonsil  will  often  be  found  enlarged. 
Later  in  the  disease  all  these  morbid  conditions  become  more  marked. 
The  hypertrophic  tissue  becomes  more  dense ;  and  in  addition  to  the  tur- 
binal enlargements   we   have  ecch (roses   from   the  septum  and   exostoses 

from  the  anterior  nasal   spine  of  the  superior  maxillary   hone. 

The  middle  turbinals  -how  a  hard,  resisting  surface,  filling  the  whole 
meatus,  tightly  pressed  against  the  septum  ;  although  frequently  the  mucous 
membrane  covering  them  becomes  the  seal  of  a  myxomatous  degeneration, 
giving  rise  to  masses  which,  from  their -oft  and  gelatinous  appearance,  may 
be  mi-taken  for  polypi. 

( >n  the  posterior  portion  of  the  3eptum  there  are  thick-  cushion-like  swell- 
ings of  the  same  color  as  the  surrounding  mucous  membrane,  and  from  the 
floor  of  the  nose  and  from  the  posterior  extremity  of  the  inferior  turbinals 
appear  firm  elastic  hypertrophies,  usually  lighl  in  color,  either  smooth  or 
papillan  d.  although  when  their  surface  is  rough  they  are  frequently  oi  a 
darker  hue.     When  the  hypertrophies  appear  on  the  septum  they  are  often 

symmetrical  in  both  nostrils.        The  vault  of  the    pharynx  and    the    larynx  are 

usual h  involved  in  the  last  stage  of  the  affection. 


SYMPTOMS.  907 

Symptoms.  —  In  the  first  stage  of  the  disease  the  symptoms  are  those 
of  ordinary  catarrh.  The  secretion  in  most  eases  is  thick  and  scanty,  con- 
taining large  quantities  of  mucin.  It  is  muco  purulent,  and  on  account  of 
its  toughness  dries  most  readily  and  appears  as  odorless  yellow  and  yellow- 
ish-green crusts  on  the  walls  of  the  nasal  cavity  and  at  its  entrance.  In  rare 
cases  the  secretion  is  free,  thin,  and  serous,  as  in  acute  catarrh. 

The  principal  symptom,  however,  and  the  one  most  complained  of,  is  thai 
of  more  or  less  nasal  obstruction,  the  degree  varying  with  the  size  of  the  -well- 
ing and  the  character  and  quantity  of  the  secretion.  Accompanying  this  is 
the  discomfort  produced  by  the  accumulation  of  secretion  in  the  naso-pharynx, 
where  it  either  dries  and  is  hawked  out  with  difficulty,  or  is  expectorated  or 
swallowed.  There  is  fulness  of  the  head,  especially  in  the  frontal  region 
and  over  the  eyes,  frequently  followed  by  severe  migraine  ;  in  addition  there 
is  a  sense  of  dryness  of  the  tongue  and  throat,  which  is  almost  continuous. 
The  secretion  of  mucus  in  the  throat  is  abundant  in  the  mornings,  and  fre- 
quently the  patient  vomits  in  the  effort  to  be  rid  of  it. 

A  common  fact  noticed  is  the  filling  of  the  hypertrophied  turbinal  with 
blood  by  gravitation.  It  frequently  happens  that  when  a  patient  lies  on  the 
side  the  corresponding  hypertrophied  part  will  be  distended,  while  bending 
the  head  forward  will  cause  occlusion  of  both  sides  ;  a  reversal  of  position 
will  favor  the  return  of  the  blood  and  the  restoration  of  function  of  the  part. 

Mouth-breathing,  with  all  its  attendant  evils,  is  a  prominent  feature  of 
the  disease,  and  a  nasal  twang  to  the  voice  is  a  common  accompaniment. 
The  sense  of  smell  is  affected,  and  frequently  complete  anosmia  results,  in 
which  case  the  sense  of  taste  is  also  impaired.  As  a  result  of  the  attempt  to 
clear  the  nose  of  adherent  secretion,  small  hemorrhages  occur ;  and  the  fre- 
quent use  of  the  handkerchief  often  gives  rise  to  painful  eczemas  at  the 
nasal  orifices. 

When  the  middle  turbinals  are  involved,  frequent  and  severe  frontal 
headaches  occur,  the  result  of  pressure  on  the  nasal  branch  of  the  fifth  pair. 
Pharyngitis,  laryngitis,  and  bronchitis  are  also  present  as  the  result  of  the 
nasal  lesion.  Most  common,  however,  as  the  result  of  the  obstruction  of  the 
nasal  passage  we  find  affections  of  the  ear.  Chronic  catarrh  of  the  middle 
ear  and  of  the  Eustachian  tubes  are  frequent  sequelae,  while  tinnitus  and 
vertigo  also  occur. 

The  eyes  also  suffer  as  a  result  of  hypertrophic  catarrh.  Conjunctivitis 
is  not  uncommon.  In  asthenopia  with  headache,  where  correction  of  refrac- 
tion has  not  cured,  the  cause  has  often  been  found  to  be  in  an  enlarged  mid- 
dle turbinal  body,  the  removal  of  which  relieved  all  the  symptoms. 

Among  other  symptoms  due  to  hypertrophic  rhinitis  are  reflex  neuroses  ; 
not  very  common,  it  is  true,  but  still  sufficiently  so  to  warrant  our  examining 
the  nasal  cavities  for  their  probable  cause.  Hay  fever  is  often  relieved  by 
the  removal  of  hypertrophied  tissue  on  the  inferior  or  middle  turbinated 
bodies.  Schech  speaks  of  a  nervous  catarrh  of  similar  origin  where  a  thin, 
clear,  and  extremely  profuse  secretion  makes  its  appearance  suddenly  and  at 
intervals,  associated  with  diminution  or  loss  of  smell,  obstruction  of  t lie  nose, 
and  violent  sneezing.  These  attacks  last  several  hours,  and  arc  most  frequent 
at  the  menstrual  period-.  Vasb-motor  disturbances  are  nol  uncommon. 
Reddening  and  -welling  of  the  face  and  conjunctiva  often  appear  on  the 
slightest  irritation,  and  disappear  as  suddenly,  leaving  no  trace. 

Asthma  is  the  mosl  common  of  the  reflex  disturbances  in  hypertrophic 
rhinitis.  It  usually  comes  on  during  sleep,  and  may  be,  as  suggested  by 
Schech,  the  direct  consequence  of  irritation  of  the  vagus — the  result  of  dis- 


CHRONIC  AFFEl  TIONS  OF  THE  NOSE. 

eased  nasal  mucous  membrane.  Too  much  stress,  he  thinks,  lias  been  laid 
mi  the  pan  the  spongy  tissue  play-  in  the  origin  of  nocturnal  asthma,  though 
ii  certainly  is  a  factor  in  its  production. 

Other  reflex  symptoms  thai  have  been  observed  are  aphonia,  laryngeal 
spasm, and  supra-orbital  and  facial  neuralgias.  Spasmodic  cough  is  not  infre- 
quently found  i"  be  the  result  of  intranasal  pressure,  and  1  have  often  re- 
lieved a  cough  of  long  standing  by  removal  of  the  hypertrophied  turbinal 
body. 

'it  has  been  my  experience  thai  asthma  and  hay  fever,  when  they  can  he 
referred  to  the  nose,  depend  upon  the  hypertrophy  of  the  inferior  turbinals; 
while  neuralgias  and  headaches  were  as  invariably  the  result  of  pressure  of 
the  middle  turbinal  on  the  septum.  Epileptic  attacks  and  vertigo  may  be 
also  included  among  the  affections  induced  by  this  disease.  It  will  be  seen, 
then,  thai  the  results  of  a  diseased  condition  of  the  intranasal  regions  may 
produce  complications  far  beyond  the  local  trouble  in  sight  ;  and  bearing  this 
in  mind,  the  ophthalmic  or  aural  surgeon  of  to-day  can  scarcely  be  said  to 
have  made  a  thorough  examination  of  a  patient  when  the  na>al  cavities  have 
nor  Keen  included.  It  i-  very  certain  that  the  presence  of  spurs,  hypertro- 
phies, and  deviations  play  a  very  considerable  pari  in  the  production  of 
catarrhal  troubles  both  of  the  eye  and  ear.  Affection  of  the  lachrymal  ducts, 
keratitis,  purulent  dacryocystitis,  and  impaired  vision,  together  with  all  the 
distressing  symptoms  that  belong  to  mouth-breathing,  as  anxiety  at  night, 
disturbed  sleep,  dryness  of  the  pharynx,  larynx,  and  trachea,  with  sometimes 
resulting  inflammation,  disordered  digestion,  and  mental  dulness,  all  these 
may  follow  the  condition  of  the  nostrils. 

Externally  we  may  have  eczema  of  the  nostrils,  the  result  of  irritation, 
sycosis  from  the  <•« >nstan1  maceration  of  the  upper  lip,  pustules,  erysipelas, 
and  redness  at  the  tip  of  the  uo-e  from  engorgement,  the  swollen  spongy 
tissue   preventing  a   return  of  the  blood. 

When  we  examine  a  patient  we  find  appearances  varying  with  the  stage 
of  the  disease.  In  its  firsl  stage  the  nostril  is  more  or  less  occluded  ante- 
riorly by  an  enlarged  inferior  turbinal  body,  which  is  either  red  or  normal  in 
color.  The  enlargement  is  spongy  and  elastic,  and,  although  usually  occu- 
pying the  anterior  extremity  of  the  inferior  turbinal,  it  may  also  he  found 
to  involve  the  middle,  causing  it  to  press  against  the  septum.  Hypertrophy 
of  the  inferior  turbinal  can  he  temporarily  reduced  by  pressure  with  a  flat 
probe,  the  enlarged  sinuses  emptying,  but  immediately  filling  again.  This 
rapid  resumption  of  shape  tend-  to  distinguish  the  hypertrophic  from  the 
chronic  form  of  rhinitis  where  pressure  by  a  probe  -imply  displaces  a  certain 
amount  of  infiltration. 

Cocain  in  from  2  to  .">  pei  cent,  solution  has  the  same  effect  in  rapidly 
contracting  the  spongy  tissue,  bu1  doe-  not  entirely  dissipate  it-  tumefaction. 
Those  swellings  that  disappear  entirely  under  cocain  belong  to  simple  chronic 
rhinitis,  and  not  to  the  hypertrophic  variety. 

Diagnosis. — There  should  lie  no  difficulty  in  making  a  diagnosis  of  this 
affection.  The  only  disease  with  which  it  might  be  confused  is  nasal  polypus, 
hut  the  u-e  of  the  sound  ami  of  cocain  should  easily  differentiate  the  two 
conditions.  An  important  point  when  making  the  diagnosis  is  to  ascertain 
whether  the  hypertroph)  Ifi  primary  or  due  to  a  constitutional  cause,  such  as 
syphilis,  a-  this  ha-  an   important   bearing  on  tin    prognosis  and  treatment. 

The  prognosis  i-  'jo<.d  it'  there  are  no  complications. 
Treatment.      In  the  first   stage  of  the  disease  the  treatment  should  he 
mild,  attention  paid  to  hygienic  surroundings,  the  nasal   passage  protected 


TREATMENT.  909 

from  vitiated  atmosphere,  and  in  some  cases  removal  to  another  climate 
recommended.  Excess  of  any  kind  must  be  prohibited,  and  any  constitu- 
tional vice  which  might  be  a  factor  in  producing  the  disease  is  to  be  sought 
for  and  eradicated,  it'  possible. 

It  i<  astonishing  how  much  good  can  be  done  in  the  first  stage  of  the  dis- 
ease simply  by  attention  to  the  ordinary  laws  of  health.  The  local  treatment 
must  be  unirritating.  At  first  only  the  simplest  remedies  should  be  used,  by 
means  of  the  spray  or  irrigation,  by  the  nasal  douche,  the  nasal  douche-cup, 
and  insufflation  of  appropriate  solutions  through  the  anterior  nasal  passage 
into  the  pharynx.  The  spray,  many  formulae  for  which  are  in  constant  use, 
should  be  applied,  if  the  application  be  made  by  the  patient  himself,  by 
mean-  of  the  hand-hall  atomizer  such  as  is  usually  sold  in  the  -hop-,  provided 
with  a  blunt  nozzle  to  prevent  injury  to  the  nostril.  \\  hen  the  spray  is  used 
by  the  physician  in  his  office,  compressed  air  is  usually  the  motive  power, 
contained  in  a  cylinder  rilled  by  means  of  a  hand-pump,  although  the  pump- 
ing may  be  done  by  means  of  water-power  or  an  electric  motor.1 

While  I  am  accustomed  to  use  the  spray  in  the  treatment  of  chronic 
rhinitis,  I  do  not  look  upon  it  as  a  curative  measure,  except  in  very  slight 
and  recent  cases,  when  the  clearing  away  of  secretion  gives  the  affected  mucous 
membrane  an  opportunity  to  regain  its  normal  condition.  I  do  find  the 
spray  very  useful,  however,  when  the  pressure  is  raised  to  forty  pounds,  to 
wash  away  crusts  from  the  posterior  nares  and  especially  from  the  vault  of 
the  pharynx — so  much  so  that  I  have  never  had  occasion  to  use  a  posterior 
nasal  syringe  for  the  purpose.  In  atrophic  cases  of  long  standing,  where  the 
secretion  is  very  adherent,  I  have  sometimes  made  use  of  dry  cotton,  wrapped 
on  an  applicator  bent  at  a  right  angle,  to  remove  it,  but  usually  the  force  of 
the  spray  is  sufficient.  If  the  force  of  the  spray  is  increased  gradually  there 
is  no  discomfort,  nor  is  any  injury  inflicted  either  in  the  nostrils  or  the 
Eustachian  tube.  A  very  slight  stain  of  blood  may  follow  the  application. 
but  there  is  no  epistaxis  nor  any  consequence  to  alarm  the  patient. 

The  solution  used  in  the  atomizer  varies  rather  with  the  fancy  of  the 
operator  than  with  the  exigency  of  the  case,  for  any  detergent  alkaline  fluid 
may  be  used.  Normal  salt  solution,  boric  acid  gr.  x  to  5]  aq.,  Dobell's  solu- 
tion with  the  addition  of  listerin,  or  a  combination  with  thymol-menthol 
and  eucalyptol  as  in  Seller's  tablets,  are  all  in  frequent  use.  Sajous  recom- 
mends a  solution  of  bicarbonate  of  soda  and  borax,  da  gr.  viij  ;  ext.  fluid,  pini 
canaden-is,  ]]\  xv  ;  glycerin,  ~ij  :  aquas  ad,  siv.  Alum  1  or  '2  grains  to  aq. 
oj  is  used  ;  but  in  common  with  the  salts  of  zinc  and  lead  is  said  to  produce 
anosmia. 

Of  more  importance  than  -prays  in  their  curative  properties  are  applica- 
tions made  locally  to  the  affected  membrane.  Nitrate  of  silver  is  probably 
the  most  efficient  of  all  the  simple  applications  :  it  can  be  applied  in  strengths 
of  two  to  ten  grains  to  the  ounce,  but  should  never  exceed  this.  It  must  be 
used  with  regularity,  a-  an  occasional  application  of  it  is  of  no  advant 

'In  my  clinic  al  the  New  Y<>rk  Eye  and  Ear  [nfirmary,  where  sprays  are  largely  used  ;is 
cleansers  in  all  cases  of  nasal  disease,  every  table  ;it  which  a  Mir<_renn  is  seated  is  supplied  with 
a  rubber  tube  which  connects  with  an  atomizer  by  means  of  a  bayonet  joint.  The  compressed 
air  is  forced  into  a  large  cylinder  in  the  basemenl  of  the  institution  by  means  <>f  an  air-com- 
pressing engine  driven  by  steam,  which  is  in  constanl  action  during  the  service  of  the  clinic 
A  safety-valve  on  the  cylinder,  usually  sel  al  forty  pounds,  prevents  tin-  pressure  ever  rising 
beyond  this  point.  The  cylinder  connects  by  means  of  an  iron  tube  with  the  clinic-room,  where 
it  i<  distributed  to  each  of  the  tables  at  which  patients  are  treated.  In  consequence  of  the  dis- 
tance traversed  by  the  tubes  some  of  tin-  pressure  is  I"<t  before  reaching  the  operator,  -"  that 
the  spray  i-  usually  made  at  a  pressun  of  about  thirty  pounds,  which  is  the  strength  I  find 
rno-t  convenient,  but  which  can  he  -till  further  modified  by  the  cut-oft' regulating  the  spray. 


910  CHRONIC  AFFECTIONS  OF  THE  NOSE. 

Storck  objects  t"  its  use  in  consequence  of  the  stains  it  sometimes  produces 
on  the  exterior  of  the  nose,  and  of  the  disagreeable  sensation  resulting.  It 
should  never  be  used  as  a  spray,  but  applied  carefully  with  a  piece  of  lint 
wound  on  the  extremity  of  a  fine  nasal  applicator  there  should  be  no  external 
mark,  and  any  disagreeable  sensation  resulting  can  easily  be  relieved  by  the 
snuffing  up  of  a  little  salt  water.  There  is  a  possibility  that  a  pocket  hand- 
kerchief used  jusl  after  the  application  may  be  stained.  This  can  he  guarded 
against  by  giving  the  patient  a  Japanese  paper  handkerchief  to  use  for  a  little 
time  after  the  treatment.  I. -din  and  glycerin  made  according  to  the  follow- 
ing formula  :  Eodini,  gr.  yj  ;  iodidi  potassii.,  gr.  xij  ;  glycerinae,  aqua?,  <1<~'  §j,  is 
an  application  of  great  value. 

ftrieg  recommends  soziodal  of  soda  and  menthol  in  lanolin  and  vaselin: 
Sodii  soziodal,  menthol,  da  gr.  xv  ;  lanolin,  §ss  ;  vaselin,  §j,  to  be  used  as  an 
ointment.  Resorcin  in  10  per  cent,  solution  has  been  recommended  as  an 
efficient  application,  ami  a  host  of  other  astringent  and  alterative  substances 
which  too  often  fail  to  accomplish  the  good  result  promised.  Powders  are 
used  by  some  writers,  insufflated  into  the  nostril,  hut  they  more  frequently 
clog  the  passages  and  produce  irritation  than  bring  relief.  They  are  to  be 
used,  if  at  all,  when  the  discharge  is  profuse.  Camphor,  tannin,  bismuth, 
iodoform,  subnitrate  of  bismuth,  and  borax,  all  have  been  used  in  this  way, 
either  snuffed  up  into  the  nose  or  blown  in  by  an  insufflator.  I  am  inclined 
to  believe  that  more  harm  than  good  is  produced  by  this  method  of  nasal 
medication,  except  when  there  happens  to  he  an  ulcerated  surface,  which  is 
not   likely  to  occur  in  the  affection  we  are  discussing. 

Occasionally  in  hypertrophic  rhinitis,  when  it  happens  that  the  obstruction 
i-  located  at  the  anterior  extremity  of  the  inferior  turbinal,  and  is  soft,  the 
patient  suffers  great  inconvenience  at  night  from  his  inability  to  breathe 
through  the  nostrils.  In  such  eases  I  have  found  that  great  relief  can  be 
given  by  the  introduction  of  a  vulcanized  rubber  nasal  tube,  such  as  I  use 
after  the  operation  for  deviated  septum,  which  should  be  just  large  enough 
to  remain  in  the  nostril  when  inserted.  This  gives  rise  to  no  irritation,  and 
enable-  the  patient  to  sleep  in  comfort.  It  i-  not  intended  to  bring  about  a 
cure  of  the  hypertrophy  by  pressure,  but  merely  to  serve  as  a  palliative 
during  the  temporary  nocturnal  swelling  that  occurs  so  frequently  in  this 
disease. 

When  we  find  the  hypertrophic  process  to  lie  so  far  advanced  that 
ordinary  treatment  is  of  no  avail,  we  must  have  recourse  to  measures 
calculated  to  cure  by  removing  a  sufficient  quantity  of  the  redundant  tis- 
sue,  and  by  means  of  the  resulting  cicatrix  insure  its  permanent  reduction. 
To  do  tin-  we  use  cau-tic-,  acid-,  the  gal vano-cautery,  the  snare,  either  with 
the  cold  win-  or  galvano  caustic  loop,  and,  in  case  of  posterior  enlargement, 
curette-  or  ring-knives.  The  can-tic  acids  are  used  only  when  the  hyper- 
trophy is  anterior  and  i-  soft.     Those  in   most  general   use  are  the  chromic 

and    monochloracetic    acid-.       When  the  Use  of  an    acid    ha-    been   decided  on, 

the  nostril  i-  well  washed  out  with  a  modified  Dobell's  solution,  dried  with 
absorbenl  cotton,  and  if  the  (patient  i-  sensitive  it  is  anesthetized  with  a  solu- 
tion of  cocain  varying  from  2  to  s  per  cent,  in  strength,  according  to  his 
susceptibility.  It  frequently  happen-  that  the  weaker  solution  is  quite  suf- 
ficient to  deaden  sensation,  and  it  i-  certainly  safer  to  use  it  incases  where 
only  a  brief  time  will  be  taken  up  in  any  operative  proceeding,  in  view  of 
the  toxic  edict-  not  infrequent!)  observed  after  it-  intranasal  use. 

The  cocain   should  be  applied  by  mean-  of  a  pledget  of  absorbenl  cotton, 

allowed  to    remain   in    contact   with    the   affected   tiirbinal    for  about    five    mill- 


Tin:.  I  TMENT.  911 

utes ;  it  is  then  removed  and  the  part  dried.  The  chromic  acid  is  applied 
by  mean-  of  a  fine  probe  wrapped  with  cotton-wool,  which  is  moistened  and 

dipped  in  the  acid,  so  as  to  permit  but  a  .-mall  quantity  to  adhere.  This 
is  pressed  firmly  against  the  tnrbinal  tor  a  few  seconds,  taking  care  not  to 
affect  too  large  a  surface.  The  acid  remaining  is  neutralized  by  an  alkaline 
solution.  After  a  little  while  cicatrization  with  contraction  follows,  but  the 
process  must  be  repeated  several  times  before  any  appreciable  improvement 
is  noticed.  An  interval  of  a  week  at  least  should  intervene  before  an  appli- 
cation of  the  acid  is  repeated. 

The  acetic  acid  is  to  be  used  with  the  same  precaution  and  in  the  same 
mnnner  as  the  chromic  acid,  except  that  an  aluminum  applicator  with  a 
pocket  to  hold  the  dry  acid  is  used.  In  the  advanced  stage  of  anterior  hyper- 
trophy, when  the  fibrous  change  has  become  marked,  the  more  powerful 
agency  of  the  galvano-cautery  must  be  invoked.  The  various  forms  of  bat- 
teries and  the  methods  of  heating  the  cautery-knife  having  been  mentioned 
elsewhere,  it  only  remains  to  describe  the  technique  of  its  application.  The 
nostril  having  been  anesthetized  with  cocain,  the  margins  of  the  oostril  are 
protected  by  a  speculum — Duplay's  or  a  large  aural  speculum  answering  the 
purpose  very  well — otherwise  they  are  likely  to  be  burned.  The  electrode 
should  not  be  large,  a  small  knife  answering  every  purpose.  It  should  be 
heated  to  a  cherry  red.  ami  a  linear  incision  of  the  required  length  made 
through  the  mucous  membrane.  It  is  very  important  that  the  knife  should 
be  heated  to  the  proper  temperature  ;  a  lower  degree  of  heat  than  the  cherry 
red  will  give  rise  to  severe  pain,  while  with  a  white  heat  profuse  hemorrhage 
may  ensue.  Care  must  also  be  taken  not  to  burn  the  septum,  otherwise  the 
resulting  inflammation  may  cause  synechia?  to  form.  After  the  cauterization 
the  parts  are  to  be  sprayed  with  Dobell's  solution  or  with  liquid  vaselin, 
repeated  daily  for  a  week,  at  which  time  another  cauterization  maybe  per- 
formed. Several  applications  of  the  galvano-cautery  are  usually  required  to 
produce  any  appreciable  result. 

The  resulting  inflammation  is  .-light,  and  usually  there  are  no  uncomfort- 
able sequences  if  the  application  has  been  carefully  and  judiciously  made ; 
yet  there  are  cases  on  record  where  serious  results  have  followed  either  a  too 
extended  and  deep  cauterization  or  when  it  had  been  made  too  freely  to  the 
po-terior  extremity  of  the  tnrbinal  ;  for  it  must  be  laid  down  as  an  axiom  that 
this  procedure  can  only  be  safely  applied  to  the  anterior  hypertrophies.  Storck l 
protests  strongly  against  the  indiscriminate  use  of  the  galvano-cautery,  while 
believing  it  to  be  the  best  means  of  application.  He  complains  that  it  is  used 
too  frequently,  and  especially  by  inexperienced  men  who  do  not  know  when 
and  how  galvano-cautery  i-  to  be  done,  who  burn  away  the  mucous  mem- 
brane in  all  direction-,  from  which  eventual  recovery  never  occurs.  ( >n  the 
contrary,  there  results  a  still  worse  condition  of  the  mucous  membrane,  which 
becoming  adherent  to  the  opposite  -ide.  causes  synechia?  and  often  complete 
occlusion.  Where  a  patient  has  only  had  chronic  nasal  catarrh,  he  now  has 
an  occlusion  of  his  nose  that  makes  his  life  unhappy.  No  application  of  the 
galvano-cautery  should  be  made  except  to  parts  clearly  in  the  field  of  vision. 
II,.  js  so  strongly  impressed  with  the  abuse  of  this  method  of  treatment  that 
he  declares  that  if  it  were  possible  to  forbid  the  use  of  the  remedy  by  police 
regulation,  he  would  be  the  first   who  would   vote  for  it. 

If  the  galvano-cautery  i-  ever  applied  to  the  posterior  extremity  of  the 
inferior  tnrbinal  body,  it  should  only  be  by  mean-  of  a  guarded  electrode  in 
the    hand-  of  an    experienced  operator;  and  even   then    there   is   danger  of 

1  Di  ■  a  ■    of  Nb» .  Throaty  and  I 


912  CHRONIC  AFFECTIONS  OF  THE  NOSE. 

inflammation  of  the  Eustachian  tube  with  resulting  purulent  otitis.  Ery- 
sipelas, conjunctivitis,  meningitis,  and  septicemia  are  complications  thai  have 
followed  too  bold  a  use  of  the  galvano-cautery. 

Electrolysis  has  been  recommended  by  some  authors;  but  the  uncertainty 
of  it-  results  and  the  slowness  of  the  method  have  prevented  it.-  being  used 

asively. 

When  the  hypertrophied  tissues  arc  too  extensive  to  be  removed  by  caustics, 
or  when  they  are  soft  and  pendulous  or  aircumscribed,  we  resort  to  surgical 
means  for  their  removal — forceps,  the   ring-knife,  or  the  snare  being  used. 

In  this  country  the  ring-knife  is  rarely  employed,  although  in  England 
Wingrave  and  in  Germany  Stbrck  approve  its  use.  Wingrave,  in  a  com- 
munication made  to  the  British  Medical  Association  at  Bristol  in  L894,  re- 
port- over  "Jni i  cases  of  turbinal  varix  treated  in  this  way,  and  as  the  result 
recommends  the  use  of  the  ring-knife  of  Carmalt  Jones. 

In  hypertrophies  of  the  middle  turbinal  body  it  not  infrequently  hap- 
pen- that  the  part  cannot  be  satisfactorily  encircled  by  the  wire-loop;  in 
such  cases  strong  forceps,  such  as  are  figured  elsewhere,  are  used  to  remove 
the  superfluous  tissue  and  relieve  the  obstruction.  But  by  far  the  most  sat- 
isfactory method  for  the  removal  of  intranasal  growth  is  the  cold  wire  snare, 
used  in  the  instrument  devised  by  the  late  Dr.  Jarvis,  or  one  of  its  many 
modifications.  This  method  is  preferable  for  several  reasons.  It  is  easily 
applied  and  can  be  used  in  the  narrow  passages  of  the  nose,  which  would  be 
impassable  to  anything  larger  than  the  wire;  the  inflammatory  reaction 
which  follow-  ii-  use  is  less  intense  and  less  lasting  than  that  following  the 
cautery  ;  there  is  less  danger  of  infection,  and  if  proper  care  be  taken  there 
i-  less  danger  of  hemorrhage  :  but  in  order  to  insure  this  it  is  necessary  that 
the  section  be  made  slowly,  from  twenty  minutes  to  half  an  hour  being 
occupied  in  the  removal  of  a  larire  hypertrophy.  If  this  precaution  is  not 
taken  serious  hemorrhage  may  result,  especially  when  cocain  has  been  used 
:i-  ;i  local  anesthetic,  for  tin-  not  only  prevents  sensation,  but  masks  the  bleed- 
ing by  the  temporary  contraction  it  produces.  While  it  may  be  said  that 
cocain  should  1m-  n-ed  in  ;ill  cases,  still  it  has  the  disadvantage  of  rendering 
the  operation  much  more  difficult  in  those  cases  where  the  enlargement  i< 
principally  of  the  soft  tissue,  especially  in  the  posterior  portion  of  the 
inferior  turbinal-.  for  it  SO  contracts  the  tissues  that  it  is  almost  impossible  to 
encircle  them  in  the  loop. 

I  .nil  in  the  habil  in  operating  by  tin-  method  of  using  the  Jarvis  snare, 
with  a  modification  in  the  manner  of  fastening  the  wire.  In  place  of  the 
pin-  around  w  hich  the  wire  i-  wound,  in  order  to  hold  it,  on  the  original  instru- 
ment, there  is  at  the  end  of  the  movable  cannula  a  steel  clamp  with  its  inner 
surface  finely  grooved,  ami  which  i-  governed  l>v  a  screw.  The  end-  of  the 
loop  of  wire  pass  between  the  surfaces  of  the  clamp  and  are  retained  in  posi- 
tion by  a  Bcrew  working  on  :i  mule  screw  passing  through  the  lower  clamp. 
This  arrangement  has  the  -rem  advantage  that  a  small  loop  can  be  passed 
into  the  narrowed  nostril  and  enlarged  at  the  will  of  the  operator.  When 
the  loop  has  been  sufficiently  enlarged  and  sometimes  it  is  necessary  to 
make  it  larger  than  the  turbinal  iii  order  to  permit  of  it-  encircling  the  pro- 
jecting extremity — it  i-  drawn  upon  until  it  i-  felt  that  it  ha-  the  hyper- 
trophy in  it-  grasp.  Tin'  clamp  i-  then  tightened  and  the  loop  gradually 
drawn   in   by   the  screw   provided   for  thai    purpose. 

'flie  advantage  of  fastening  the  wire  by  means  of  the  clamp  over  pins  or 
any  method  thai  fixes  the  end-  of  the  win-  i-.  that  if  by  any  chance  the  can- 
nula  should  have  been  screwed  down  to  it-  fullest  extent   without  cutting 


77.7:.  I  TMENT.  913 

through  the  growth,  by  simply  Loosening  the  clamp  the  cannula  can  be  run 
along  the  wire  to  its  original  position,  and,  the  clamp  being  refastened,  the 
tightening  of  the  loop  is  begun  anew.  This  maneuver  is  very  useful  and 
has  served  me  more  than  once  in  difficult  raises.  \\  hen  the  anterior  ex- 
tremity of  the  inferior  turbinal  is  to  be  removed,  cocain  may  be  used  if  the 
patient  is  unwilling  to  bear  the  slight  amount  of  suffering  entailed  by  the 
operation,  although  it  renders  the  operation  more  difficult.  A.s  before  re- 
marked, the  loop  must  be  tightened  very  gradually,  or  profuse  and  even 
serious  hemorrhage  may  occur. 

When  the  posterior  extremity  of  the  turbinal  is  to  be  removed  the  opera- 
tion becomes  much  more  difficult.  The  location  of  the  swelling  make-  it 
more  difficult  to  grasp  and  the  prolonged  manipulation  is  harder  to  hear.  It 
is  not  possible  to  give  any  detailed  instruction  as  to  the  method  of  operating. 
Each  operator,  as  a  rule,  has  a  method  of  his  own,  being  governed  by  his  own 
peculiar  facility.  Some,  by  a  special  knack  of  giving  direction  to  the  wire, 
are  able  to  easily  encircle  the  mass.  Others  put  the  loop  which  has  been 
passed  through  the  nostril  in  place  by  means  of  a  finger  introduced  into  the 
naso-pharynx.  while  others  guide  it  into  position  by  means  of  the  rhinoscopic 
mirror.  Whatever  method  i<  used,  two  objects  must  be  carefully  looked  out 
for — viz.,  prevention  of  hemorrhage  and  avoidance  of  infection.  To  insure 
this  it  is  necessary,  after  the  operation  has  been  performed  in  the  cautious 
manner  advised  above,  to  use  antiseptics.  Aristol  or  dermatol  blown  into 
the  nostril  answers  the  purpose  very  well.  A  pledget  of  corrosive-sublimate 
gauze  is  then  inserted  and  removed  in  twenty-four  hours,  after  which  it  need 
not  be  replaced;  but  the  wound  must  be  sprayed  with  a  modified  DobelPs 
solution,  consisting  of  the  ordinary  Dobell's  with  the  addition  of  ten  grains 
each  of  thymol,  eucalyptol,  and  menthol  to  the  pint,  and  afterward  insufflated 
with  the  antiseptic  powder  every  day  until  cicatrization  is  complete. 

When  the  operation  has  been  performed  too  quickly  and  hemorrhage  fol- 
lows, cold  or  astringents  should  be  applied,  or  the  nose  may  be  sprayed  with 
peroxid  of  hydrogen  or  a  solution  of  antipyrin.  If  these  means  fail  to  stay 
the  bleeding,  it  will  be  necessary  to  plug  the  nostril.  This  1  do  in  the  fol- 
lowing manner:  I  take  a  wad  of  antiseptic  cotton  the  size  of  a  two-drachm 
vial  or  larger,  according  to  the  size  of  the  nostril,  and  tie  a  silk  ligature  to 
it-  center  ;  this  is  forced  into  the  nostril  so  as  to  close  it<  posterior  opening. 
leaving  Che  end  of  the  ligature  projecting  beyond  the  nostril.  On  top  of 
thi-.  antiseptic  cotton  is  packed  until  the  nostril  is  filled  and  the  hemorrhage 
checked.  The  end  of  the  ligature  is  then  cut  to  the  proper  length  and  fast- 
ened to  the  cheek  alongside  of  the  ala  of  the  oose  with  a  bit  of  adhesive 
plaster.     If  this  fails  to  prove  effective,  the  packing  must  be  taken  out  and 

replaced   in   the  same  manner.      This  method  has  always  stood    me  in   g f 

stead,  and  I  have  never  had  to  use  any  other  means  to  restrain  bleeding,  even 
when  very  alarming.  The  packing  musl  be  left  in  place  forty-eight  hour-. 
If  removed  before  that  time  the  bleeding  is  likely  to  recur,  ami  occasionally 
even  then,  in  which  case  it  must  be  replaced  as  before.  If,  however,  there 
should  be  no  return  of  bleeding,  the  nostril  should  be  cleansed  with  a  very 
gentle  spray,  an  antiseptic  powder  insufflated,  and  the  case  treated  a-  where 
there  ha-  been   no  complication. 

When  instead  of  the  cold  wire  the  galvanic  loop  i-  used,  the  -nmr  pre- 
caution as  to  -low  section  ami  antiseptics  alter  the  operation  musl  be  observed. 
If  the  wire  is  heated  to  a  white  heat  and  the  section  made  rapidly,  hemorrhage 
will  inevitably  ensue.  It  sometimes  happen-  in  a  narrow  uose  that  the  por- 
tion of  the  turbinal   removed  by  the  snare  is  too  large  to  pa--  the  external 

58 


914  CHRONIC  AFFECTIONS  OF  THE  NOSE. 

orifice  ;  in  such  cases  it  falls  backward  into  the  pharynx  and  is  expectorated 
through  the  mouth,  or,  as  occasionally  occurs,  is  swallowed  by  the  astonished 
patient. 

In  addition  to  hypertrophy  of  the  extremities  of  the  inferior  turbinal, 
other  enlargements  demand  treatment  :  myxomatous  degeneration  of  the  mu- 
cous membrane  of  the  middle  turbinal,  hypertrophies  of  the  floor  of  the  nose, 
and  thickening  of  the  posterior  portion  of  the  septum.  Each  one  of  these 
musl  be  treated  according  to  the  nature*  of  the  hypertrophy  and  its  location. 
The  polypoid  thickening  of  the  middle  turbinal  is  best  removed  by  snare, 
although  in  careful  hands  the  contact  of  the  galvano-cautery  will  accomplish 
a  "_r""d  result.  For  hypertrophy  of  the  floor  of  the  nose  when  cartilaginous 
or  osseous  the  electro-trephine  is  best  suited;  when  soft  the  galvano-cautery 
must  be  used.  The  swellings  on  the  posterior  portion  of  the  septum  are 
more  difficult  to  manage.  They  should  only  be  subjected  to  surgical  inter- 
ference when  they  add  to  the  obstruction  of  the  posterior  nasal  passage. 
They  are  usually  soft,  and  under  the  guidance  of  the  rhinoscope  can  be 
touched  with  the  galvano-cautery.  There  is  not,  to  my  mind,  the  same 
risk  in  its  use  here  as  when  applied  to  the  posterior  extremity  of  the  inferior 
turbinal,  for  the  orifice  of  the  Eustachian  tube  is  less  likely  to  be  injured 
and  there  are  do  important  structures  in  the  immediate  vicinity.  When  the 
nasal  passage  permit-,  a  small  electro-trephine  may  be  introduced  and  the 
projection  shaved  away  :  but  it  is  only  rarely  that  this  can  be  done  satisfac- 
torily. 

Before  using  surgical  measures  of  any  kind,  however,  it  is  well  to  give  a 
trial  to  local  applications  of  the  iodin  and  iodid  of  potash  solution,  which  in 
-Mine  comparatively  recenl  cases  will  cause  the  hypertrophy  to  disappear. 

Some  writer-  divide  the  treatment  of  chronic  hypertrophic  rhinitis  accord- 
ing to  the  early  or  late  stage  of  the  disease,  but  in  whatever  stage  the  disease 
come-  under  treatment,  the  rule  is  always  to  use  the  mildest  method  that  will 
accomplish  the  desired  result.  Only  when  loeal  applications  fail  to  reduce 
the  enlarged  structure  should  recourse  be  had  to  surgical  measures,  and  then 
only  that  surgical  method  should  be  employed  that  will  do  least  harm  to  the 
surrounding  healthy  tissue.  Cases  have  far  too  frequently  occurred  where 
the  discomforl  of  the  patient  resulting  from  too  radical  an  operation  has 
brought  about  annoyance  exceeding  that  of  the  original  disease. 

Attention  must  be  paid  to  proper  hygienic  measures.  The  same' rules  are 
to  be  observed  as  in  patients  suffering  from  simple  chronic  rhinitis.  Exer- 
cise in  the  open  air,  bathing  and  friction  of  the  skin  arc  particularly  to  be 
insisted  upon.  The  whole  body  should  be  vigorously  rubbed  every  morning 
on  rising  with  :i   horse-hair  gloveora  dry  coarse  towel  and  then  exposed  to 

the  air  for  - ■  minute-.     ( !old  plunge-baths  are  not  to  be  advised,  but  the 

patient-,  if  not  too  susceptible,  may  use  cold  sponging. 

Local  hygienic  measures  consist  in  removing  the  patient  from  an  irritating 
or  dust-laden  atmosphere,  or  in  cases  where  a  person's  trade  or  profession 
make-  this  impossible,  a  respirator  may  be  worn  or  the  irritating  air  be  pre- 
vented from  entering  the  nostril  by  a  thin  wad  of  A.ngora  wool  inserted  just 
within  the  vestibule,  as  proposed  by  Dr.  J.  Solis-Cohen.1 

The  constitutional  measures  to  lie  employed  depend  on  the  condition  pro- 
ducing the  disease.  When  the  gouty  diathesis  is  prominent,  suitable  means 
must  be  taken  to  antagonize  it.  So  with  syphilis,  malaria,  anemia,  neuras- 
thenia, etc.  No  specific  medication  i-  indicated,  only  such  remedies  should 
l.e  administered  as  are  culled   lor  by   the  condition  of  each   patient. 

'  /'  '<•   Throai  "ml  A 


DEVIATION  OF  THE  NASAL  SEPTUM.  915 

DEVIATION   OF   THE  NASAL   SEPTUM. 

Deviation  of  the  nasal  septum  is  one  of  the  most  prominent  causes  of 
ehronic  disease  of  the  nose,  carrying  with  it  maladies  of  the  accessory  sinuses, 
troubles  of  audition,  and  various  nervous  affections  classed  as  reflex,  such  as 
asthma,  chorea,  and  headaches.  It  is  not  to  be  confounded  with  the  simple 
thickenings  of  the  mucous  membrane  over  the  vomer  and  cartilaginous  sep- 
tum which  frequently  cause  stenosis;  but  consists  in  a  decided  bending  of 
the  triangular  cartilage  of  the  nose  to  either  side,  nearly  always  accompanied 
by  a  corresponding  alteration  in  the  shape  of  the  vomer  and  invariably  by  a 
redundant  amount  of  material  in  the  cartilage  itself,  which  maybe  so  great  in 
some  cases  as  entirely  to  occlude  the  uostril,  and  by  interfering  with  proper 
drainage  and  respiration  cause  the  varied  inconveniences  which  call  attention 
to  the  malformation.  The  character  of  the  deformity  varies  in  different 
cases.     There  are  five  varieties  of  deviation  to  be  observed.     There  maybe — 

First.  Simple  deviation  of  the  cartilaginous  septum  to  either  side  where 
there  is  a  simple  rounded  convexity  on  one  side  and  concavity  on  the  other, 
with  little  or  no  thickening  of  the  mucous  membrane. 

Second.  Deviation  of  the  cartilaginous  septum  in  the  same  manner,  accom- 
panied by  corresponding  deviation  of  the  anterior  portion  of  the  vomer. 

Third.  Sigmoid  deviation  where  the  cartilage  is  bent  in  an  "S"  shape, 
with  a  convexity  at  its  superior  and  inferior  portion  in  one  nostril,  and  con- 
vex at  the  middle  portion  in  the  other,  making  a  sharp  longitudinal  ridge 
running  posteriorly. 

Fourth.  The  deviation  may  be  angular. 

Fifth.  It  may  be  vertical,  in  which  case  the  cartilaginous  septum  is  alone 
involved.  In  nearly  all  cases,  though  not  invariably,  the  deviation  is  toward 
the  left.  Sex  seems  to  have  some  influence,  as  more  cases  are  observed  in 
males  than  in  female-. 

Htiology. — There  are  several  causes  of  deviation  of  the  septum.  Dela- 
van1  divides  them  into  predisposing  and  exciting;  he  considers  diathesis  and 
racial  characteristics  as  the  most  important  of  the  predisposing  causes,  and 
believes  that  persons  suffering  from  the  strumous,  syphilitic,  tubercular,  or 
rachitic  diatheses  are  most  liable.  This  view  of  its  diathetic  origin  is  hardly 
borne  out  in  the  cases  that  have  fallen  under  my  observation,  where  the 
majority  of  them  seemed  to  be  free  from  any  constitutional  taint.  As  regards 
the  influence  of  race,  deviated  septa  are  much  more  common  among  the  civil- 
ized than  the  savage  races.  This  is  attributed  to  the  greater  admixture  of 
types  occurring  in  civilized  countries  as  the  result  of  immigration,  while  the 
rarer  occurrence  of  deviation  among  the  less  civilized  races  is  due  to  the 
purity  of  the  race.  Races  with  aquiline  noses  are  more  apt  to  have  deviated 
septa,  except  the  American  Indian-,  who  are  singularly  free  from  the  deformity. 

Exciting  causes  may  be  imperfect  or  unequal  development  of  the  plate  of 
the  vomer,  the  result  of  malnutrition  or  inflammation. 

(  Abstraction  of  the  anterior  part  of  one  nan's  is  considered  by  <  'oilier2  to 
be  a  factor  in  the  production  of  the  deformity  by  producing  rarefaction  pos- 
teriorly, the  resulting  pressure  causing  deviation  on  that  side. 

Deflections  of  the  septum  are  usually  observed  in  adult-  or  adolescents, 
but  cases  have  been  observed  in  my  clinic  at  the  New  York  Eye  and  Ear 
Infirmary  whose  age  did  not  exceed  four  years.  Traumatism  is  an  occasional 
cause  of  deflection,  but  the  cases  due  to  this  cause,  unaccompanied  by  fracture 

1  Trans.  Amer.  Laryng.  Assn.,  \^-7. 

■  J  I  i  yng.  ana  Rhimology,  vol.  v.  p.  91. 


916  CHRONIC  AFFECTIONS  OF  Till:  xosi:. 

of  the  nasal  bones,  are  so  rare  thai  it  can  hardly  be  considered  as  an  import- 
ant factor  in  the  causation  of  the  deformity.  A  very  important  cause  is  the 
defective  development  of  the  bony  septum.  The  vomer  consists  in  its  early 
stages  of  two  laminae  enclosing  a  plate  of  cartilage  which  forms  the  carti- 
laginous septum  ;  these  lamina?  do  not  coalesce  until  after  puberty,  conse- 
quently unequal  development  of  one  of  these  lamina'  would  push  the  other 
out  of  line  and  cause  a  corresponding  deviation.  This  unequal  development 
in  different  direction-  gives  rise  to  the  various  forms  of  deviation  observed. 

Local  malnutrition  is,  according  to  In-rals,1  an  important  factor  in  the 
production  of  deflection.  Jarvis  regards  the  high-arched  palate  a-  a  cause  of 
deflection,  the  septum  being  crowded  upward  by  the  hard  palate  until  it  yields 
to  the  pressure  brought  to  hear  on  it,  the  cause  of  the  palatal  deformity  being 
explained  on  the  theory  of  atmospheric  pressure,  occlusion  of  the  nasal  pas- 
sages  creating  in  them  through  inspiration  a  partial  vacuum,  disturbing  the 
equilibrium  of  pressure  upon  the  upper  and  lower  aspects  of  the  roof  of  the 
mouth.  This  inequality  of  atmospheric  pressure,  exerted  during  infancy  and 
early  growth  of  the  child,  u'ives  rise  to  the  permanent  deformity  of  the  hard 
palate,  thus  interfering  with  the  normal  development  of  the  septum,  in  turn 
further  disturbed   by  the  disturbance  of  respiration. 

The  bony  ridges  found  along  the  line  of  suture  of  the  septum  with  the 
superior  maxillary  hone  are  d\w  probably  to  primary  injury,  aggravated 
afterward  l>\  hypernutrition.  They  can  scarcely  he  classed  as  deviations, 
though  considered  so  by  many  authors  who  have  treated  of  the  subject. 

I,'.  e,2  in  a  paper  on  the  etiology  of  deviation-  of  the  nasal  septum,  con- 
siders that  heredity  play-  an  important  part  as  a  predisposing  cause,  not  only 
by  the  dyscrasias  which  may  be  transmitted,  but  also  by  the  blending  of  dif- 
ferent races,  bringing  about  an  infinite  variation  in  the  conformation  of  the 
osseous  and  cartilaginous  structures ;  and  that  trauma,  nasal  obstruction,  and 
unequal  growth  of  the  component  part- of  the  vomer  are  the  most  frequent 
exciting  causes. 

Symptoms.  —  Attention  i-  usually  called  to  the  existence  of  the  deformity 
by  the  functional  troubles  which  give  rise  in  many  cases  to  serious  incon- 
venience. Obstructed  respiration  is  the  most  noticeable  annoyance,  thereby 
causing  mouth-breathing  with  it-  accompanying  inconveniences,  nasal  voice 
and  post-nasal  catarrh.  Mackenzie 3  reports  a  case  where  the  most  trouble- 
some symptom  was  epistaxis  caused  by  erosion  of  the  outer  wall  of  the  nose  ; 
but  the  greal  majority  of  patient-  who  have  come  under  my  observation  have 
complained  of  the  impeded  respiration  caused  by  the  obstructed  nostril,  and 
have  sought    relief  on  this  account  only. 

re  headache-  are  often  caused  by  a  deviated  septum,  when  a  deviation 
in  the  upper  portion  of  the  septum  presses  on  the  middle  turbinal  body, 
while  asthma  and  affections  of  the  larynx  are  not  infrequent  results.  A  very 
common  symptom  1-  the  nasal  voice  which  is  nearly  always  present  in  well- 
marked  cases.  <  'a-c-  have  been  -ecu  by  me  where  chronic  headache  and  asthma 
were  present  and  were  relieved  on  restoration  of  the  respiratory  function  of 
the  occluded  -ide.  W Inn  there  i-  considerable  deviation  the  nose  is  often 
twisted  to  one  -ide.  but  frequently  there  is  only  a  slight  twist  of  the  tip. 

Diagnosis. — The  diagnosis  of  the  affection  i-  very  easy  and  can  be  made 
even  on  a  verv  superficial  observation.  Examining  the  nostrils  anteriorly 
there  i-  found  a  bulging  of  the  cartilaginous  septum  into  one  side,  either 
entirely  or  partially  occluding  it.      <  )n  the  opposite  Bide  there  i-  a  correspond- 

l         /  '  '/'runs.  Amer.  La/ryng.  Assn.,  Li 

1  /  Vhroai  and  Nose,  vol.  ii.  p.  126. 


DEVIATION  OF  THE  NASAL  SEPTUM.  917 

rag  enlargement  of  the  nasal  cavity,  frequently  filled  by  a  hypertrophied 
inferior  fcurbinal  body.  This  is  so  frequent  a  condition  as  almost  to  be  con- 
stant. The  septum  itself  is  rarely  increased  in  thickness  when  there  is  devia- 
tion ;  but  it  often  happens  that  the  septum  is  thickened  to  such  a  degree  a-  to 
cause  obstruction,  and  unless  attention  has  been  called  to  the  condition  an 
error  in  diagnosis  might  easily  he  made.  Inexperienced  observers  have  mi- 
taken  a  deviated  septum  for  a  myxoma,  which  should  easily  he  recognized  by 
it-;  mobility,  softness,  and  pale  color.  Whatever  the  form  of  the  deviation, 
the  symptoms  are  the  same  ;  they  do  not  differ  whether  it  be  sigmoid,  vertical, 
or  a  simple  curved  bending.  It  is  not  always  possible  to  ascertain  by  ante- 
rior rhino-copy  whether  the  cartilaginous  deviation  is  continuous  with  the 
bony  septum  ;  but  if  the  case  permits  it,  posterior  rhino-copy  will  reveal  its 
existence,  if  present. 

Practically,  the  coexistent  deformity  of  the  bony  septum  is  of  no  import- 
ance, as  the  correction  of  the  deformity  in  the  cartilaginous  portion  will 
almost   invariably  restore  the  function  of  the  nose  and   permit    respiration. 

Treatment. — Treatment  of  deviation  of  the  septum  i-  uecessarily  surgi- 
cal ;  all  palliative  methods  are  useless,  and  simply  waste  the  time  of  the  sur- 
geon and  exhaust  the  patience  of  the  invalid.  Pressure,  digital  and  instru- 
mental, the  use  of  metallic  sounds,  or  of  laminaria  for  gradual  dilatation,  .ire 
methods  which  have  all  been  tried  and  relinquished — the  irritation  caused  by 
them  more  than  equalling  the  discomfort  produced  by  the  original  trouble, 
while  the  results  are  negative. 

Several  methods  have  been  devised  for  the  correction  of  the  deformity  ; 
tiny  vary  largely  in  method  and  principle,  and  most  of  them,  because  com- 
plicated in  their  technique,  have  given   way  to  simpler  processes. 

Pieffenbach,  as  early  as  1845,  excised  the  projecting  portion  of  the  deflected 
cartilage  with  a  knife.  Huyler  dissected  up  the  mucous  membrane  from  the 
prominent  portion  of  the  septum  and  removed  the  redundant  cartilage  with 
scissors.  Adams,  in  1875,  proposed  to  correct  the  deformity  by  mean-  of  the 
forceps  which  are  known  by  his  name.  He  fractured  the  septum  with  them, 
retaining  it  in  its  proper  place  afterward  by  means  of  ivory  plugs  or  steel 
plates  adjusted  by  screws. 

Ingals  proposed  an  oblique  incision  through  the  convexity  of  the  sep- 
tum, then,  having  detached  the  mucous  membrane  from  the  cartilage,  he 
excised  a  V-shaped  piece,  bringing  the  parts  together  by  suture  and  holding 
them   in  place  by  tampons. 

Glasgow,  in  1881,  presented  to  the  American  Laryngological  Association 
the  method  of  Steele,  which  consists  in  making  a  stellate  incision  over  the 
deviation,  through  the  mucous  membrane  and  cartilage;  the  septum  is  then 
crowded  hack  and  an  ivory  plug  inserted,  which  is  worn  until  the  cure  i- 
complete. 

Jarvis,  in  1882,  proposed  the  removal  of  the  projecting  portion  of  the 
cartilage  by  means  of  the  needle  and  snare.  He  pierce-  the  base  of  the  pro- 
jection with  a  transfixion-needle  until  the  point  appears,  a  wire  loop  of  a 
snare  is  passed  over  the  projecting  point,  and  the  engaged  portion  is  severed. 

Roberts  of  Philadelphia  uses  pin-  to  hold  the  septum  in  place  after 
having  corrected  the  deformity.  He  makes  an  incision  through  the  septum 
along  the  line  of  convexity  ;  then  pushes  a  long  steel  pin  through  the  septal 
cartilage  of  the  normal  uostril  a  -hurt  distance  above  and  in  front  of  the 
incision.  Pressing  the  end  of  the  nose  and  septum  into  proper  position,  he 
brings  the  head  of  the  pin  close  to  the  anterior  part  of  the  septum,  causing 
the  part   lying  in  the  obstructed  nostril  to  lie  across  the  incision  and  adapt 


918 


rllltosic  AFFECTIONS   OF  Till:  XOSF. 


itself  lengthwise  along  the  surface  of  the  septum  beyond.  The  pin  is  then 
pushed  in  to  the  head  and  it-  poinl  deeply  embedded  in  the  soft  tissues  of  the 
septum  and  upper  and  posterior  part  of  the  obstructed  nostril. 

line,  in  L891,  devised  a  fenestrated  forceps  for  rectifying  the  deformity  by 
pressure  after  having  partially  incised  the  cartilage  by  means  of  a  modified 
Steele's  forceps  with  which  be  cuts  through  the  cartilage  and  mucous  mem- 
brane of  one  side  only,  leaving  the  mucous  membrane  of  the  other  side  intact. 
\-  the  incision  must  be  made  over  t lie  convex  portion  of  the  deviation,  it 
necessarily  follows  that  in  aggravated  cases  it  will  not  be  possible  to  intro- 
duce the   instrumenl    in  order  to  make  the  incision. 

Watson  of  Philadelphia  proposed  a  bevelled  incision  along  the  crest  of 
the  deviation  through  the  cartilage,  but  not  through  the  mucous  membrane 
of  the  opposite  side  :  the  upper  portion  is  then  pressed  over  toward  the  other 
side  until  it  1 ks  itself  onto  the  lower  and  is  thus  held  in  place.  The  pro- 
jecting base  that   is  left  can  then,  or  after  healing,  be  removed  by  the  saw. 

The  method  that  I  prefer  and  with  which  I  have  had  the  most  satisfactory 
results  is  one  presented  by  me  at  the  meeting  of  the  American  Laryngological 
Association  in  1890.  It  has  been  performed  by  myself  and  colleagues  very 
many  times  and  has  been  uniformly  successful.  The  principle  is  the  same  as 
that  of  other  operations — viz.,  the  destroying  of  the  resiliency  of  the  septum, 
bul  the  technique  of  the  operation  differs,  and  in  that  lies  the  secret  of  its 
success.  The  operation  has  been  slightly  modified  by  me  since  I  proposed  it, 
but  in  it-  important  features  it  remains  the  same.  It  consists  in  making- a 
crucial  incision  through  the  cartilaginous  septum,  breaking  down  by  the 
finger  or  forceps  the  bases  of  the  segment  thus  formed,  and  the  insertion  of  a 
hollow  splint.  The  rapidity  and  simplicity  of  the  operation  commend  it,  for 
it  can  be  completed  in  a  very  few  minutes,  even  in  complicated  cases.  The 
instruments   I   employ  in  the  operation  are: 

First.  A  pair  of  strong  cartilage-scissors,  one  blade  blunt  and  narrow  for 
introduction   into  the  obstructed  nostril,  the  other,  the  cutting  blade,  of  a 


tight  scissors. 


curved  wedge-shape  (Fig.  570),  the  shanks  of  both  blades  being  curved  out- 
ward so  as  to  admit  of  closing  without  interfering  with  the  column  ;  the  han- 


1      Angular 


die-  being  of  Bteel  and  curved  like  those  of  a  dental  forceps.  I  sometime-  use 
a  scissors  with  blades  benl  at  a  right  angle  with  which  to  make  the  horizontal 
cut,  hut   it   is  not   indispensable  (Fig.  571). 


DICTATION  OF  THE  NASAL  SEPTUM. 


919 


Second.  A  curved  elevator  Cor  breaking  up  any  adhesions  that  'nay  exisl 
between  the  septum  and  turbinal  body. 

Third.  An  Adams's  forceps  or  one  with  stout  parallel  blades,  as  in 
Fig.  572. 


Fig.  572.— Compressing  forceps. 

Fourth.  A  hollow  vulcanite  splint  of  oval  form  and  of  a  size  according  to 
the  nature  of  the  ease.  I  formerly  used  a  triangular  tin  splint,  cut  to  adapt 
itself  to  the  cartilage  and  held  in  place  by  a  tampon  of  antiseptic  gauze,  but  the 
discomfort  experienced  from  the  packed  nostril  and  the  danger  of  sepsis  led 
me  to  devise  the  hollow  splint  (Fig.  573),  which  is  thoroughly  effective  and  by 
permitting  the  passage  of  air  is  more  satisfactory  to  the  patient.  This  splint 
is  a  tube  of  hard  rubber  of  a  proper  shape  to  enter  the  nostril  and  hold  the 


Fig.  573. — Asch's  hollow  splint. 


Fig.  574.— Mayer's  hollow  splint. 


replaced  septum  in  its  new  position.  The  splint  as  originally  devised  by  me 
was  rounded  on  its  external  surface — with  perforations — which  serve  to  retain 
it  in  place  (Fig.  573).  Dr.  Emil  Mayer  of  New  York  modified  it  by  making  it 
more  oval  in  its  caliber  and  consequently  natter  on  the  sides  (Fig.  o74)  and  also 
larger.  The  splint  slips  up  under  the  tip  of  the  nose  and  is  easily  retained  in 
its  position.  There  have  been  other  modifications  proposed,  but  I  am  in  the 
habit  of  using  one  or  the  other  of  these  two,  as  the  shape  or  size  of  the  nos- 
tril may  indicate.      Both  splints  are  made  in  various  sizes. 

The  mode  of  performing  the  operation  is  as  follows  : 

Before  etherizing,  the  nostrils  are  sprayed  out  with  an  antiseptic  solution. 
I  am  accustomed  to  use  Dobell's  solution  with  the  addition  of  a  few  drop-  of 
thymol  and  eucalyptol.  The  patient  then  having  been  etherized  and  the  head 
drawn  over  the  edge  of  the  operating-table  so  as  to  permit  the  blood  to  flow 
into  the  naso-pharynx,  the  steel  elevator  is  introduced  into  the  obstructed  nos- 
tril and  any  adhesions  which  may  exisl  between  the  septum  and  the  turbinal 
body  are  broken  up.  When  a  deviation  is  the  result  of  traumatism  or  com- 
plicated by  it,  these  adhesions  are  sometimes  bony  and  require  a  good  deal 
of  force  to  divide  them  ;  in  such  cases  I  lind  a  convex  gouge  to  be  of  ser- 
vice. The  blunt  end  of  the  scissors  is  t hen  introduced  into  the  obstructed 
nostril  and  the  cutting  blade  into  the  other  end.  An  incision  i<  made  in 
;i  horizontal  direction  across  the  greatest  convexity  of  the  deviation.  The 
scissors  are  then  removed  and  reintroduced  and  a  vertical  incision  made  at 
right,  angles  to  and  across  the  center  of  the  horizontal  one.  forming  a  crucial 
incision  as  near  a-  possible  over  t  he  most  prominent  portion  of  the  deviation. 
The  finger  is  then  introduced  into  the  obstructed  nostril,  and  with  it  the  seg- 


920  '  HBONIC  M//:<  riOJVS  OF  THE  .vox/;. 

ments  made  by  the  incision  arc  pushed  into  the  opposite  one  until  they  are 
broken  at  their  base  and  the  resiliency  of  the  septum  destroyed. 

( >n  this  point  depends  the  success  of  the  operation,  for  unless  the  fracture 
of  these  segments  is  assured,  the  resiliency  of  the  cartilage  will  not  be  over- 
come and  the  operation  will  tail.  'I 'lie  septum  is  then  straightened  with  for- 
ceps,and  the  hemorrhage,  which  in  many  cases  i>  quite  brisk,  is  cheeked  by  a 
spray  "f  ice-cold  Dobell's  solution.  A  hollow  splint  of  a  size  and  shape 
suited  to  the  case  is  then  introduced  into  the  affected  uostril,  a  smaller  one 
into  the  other,  and  the  operation  is  completed.  The  splint  in  the  patent 
nostril  i-  introduced  merely  to  assist  in  preventing  bleeding,  and  is  removed 
in  twenty-four  hours,  a-  the  one  in  the  contracted  nostril  suffices  to  hold  the 
septum  in  position.  This  splint  is  removed  on  the  second  day  after  the  opera- 
tion, cleansed  thoroughly  and  replaced,  after  which  it  is  taken  out,  cleansed 
and  replaced  every  day  for  al  least  five  week-,  by  which  time  the  healing  of 
the  septum  in  its  modified  position  should  he  complete.  After  the  fourth  day 
it  will  he  easy  \'><v  the  patient  himself  to  remove  and  replace  the  splint,  re- 
porting to  the  surgeon  once  or  twice  a  week  for  observation  until  there  is  no 
further  use  t'"i-  it-  application. 

It  sometimes  happens  that  the  lower  segment  of  the  cartilage  projects  into 
the  nostril.  Nearly  always  this  projection  i>  absorbed  if  left  to  time,  but  it 
can  easily  he  removed  by  the  electro-trephine  or  the  galvano-cautery.  Per- 
foration following  the  operation  i-  so  rare  as  not  to  he  considered  as  a  prob- 
able sequence.  The  few  cases  which  I  have  seen  where  it  occurred  were  due 
to  cachexia  and  to  unskilful  performance  of  the  operation.  It  will  not  suf- 
fice, however,  to  make  the  incision,  insert  the  splint,  and  let  the  wound  take 
care  of  it-elf  iii  order  to  get  a  successful  result.  The  patient  must  he  seen 
every  day   for  the  first    Week,  and  at    least   twice  a  week  after  that   until  cured. 

The  operation  i-  equally  effective,  whatever  may  he  the  character  of  the 
deviation  :  w  hether  simple  convexity,  sigmoid,  or  vertical,  the  same  procedure 
will  apply  to  all.  merely  taking  care  that  the  incision  he  made  with  reference 
to  the  shape  of  I  he  deformity. 

<  )ther  operation-  for  the  deformity  consist  of  the  removal  of  the  prominent 
portion  of  the  convexity  by  saws,  chisels,  <>r  burrs  operated  by  the  electro- 
motor; hut  these  method-  are  only  available  where  there  is  much  thickening 
of  the  septum  and  when  the  permeability  of  the  nostril  can  he  attained  with- 
out the  risk  of  perforation.  It  sometimes  happen-  that  the  thickening  of  the 
septum  i-  so  great  ;i~  to  permit  of  this  being  done,  hut   this  condition  is  rare. 

Thoroughly  unsurgical  i-  the  method  of  Blandin,  in  which,  by  means  of 
a  punch,  a  circular  piece  i-  removed  from  the  most  prominent  part  of  the 
deviation  a  procedure  which  doe-  not  cure  the  deformity,  hut  simply  allows 
the  air  to  pa--  out  from  the  unobstructed  nostril  into  the  occluded  one,  while 
it  substitutes  one  deformity  lor  another,  and  there  ensues  a  permanent  ulcera- 
tion with  it- attendant  hemorrhage  and  crusts. 

Cauteries  and  electrolysis  have  been  used  to  remedy  deviations  of  the 
septum,  hiit  a-  in  the  case  of  the  sav  these  methods  can  only  avail  where  the 
thickened  septum  i-  the  cause  of  the  obstruction. 

Stoker  and  Hubert  advise  the  use  of  laminaria  bougies  and  of  tampons, 

hut  it  may  he  -aid  with  certainty  that  all  such  measures  harelv  palliate.  They 
cause  irritation  and  produce  conditions  .1-  unfavorable  a-  the  disease  they  are 
employed  to  cure. 

A  1(  rience  has  shown  me  that  it  is  unwise  to  treat  deviations  of  the 

septum  otherwise  than  radically,  rn  no  other  way  can  the  discomfort  pro- 
duced h\  it  he  alleviated  and  the  respiratory  functions  of  the  no-.'  restored. 


DISEASES  OF    THE   TONSILS,    PALATE,    AND 

PHARYNX. 

By  JAMES  EDWARD   NEWCOMB,   M.  D., 

OF    NEW    YORK    CITY. 


DISEASES  OF  THE  TONSILS. 

General  Considerations.— A  proper  understanding  of  the  relations  of 

the  various  tonsil-  to  each  other  is  obtained  by  regarding  them  all  :i-  seg- 
ments  of  the  so-called  tonsillar  ring — that  is,  the  circular  continuity  of  lym- 
phoid tissue,  starting  in  the  naso-pharynx  and  extending  on  each  side  to  the 
lips  of  the  Eustachian  tubes,  thence  to  the  posterior  surface  of  the  soft  palate, 
to  the  space  between  the  faucial  pillars  (forming  in  the  latter  region  the 
faucial  tonsils),  and  finally  uniting  in  the  so-called  fourth  or  lingual  tonsil  at 
the  base  of  the  tongue. 

The  faucial  tonsils  are  limited  above  by  the  approximation  of  the  faucial 
pillars,  but  extend  a  variable  distance  below.  They  may  be  said  to  lie  in 
the  anterior  part  of  the  pharyngo-maxillary  "interspace" — that  is,  a  -pace 
between  the  lateral  wall  of  the  pharynx,  the  internal  pterygoid  plate,  and  the 
upper  cervical  vertebrae — lying  almost  directly  back  from  the  pharyngo-pala- 
tine  arch.  This  "interspace"  is  filled  with  connective  tissue.  Behind  it  are 
both  carotid  arteries,  the  internal,  1^  cm.,  and  the  external  2  cm.  distant  from 
its  lateral  periphery.  In  healthy  throats  at  rest  the  tonsils  do  not  protrude 
beyond  the  level  of  the  pillars. 

Structure. — A  tonsil,  says  Harrison  Allen,  is  an  association  of  divertic- 
ula developed  from  the  epithelial  layer  of  the  mucosa,  in  the  walls  of  which 
are  grouped  muciparous  glands  and  lymph-follicles.  The  various  tonsillar 
deposits  vary  only  in  the  arrangement  of  these  diverticula.  In  the  lingual 
tonsil  they  arc  single  ;  but  in  the  pharyngeal  and  faucial,  compound,  in  the 
latter  the  arrangement  is  such  as  to  render  especially  noticeable  the  depres- 
sions— cryptsor  lacunae  (not  follicles) — upon  thesurface.  Soft  in  infancy,  they 
become  harder  a-  age  advance-,  partly  from  the  growth  of  connective  tissue 
and  partly  from  a  cortical  hardening  due  to  the  constanl  impact  of  food. 
They  begin  to  atrophy  .it  middle  life.  Their  more  detailed  anatomy  ami 
their  physiology  are  elsewhere  discussed.  It  may  only  be  said  here  that  a 
rarefaction  of  the  epithelium  is  constantly  going  on  at  the  surface  even  in 
health,  and  -till  more  iu  disease  ;  SO  that  at  times  and  in  place-  tin-  epithelial 
layer  i<  only  one  or  two  cells  thick.  Hodenpyl  has  shown  that  the  intact 
epithelium  practically  prevent-  any  absorption  whatever,  but  tliat  it-  removal 
affords  free  access  of  infectious  material  to  the  lymph-channels  :  yet  tlii-  claim 
mii-t  be  modified  in  view  of  Goodale's  recent  experiment-. '     Various  micro- 

1  Trans.  Amer.  Ziaryng.  Soc,  1898. 


922      DISEASES  OF   THE   TONSILS,   PALATE,   AND   PHARYNX. 

organisms  may  effed  a  breach  through  this  thinned  epithelial  layer.  Hence 
the  frequency  with  which  the  tonsils  serve  as  the  channel  of  entrance  of 
various  disease-poisons  to  the  system. 

Finally,  it  is  to  be  borne  in  mind  that  the  pathological  processes  affed  all 
the  tonsils  alike,  and  that  variations  in  local  symptoms  are  mainly  due  tu 
locality. 

Acute  Tonsillar  Inflammations. 

This  group  includes  the  acute  catarrhal,  lacunar  (wrongly  called  follic- 
ular), croupous,  parenchymatous,  and  suppurative  varieties.  The  catarrhal 
form  rarely  occurs  apart  from  an  acute  catarrhal  pharyngitis,  under  which 
heading  it  will  be  considered.  The  suppurative  form,  or  quinsy,  is  really  a 
peri-  rather  than  an  intratonsillar  affection. 

Acute  lacunar  tonsillitis  is  often  associated  with  the  parenchymatous 
variety,  into  which  it  frequently  run.-.  It  consists  of  an  inflammation  chiefly 
manifested  by  a  filling  of  the  crypts  with  whitish  plugs  of  inflammatory 
exudation,  together  with  a  general  congestion  of  surrounding  parts,  associated 
with  a  constitutional  febrile  reaction. 

Causes. — Perhaps  the  mosl  frequently  assigned  cause  is  exposure  to  cold. 
Bui  at  the  outsd  it  musl  he  premised  that  in  the  light  of  our  present  views 
on  pathology  exposure  to  cold  has  very  little  significance  as  a  causative  factor 
in  this  class  of  diseases  :  it  probably  acts  hut  indirectly  and  means  only  les- 
sened resistance  to  morbific  action.  All  sorts  of  micro-organisms  are  con- 
stantly  presenl  in  the  throat,  the  harmful  influence  of  which  i-  nullified  by  a 
sound  condition  of  the  organism.  Exposure  to  cold,  by  temporarily  lowering 
tin-  resisting  power  of  the  tissues,  allows  the  pathogenic  germs  to  exert  their 

efl'eet. 

A  disordered  gastro-intestinal  canal  is  found  in  many  instances,  particu- 
larly in  patient-  subjed  to  the  so-called  bilious  attacks.  Causative  factor- 
are  also  found  in  the  rheumatic  and  gouty  diatheses.  In  regard  to  rheuma- 
tism, it-  frequency  as  a  cau-e  has.  in  the  opinion  of  the  writer,  been  greatly 
exaggerated.  Hi-  records  of  586  cases  of  various  forms  of  tonsillitis  and 
pharyngitis  -how  154  presenting  evidence-  of  rheumatic  tendency,  or  26.2 
percent.;  while  132,  or  73.8  per  cent.,  presented  no  such  evidences.  These 
figures  differ  from  those  of  Haig  Brown,  oul  of  whose  119  cases  64,  or  54  per 
cent.,  had  some  rheumatic  tendency.  Fowler  believes  that  80  per  cent,  of 
all  cases  of  rheumatism  have  had  previous  sore  throats  ;  hut  the  line  of  argu- 
ii n - 1 1 1  followed  by  him  doe-  not  seem  convincing  with  reference  to  the  point 
at  issue.  Hope  denies  thai  the  tonsils  are  a  selective  area  for  the  rheumatic 
poison  which,  he  says,  attacks  sero-fibrous  rather  than  muco-fibrous  structures, 

BUch    a-    the    tonsils    really    are.       He    even     regards    it    as    rare    to   meet   with 

example-  of  recurring  angina  in  those  who  earn  recent  or  unmistakable 
evidences  of  a   rheumatic  attack. 

Chronic  enlargements  of  the  tonsils  naturally  invite  recurring  inflam- 
mations. Suppressed  menstruation  seems  to  he  a  factor  in  some  cases. 
Entrance  of  foreign  bodies,  sudden  chance-  in  atmospheric  conditions,  and 
exposure  to  odors  from  defective  drainage  are  also  causative  factors.  The 
latter  may  '"•  regarded  a-  a  type  of  a  wide  range  of  septic  influences. 
Hospital  attendants  frequently  suffer  from  this  affection. 

rriinkel  and  Lennox  Browne  find  intranasal  operations  to  be  a  frequenl 
excitant  of  this  form  of  tonsillitis.  It  seems  t<»  follow  the  use  of  the  galvano- 
cautery  rather  than  that  of  cutting  instruments,  'the  reason  assigned  i-  that 
for  a  time  after  the  cauterization  the  filtering  function  of  the  nan-  is  held  in 


DISEASES  OF  TUN   TONSILS.  923 

abeyance,  and  that  some  of  the  bacteria  found  in  the  aose  are  stimulated 
into  an  abnormal   virulence. 

Pathology. —  Either  one  <>r  both  organs  may  be  affected.  They  are  swol- 
len and  reddened,  while  the  surrounding  tissues  become  more  or  less  edemat- 
ous. This  edema  is  frequently  marked  in  the  soft  palate  and  uvula,  the  latter 
often  being  deviated  to  one  side.  The  months  of  the  lacunae  are  filled  with 
whitish  plugs  composed  of  dead  epithelium,  leukocytes,  and  various  micro- 
organisms. Sometimes  more  or  less  thick  tenacious  mucus  i-  so  evenly 
spread  over  the  walls  of  the  lacuna'  as  to  suggest  a  false  membrane,  bul  ii  can 
he  easily  brushed  off,  leaving  no  bleeding  surface,  and  it  does  not  contain 
fibrin. 

As  to  bacteriological  findings,  both  staphylococci  and  streptococci  are 
present.  Frankel  believes  the  latter  to  be  the  pathogenetic  cause.  Meyer 
found  in  53  cases,  14  with  staphylococci  (generally  staphylococcus  aureus),  24 
with  a  mixture  of  the  two,  and  15  with  streptococci,  in  pure  culture.  A 
diplococcus  resembling  (and  perhaps  identical  with)  that  of  pneumonia  has 
also  been  met  with.  The  varying  proportion  of  these  two  micro-organisms 
causes  no  appreciable  variation  in  the  clinical  features  of  the  disease.  Meyer's 
researches  show  that  the  secretion  from  non-inflamed  tonsils  ordinarily  con- 
tains a  coccus  very  analogous  to  the  streptococcus  pyogenes,  a  small  growth 
often  arranged  in  pairs,  staphylococci,  and  leptothrix   growths. 

Acute  Parenchymatous  Tonsillitis. — Very  frequently  the  fore- 
going condition  is  present  without  any  marked  enlargement  of  the  tonsil  ;  but 
often  the  organ  becomes  ^reatlv  increased  in  size  from  the  exudation  of 
inflammatory  products  into  its  substance,  so  that  we  have  a  combination  of 
the  lacunar  and  parenchymatous  forms;  or,  again,  the  organ  may  be  greatly 
swollen  while  the  mouths  of  the  crypts  are  clear. 

Symptoms. — The  symptoms  in  both  forms  are  essentially  the  same. 
The  local  manifestations  may  either  precede  or  follow  the  general.  The 
latter  assume  the  type  of  an  acute  infectious  disease.  There  is  more  or  less 
chilliness,  followed  by  fever  of  rapid  rise  (104°  F.),  with  corresponding 
changes  in  pulse  and  respiration,  headache,  constipation,  thirst,  anorexia, 
general  malaise,  and  bodily  pains,  with  an  amount  of  prostration  out  of  all 
proportion  to  the  apparent  severity  of  the  local  lesion.  The  worst  cases 
show  clammy  sweats,  restlessness,  insomnia,  and  even  delirium.  The  local 
manifestations  begin  with  pricking  or  tingling  sensations  referable  to  the 
throat,  soon  changing  to  a  continuous  pain,  ft  becomes  increasingly  dif- 
ficult, especially  in  the  parenchymatous  variety,  to  open  the  month  ;  the 
glands  of  the  neck  become  swollen  and  painful,  the  [tain  radiating  to  the 
ears.  Partial  blnntness  of  hearing,  taste,  and  smell  is  not  uncommon.  A 
sense  of  suffocation  (occasionally  a  real  danger  thereof)  results  from  the 
glandular  swelling.  The  throat  is  constantly  tilled  with  a  thick,  tenacious 
mucus,  attempt-  at  swallowing  which  (or  also  talking)  greatly  increase  the 
patient's  distress.  The  tongue  is  coated  and  the  breath  offensive.  Degluti- 
tion is  often  agonizingly  painful,  and  fluid-  sometimes  regurgitate  through 
the  nose.  Persistence  of  the  fever  sometimes  brings  oul  a  rash  oi  an  ery- 
thematous type. 

Differential  Diagnosis. — Scarlatinal  throats  sometimes  present  lacunar 
inflammation,  but  here  the  disease  is  usually  ushered  in  with  vomiting;  and 
the  appearance  of  the  rash  within  twenty-four  hours  settles  the  question. 
Also,  the  faucial  congestion  i-  generally  much  more  extensive,  while  the 
actual    swelling  of  the    parts    i-    much    less.      The   appearance   of  the    ton-nc 

also  help-  us. 


924      DISEASES  OF  THE   TONSILS,    PALATE,   AM)  PHARYNX. 

In  primary  specific  sore  throat  the  Lesion  generally  appears  in  symmetri- 
cal areas  on  both  sides.  The  congestion  is  of  a  duller  red  hue;  pain  is 
slight  and  fever  generally  absent.  In  fact,  it  is  rather  from  the  simple 
catarrhal  than  the  lacunar  form  of  tonsillitis  that  this  condition  has  to  he 
separated. 

From  diphtheria  the  diagnosis  is  not  always  easy.  We  now  recognize 
bacteriologically  a  lacunar  diphtheria — that  is.  a  true  diphtheria  with  the 
exudate  confined  to  the  walls  of  the  laeiina'.  'To  the  eye  and  in  its  clinical 
features  it  resembles  precisely  the  lacunar  form  of  acute  tonsillitis.  The 
culture-medium  alone  will  enable  us  to  decide.  Many  instances  of  reported 
contagion  in  lacunar  tonsillitis  have  doubtless  been  truly  diphtheritic.  It 
may  be  said  that  in  diphtheria  the  exudate  occurs  in  large  patches,  is  gener- 
ally of  a  grayish  line,  and  of  a  more  ragged  appearance.  A  bleeding  sur- 
face after  removal  is  no  proof  of  true  diphtheria,  bul  only  of  a  croupous 
inflammation — that  is,  exudation  with  degeneration  of  tis>ue.  Moreover, 
here  the  consl it ut iona  1  symptoms  come  on  more  slowly  and  the  temperature 
rarely  rises  so  high  ;  indeed,  may  be  even  subnormal. 

Course. — The  disease  lasts  from  one  to  fourteen  days,  averaging  four  or 
five.  It  may  leave  the  tonsils  chronically  enlarged,  or  before  subsiding  go 
on  to  a  quinsy.  A  few  cases  have  resulted  fatally,  bul  the  prognosis  is  regu- 
larly gOl  >d. 

Treatment. — If  cases  are  -ecu  at  the  very  outset,  the  disease  can  some- 
time- he  aborted  by  painting  the  tonsils  with  strong  solutions  of  cocain,  with 
pun-  guaiacol,  or  with  silver  nitrate  (15  per  cent,  solution).  A  mercurial 
purge  followed  by  a  -aline  should  he  administered,  and  small  and  frequent 
doses  of  aconite,  belladonna,  or  opium  should  he  given.  The  writer  has 
used   with  success  the  familiar  "tonsillitis  tablet"  composed  of — 

\\.  Tr.  aconit.,  111  i; 

Tr.  bryoniae,  m  TV  ; 

Tr.  belladonna;,  til  TV  ; 

Red  iodid  of  mercury,  gr.  j^-q. — M. 

Of  these,  one  may  he  taken  hourly  for  three  hours,  and  one  every  two 
hour-  thereafter.  At  the  outset,  cold  compresses  may  he  applied  to  the  neck  ; 
while  if  the  case  goes  on  to  full  development,  hot  applications  will  afford 
greater  relief.  Frequent  gargling  with  a  hot  solution  of  bicarbonate  of  soda 
in   water  will   remove  the  clogging  mucus. 

Most  cases,  however,  are  well  advanced  when  they  come  under  medical 
care,  and  of  remedies  proposed  in  this  and  later  stages  there  is  no  end. 
Guaiac  given  in  the  form  of  lozenges  or  dram  doses  of  the  ammoniated 
tincture  ha-  long  enjoyed  a  reputation  in  curing  thi-  condition;  but  it 
i-  uncertain  in  effecl  and  very  disagreeable  in  taste.  For  some  years  the 
writer    ha-    hid    the   he-t     results   with    salol,   given    in    hourly    doses  of    five 

grains  in  mucilaginous  suspension  not  tablets)  flavored  with  some  essen- 
tial  oil.       lie    ha-   found    that    in    a    series   of    81    eonseeiit  ive   Cases,    watched 

with  reference  to  tin-  fact,  the  pain  was  relieved  on  an  average  in  fifteen 
hour-.  Allowing  for  sleep,  not  more  than  ninety  grains  are  taken  in  the 
twenty-four  hour-,  and  thi-  daily  dosage  is  perfectly  safe  unless  there  he 
definite  kidney-trouble.  In  a  few  cases  of  the  above  series  the  urine  assumed 
a  darkish  color.  Salioin  has  been  credited  (if  continued  for  a  week  or  more 
after  the  subsidence  of  the  active  symptoms)  with  the  power  of  preventing 
subsequent    persisting  hypertrophy.     Other  drugs  of  value  are  -odium  sal- 


DISEASES  OF  THE   TONSILS.  925 

icylate,  antipyrin,  and  the  muriated  tincture  of  iron.  The  latter  sometimes 
proves  surprisingly  efficacious  alter  one  has  used  in  vain  -nine  of  the  newer 
and  much-praised  remedies.  The  self-limited  nature  of  the  affection  must  be 
borne  in  mind  when  estimating  the  value  of  any  remedy.  Scarifications, 
incisions,  or  punctures  are  not  recommended  in  this  form  of  tonsillitis.  Occa- 
sionally relief  follows  the  digging  out  of  the  crypts  with  a  -mall  sharp  scoop. 

It  is  well  to  isolate  every  ease  of  sore  throat,  although  the  direct  con- 
tagious nature  of  lacunar  tonsillitis  is  still  a  matter  of  dispute. 

Acute  Croupous  Tonsillitis. — By  the  term  "croupous"  is  here  meant 
an  exudative  inflammation  leading  to  the  degeneration  or  death  of  tissue. 
The  change  may  involve  the  epithelial  covering  only,  or  may  extend  through 
the  entire  mucosa  with  swelling  of  the  surrounding  tissues.  The  exuded 
fluid,  rich  in  fibrino-plastic  material,  coagulates  on  the  surface  of  the  mucosa, 
forming  the  false  membrane. 

Causes. — This  variety  frequently  occurs  as  a  complication  of  the  exan- 
themata and  various  infectious  diseases.  It  is  seen  occasionally  in  the  later 
stages  of  renal  trouble  and  of  the  wasting  maladies.  In  one  sense  it  may  he 
said  that  the  special  form  due  to  the  Loffler  bacillus  is  the  lesion  of  diph- 
theria, but  that  i-  not  what  is  meant  by  the  title  above  used.  It  may  also 
occur  as  a  primary  affection  from  almost  any  of  the  causes  mentioned  under 
the  lacunar  form. 

Pathology. — We  find  here  the  typical  false  membrane  from  the  coagula- 
tion of  the  exuded  liquor  sanguinis,  rich  in  fibrino-plastic  material, and  from  the 
emigration  of  leukocytes.  Fibrin  is  thereby  formed  on  the  mucosa  entangling 
the  leukocytes,  now  appearing  as  pus-cells  in  its  meshes.  Subsequent  coagu- 
lation-necrosis leaves  either  superficial  erosions  or  ulcers  of  varying  depth. 
Bacteriological ly  the  staphylococcus  and  streptococcus  are  the  most  common 
excitant  organisms.  Some  classifications  would  include  the  pseudo-bacillus 
of  Loffler.  It  is  not  yet  proven  that  a  simple  streptococcals  sore  throat  is 
necessarily  contagions  in  the  popular  acceptation  of  the  word. 

Symptoms. — These  are  in  a  general  way  the  same  as  those  of  lacunar 
tonsillitis,  although  generally  of  a  greater  severity.  The  tonsil  maybe  but 
little  swollen  and  the  exudate  limited  to  its  convexity.  The  swelling  of  the 
cervical  glands  is  generally  noticeable,  as  is  also  the  prostration. 

Diagnosis. — The  disease  most  nearly  resembling  simple  croupous  tonsil- 
litis is  diphtheria.  Here,  again,  it  is  asserted  with  much  emphasis  that  cul- 
ture-tests alone  can  decide  in  doubtful  cases.  The  local  appearance  may,  in 
the  light  of  each  practitioner's  experience,  incline  him  to  this  or  that  view, 
but  bacteriology  alone  can  settle  the  question.  The  disease  generally  runs 
from  six  to  eight  days,  often  leaving  the  patient  very  weak  and  anemic.  Re- 
covery is  the  regular  rule. 

Treatment. — The  measures  outlined  for  the  treatment  of  the  lacunar 
form  may  be  tried  ;  but  in  the  majority  of  cases  it  i-  better  to  rely  on  a  con- 
stitutional tonic-treatment  and  keep  the  month  as  thoroughly  disinfected  as 
possible.  A  1  :  3000  bichlorid  mouth-wash  is  as  efficient  as  any,  and  when  the 
membrane  begins  to  come  away,  hydrogen  dioxid  solution-  (equal  parts 
freshly  mixed   with   lime-water)  may  be  employed. 

Acute  Circumtonsillar  Inflammation. — It  has  been  customary  to 
-peak  of  this  disease  as  a  suppurative  tonsillitis  or  quinsy.  The  former  is 
objectionable  in  that  it  implies  that  the  tissue  of  the  tonsil  proper  suppurates, 
while  the  truth  is  that  this  change  take-  place  in  the  va-t  majority  of  cases 
in  the  connective  tissue  surrounding  the  tonsil,  especially  in  front  of  and 
above  it. 


MiM      DISEASES  OF  THE   TONSILS,   PALATE,   AND  PHARYNX. 

Causes. — These  are  the  same  as  those  of  the  varieties  «•{'  inflammation 
previously  described.  Any  case  beginning  as  lacunar  or  parenchymatous 
niav  go  on  t<>  suppuration.  The  latter  may  follow  a  specific  affection  of  the 
organ,  as  in  the  case  reported  by  J.   II.   Bryan. 

Pathology. — We  have  lure  a  pure  phlegmon  of  the  circumtonsillar 
cellular  tissue.  The  tonsil  may  be  pushed  inward  from  the  pressure  of  the 
inflammatory  products  and  appear  enlarged  where  it  really  is  not.  Occa- 
sionally the  suppurative  process  actually  invades  the  tonsillar  substance. 
The  abscess  is  more  apt  to  point  in  the  upper  part  of  the  anterior  pillar  or 
jusl  above  it  ;  less  frequently  lower  down  in  the  posterior  pillar.  Occasion- 
ally tin-  pus  burrows  it-  way  to  the  bottom  of  one  of  the  tonsillar  crypts, 
through  which  it   may  lie  -ecu  oozing  to  the  surface. 

Symptoms. — These  are  of  much  the  same  character  as  before  given, 
and  are  generally  of  a  severe  type.  If  the  suppuration  is  secondary  to 
one  of  the  other  forms,  the  pus-formation  may  engraft  upon  the  preceding 
symptoms  a  distinct  additional  rigor,  with  high  fever  and  profuse  sweating. 
The  swelling  in  the  fauces  becomes  extreme.  The  whole  side  of  the  pharynx 
becomes  enlarged,  tense,  and  brawny.  The  soft  palate  is  pushed  forward 
and  a  tumor  may  be  felt  in  the  neck.  It  is  often  impossible  for  the  patient 
to  open  the  month  at  all.  even  to  admit  a  tongue-depressor.  Swallowing 
i<  also  often  impossible.  The  uvula  becomes  edematous  and  obstructs  free 
respiration.  If  left  to  itself  and  only  one  tonsil  is  attacked,  the  disease 
generally  runs  its  course  in  a  week,  by  which  time  the  abscess  will  have 
burst.  Recovery  i-  prompt.  The  involvement  of  the  other  tonsil  means 
another  period  of  misery.  A  serious,  though  fortunately  a  rare,  complication 
i-  edema  of  the  glottis.  The  bursting  of  the  abscess  during  sleep  may  cause 
some  of  the  pus  to  he  -wallowed  and  the  patient  may  awake  choking.  No 
fatal  cases  from  this  can-e  alone  are  personally  known  to  the  writer,  hut  one 
or  two  are  on  record. 

Treatment. — This  is  at  the  outset  the  same  as  for  the  lacunar  and  paren- 
chymatous forms.  If  pus-formation  is  apparently  brewing,  hot  sponges  to 
the  neck  and  the  vapor  from  hops  in  boiling  water  are  grateful  to  the 
patient.  Alkaline  washes  help  to  keep  the  month  clear  from  thick  mucus. 
Marly  incision  i-  advocated.  It  is  permissible  as  soon  as  there  is  any  ful- 
ness about  or  protrusion  of  the  faucial  pillar,  and  should  be  followed  up  by 
flushing  the  month  oul  with  hot  water.  Where  we  suspect  pus  the  blade  of 
the  scalpel  should  be  passed  in  at  least  half  an  inch,  held  horizontally,  and 
the  direction  of  the  incision  should  lie  from  without  inward  toward  the 
median  line.  Deep-seated  pus  i-  in  this  way  frequently  evacuated  where 
more  superficial  puncture  would  be  useless.     In  other  words,  our  aim   is  the 

genera]  one   to  get   rid  of  the    pus   a-   s a-   it    is  formed,  and  we   treat   the 

abscess  on  general  surgical  principles.  Internal  remedies  are  useless  after 
pus  ha- once  formed.  The  syringing  of  the  pus-cavity  with  a  long  curved 
tub.-  attached  to  a  syringe  lull  of  antiseptic  solution  has  in  some  cases 
apparently   hastened  convalescence. 

The  Lingual  Tonsil.— The  fourth,  or  lingual,  tonsil  i-  situated  be- 
tween the  circumvallate  papillae  and  the  anterior  surface  of  the  epiglottis. 
h  resembles  the  faucial  bodies  in  structure,  except  in  that  the  arrangement 
of  the  diverticula  of  it-  epithelial  layer  i-  single,  while  in  the  faucial  bodies 
it  i-  compound.  Concerning  physiology  and  pathology,  the  same  general 
remarks  apply  to  both  regions. 

Simplicity  of  classification  i-  furthered  by  Baying  that  we  may  have  here 
the   simple  catarrhal,  the  lacunar  and  parenchymatous,  and  the  circumtoh- 


DISEASES  OF  THE  TONSILS.  927 

sillar  varieties,  as  previously  outlined.  The  lisl  of  causes  and  the  nature 
of  the  Lesions  are  identically  the  same.  Ruault  states  thai  poisoned  saliva 
from  dental  caries  has  a  special   effect  on  the  lingual  tonsil. 

The  general  symptoms  are  those  already  described  under  the  faucial 
tonsillar  inflammations.  The  local  symptom-  vary  somewhal  from  the 
faucial  type,  and  this  variation  is  due  to  the  differenl  area  affected.  Thus, 
the  feeling  as  of  a  foreign  body  in  the  throat  is  especially  prominent. 
Cough  i-  frequently  referred  to  the  larynx,  while  the  pain  is  especially 
referred    to   the    root    of  the    tongue. 

In  the  lacunar  type  of  the  disease  the  constitutional  symptoms  are  apt  to 
be  more  severe  than  in  the  corresponding  inflammation  of  the  faucial  bodies. 
The  epiglottis  may  become  swollen  and  even  the  structure- around  the  glottic 
opening,  thus  causing  dyspnea,  which  i-  at  times  alarming  and  sometime- 
demands  operative  relief.  The  initial  pain  is  frecpaently  referred  to  the  hyoid 
region. 

The  circumtonsillar  or  suppurative  form  (lingual  quinsy)  is  less  common 
than  in  the  fauces,  owing  to  the  scanty  amount  of  connective  tissue  at  the 
root  of  the  tongue.  The  special  point  of  importance  is  the  recognition  of  the 
precise  malady  with  which  we  have  to  do.  The  mirror  and  the  finger  should 
both  be  used  as  aids  to  diagnosis.  Incision  of  a  fluctuating  area  is  preferably 
made  with  the  galvano-eautery.  It  is  worth  remembering  that  these  cases 
are  sometimes  ushered  in  by  an  attack  of  edema  of  the  glottis.  Spontaneous 
evacuation  of  the  abscess  during  sleep,  especially  if  it  discharges  posteriorly, 
introduces  an  element  of  great  danger.  Cases  of  chronic  abscess  and  of  reten- 
tion-cysts in  this  region  are  on  record. 

The  various  forms  are  often  overlooked  because  the  physician  contents 
himself  with  simply  using  the  tongue-depressor,  a  procedure  which  does  not 
bring;  the  area  of  the  linsrual  tonsil  into  view.  The  larvngreal  mirror  will 
reveal  the  lacuna?  choked  up  with  inflammatory  plugs  and  show  the  enlarge- 
ment of  the  tonsil  as  a  whole,  either  as  a  median  single  mass  or  as  bilateral 
masses  separated  by  a  furrow.  Palpation  with  the  finger  will  reveal  the 
existence  of  fluctuation  when  pus  has  formed. 

The  treatment  of  these  various  forms  of  lingual  tonsillitis  is  identical 
with  that  of  the  corresponding  forms  of  the  faucial  affections.  As  local 
applications  we  may  use  tannin  and  morphin,  glycerite  of  boro-glycerin, 
weak  cocain  solutions,  and  menthol  in  olive  oil  or  albolene  (gr.  xv-.sj). 
During  the  acute  stages  the  vapor  of  boiling  water  poured  on  hop-  i-  grate- 
fully borne,  and  convalescence  may  be  hastened  by  swabbing  with  diluted 
perchlorid  of  iron  (one  part  to  eight  or  ten  of  water).  The  worsl  cases  of  this 
variety  may  suggest   Ludwig's  angina. 

Acute  Ulcerative  Tonsillitis. — ruder  this  heading  Moure  has  re- 
cently called  attention  to  a  sub-variety  of  lacunar  tonsillitis  characterized  by 
the  presence  of  large  ulcer-  which  closely  resemble  syphilitic  lesions.  The 
tonsils  present,  more  frequently  on  their  mesial  aspects,  grayish  patches 
covered  with  a  cheesy  coining  of  some  thickness,  but  easily  removed  and 
leaving  a  mammillated  surface.  The  borders  of  the  ulcer  are  clean  cut  but  not 
particularly  swollen.     The  remainder  of  the  organ  may  or  may  not  be  enlarged. 

These  ulcers  may  be  single  or  multiple,  without  any  tendency  to  coalesce. 
They  may  follow  one  another  on  the  same  tonsil, so  thai  theorgan  may  ;it  <>'.u- 

time  exhibit  different   stages  of  the  lesion.     The  proct ems  i"  starl  as  an 

acute  inflammation  in  the  crypt-.  The  gross  appearance  is  compared  by 
Moure  to  thai  of  a  cauterized  tonsil  from  which  the  -lough  is  about  to  sepa- 
rate ( Fig.  575). 


928      DISEASES  OF  THE   TONSILS,    PALATE,   AND   PHARYNX. 

No  special  cause  for  this  sub-variety  has  as  yel  been  proven.  The  dis- 
ease seems  to  attack  l>y  preference  young  adult.-,  and  to  be  mere  prevalent  in 
the  spring  and  fall. 

Symptoms.- — These  correspond  toau  extremely  mild  form  of  the  ordinary 
lacunar  disease.     Thecervical  glands  are  rarely  affected. 

Treatment. — The  ulcers  should  be  thoroughly  cleansed  with  zinc-chlorid 
solution  (1  :30)  containing  a  little  cocain,  and  then  a  bromid  gargle  in  glyce- 


,">.— Acute  ulcerative  tonsillitis  (Moure). 

riii   and   water  should    follow.      All   pharyngeal  irritants  should  be  avoided. 
Initial   curetting  of  the  affected  area   has  been  done  with  success. 

The  writer  ha-  seen  hut  one  case  which  he  would  place  under  this  head- 
ing. In  this  instance  the  left  tonsil  of  an  Italian,  about  thirty-five  years  old, 
presented  a  crateriform  ulcer  corresponding  to  the  description  above  given. 
Doubtless  certain  cases  of  this  nature  have  been  regarded  as  ulcerating  gum- 
mata.  The  gumma,  however,  is  generally  near  the  periphery  of  the  tonsil, 
so  that  the  neighboring  parts  are  rapidly  invaded.  Moreover,  the  edges 
of  the  specific  ulcer  are  generally  surrounded  by  an  angry  red  zone  which 
i-  wanting?  in  the  lacunar  ulceration. 


Chronic  Tonsillar  Inflammations. 

Modem  pathological  views  enable  us  to  distinguish  the  same  varieties  of 
chronic  a-  of  acute  tonsillar  inflammation-.  The  chronic  catarrhal  form  is 
reallj  one  elemenl  of  a  chronic  pharyngitis,  under  which  heading  it  is  referred 
to.  The  existence  of  a  chronic  croupous  form  is  a  matter  of  some  doubt.  A 
special  variety  attended  with  an  exudate  i\\w  to  the  bacillus  coli  communis 

b    referred  to  later  in  this  article. 

Chronic  lacunar  Tonsillitis. — Pathology. —  In  this  condition  the 
tonsils  are  hut  little  if  at  .ill  enlarged,  hut  the  crypts  become  filled  from  time 
to  time  with  cheesy  masses.  This  seems  to  result  from  the  narrowing  or 
bridging  over  of  the  crypt-orifices,  either  by  inflammatory  processes  or  by  a 
Borl  of  villous  ingrowth  (Sokolowski)  of  the  epithelium  into  the  lacunas. 
Retention  of  crypt-contents  leads  to  dilatation,  irritation,  anil  inflammation. 

The  plugs    thus    retained   are   Composed    of  epithelial  debris,  leukocytes,  fatty 

granules,  cholesterin,  and  various  mycotic  element-.     They  frequently  emit 
a  very  offensive  odor. 

Symptoms. — The    symptoms    of   the   condition    are    faucial    irritability 


DISEASES  OF  THE   TONSILS.  929 

(tickling,  burning,  feeling  as  of  foreign  body),  with  pain  radiating  toward  the 
ears,  and  increased  on  swallowing.  The  breath  is  fetid  and  the  tongue  fre- 
quently coated.  Singing  and  smoking  aggravate  the  symptoms.  The  expul- 
sion of  the  plugs  is  followed  by  relief.  The  patients  are  frequently  very 
much  worried  about   themselves. 

[inspection  does  not  always  reveal  the  condition.  The  probe  must  l>e  used 
and  the  crypts  explored.  According  to  Gumpert,  two  sites  must  be  closely 
scrutinized:  (1)  the  upper  extremity  of  the  tonsil,  between  the  pillars — the 
so-called  epitonsillar  fossa;  and  (2)  the  middle  of  the  tonsil,  directly  behind 
the  anterior  pillar.  The  condition  is  frequently  overlooked,  and  the  faucial 
dysesthesia  is  referred  to  dilated  lingual  veins,  enlarged  pharyngeal  follicles, 
hysteria,  etc.     Meanwhile,  the  patient  gets  no  better. 

Treatment. — The  crypts  should  all  be  cleared  out  by  some  spud-like 
instrument  or  scoop  and  then  slit  up  thoroughly.  The  bared  areas  should 
then  be  vigorously  rubbed  with  a  strong  solution  of  iodin  and  potassic  iodid, 
of  each  sjss  to  water  .V).     This  generally  effects  a  permanent  cure. 

Chronic  Tonsillitis  Due  to  the  Bacillus  Coli  Communis. — Recent 
French  writers  have  insisted  that  there  exists  a  form  of  chronic;  tonsillitis 
due  to  the  bacillus  coli  communis,  and  with  a  definite  clinical  course.  Its 
characteristics   are  : 

1.  Its  chronic  course,  beginning,  it  is  true,  with  a  brief  stage  of  acute 
inflammation. 

2.  Its  extreme  persistence,  since  none  of  the  therapeutic  measures  habit- 
ually directed  against  anginas  are  able  to  modify  it.  in  one  case  only  ex- 
cision of  the  tonsil  sufficed  to  remove  it. 

3.  The  slight  intensity  of  the  local  subjective  symptoms,  no  pain  in  the 
throat,  no  dryness  or  hypersecretion  ;  at  times  a  slight  difficulty  in  swallow- 
ing when  the  exudate  becomes  confluent. 

4.  A  notable  deterioration  out  of  all  proportion  to  the  local  condition, 
and  generally  manifested  in  digestive  disorders.  These  features  are  clearly 
of  tonsillar  origin,  as  they  lessen  after  the  clearing  out  of  the  crypts,  but 
return  upon  the  reappearance  of  the  exudate. 

5.  The  characteristic  appearance  of  the  tonsillar  exudate — viz.,  a  dull- 
white  color,  semisoft  consistence,  punctiform  masses  emerging  from  the 
crypts,  but  not,  as  a  rule,  encroaching  upon  the  intercryptic  surface,  the 
mucosa  covering  which  presents  only  a  slight  redness.  Occasionally  the 
masses  coalesce,  suggesting  a  pseudo-membrane,  slightly  adherent  but  re- 
movable without  leaving  a  bleeding-surface,  resistant,  and  not  disintegrating 
when  placed  in  water. 

<i.  The  integrity  of  the  peritonsillar  and  pharyngeal  regions. 

7.  The  absence  of  glandular  enlargements. 

Bacteriologically,  the  exudate  -hows  a  pure  culture  of  the  bacterium  coli 
commune,  not  only  on  the  surface  but  in  sections  of  the  tonsillar  tissue. 
The  micro-organism  differs  from  that  isolated  from  the  intestine  in  certain 
minor  culture-reactions. 

The  authors,  moreover,  declare  that  this  germ  is  frequently  found  in 
healthy  human  mouths,  and  express  the  belief  that  thi-  form  of  tonsillitis  is 
frequently  overlooked.  The  most  common  condition  with  which  it  might  be 
confounded  is  the  ordinary  leptothris  mycosis.  P>nt  in  the  latter  the  exudate 
is  generally  hard  and  horny,  is  removed  with  difficulty,  and  under  the  micro- 
scope reveals  its  characteristic  mycelial   threads  and  spores. 

Chronic  Parenchymatous  Tonsillitis.— This  is  one  of  the  most 
common  affections  with  which  we  have  to  do.      It   may  occur  as  the  result 

59 


930      DISEASES  OF  THE   TONSILS,   PALATE,   AND  PHARYNX. 

of  preceding  acute  attacks;  or  it  may  be  seen  so  early  in  life  that  it  is 
impossible  to  sayjusl  when  it  began.  It  is  regularly  found  in  strumous 
children  and  in  those  living  under  bad  hygienic  surroundings.  It  may, 
however,  occur  in  grown  people  without  any  dyscrasia  and  in  those  com- 
fortably boused  and   fed. 

Pathology. — The  entire  tonsil  is  enlarged  (one  or  both)  and  of  varying 
consistency.  In  the  child  or  in  very  recenl  cases  in  the  young  adult  it  feels 
more  or  less  pulpy,  while  in  the  older  cases  it  is  distinctly  hard.  Under 
the  microscope  it  is  seen  thai  the  lymphoid  elements  have  undergone  a  true 
hyperplasia  and  that  more  or  less  connective  tissue  has  developed.  This 
may  be  seen  even  by  the  naked  eye  as  irregular  trabecular  running  through 
the  mass,  and  by  their  contractile  tendency  hardening  the  latter  (.Fig.  o76). 

Not  infrequently  we  find  thai  the  anterior  pillar  of  the  fauces  appears  as 
:i  broad  and  thick  fibrous  hand,  which  completely  envelops  the  anterior  half 
of  the  tonsil;  and  by  a  process,  apparently  of  contraction,  has  pressed  and 
rotated  the  latter  backward,  so  that  whatever  remain-  of  it-  free  surface  pre- 
sents toward  the  posterior  wall  of  the  pharynx.  Adhesion  to  the  posterior 
faucial   pillar  may  also  occur. 

This  connective-tissue  development  hears  on  the  question  of  possible 
hemorrhage  after  tonsillotomy.  It  leads  to  a  canalization  of  the  blood- 
vessels, SO  that  alter  section  their  months  arc  held  open  and  they  cannot 
retracl  within  their  sheaths,  'flu-  organ  may  feel  soft  at  the  surface  but  be 
quite  hard  at  the  plane  of  the  section.  Its  general  state  constantly  invites 
fresh  inflammatory  attacks.     The  crypts  become  clogged  up,  and  the  waste 


:/y$ ':     :  '&& 


! 


•  i 


rophy  of  the  faucial  tonsil  (Seiferl  and  Kahn). 

products  accumulating  behind  these  plugs  lead  to  renewed  inflammation. 
Removal  of  a  layer  of  surface-tissue  corresponding  to  the  depth  of  these 
crypts  will  often  give  surprising   relief  to  the  constanl   series  of  outbreaks, 

although,  of  course,  such  a   plan  of  treatraenl    is  to  be  c lemned  as   nol 

being   sufficiently  thorough. 


DISEASES  OF   THE   TOXSILS.  931 

Symptoms. — Enlarged  tonsils  arc  in  a  sense  foreign  bodies  and  give 
rise  to  symptoms  accordingly.  All  functions  of  the  surrounding  parts  are 
more  or  less  hindered.  An  enlarged  pharyngeal  tonsil  (so-called  "adenoid 
vegetations")  may  coexist  with  enlarged  faucial  tonsils;  and  it  i-  difficult  to 
determine  to  which  of  the  two  areas  of  diseased  tissue  a  given  symptom  is 
to  be  referred.  The  voice  is  thick,  the  patient  speaking  as  if  the  month  was 
partially  full,  and  some  of  the  normal  nasal  resonance  of  phonation  is  lack- 
ing. Breathing  is  somewhat  interfered  with,  although  in  adults  true  dyspnea 
is  rare.  In  children,  however,  the  oro-pharynx  seems  to  be  encroached 
upon,  so  that  a  slow  carbonic-acid  accumulation  in  the  system  takes  place. 
Snoring  and  mouth-breathing  may  occur.  The  need  of  oxygen  finally  be- 
comes so  great  that  the  child,  if  asleep,  will  wake  up  suddenly,  presenting 
the  familiar  "night-terrors."  The  senses  of  taste,  smell,  and  hearing  are 
more  or  less  blunted,  and  there  may  he  actual  aural  inflammation.  The 
enlarged  tonsils,  moreover,  interfere  mechanically  with  the  actions  of  the 
delicate   muscles  which  govern  the  functions  of  the   Eustachian   tube-. 

Children  with  enlarged  tonsils  are  apt  to  surfer  from  defects  of  chest- 
development  and  general  physique.  They  will  sometimes  improve  with 
marvellous  rapidity  after  the  pharynx  is  cleared  out.  Doubtless  many  chest- 
deformities  referred  to  enlarged  tonsils  should  be  referred  along  with  the 
latter  to  some  underlying  diathesis.  The  breath  is  offensive,  the  stomach 
frequently  disturbed,  and  the  bowels  disordered.  The  inspired  air  passing 
over  the  diseased  crypts  containing  cheesy  plugs  of  decayed  epithelia,  fer- 
menting mucus,  and  particles  of  food,  the  child  is  constantly  inhaling  a  viti- 
ated atmosphere.     Nocturnal  enuresis  is  sometimes  present. 

Diagnosis. — Even  a  casual  inspection  of  the  fauces  will  reveal  the 
enlarged  masses,  which  the  act  of  gagging  throws  out  still  more  prominently 
into  view. 

Treatment. — The  condition  offers  no  hope  of  improvement  if  left  to 
itself.  It  is  true  that  the  tonsils  will  atrophy  in  later  years,  but  by  this 
time  irreparable  damage  may  have  been  done  in  various  direction-.  If  the 
tonsils  are  large  enough  to  cause  any  of  the  foregoing  symptoms,  they  should 
be  removed.  The  only  question  is  as  to  preference  of  methods  in  such 
removal. 

In  children  tonsillotomy  with  some  approved  instrument  is  preferable 
(for  operation,  see  page  1205),  and  it  is  the  writer's  experience  that  a  more 
satisfactory  removal  can  be  accomplished  without  anesthesia   than  with  it. 

Where  the  tonsils  are  large  but  Hat  and  non-projecting  it  is  difficult,  if 
not  impossible,  to  engage  any  considerable  portion  of  them  within  the  ring 
of  the  guillotine.  Under  these  circumstances  we  may  employ  ignipuncture 
(see  below)  or  the  method  of  liuault — "traitement  par  morcellement."  lie 
has  devised  a  tonsil  punch-forceps,  by  which  pieces  of  the  tonsillar  substance 
may  be  bitten  oil'.  This  instrument  will  engage  in  the  tonsillar  tissue  if  the 
surface  of  the  latter  is at  all  uneven.  If  it  is  smooth,  the  crypts  should  firsl 
be  scraped  out.  adhesions  to  the  faucial  pillars  broken  down  with  a  palate- 
hook,  and  the  tonsillar  surface  incised  with  a  small  blade  sel  at  a  right  angle 
to  the  axis  of  it-  shaft.  In  this  way  hit-  of  tissue  are  presented  to  the 
punch-forceps  for  removal.  A  fter  bleeding  has  ceased,  the  raw  surface  should 
lie  vigorously  rubbed  with  a  cotton-carrier  dipped  in  a  solution  of  iodin  1 
part,  potassium  iodid  1  part,  water  s  part-.  A  -mart  stinging  sensation 
en-iie-.  which  passes  off  in  twenty  minutes.  Secondary  retraction  ol  the 
stump  greatly  increases  the  amount   of  reduction   in  size. 

Iii  older  patient-  tin'  use  of  the  guillotine  is  somewhat   hazardous,  owing 


932      DISEASES  OF  THE   TONSILS,    PALATE,   AND   PHARYNX. 

to  the  liability  to  hemorrhage.  We  ma}  use  here  either  the  cold-wire  or 
galvano-cautery  snar< — the  latter  being  the  one  more  frequently  employed. 
The  cold  snare  can  be  used  with  a  stiff  wire  which  can  be  accurately  adjusted. 
Ii  can  be  tightened  slowly  and  hemorrhage  thereby  avoided.  It  is  extremely 
painful,  and  owing  t<>  the  time  it-  use  requires,  the  latter  necessitates  in 
children  a  general  anesthetic.  In  adult-  the  cold  snare  can  l>c  used  under 
cocain. 

The  hoi  snare  (galvano-cautery  loop)  lias  the  advantage  of  being  practi- 
cally a  bloodless  operation.  The  wire  should  be  of  irido-platinum,  which  is 
much  -tiller  than  pure  platinum  wire,  while  retaining  also  all  of  the  La-tier's 
advantages.  It  issomewhal  difficult  toadjust  the  loop  and  hold  it  in  position 
until  the  current  can  be  tinned  on,  unless  the  tonsillar  mass  to  be  removed  is 
of  considerable  size.  It  is  therefore  often  of  service  to  make  on  the  posterior 
aspecl  of  the  tonsil  a  groove  either  with  a  bent  electrode  or  with  the  con- 
cavity of  the  loop  itself.  In  tin-  way  the  latter  will  hold  and  not  slip  off 
when  it  i-  tightened.  The  current  should  be  turned  on  and  oil'  alternately, 
tin-  snare  being  tightened  in  the  meantime,  the  latter  part  of  the  cautery-sec- 
tion being  -lowly  made. 

It  i-  not  necessary  to  remove  the  entire  tonsil.  A  thick  slough  will 
eventually  come  away,  causing  a  still  further  shrinkage  of  the  tonsil.  It 
iia-  been  said  that  entire  removal  of  the  latter  leaves  an  annoying  dryness 
<>f  the   mouth,    hut    this   ha-   not    been   the  personal   experience  of  the  writer. 

Where  the  shape  or  disposition  of  the  tonsillar  structures  is  such  as  to  neces- 
sitate removal  by  piecemeal  or  gradually,  we  have  in  addition  to  the  method 
of  Iv'uault  that  of  ignipuncture.  This  can  he  made  practically  painless  by 
injecting  one  or  two  drop-  of  a  5  per  cent,  cocain  solution  under  those  areas 
-elected  for  operation.  The  cautery-tip  should  he  inserted  deeply  into  a 
crypt,  the  current  then  turned  on,  and  the  tip  he  made  to  burn  its  way 
diagonally  outward.  Eight  or  ten  such  punctures  can  he  made  at  each  sitting. 
The  throal  is  quite  sore  for  ;i  day  or  two.  and  it  is  better  to  attack  only  one 
tonsil  at  a  time.  Ice-water  gargles  and  antiseptic  mouth-washes  can  he  used 
<i<l  interim.  There  is  a  great  variation  in  the  rapidity  of  shrinkage  after 
such  treatment — some  tonsils  rapidly  melting  away,  as  it  were,  while  others 
require  repeated  seances.  <  !are  should  he  taken  to  avoid  burning  the  faucial 
pillars,  for  the  minute  cicatrices  thus  formed  are  apt  to  become  neuralgic  foci 
on  every  slight  cold  in  the  throat. 

Of  course,  neither  the  cautery-snare  nor -tip  should  he  w^cd  without  a 
rheostat.  It  must  he  remembered  that  contact  with  moisl  tissues  quickly 
abstracts  heal   from   the  wire,  and  allowance  must   he  made  accordingly. 

Chronic  Inflammation  of  the  lingual  Tonsil. — For  all  practical 
purposes  only  the  parenchymatous  variety  need  he  mentioned.  One  case 
(perhaps  others)  ha-  keen  recorded  of  chronic  encysted  abscess  in  this 
situation. 

The  affection  has  been  commonly  regarded  a-  more  frequenl  in  women 
aboul  middle  life  and  with  .-i  history  of  previous  menstrual  disorders  than  in 
men.  Out  of  17,566  cases  of  throat>-trouble,  Lennox  Browne  found  varicose 
vein-  at  the  ha-e  of  the  tongue  associated  with  hypertrophy  of  the  lingual 
tonsil  in  1866,  or  10.6  percent.  A.gain,  in  1547  cases,  138,  or  28.3  percent. 
Of  tlii—  latter  group,  however,  only  .">1  per  cent,  were  in  women,  while  <>!> 
percent,  were  in  men.     Of  hi-  private  cases,  99  percent,  were  voice-users. 

In  any  evenl  the  affection  i-  one  belonging  to  the  period  of  middle  life. 
and  this  i-  :i  point  worthy  of  note,  because  al  this  age  atrophy  of  all  the  tonsil- 
lar structures  is  g<  nerall)  present.    Hickman  has  recorded  the  case  of  a  child 


DISEASES  OF  THE  TONSILS.  933 

dying  of  asphyxia  a  few  hours  after  birth,  supposedly  from  a  congenital 
glottic  tumor,  but  the  autopsy  revealed  an  enormous  hypertrophy  of  the 
normal  tissue  on  the  posterior  part  of  the  tongue. 

<  hlier  causes  are  those  in  general  of  the  various  forms  of  chronic  tonsillar 
inflammation,  including  especially  all  forms  of  irritant  ingesta. 

Pathology. — The  enlarged  lymphoid  mass  may  be  situated  in  the  middle 
line,  or  there  may  l»e  a  mass  on  each  side  with  a  deep  furrow  between.  The 
growths  often  project  sufficiently  to  infringe  upon  the  edges  of  the  epiglottis 
and  even  to  compress  the  latter  (the  so-called  "incarceration  of  the  epi- 
glottis").    Minutely  examined,  we   find  nodular  elevations  which  exhibit  a 


i>;;vs,. 


a 


>'-•<::. 


'-*■•■ 


•&  -':-3&r  ''■'-■;-     sji&zgy' 


-  iy 


Fig.  577.— Hypertrophy  of  the  lingual  tonsil  (Seifert  and  Kahm. 

well-marked  umbilication.  This  latter  is  a  central  crypt  due  to  a  depression 
of  the  stratified  epithelium.  Such  crypts  are  sometimes  lined  with  ciliated 
epithelium.  In  minor  cases  the  enlargement  may  consist  almost  entirely  <>f 
an  epithelial  hyperplasia,  which  is  hard  and  wart-like  rather  than  soft  like 
the  typical  lymphoid  overgrowth  (Fig.  577).  The  lymphatic  channels  from 
this  region  pass  directly  backward,  and  after  coursing  through  the  deep  lin- 
gual glands  join  the  deep  cervical  glands  in  the  neighborhood  of  the  bifur- 
cation of  the  common  carotid  artery. 

Symptoms. — The  principal  symptom  is  pharyngeal  dysesthesia,  mani- 
fested in  a  great  variety  of  ways.  There  may  be  every  intervening  grade 
between  a  slight  tickling  and  a  sharp  stinging  pain.  At  other  times  there  i-; 
a  sensation  as  if  the  throat  was  grasped  from  the  outside  and  forcibly  com- 
pressed, or  there  may  be  the  sensation  as  of  a  foreign  body  stuck  in  the 
tissues,  with  a  constant  desire  t<>  clear  the  throat. 

Manifold  varieties  of  reflex  or  direct  neuroses  are  often  present.  The 
purity  and  vigor  of  the  singing  voice  become  impaired  :  esophageal  spasm  is 


934      DISEASES  OF  Till.    TONSILS,    PALATE,   AND  PHARYNX. 

frequently  evoked,  and  the  condition  of  the  lingual  tonsil  should  never  he 
overlooked  in  searching  for  the  cause  of  globus  hystericus.  Asthmatic  attacks 
are  not  uncommon.  The  patients  arc  as  a  rule,  extremely  neurotic,  and 
women  especially  are  apt  to  fear  that  these  pharyngeal  disturbances  are  the 
forerunners  of  cancer. 

Treatment. — The  condition  is  not  ;i  serious  one,  and  the  annoyance  it 
causes  is  out  of  all  proportion  to  its  real  pathological  importance.  But 
patients  have  a  jn-t  grievance  and  have  a  right  to  demand  relief.  This  does 
not  come  without  interference.  (  >ut.-ide  of  the  cessation  of  any  vicious  prac- 
tice in  eating,  drinking,  voice-use,  etc.,  the  end  to  be  sought  is  the  reduction 
in  size  of  the  offending  mass. 

It'  necessary,  a  previous  application  of  cocain  should  he  made  before  any 
manipulative  measures  are  attempted.  If  the  masses  are  large  enough  to 
engage  in  the  ring  of  the  tonsillotome  (especially  the  Mackenzie  instrument, 
curved  to  correspond  with  the  curve  of  the  tongue),  the  latter  may  he  used  to 
remove  them.  We  may  also  use  the  cold-wire  snare  in  a  curved  cannula, 
employing  transfixion-needles  to  insure  engagement  of  the  snare  in  tin1  tissue. 
The  ordinary  curved  uvulotomy  scissors  will  answer  in  some  cases,  or  we 
have  also  at  our  disposal  the  hoi   snare. 

When  the  growth  is  diffused,  some  sort  of  caustic  must  be  employed. 
Nitrate  of  silver  is  1 1-<  1*  —  because  its  action  is  too  superficial.  Chlorid-of- 
zinc  solutions,  caustic  pyrozone,  and  chromic  acid  are  at  our  disposal. 
Perhaps  the  cauterizing  agent  most  frequently  employed  is  the  galvano- 
cautery  tip  at  a  dull-red  heat,  five  or  six  punctures  being  made  at  each  sitting. 
Caustics  should  not  be  recklessly  used  in  this  situation,  for  the  formation  of 
too  much  cicatricial  tissue  at  this  point  may  eventually  aggravate'  the  very 
condition  we  hope  to  relieve.  More  important  than  this,  however,  is  the  fact 
that  too  much  irritation  might  start  a  neoplastic  formation  liable  to  assume  a 
malignant   character. 

Hemorrhage  after  any  cutting  operation  here  is  usually  slight.  Swelling 
b  fora  time  very  painful.  Ice-pellets  should  be  freely  used.  All  hot  drinks, 
spices,  condiments,  and  coarse  food-  should  be  avoided  for  a  day  or  two. 

In  tin'  use  of  caustics  special  care  must  be  taken  to  avoid  injuring  the 
I  piglottis,  which  b  apt  to  react  severely  to  very  slight  trauma. 

Lingual  Varix. 

Apart  from  the  enlargement  of  the  lingual  tonsil,  the  veins  in  this  situa- 
tion may  become  tortuous  and  dilated,  assuming  a  varicose  condition.  To 
this  have  been  given  the  names  of  lingual  varix,  hemorrhoids  of  the  tongue, 

etc.      A-  to  the  local  physical  c lition,  it  is  practically  identical  with  that  in 

rectal   hemorrhoids. 

Causes. — The  affection  is  rare  before  the  twentieth  year,  and  far  more 
common  aboul  middle  life,  h  most  frequently  occurs  in  patients  with 
torpid  liver  and  those  who  suffer  from  chronic  dyspepsia  associated  with 
constipation  and  pile-.  It  may  be  present  in  almost  any  chronic  visceral 
affection  obstructing  free  venous  return,  and  occasionally  seems  to  be  one  of 
the  local  manifestations  of  ;i  general  tendency  to  vaso-motor  neuroses. 

Pathology. — The  vein-  are  entangled  and  appear  as  a  network  of  dark- 
led <>r  reddish-blue  streaks  or  bands,  with  here  and  there  local  dilatations: 

"'•  there  may  !"■  actual  nodosities,  small  ampullae  in  which  the  hi l-currenl 

stagnates. 

Symptoms. — The  symptoms  are  the  same  as  those  of  simple  enlarge- 


DISEASES  OF  Till-;   TONSILS.  935 

ment,  with  the  important  addition  that  from  time  to  time  small  hemorrhages 
may  occur.  These,  while  rare,  generally  give  great  alarm  to  the  patient,  as 
he  is  apt  to  regard  them  as  the  forerunner  of  lung-trouble. 

Treatment. — The  digestive  apparatus  and  bowels  should  be  regulated 
and  any  dietetic  errors  corrected.  The  vessels  are  best  obliterated  by  the 
galvano-cautery  tip  at  a  dull-red  heat  and  tinder  the  general  precautions 
already    noted. 

Chronic  Encysted  Tonsillar  Abscess. 

Among  the  causes  of  tonsillar  enlargement  may  be  mentioned  the  occur- 
rence of*  chronic  encysted  abscess.  This  condition  has  Keen  carefully  studied 
by  Peyrissac,  who  has  analyzed  ten  cases.  Some  presented  a  hard  condition 
of  the  organ,  suggesting  a  fibroma.  They  are  to  be  regarded  as  similar  in 
their  mode  of  origin  to  the  ordinary  cold  abscess,  although  thev  have  no 
tubercular  element.  Bacteriologically,  they  have  no  characteristics  other  than 
those  of  abscesses  in  general,  and  do  not  seem  to  have  any  relation  to  a 
special  diathesis. 

An  intermittent  purulent  discharge  may  suggest  the  nature  and  under- 
lying cause  of  the  tonsillar  enlargement.  The  contents  of  the  abscess-cavity 
may  be  grumous  or  syrupy  in  consistency.  The  pus-cells  show  marked  fatty 
and  granular  degeneration,  and  are  rich  in  cholesterin-crystals.  The  lining 
wall  is  apparently  of  a  low  grade  of  connective  tissue,  organized  from  the 
surrounding  tonsillar  parenchyma. 

The  treatment  is  not  attended  with  any  particular  difficulty. 

Polypoid  Hypertrophy  of  the  Tonsil. 

Apart  from  hypertrophy  of  the  tonsil  as  a  whole,  we  may  have  a  local- 
ized enlargement  giving  rise  in  a  lesser  degree  to  the  same  symptoms  as 
general  hypertrophy  and  remediable  by  the  same  measures,  especially  tin- 
snare.  In  these  adjunct  masses  there  is  generally  an  excessive  development 
of  connective  tissue,  resembling  at  times  an  actual  sclerosis. 

Such  growths  arise  from  one  of  three  possible  sources  : 

1.  They  may  be  accessory-tonsils. 

'1.  There  may  be  an  elongation  at  the  site  of  implantation  of  one  or 
several   lobules  of  a  multilobular  and  hypertrophied  tonsil. 

3.  The  entire  tonsil  may  become  pedunculated. 

Calculi  of  the  Tonsil. 

Not  infrequently  -mall  -tone-like  bodies,  tonsilloliths,  :is  they  are  called, 
are  found  in  the  tonsil  or  are  discharged  from  it-  surface.  They  vary  in 
si/e  from  a  pin's-head  to  a  pea,  and  a  few  very  large  one-  have  been  reported. 
Their  composition,  as  determined  by  Langier,  is:  calcium  phosphate,  50; 
calcium  carbonate,  L2.5;  mucus,  12.5 j  water,  25  percent.  The  constanl 
occurrence  therein  of  cholesterin  is  a  disputed  point.  It  certainly  has  been 
found  in  some  instances,  as  have  also  magnesium  salts.  The  starting-point 
of  formation  may  be  a  minute  foreign  body  ;  but  i-  generally  a  ma—  o! 
retained  secretioo  in  the  crypts.  Various  micro  organisms  have  been  found 
embedded   in  these  calculi. 

The  symptoms  are  those  of  a  foreign  body,  sometimes  causing  tonsillar 
enlargement.  Palpation  and  the  exploring-needle  will  render  the  diagnosis 
certain. 


936      DISEASES  OF  THE   TONSILS,   PALATE,   AND   PHARYNX. 

Treatment  consists  in  incising  the  tissue  over  the  calculus,  scooping  the 
latter  out  ami  cauterizing  it-  bed. 

Foreign  Bodies  in  the  Tonsil. 

These  are  generally  either  chicken-  or  fish-bones,  pins,  hairs,  or  bristles 
from  a  tooth-brush.  Occasionally  the  entire  foreign  body  becomes  embedded 
in  the  tissue,  but  generally  a  portion  projects  and  can  be  seen  or  felt.  In 
case  inspection  reveal-  oothing  we  must  always  palpate.  Removal  by 
forceps  is  generally  easy  enough. 

That  large  class  of  cases  musl  not  be  forgotten  in  which  the  body  has 
been  swallowed  but  has  left  a  slight  lesion,  causing  much  pharyngeal  dis- 
comfort. This  dysesthesia  can  be  relieved  by  a  mild  cocain-spray.  Even 
then   it  is  difficult   to  persuade  patients  of  the  groundlessness  of  their  fears. 

Xerostomia  (Dry  Mouth). 

This  condition  was  first  described  in  1868  by  J.  Hutchinson  who  gave 
it  the  name  it  bears.  Since  that  time  some  twenty-five  cases  have  been 
recorded.  The  most  prominenl  feature  in  all  has  been  a  persistent  and 
extr<  me  dryness  of  the  buccal  mucosa.  The  dryness  may  begin  in  the  eyes 
and  Dose,  extending  thence  to  the  pharynx  and  trachea.  The  teeth  arc 
apl    to  crumble.      All   the  cases  thus  far  reported  have  been  in  women. 

The  nature  of  the  disease  i>  unknown.  It  shows  no  constant  lesion.  In 
<>ne  or  two  instances  the  parotid  elands  have  been  enlarged,  but  the  duct- 
have  remained  pervious.  Many  of  the  case-  have  presented  coincident  tro- 
phic changes  in  other  parts  of  the  body,  suggesting  the  central  origin  of  the 
affection. 

All  local  or  constitutional  remedies  have  thus  far  proven  useless.  Pilo- 
carpi  and   potassium    iodid   seem   to  exert    no  effect   on   the  condition. 

DISEASES  OF  THE  EPIGLOTTIS. 

It  i-  unusual  for  the  epiglottis  to  be  the  seat  of  primary  inflammatory 
affections.  It  i-  generally  secondarily  involved,  a-  in  lupus,  tuberculosis, 
and  sj  philis,  in  which  it  presents  the  lesions  characteristic  of  these  respective 
affections.  It  shares,  so  far  a-  it-  mucous  covering  is  concerned,  in  the 
various  catarrhal  conditions  of  the  pharynx  and  larynx.  In  enlargement 
of  the  lingual  tonsil  the  latter  sometimes  compresses  the  edges  of  the  epi- 
glottis, giving  rise  to  tin-  so-called  "incarceration"  of  the  latter.  The 
epiglottis  itself  frequentl}  responds  to  tin-  irritation  by  growing  larger,  but 
tlii-   increase   in  size  will   disappear  when   the  tonsil    is  properly  removed. 

The  organ  in  health  may  be  curved,  angular,  pendulous,  or  folded.  Its 
edgee  maybe  smooth,  serrated,  or  crenated.  The  under  surface  is  always 
of  ;i    redder    hue    than    the    upper. 

Concerning  it-  function,  vve  are  -till  in  considerable  ignorance.  It 
undoubtedly  does  help  to  proteel  the  larynx  from  the  entrance  of  (bod;  but 
we  know.  I„,tli  from  animal  experimentation  and  from  the  results  of  disease, 
that  absence  of  the  organ  is  nol  incompatible  with  easy  deglutition.  It  has 
also  been  regarded  a-  ;i  "sounding-board,"  reflecting  the  vocal  sound-wave 
to  the  pharynx,  where  it  i-  in  pint  articulated.  If  it  is  destroyed,  the  voice 
i-  less  distinct,  and  if  it-  edgee  are  irregular  and  jagged,  the  voice  maybe 
rough  :oid  harsh. 


DISEASES  OF  THE  UVULA.  937 

The  specific  affections  of  the  epiglottis  arc  elsewhere  considered.  We 
have  here  to  treat  of  simple  enlargement. 

Enlargement  of  the  Epiglottis. — This  is  a  pure  hyperchondrosis, 
with  more  or  less  thickening  of  the  mucosa  covering  it. 

The  causes  arc  the  same  in  general  as  those  which  lead  to  the  production 
of  chronic  pharyngeal  catarrhs. 

Symptoms. — It  is  difficull  to  separate  the  symptoms  of  an  enlarged 
epiglottis  from  those  which  may  be  referred  to  an  enlarged  lingual  tonsil  or  a 
varicose  condition  of  the  Lingual  veins.  We  Hud  here  the  same  pharyngeal 
dysesthesia,  pain  in  varying  degree,  irritative  cough,  empty  swallowing,  sensa- 
tion as  of  a  foreign  body,  vocal  impairment,  and  gastric  irritability.  During 
acute  exacerbations  of  catarrhal  states  painful  swallowing  is  perhaps  the  most 
disturbing  feature. 

Rice  has  described  a  form  of  epiglottic  inflammation  caused  by  a  natural 
size  of  the  organ  sufficient  to  bring  it  into  contact  with  surrounding  parts. 
The  organ  is  abnormally  hard  throughout.  In  such  cases  the  least  exciting 
cause,  a-  talking,  singing,  eating,  going  out  into  the  cool  air,  change  of  body 
posture,  etc.,  may  cause  an  attack  of  coughing,  or  at  least  render  the  voice 
temporarily  incompetent  for  any  vocal  effort. 

Treatment. — This  is  in  a  general  way  that  of  the  catarrhal  condition 
always  found  in  these  cases,  including,  of  course,  the  removal  of  all  sources 
of  irritation.  Such  measures,  if  faithfully  carried  out,  will  often  reduce  an 
enlarged  epiglottis  to  its  normal  size.  Astringent  applications  alone  are  of  hut 
little  value.  Cocain  and  oily  sprays  are  but  palliative,  and  their  continued 
use  is  objectionable.  The  employment  of  the  galvano-cautery  generally  pro- 
vokes severe  inflammatory  reaction.  Rice  advises  trimming  off  about  one- 
eighth  of  an  inch  from  the  margins  of  the  cartilage  where  they  impinge  upon 
the  pharyngeal  walls,  using  for  this  purpose  long-handled  curved  scissors. 
Reaction  i-  but  moderate  and  hemorrhage  is  not  excessive.  lie  specially 
cautions  against  the  removal  of  more  than  a  narrow  ribbon  of  tissue.  Price 
Brown  ha<  used  the  galvano-cautery  in  one  case  where  the  epiglottis  was  long 
and  narrow,  but  with  its  tip  turned  up  into  a  horizontal  position.  No  evil 
results   followed. 

DISEASES  OF  THE  UVULA. 

The  anatomy  of  the  uvula  is  elsewhere  described.  Concerning  its  phys- 
iology we  are  -till  uncertain,  for  the  various  functions  assigned  to  it  do  not 
-eein  to  suffer  by  its  removal. 

Malformations. — We  can  do  no  better  than  quote  the  statistics  of  < '. 
Berens,  who  found  in  3000  throat-.  Si  cases  of  abnormality  in  shap< — viz.: 
hypertrophy,  11;  pendulous,  -\  fish-tailed  shape,  ■"'-'■' :  attached  to  other 
parts,  li  ;  deeply  cleft,  11;  worm-like  shreds,  8 ;  completely  separate,  2; 
supernumerary,  4;  also  absent,  2. 

Acute  Uvulitis. — This  is  generally  seen  in  connection  with  acute 
pharyngitis  and  tonsillitis,  but  may  occur  independently.  It  may  arise  from 
trauma  (including  excessive  vocal  effort),  septic  absorption,  mid  occasionally 
after  ignipuncture  of  the  tonsils.  The  uvula  becomes  swollen  and  edematous. 
It  may  even  bleed,  and  one  or  two  cases  have  been  reported  in  which  there 
was  a  hemorrhage  into  the  Bubstance  of  the  uvula  itself. 

Symptoms. — These  arc  (1  |  general,  in  the  form  of  a  slight  febrile  reac- 
tion; and  (2)  local,  as  dysphagia,  pain.  ;i  feeling  that  the  throat  i-  filled  up, 
rarely  dyspnea.  There  is  generally  -light  dry  cough,  thick  voice,  and 
general   pharyngeal  discomfort. 


938      DISEASES  OF  THE   TONSILS,    PALATE,   AND  PHARYNX. 

Treatment. — The  uvula  should  be  punctured  freely  with  a  finely  pointed! 
bistoury,  especially  when  the  edema  is  marked.  Demulcent  washes,  hot 
alkaline  gargles,  etc.,  may  then  be  used,  followed  later  by  an  astringent 
preparation,  as  : 

K.   Tr.  kin... 

Tr.  catechu  co., 

Glycerit.,  acidi  tannici,  aa%y — M. 

S. — Teas] uliil  in  one  half  glass  cold  water  for  gargle. 

Chronic  Uvulitis. — This  is  generally  secondary  to  chronic  catarrhal 
condition-  of  surrounding  parts  and  cured  by  the  treatment  of  the  latter.  It 
is  an  essential  part  also  of  elongated  uvula,  to  be  next  considered. 

Enlarged  Uvula. — This  condition  is  present  in  varying  degree  in 
Dearly  all  patients  who  are  subject  to  frequent  sore  throats  of  any  kind,  and 
especially  in  those  who  indulge  in  forced  and  unregulated  vocal  effort. 

Pathology. — The  enlargement  may  be  a  general  thickening  or  merely 
an  elongation.  The  hitter  may  be  merely  a  prolapse  of  the  mucous  mem- 
brane upon  the  muscular  substance,  or  may  be  a  true  hypertrophy  of  the 
entire  organ  with  downward  extension,  so  that  the  tip  rests  on  the  dorsum  of 
the  tongue.     There  is  always  more  or  less  paresis  of  the  soft  palate. 

Symptoms. — The  amount  of  disturbance  produced  by  this  condition 
varies  greatly  in  differenl  patients.  Some  with  very  long  uvulae  make  no 
complaint  whatever.  Generally  there  is  more  or  less  tickling,  coughing, 
retching,  and  even  vomiting.  These  may  be  excited  by  the  sudden  change 
from  one  temperature  to  another.  by  diffused  cold  to  the  skin  (as  in  bath- 
ing), or  when  fatigued.  In  the  worse  cases  there  may  he  nocturnal  glottic 
spasm,  the  uvula  being  most  relaxed  during  sleep.  The  constant  coughing 
sometimes  causes  rupture  of  the  superficial  vessels  of  the  lower  pharyngeal 
mucosa,  ami  the  patients  bring  up  an  occasional  tinge  of  blood  in  the  gelatin- 
ous pellets  they  expel.  All  these  symptoms  sometimes  lead  the  sufferer  to 
believe  that  he  has  serious  lung-disease,  but  a  removal  of  the  offending  tissue 
quickly  reassures  him.  To  vocalists  an  enlarged  uvula  is  a  serious  menace. 
The  voice  becomes  easily  fatigued,  loses  its  range,  strength,  and  clearness,  and 
frequently  becomes  tremulous. 

In  examining  these  cases  the  parts  must  be  relaxed  and  nasal  respiration 
maintained,  else  the  -oft  palate  will  be  drawn  up  and  a  wrong  perspective 
of  t he  parts  be  presented. 

Treatment. —  In  those  cases  where  the  mucosa  is  merely  edematous  and 
prolapsed  on  the  muscle,  simple  astringent  troches  and  mouth-washes  may 
suffice.  If  however,  their  use  for  a  reasonable  length  of  time  does  not 
effect  the  requisite  shortening  of  the  organ,  or  if  there  is  a  true  hypertrophy 

with  elongate I'  the   sole,  a   portion  of  the  latter  should  be  removed. 

(  For  I  'vtilotoiny,  see  page  1  208.) 

The  normal  organ  averages  in  the  adult  about  three-eighths  of  an  inch 
in  length,  and  when  the  mouth  is  closed  should  hang  free  in  the  fauces  with- 
out touching  the  tongue.  It  musl  not  be  forgotten  that  the  frequent  hawking 
caused  l>\  enlarged  uvula  tend-  mechanically  to  aggravate  -till  further  the 
condif  ion. 

DISEASES  OE  THE  PHARYNX. 

The  pharynx  is  a  fibro  muscular  funnel-shaped  tube,  extending  from  the 
under  surface  of  the  basilar  process  of  the  occipital  to  a  point  about  opposite 


DISEASES  OF  THE  I'llARYNX.  939 

to  the  sixth  cervical  vertebra  and  on  a  level  with  the  cricoid  cartilage  below. 
The  upper  part  of  the  tube  is  expanded  into  a  dome,  imperfect  in  front,  and 
likened  to  a  "  carriage- hood  with  the  front  window  half-way  down."  At 
its   sides  are  the  common  and  internal  carotid  arteries. 

A  hove,  it  communicates  anteriorly  with  the  posterior  aares,  laterally  with 
the  Eustachian  tubes,  in  the  middle  with  the  month,  and  below  with  the 
larynx  and  esophagus.  It  has  a  strong  fibrous  investment,  with  a  series  of 
muscular  constrictors  and  a  mucous  lining  continuous  with  that  of  the 
surrounding  cavities. 

The  epithelial  lining  is  of  the  columnar  ciliated  variety  in  the  dome  and 
as  low  down  as  the  floor  of  the  nose;  below  it  assumes  the  squamous  type. 
It  has  a  rich  glandular  supply,  the  acinous  variety  being  generally  distrib- 
uted, less  abundantly,  however,  in  the  vault;  while  the  lymphoid  deposits 
(not  true  glands)  are  massed  about  the  orifices  of  the  Eustachian  tube-  and 
in  the  dome,  forming  in  the  latter  the  third,  pharyngeal,  or  Luschka's,  tonsil. 

In  any  consideration  of  pharyngeal  maladies,  two  facts  should  be  borne 
in  mind.  One  is  inherent  in  its  structure  and  the  other  in  its  function. 
Being  a  combination  of  mucous  membrane,  muscle,  and  fibrous  aponeurosis, 
it  is  naturally  subject  to  the  general  run  of  acute  inflammatory  conditions; 
but  it  also  bears  the  brunt  of  many  outbreaks  due  to  the  gouty  and  rheu- 
matic diatheses. 

Moreover,  the  pharynx  is  a  food-  as  well  as  an  air-conduit.  It  has  thus 
a  relation  to  the  digestive  as  well  as  to  the  respiratory  tract ;  and  disturb- 
ances of  either  may  be  caused  by  pharyngeal  disturbances,  or  may  even  cause 
them.     The  existence  of  a  scrofulous  taint  acts  in  the  same  direction. 

Acute  Catarrhal  Pharyngitis.— This  is  an  acute  exudative  inflam- 
mation of  the  mucous  lining  of  the  pharynx.  This  cavity  is  a  veritable 
breeding-place  for  all  sorts  of  micro-organisms,  and  yet  in  a  condition  of 
health  they  are  harmless.  Exposure  to  cold  really  means  lessened  resist.! nee 
of  the  tissues  to  germ-vitality  and  germ-entrance  into  the  substance  of  the 
membrane.  The  excessive  use  of  alcohol  and  tobacco,  the  ingestion  of 
irritant  food,  the  presence  of  foreign  bodies,  etc.,  are  accountable  for  many 
attacks.  Gouty  and  rheumatic  poisons  frequently  expend  themselves  upon 
this  area.  Another  frequent  exciting  cause  is  a  disordered  state  of  the 
stomach  and  a  torpid  liver,  especially  that  group  of  symptoms  collectively 
known  as  a  "bilious  attack." 

As  predisposing  causes  we  may  have  a  bad  general  environment,  poor 
ventilation,  improper  clothing,  the  breathing  of  noxious  gases,  and  occupa- 
tions of  a  sedentary  character.  The  disease  is  more  prevalent  during  the 
damp  seasons  of  spring  and  fall,  affecting  especially  those  exposed  to  sudden 
temperature-changes.     All  ages  suffer  from  it. 

Pathology. — The  affection  is  the  simple  type  of  acute  exudative  inflam- 
mation occurring  in  a  mucous  membrane,  with  its  stages  of  congestion, 
swelling,  dryness,  and  later  increased  secretion.  It  may  be  confined  to 
various  areas,  as  the  post-pharyngeal  wall,  the  palatal  folds,  the  fauces,  or 
may  affecf  the  entire  cavity.  Pretty  generally  the  covering  of  the  tonsils  is 
involved,  and  we  really  have  an  acute  catarrhal  tonsillitis  as  well  as  pharyn- 
gitis.    The  mucosa  may  be  shining  and  smooth  or  of  a  granular  appearance. 

Symptoms. —  In  a  simple  case  there  is  generally  a  very  mild  constitu- 
tional febrile  reaction.  Locally,  we  have  pain  of  various  degrees  of  intensity, 
painful  swallowing,  irritative  cough,  with  a  con-taut  desire  to  clear  the 
throat.  Viscid  mucus  is  expectorated,  sometimes  in  pellets  and  occasionally 
blood-streaked.     Smell,  taste,  and  even  hearing  may  be  impaired — the  latter 


940      DISEASES  OF  THE  TONSILS,    PALATE,   AND   PHARYNX. 

especially  when  the  attack  is  engrafted  upon  an  old  tonsillar  enlargement. 
The  attack   may  pass  off  into  "a  cold   in  the  head." 

The  prognosis  is  always  good,  the  inflammation  rarely  extending  to  the 
deeper  structures. 

Treatment. — At  the  outset  a  mercurial  and  saline  should  be  given, 
followed  by  aconite  and  belladonna  in  small  but  frequent  and  alternating 
doses.  Pellets  of  ice  are  grateful,  and  in  the  milder  cases  relief  may  come 
from  the  free  use  of  some  astringent  lozenge,  such  as  the  krameria  or  red- 
gum  troches.  Weak  cocain  solutions  may  be  sparingly  sprayed  on  to  relieve 
pain,  but  a  graduated  atomizer  should  always  be  employed,  so  as  to  register 
the  amount  of  the  drug  used.  Menthol  in  albolene  (gr.  xv-sj)  is  of  ten  just 
as  efficacious.  For  this  and  similar  purposes  the  "  pyrozone-atomizer "  may 
be  employ  ed. 

In  the  diathetic  cases,  guaiac,  salicylates,  colchicum,  and  syrup  of  iodid 
of  iron  find  their  proper  application.  Iced  compresses  may  be  used  exter- 
nally. An  edematous  uvula  or  palate  should  be  freely  punctured.  Food 
should  be  soft  and  non-irritating. 

A  simple  tonic  is  often  advisable  alter  the  subsidence  of  the  acute  symp- 
toms. For  the  exce.-.-ive  secretion  some  form  of  astringent  gargle  is  gener- 
ally employed.     A   good   formula  is  that  given  on  page  938. 

It  has  become  fashionable  in  certain  circles  to  decry  the  use  of  gargle-  on 
the  ground  that  the  fluid  comes  in  contact  with  only  a  very  small  part  of  the 
affected  area,  never  passing,  as  ordinarily  used,  beyond  the  anterior  faucial 
pillar-.  The  ideal  met  hud  of  gargling  is  that  known  as  the  "Von  Troltsch  " 
plan.  The  patient  sits,  or  better  lies  down,  with  the  head  thrown  back.  He 
take-  a  mouthful  of  the  gargle  ami  begins  the  movement  of  swallowing  with- 
out letting  the  liquid  go  down  hi-  throat.  He  next  throws  the  head  suddenly 
forward,  when  part  of  the  fluid  will  go  up  into  the  naso-pharynx  and  find  its 
exil  through  tin-  uostrils,  while  the  rest  escape-  through  the  mouth. 

It  i-  obvious  that  hut  tew  patients  can  thus  juggle  with  their  swallowing- 
apparatus.  Moreover,  the  method  i-  painful  at  any  time,  and  therefore  prac- 
tically  inadmissible  in  many  acute  inflammatory  states.     Asa  matter  of  fact, 

however,  Swain  has  de istrated   that   by  this  method   fluid  may  he  brought 

in  contact  with  the  outer  or  extralaryngeal  surface  of  the  epiglottis,  the  ary- 
epiglottic  ligament,  the  arytenoid  cartilages,  and  the  posterior  commissure  of 
the  larynx,  m-  well  a-  with  the  upper  surfaces.  In  the  later  stages  of  acute 
catarrhal  pharyngitis  mild  antiseptic  troches  or  mouth-washes  may  he  of  ser- 
vice. To  avoid  a  repetition  of  the  attack-  proper  foot-wear  and  woollen  un- 
derclothing should  he  worn.  The  neck  and  upper  che.-t  should  he  douched 
night  and  morning  with  cold  water  and  briskly  rubbed  with  a  coarse  towel. 

Chronic  Catarrhal  Pharyngitis. — Under  this  heading  are  to  he  con- 
sidered the  chronic  catarrhal  conditii f  the  membrane  ;i-  a  whole,  and  also 

that  distincl  affection  of  it-  lymphoid  elements  known  a-  "follicular  pharyn- 
gitis."    A    localized  variety  of  the  latter  is  known  a-  pharyngitis  lateralis. 

Simple  Chronic  Catarrhal  Pharyngitis. —  In    this  form  the  lesion 

enerally  confined  to  the  pharyngeal  mucosa  proper.  The  uvula,  palate, 
and  faucial  pillars  usually  escape.  The  tonsils,  however,  are  frequently 
enlai 

<^uitc  a  difference  of  opinion  exists  a-  to  the  cause  of  this  affection.  The 
majority  of  writer-  would  seem  to  regard  it  either  a-  a  result  of  repeated 
acute  catarrhal  processes,  as  in  the  case  of  mucous  membranes  generally,  or 
a-  a  disease  3el  up  l>v  some  of  the  long-acting  causes  named  below.  Bos- 
worth  emphatically  -late-  hi-  conviction  thai   •'chronic  pharyngitis  is  in  no 


DISEASES  OF  THE  I'll  Alt  YXX.  941 

instance  the  result  of  repeated  attacks  of  acute  inflammation;  but,  on  the 
contrary,  the  chronic  process  sets  in  first,  whereupon  it-  clinical  history  is 
marked  by  repeated  attacks  of  acute  catarrhal  sore  throat."  According  to 
his  view,  the  condition  is  generally  secondary  to  a  chronic  gastritis,  espec- 
ially that  form  due  to  alcohol. 

A  frequent  cause  is  the  inhalation  of*  all  sorts  of  irritants,  including 
tobacco-smoke.  Here  again  we  tread  on  disputed  ground,  some  claiming  that 
the  nicotin  and  irritating  salts  of  the  smoke  will  set  up  a  pharyngitis  ab 
initio,  and  others  that  they  merely  aggravate  a  pre-existing  condition.  Some 
cases  seem  to  arise  from  the  extension  of  a  naso-pharyngeal  process  or  to 
be  aggravated  by  the  constant  hawking  and  straining  of  the  pharyngeal 
muscles. 

Finally  it  must  not  be  forgotten  that  the  pharyngeal  mucosa  i-  bathed  by 
all  the  air  inspired  through  the  nose.  Hence,  if  this  air  is  not  (owing  to 
intranasal  abnormalities)  properly  strained,  moistened,  and  warmed,  it  will 
act  as  an  irritant.  Particularly  is  this  the  case  if  nasal  obstruction  is  suffi- 
cient to  cause  mouth-breathing. 

Pathology. — We  have  here  to  deal  with  a  proliferative  inflammation  occur- 
ring in  a  mucous  membrane.  The  blood-vessels  take  no  share  in  the  process, 
which  consists  in  the  formation  of  a  low  grade  of  connective  tissue  in  the 
deeper  layers.  The  mucous  glands,  which  are  here  scanty,  are  not  much 
affected.  The  secretion  is  apparently  increased  and  abnormally  viscid.  The 
lymphoid  elements  are  not  involved.  In  some  of  the  older  cases  enlarged 
veins  may  course  over  the  surface. 

Symptoms. — As  the  affection  is  so  frequently  associated  with  gastric  dis- 
orders, the  symptoms  of  the  latter  are  very  much  in  evidence  in  the  form  of 
flatulency,  gagging,  nausea,  and  even  vomiting.  Combined  with  these  is  a 
continuous  smarting  feeling  in  the  pharynx,  with  special  discomfort  in  swal- 
lowing spiced  foods  or  hot  drinks.  A  coexisting  naso-pharyngitis  aggravates 
all  symptoms.  The  whole  mucous  lining  of  the  pharynx  is  excessively  irri- 
table. It  is  often  impossible  at  the  first  sitting  to  make  a  satisfactory  exami- 
nation. Particularly  is  this  the  case  in  institution  patients,  with  their  usual 
excesses  in  malt-litptors  and  inferior  tobacco.  The  mucosa  is  of  a  dark-red, 
beefy  color,  which  rarely  extends  forward  beyond  the  posterior  faucial  pillars. 
The  breath  is  sour  and  offensive,  while  the  tongue  is  more  or  less  coated. 

Treatment. — In  many  cases  the  pharynx  itself  is  best  left  alone  for 
awhile  and  attention  directed  toward  the  removal  of  vicious  practices  in 
eating  and  drinking.  If  irritability  of  the  mucosa  prevents  proper  examina- 
tion, weak  cocain  applications  may  be  made,  or  the  patient  may  be  put 
under  the  influence  of  the  bromids,  using  also  a  strong  solution  of  the  latter 
for  a  gargle.  Alcohol  and  tobacco  must  be  cut  off  entirely,  and  tea  and 
collie  during  treatment.  The  bowel-  should  be  regulated  with  -aline-  and 
cholagogues.  An  alkali  with  a  bitter  maybe  given  after  meal-.  Greasy 
food-,  pastries,  etc.,  fall  under  the  ban.  But  little  fluid  should  lie  taken  at 
meals,  so  as  to  ensure  the  proper  mastication  of  the  food. 

These  procedures  will  alone  cure  many  cases  of  chronic  catarrhal  pharyn- 
gitis. If,  however,  local  discomfort  persists  after  the  stomach  is  regulated, 
we  may  make  local  applications  to  the  pharyngeal  mucosa.  Silver  nitrate 
(gr.  \v-5J)  or  the  zinc  salts  (except  the  chlorid)  in  the  same  strength  may  !"■ 
u^-(\.     These  remedies  are  exactly  a-  good  as  the  host  of  new  ones  recently 

placed   on    the  market.     Nothing   is  gained    in   the  care  of  these  conn 1 

maladies  by  running  after  strange  therapeutic  gods. 

A  valuable  menstruum  for  many  topical   agents  is  the  new  oleo-stearate 


942      DISEASES  OF  THE   TONSILS,    PALATE,   AND   PHARYNX. 

of  /inc.  a  union  of  stearate  of  zinc  with  benzoinated  albolene.  It  forms  a 
viscid  whitish  mixture,  not  disagreeable  to  the  taste.  It  can  be  used  as  a 
vehicle  for  the  ordinary  run  <>f  topical  agents. 

Chronic  Follicular  Pharyngitis. — In  this  affection  the  brunt  of 
the  pathological  process  (alls  upon  the  lymphoid  structures  which  lie  in  the 
deeper  layers  of  the  mucosa.  Tin-  change  is  of  the  greater  clinical  import- 
ance in  that  the  process  seems  to  involve  in  sonic  way  not  entirely  clear 
ill.'  sensory  nerve-filaments  of  the  area,  giving  rise  to  symptoms  causing 
-iv.it  discomfort. 

Causes. — Over  and  above  all  there  lies  a  diathesis  to  which  has 
been  given  the  name  of " lymphatism."  It  is  a  tendency  of  all  lymphoid 
-t  ructures  at  an  early  period  of  life  to  take  on  an  overgrowth.  With  the  earlier 
writer-  this  tendency  figures  under  the  category  of  scrofula.  At  the  present 
time  we  are  disposed  toadmit  the  affinity,  though  not  the  identity,  of  the  two. 
The  lymphatic  overgrowth  beginning  in  childhood  affects  more  or  less  all 
the  lymphoid  deposits  in  the  naso-phary nx  and  pharynx.  The  evidences  of 
disease  in  the  former  of  these  two  regions  greatly  predominate,  so  that  not 
until  later  year-  do  the  troubles  referable  to  the  follicular  ailment  in  the 
pharynx  distinctly  show  themselves.  Bad  hygienic. general  environment  pre- 
di-po-e-  to  tin-  form  of  catarrh  ;  hut  there  is  no  reason  to  believe  that  it  has 
any  relation  to  rheumatism  or  -out. 

Pathology. — The  follicular  enlargement  is  a  distinct  process  from  the 
beginning,  and  probably  is  never  a  passing  over  from  the  simple  catarrhal 
process  described  in  the  previous  section.  It  may  be  accompanied  by  a  sim- 
ple surface-catarrh.  It  may  be  diffused  over  the 
surface  of  the  pharynx,  which  assumes  a  granular 
X  appearance  (granular  pharyngitis),  or  may  local- 

/  \    \  i/.e  it-elf  at   the  -ides,  just  behind  the  posterior 

y  \    \         faucial  pillars.     To  these   ridges  or  bead-chain- 

/     N  \  \         like    deposits  Schmidt    has  given    the  name  of 

/  "pharyngitis     lateralis."      These     ridges    occa- 

\      sionally  become  adherent   to  the  pillars,  so  that 
\  \  |       their    union    appears    as    large   cords  on    either 
side. 
v'.  -'/  The  affection  of  the  follicles  seems  to  be  most 

\\  pronounced   near  the  month- of  the  muciparous 

/         glands.     The    process    is   really  one    of    hyper- 
/  plasia,  a  true  increase  in  the  number  of  lymphoid 

elements,  especially  aboul   the  efferent  channels 
of  the   lymph-node-.     This  hyperplasia  may  be 
iiicuiar phar-     diffused  throughout    the  deeper  as  well  as    the 
superficial    lymphatic  structure  of  the  mucosa, 
causing  a  thickening  thereof,  or  ii  may  be  localized  as  blunl  masses  projecting 
a  little  from  the  surface.     At    firsl   these  masses  are  soft,  bul   in  later  years 
they  grow  smaller  and  harder  and  may  even  disappear,  leaving  no  symptom; 
but   their  persistence  in  later  years  is  the  legacy  of  the  changes  during  the 
time  of  "  lymphatism  "  i  Fig.  579  . 

Symptoms. — A>  the  most  prominent  we  note  pharyngeal  dysesthesia,  due 

firsl  to  the  unusually  rich  nerve-supply  of  the  pharyngeal  i :osa,  and  second 

1"  the  fact  already  noted  that  the  nerve-filaments  are  involved  in  the  nodal 
changes.  We  may  have  all  grades  of  sensation,  from  a  mere  discomfort  to 
an  actual  pain.  On  account  of  this  neurotic  element  it  has  been  claimed  thai 
the  disease  is  more  common  among  women,  but   we  have  not   so  found   it. 


DISEASES  OF  THE  PHARYNX. 


943 


•Overuse  of  the  voice  aggravates  the  discomfort.  Painful  swallowing  is 
felt.  It  has  been  suggested  that  the  circulation  through  the  follic 
increased  and  that  attendant    pressure-changes  cause  a   true   neuralgia. 

The  secretion  is  not,  as  a  rule,  increased  in  amount.  Sometimes  the 
tie-  seem  to  lie  on  a  bed  of  whitish  connective  ti>>ue  and  the  whole 
looks  very  dry  (pharyngitis  sicca).  The  voice  is  husky,  probably  ft 
reflex  influence  upon  the  phonatory  muscles.  A  dry  nervous  cough  is 
present. 

The  uvula    may   he  elongated,  especially   when    an  accompanying 
pharyngitis    produces    much    hawking.      So,    also,    the    faucial    and    li 


often 

lea   is 

folli- 

area 

om  a 

often 

naso- 
neual 


-,x  .-ate  ■■■  '^4pf    ^«-S§fo    .&.-S 


•'-'%' 


■>Wfrai 


u''i^'v''C;r'\.;.'.."'''';.-~':'.-:;- 
Fig.  579. — Pharyngitis  granulosa  (Seifertand  Kahn). 

tonsils  may  be  enlarged.  Frequently  the  enlarged  veins  are  seen  coursing 
over  the  pharyngeal  wall,  hut  they  are  not  distinctive  of  this  condition. 
The  disease  may  continue  indefinitely,  although  without  any  extension  to 
neighboring  parts.  There  is  no  conclusive  evidence  that  it  predisposes  to 
phthisis. 

Treatment. — As  to  general  measures,  we  may  refer  to  the  treatmenl  of 
the  simple  catarrhal  form.  The  local  treatmenl  consists  in  the  removal  or 
destruction  of  the  diseased   follicles. 

Of  destructive  agents  we  have  chromic  and  trichloracetic  acids,  and  the 
galvano-cautery  at  a  Wright  cherry-red  heat.  Six  or  eight  follicles  may  be 
treated  at  each  sitting.  A  drop  of  5  per  cent,  cocain  solution  injected  at 
their  bases  through  a  curved  needle  will  render  the  cauterization  painless. 
E.  Mayer  curettes  these  diseased  surfaces,  and  has  devised  a  special  instru- 
ment fortius  purpose  and  obtains  excellent  results.  An  antiseptic  mouth- 
wash should  be  used  after  cauterization. 


944      DISEASES   OF   Till:   TONSILS,    PALATE,   AND   PHARYNX. 

In  pharyngitis  lateralis  the  -Mine  plans  may  be  followed.  Several  sittings 
are  required,  and  the  reaction  after  the  cautery  is  more  severe  in  this  situa- 
tion than  on  the  post-pharyngeal  wall. 

Hemorrhage  from  the  Pharynx. — A  brief  note  should  be  made 
concerning  hemorrhages  from  the  pharynx.  These  may  be  due  to  two  dif- 
ferent   classes  of  causes:  (1)  Changes   in   the   bl 1,  and    possibly  in   some 

-   in  the   1»1 l-vessels,  which  permit  the  escape  of  the  blood   in  various 

parts  of  the  body — e.  g.}  purpura,  hemophilia,  leukemia,  pernicious  anemia, 
etc.  C_')  Ulcerations  of  various  kind-,  suppuration,  trauma,  the  so-called 
"hemorrhagic  laryngitis,"  and  perhaps  varicose  veins.  The  latter  source 
has  been  alluded  to  under   "  lingual   varix." 

Pharyngeal  hemorrhages  from  the  causes  enumerated  under  the  first  of 
the  foregoing  divisions  arc  rare.  Onderthe  second  we  may  include  cancerous 
ulcerations  and  also  laryngitis  sicca  where  the  formation  of  crusts  and  their 
subsequent   dislodgemenl    may  cause  erosion  of  superficial   vessels. 

Tubercular  ulceration  of  the  larynx  rarely,  if  ever,  causes  local  bleeding, 
although   the   larynx    may  retain   blood  c ing  from  the  lungs  or  bronchi. 

Where  patients  come  to  the  physician  with  the  history  of  having  raised 
a  little  blood,  the  lung-  are  naturally  first  examined,  and  if  there  are  neither 
signs  nor  symptoms  of  pulmonary  trouble,  the  bleeding  is  referred  to  the 
throat  and  apt  to  be  regarded  as  of  slight  moment.  Such  reasoning  is  falla- 
cious. True  pharyngeal  hemorrhages  are  extremely  rare,  and  their  existence 
should  never  be  predicated  unless  a  clot  or  a  bleeding-point  can  actually  be 
seen  upon  the  mucous  membrane  of  the  pharynx.  In  the  greater  majority 
of  all  these  cases  the  blood  comes  from  some  part  of  the  respiratory  tract 
below  the  glottis — i.  e.,  signifies  lung-trouble,  whether  there  are  any  other  signs 
or  symptoms  to  correspond  with  it  or  not. 

Of  course,  the  mouth  and  gums  musl  be  carefully  searched  in  this  class 
of  cases.  So,  also,  allowance  must  be  made  for  the  existence  of  valvular 
cardiac  trouble  and  pulmonary  hyperemia.  In  some  cases  the  blood  escapes 
l>v  diapedesis  rather  than   by  actual  rupture  of  vessels. 

It  must  be  borne  in  mind  that  the  intimate  anatomical  and  physiological 
relations  of  the  pharynx  with  the  larynx  and  parts  below  permit  flood 
effused  in  one  situation  to  quickly  deposil  itself  in  another.  Hence  we  must 
be  caution-  in  our  deductions  as  to  the  actual  source  of  the  bleeding.  More- 
over, flood  effused  high  up  in  the  trad  ma)  get  into  the  lungs  and  so  pre- 
dispose to  tubercular  invasion. 

Finally,  we  must  '"■  on  our  guard  against  malingerers  who,  for  their  own 
various  purposes,  can  produce  pharyngeal  hemorrhage  with  the  greatest 
readiness. 

Pharyngo-mycosis.  —  Under  tin-  title  are  properly  included  all  my- 
cotic growths  occurring  in  tin-  situation.  Among  the  parasites  most  fre- 
quently found  here  are  the  oidium  albican-,  actinomyces,  aspergillus  fumi- 
gatus,  bacillus  fasciculatus,  and  the  growth  causing  that  rare  affection 
nigrities  linguae  or  black-tongue.  By  common  clinical  consent,  however,  the 
term,  mile--  qualified,  i-  restricted  to  oases  of  leptothrix  growth.  This  form 
wa-  lir-t  described  1>\   Frankel   in    1873. 

Causes. — As  predisposing  causes  we  have  preceding  inflammations, 
especially  of  the  tonsils,  and  carious  teeth.  It  frequently  follow-  acute 
tonsillitis,  and  ha-  doubtless  been  often  mi-taken  tin-  ,-i  chronic  lacunar  affec- 
tion, 'fhe  exciting  cause,  or  rather  the  essence  of  the  disease,  is  the  growth 
of  the  leptothrix-threads. 

holo^y. — The  deposits  occur    mosl    frequently   on    the   faucial    and 


DISEASES  OF  THE  PHARYNX.  945 

lingual  tonsils,  but  they  arc  occasionally  seeu  <>n  the  pharyngeal  tonsil,  less 
frequently  on  the  soft  palate,  post-pharyngeal  wall,  glosso-epiglottic  folds, 
and  larynx.  J.  Wright  found  them  in  one  instance  upon  the  inferior 
turbinal  body.  They  appear  as  patches  apparently  embedded  in  the  tonsillar 
crypt-  and  projecting  above  the  surface.  They  are  generally  hard  and 
horny,  being  removed  with  great  difficulty.  They  may  exist  as  isolated  areas 
of  varying  size  or  they  may  be  connected  by  threads  extending  from  one  to 
another  and  interlacing  like  the  tendrils  of  running  vines. 

It'  a  Wit  of  deposit  is  removed,  teased  in  glycerin,  and  examined  with  a 
low-power  objective,  we  note  a  mass  of  epithelia  (an  accidental  feature)  sur- 
rounded by  irregular  granules,  in  which  are  embedded  the  rod-like  cells  of 
various  species  of  the  leptothrix-fungus  (belonging  to  the  group  of  schizo- 
mycetes).  These  rods  or  mycelial  thread-  generally  occur  in  links,  and  some- 
times curl  up  at  their  end-  into  tine  hair-like  filaments.  Other  rods  appear 
colorless,  but  with  sharp,  dark  borders,  the  centers  seeming  to  be  full  of 
granular  matter.  The  loose  granules  are  in  some  instances  the  spores  of  the 
growth.  Methyl-blue  staining  will  bring  out  alternating  colored  and  un- 
colored  segments  on  the  thread-:  while  LugoFs  solution  gives  with  them 
the  characteristic  starch-reaction. 

This  fungus  has  never  been  cultivated  outside  of  living  bodies.  Lepto- 
thrix-threads  of  various  species  inhabit  every  healthy  mouth.  The  presence 
of  tartar  on  the  teeth,  an  altered  reaction  of  buccal  secretion,  and  a  disordered 
digestion  all  seem  to  promote  their  growth.  There  is  no  proof  that  the  gouty 
or  rheumatic  states  predispose  to  them.  They  are  found  in  rhinoliths,  ton- 
sillar concretions,  and  vesical  calculi  ;  in  the  secretion  of  tracheal  ozena, 
fetid  bronchitis,  and  pulmonary  gangrene;  on  the  coating  of  the  tongue 
in  low  fever-,  in  the  lachrymal  duct,  intestine,  vagina,  ami  feces.  Most  of 
the  cases  of  mycosis  reported  have  been  in  young  women.  In  any  situ- 
ation the  growth  may  precipitate  lime-salts  from  fluids  holding  them  in 
solution. 

A  somewhat  novel  view  of  the  nature  of  this  affection  is  that  advanced 
by  Siebenmann,  who  contends  that  Frankel's  benign  tonsillar  mycosis,  with  it< 
formation  of  solid  horny  matter,  should  be  taken  from  the  category  of 
mycoses  and  put  in  that  of  hyperkeratoses  of  the  mucosa.  A-  a  product  of 
a  less  complete  keratosis  should  be  regarded  the  less  complete  epithelial  kera- 
tosis which  i<  found  in  all  tonsils,  and  which  is  an  excellent  medium  for  the 
development  of  the  organisms  of  decomposition.  The  collection  of  incom- 
pletely keratosed  epithelium  is  therefore  a  constant  menace  to  the  surround- 
ing tissues,  analogous  to  cholesteatoma  of  the  middle  ear.  Siebenmann  would 
drop  the  name  ••  pharyngo-mycosis  "  and  substitute  therefor  "  lacunar  hyper- 
keratosis." 

Symptoms. — The- n-i-t    of  constant    irritation    in   the    fauces   and   a 

pricking  or  a  pasty  feeling,  with  mild  cough  and  difficulty  in  swallowing. 
In  die-  case  submaxillary  glandular  enlargement  was  noted.  Schech  has 
found  fever  with  general  malaise,  weakness,  and  anorexia  preceding  the  local 
deposits.  The  tonsils  themselves  may  be  a  little  w<\  and  swollen.  Semon 
ha-  seen  the  -..ft  palate  and  uvula  congested,  the  latter  being  also  very 
edematous. 

Course. — The  deposits  come  and  go  sometimes  regardless  of  treatment. 
There  is  no  danger  in  the  affection,  't  i-  of  inure  pathological  interest  than 
of  clinical  importance. 

Treatment.  All  functional  disorders  should  be  corrected;  the  teeth 
must  be  put  in  good  condition.     In  one  of  the  writer's  cases   the  deposits 

60 


946      DISEASES  OF  Till:   TONSILS,    PALATE,   AND   PHARYNX. 

permanently  disappeared  as  soon  as  this  was  done.  Sweet.-  must  be  cut 
off  from  the  diet.     A   change  of  climate  will  alone  cure  some  cases. 

A.s  to  topical  measures,  nearly  every  caustic  and  antiseptic  in  the  phar- 
macopeia has  beeu  recommended  -e.  g.,  solutions  of  zinc  chlorid,  balsam  of 
Peru  in  alcohol,  iodin  and  carbolic  acid  in  glycerin,  salicylic  acid  in  alcohol, 
borax,  bichlorid,  chromic  acid,  silver  nitrate,  and  pyrozone.  Smoking  is 
reported  to  have  cured  one  case,  and  an  instance  in  the  writer's  experience 
lend-  -..Hie  color  to  this  view.  Nicotm  solutions,  however,  should  not  be 
applied.  Some  of  the  larger  deposits  may  be  turn  away  with  forceps.  The 
favorite  measure  is  the  galvano-cautery  tip  carried  to  the  base  of  each 
deposit.  Tonsillotomy  may  be  done  if  the  organ  is  large  enough  to  engage 
in   the  guillotine.      Internally,  salol  and   the  alkalies  have  been   used. 

Herpes  of  the  Fauces. — This  i-  one  of  the  rare  diseases.  Obviously, 
differenl  clinicians  have  had  different  conditions  in  mind  in  their  use  of  this 
term.  Else  how  can  we  accounl  for  the  fact  that  of  two  prominent  writers, 
one  ha-  seen  only  12  cases  in  a  lifetime,  while  the  other  reports  over  100 
cases  in  six  year-'.' 

The  disease  i sists  in  the  occurrence  on  the  uvula,  soft  palate,  tongue, 

and  inside  of  the  cheeks  of  small  Misters,  resembling  somewhat  the  customary 
herpetic  patches  -ecu  on  the  skin.  The  tonsils  and  epiglottis  may  also  he 
invaded,  while  the  posterior  pharyngeal  wall  regularly  escapes.  The  affection 
may  be  unilateral  or  bilateral.  It  occurs  more  frequently  in  children,  in 
those  constitutionally  delicate,  and  in  neurotic  young  women.  It  is  especially 
prevalent  during  diphtheritic  outbreaks,  in  damp  climates,  and  during  the 
colder  months.      Many  of  the   patient-  are  distinctly  anemic. 

Pathology. —  In  the  initial  stages  small  distended  vesicles  are  seen  with 
a  surrounding  /one  of  inflamed  mucosa.  These  occur  singly  or  in  patches. 
They  may  disappear  by  absorption,  leaving  no  trace;  or  may  hurst,  leaving 
-hallow  circular  ulcers.  The  vesicular  stage  is  a  brief  one,  for  the  epithelial 
Covering  of  the  patch  i-  SO  delicate  that  it  cannot  hold  the  fluid  which  collects 
beneath  it  except  tor  a  very  shorl  time.  Still,  again,  the  patches  may  coalesce, 
formings  large  bulla,  which  after  discharging  its  content-  becomes  covered 
with  a  membranous  deposit,  suggesting  diphtheria.  Bo-worth  record-  three 
cases  where  the  eruption  assumed  the  form  of  herpes  iris — i.e.,  "small  rings 
of  minute  papule-  enclosing  a  patch  of  healthy  membrane."  He  regards  the 
process  as  a  localized  inflammation  of  the  papillae  of  the  subepithelial  layer 
of  the  mucosa  originating  principally  in  the  terminal  filaments  of  the  nerves. 

Symptoms. — These  consist  of  a  moderate  febrile  reaction  and  a  burning 
feeling  in  the  fauces,  increased  by  deglutition.  Occasionally  there  is  a  severe 
itching  about  the  part-.  The  pain  may  radiate  to  the  ears,  nose,  and  even  to 
the  Ian  n\.  A  similar  rash  may  appear  coincidently  on  the  lip-,  thus  assist- 
ing in  the  diagnosis.  The  fauces  -how  a  circular  arrangement  of  the  erup- 
tion, at  times  papular,  or  vesicular,  or  even  pustular,  with  the  later  history 
above  described. 

Cause. — The  duration  is  al t  a  week,  and  patients  always  recover ;  hut 

the  mucous  membrane  may  he  left  predisposed  to  infection.  Successive  crops 
of  eruption  occasionally  prolong  the  disease. 

Treatment. — All  neurotic  and  anemic  states  must   be  corrected,  forthese 

-  frequently  relapse.  \i  the  outset  sedative  and  demulcent  mouth- 
washes are  indicated.  Morphin  and  carbolic  acid  in  glycerin  may  be 
applied    to  the    painful    area-.       Potassium  chlorate    is    useless,  and    may  even 

increase  the  local  discomfort.  Mild  caustics  may  prevent  the  spreading  of 
tie-  patches. 


DISEASES  OF  THE  NASO-PHARYNX.  947 

DISEASES  OF  THE  NASOPHARYNX. 

Under  this  heading  are  considered  acute  and  chronic  post-nasal  catarrh 
and  enlargement  of  the  pharyngeal  tonsil,  including  lymphoid  hypertrophy  in 
the  vault  of  the  pharynx,  the  so-called  "adenoids."  Other  oaso-pharyngeal 
affections  are  dealt  with  elsewhere  in  this  work. 

Acute  Naso -pharyngitis  :  Acute  Post-nasal  Catarrh. — This 
affection  is  essentially  an  acute  exudative  inflammation  of  the  mucosa  lining 
the  oaso-pharyngeal  space.  Ir  is  frequently  associated  with  an  acute  rhinitis, 
or  lather  both  lesion-  occur  in  that  condition  known  as  a  "  cold  in  the  head  ; " 
but  it  is  possible  for  either  to  occur  separately. 

Causes. — Exposure  to  cold  and  damp  plays  the  chief  exciting  role.  Here 
also  should  be  borne  in  mind  what  has  already  been  said  regarding  such 
exposure  as  related  to  temporary  impairment  of  tissue-vitality.  As  occurring 
in  very  young  patients,  we  generally  find  acute  naso-pharyngitis  associated 
with  more  or  less  enlargement  ot*  the  pharyngeal  tonsil,  which  in  turn  may 
have  resulted  from  repeated  attacks  of  acute  rhinitis.  The  abuse  of  alcohol 
and  tobacco,  exposure  to  dust-laden  air,  noxious  vapor-,  and  various  septic 
influences  are  all  contributing  causes.  The  relation  of  any  particular  diathesis 
to  the  acute  form  of  the  disease  cannot  be  regarded  as  proven.  Disease  of 
the  nasal  mucosa  is  regularly  present,  and  is  regarded  by  some  as  the  most 
frequent  excitant  cause. 

Pathology. — As  already  suggested,  the  process  here  is  the  typical  one  of 
acute  exudative  inflammation,  with  its  successive  stages  of  congestion,  dryness, 
swelling,  and  hypersecretion.  The  follicles  are  reddened  and  enlarged  and 
bathed  first  in  mucus  and  later  in  muco-pus. 

Symptoms. — Cases  are  ushered  in  with  a  very  mild  febrile  reaction. 
general  malaise,  and  anorexia.  The  fever  rarely  rises  to  101°  F.,  and  vet 
the  patient  i-  miserable  out  of  all  proportion  to  this  temperature.  There  is  a 
dry.  smarting  feeling  in  the  back  part  of  the  throat,  with  painful  -wallowing. 
Owing  to  the  close  anatomical  relation  between  the  mucosa  and  the  bony 
vault,  this  stage  of  dryness  from  arrested  secretion  is  apt  to  be  prolonged. 
The  gastro-enteric  tract  i-  often  in  a  torpid,  sluggish  condition,  and  we  have 
coated  tongue,  nau-ea.  <>r  even   vomiting  and  constipation. 

From  this  stage  the  condition  passes  into  that  of  hypersecretion,  which 
generally  affords  some  relief' to  the  local  discomfort.  The  discharge  i-  at  first 
whitish  and  mucous  in  character;  but  later  becomes  yellowish  and  of  a  muco- 
purulent consistency.  It  trickle-  down  from  behind  the  -oft  palate  and  is 
expectorated,  or  in  very  young  patients  swallowed;  some  of  it  may  be  blown 
out  through  the  anterior  nan-.  Such  a  muco-purulent  flow  increases  the 
tendency  to  gagging  and  nau-ea.  This  secretion  is  viscid,  tenacious,  and 
glairy.  After  a  varying  period  of  these  symptoms — from  two  to  ten  days — 
there  ensues  a  third  stage  characterized  bv  progressive  improvement  in  all 
symptoms. 

During  the  course  of  the  attack  the  dry  sensation  in  the  uaso-pharynx 
may  amount  to  an  actual  pain,  and  suggests  by  it-  radiation  a  facial  neu- 
ralgia. There  may  be  a  stiffness  of  the  cervical  muscles,  as  in  muscular 
rheumatism.  The  voice  may  be  of  a  nasal  character,  and  a  short  irrita- 
tive cough  is  not  uncommon.  During  the  stage  of  hypersecretion  th< 
lining  of  the  Eustachian  tube  may  -well,  causing  occlusion  and  more  or 
less  deafness. 

Although  the  affection  is  quite  distressing  to  patient-,  it  i-  essentially 
mild,  aii<l  if  the  nares  arc  free  does  not    extend  to  part-  below.      If.  however. 


948      DISEASES  OF  THE   TONSILS,    PALATE,   AM)   PHARYNX. 

they  arc  obstructed  ami  the  air  is  not  properly  wanned,  moistened,  and 
tillered,  the  pharynx   proper  may  suffer  in  consequence. 

Treatment.  -This  should  firs!  be  directed  toward  the  gastro-intestinal 
tract,  for  a  restoration  of  the  latter  to  activity  may  abort  an  attack.  A  mer- 
curial followed  by  a  .-aline  should  be  given  immediately.  An  initial  full  dose 
of  quinin  and  Dover's  powder  with  a  hot  hath  and  other  diaphoretic  measures 
are  often  of  greatesl  service.  For  the  headache  and  general  malaise  the  coal-tar 
product- — phenacetin,  ammonol,  lactophenin,  etc. — in  five-grain  doses  every 
hour,  are  valuable.  Bosworth  advocate-  aconitia  in  j-^-grain  doses  every 
hour  or  two  until  the  pharyngeal  pain  abates. 

For  local  relief  cocain  may  first  be  used  to  deplete  the  vessels  and  allay 
pain.  The  amount  of  the  drug  employed  must  be  carefully  restricted.  After 
tree  secretion  is  established,  the  uaso-pharynx  should  be  irrigated  three  or 
four  times  daily  by  any  of  the  method-  in  common  use.  The  writer  prefersa 
small  rubber  catheter  w  ith  a  large  number  of  very  fine  perforations  at  the  distal 
end.  while  it-  proximal  end  i-  attached  to  a  rubber  hull).  This  is  tilled  by 
suction  in  the  usual  manner  and  then  passed  along  the  floor  of  each  nostril 
until  the  perforated  end  i-  in  the  naso-pharynx.  Gentle  pressureon  the  hull) 
will  discharge  a  -eric-  of  tine  currents,  which  will  bathe  the  entire  cavity  with- 
out injury  to  the  Eustachian  cushions,  hut  effectually  removing  all  secretion. 
The  solutions  to  he  used  should  he  rather  more  than  lukewarm.  They  may 
he  made  up  of  glyco-thymoline,  boro-lyptol,  listerine,  etc.,  one  teaspoonful  to 
three  ounces  of  water.  A  cheaper  and  yet  efficient  solution  is  one  teaspoon- 
ful to  the  pint  of  water  of  a  powder  composed  of  equal  parts  of  chlorid, 
biborate,  and  bicarbonate  of  sodium. 

After  the  second  stage  is  passed,  applications  may  he  made  on  the  post'- 
na-al  cotton-carrier  of  silver  nitrate  (gr.  xx-.sj),  or  Mandl's  solution  :  iodin, 
gr.  v  :  potassium  iodid,  gr.  xv  ;  acid  carbolic,  111  \\  '•  glycerin,  §j.  li'  much 
tissue-hypertrophy  remain-  in   the  vault,  the  galvano-cautery  or  cauterizing 

acids  are  indicated.     The  use  of  a  palate-1 k  greatly  facilitate-  the  necessary 

manipulation-. 

Chronic  Nasopharyngitis :  Chronic  Post-nasal   Catarrh. — By 

this  term  i-  signified  a  condition  characterized  by  the  excessive  discharge 
from  the  naso-pharynx  of  a  secretion  altered  in  quality  as  well  as  quantity. 
It  may  cling  to  the  site  of  production  or  diffuse  itself  more  or  less  over  the 
Burrounding  structures.  It-  discharge  is  generally  effected  by  a  characteristic 
nasal  screatus  or  haw  kin-. 

Tin-  disease  is  common  in  all  land-,  and  affects  especially  dwellers  near 
large  bodies  of  water  ami  in  damp  climate.-.  It  is  especially  common  in 
America,  and  i-  sometimes  spoken  of  by  English  and  Continental  writers  as 
••  American  catarrh."  It  appear-  in  every  grade  of  severity,  from  a  mere 
annoyance,  scarcely  noticeable,  to  a  condition  which  renders  the  patient  him- 
Belf  thoroughly  miserable  ami  disgusting  to  other-. 

Causes. — Many  cases  in  adult-  are  douhth—  referable  to  neglected 
disease  of  the  pharyngeal  tonsil  occurring  in  earlier  year.-.  In  childhood  all 
inflammations  are  prone  to  invade  lymphoid  structures.  Such  a  tendency  is 
often  aggravated  by  some  intercurrent  infantile  disease,  especially  the  exan- 
themata. The  various  diatheses  act  through  this  intermediate  lymphatic 
involvement.  The  u-e  of  tobacco  and  alcohol  are  to  he  considered  a-  excit- 
ing  causes,  the  former  perhaps  onl}  aggravating  a  pre-existing  disease ;  while 
the   latter   primarily  affects   the   Btomach,  between   which  and   the   pharynx 

there   exista,  a-    we    have    ?een,    an    intimate    relation. 

In    regard    to  the    effed    of  cold    alone,  a-    an    excitant   of  the    acute  form 


DISEASES  OF   Till-:  XASO-PJ/A  RYNX. 


949 


which  later  subsides  into  the  chronic,  Bosworth  strenuously  insists  thai  the 
chronic  form  precedes,  and  that  cold  produces  exacerbations  into  an  acute  or 
subacute  stage.  Modern  rhinology,  however,  assigns  the  mosl  importanl 
role  among  the  causative  factors  to  the  condition  of  the  nasal  chambers. 
The  recognition  of  their  true  function  has  been  the  greal  advance  in  this 
field  of  medicine.  They  should  be  examined  in  every  case  of  post-nasal 
catarrh,  [f  they  are  diseased,  some  naso-pharyngeal  lesion  can  be  safely  [ind- 
icated. The  normal  secretion  from  the  glands  of  the  latter  region  is  thin, 
clear,  and  bland.  If,  however,  owing  to  intranasal  disease,  it  is  constantly 
fanned  by  a  current  of  air  which  is  < 1,  dry,  and  dusty,  its  proper  elabora- 
tion will  he  interfered  with.  Cell-desquamation  in  the  oaso-pharynx  is  un- 
duly stimulated.  A  thick,  stringy,  dust-laden  mucus  appears,  very  tenacious 
and  removed  with  difficulty.  If  the  disease  progresses,  crust-formation 
finally  results. 

Pathology. —  In  addition  to  the  excessive  cell-desquamation  and  abnor- 
mal secretion  there  is  more  or  less  diffuse  hyperplasia  of  the  lymphoid 
elements  of  this  region.  A  noteworthy  impulse  was  given  in  1<SS5  to  the 
discussion  of  this  question  by  the  publication  of  Tornwaldt's  monograph  on 
the  "  Significance  of  the  Pharyngeal  Bursa."  He  assigned  as  a  frequent 
cause  of  chronic  post-nasal  catarrh  a  diseased  condition  of  this  bursa.  It 
may  be  the  seat  of  chronic  catarrhal  inflammation  or  may  be  cystic,  with  a 
closure  of  the  outlet.     To  such  a  condition,  also,  Tornwaldt  referred  a  host 


l'li..  580.     Pharyngeal  \ ault,  showing  median  ami 
lateral  folds;  also,  orifii f  bursa  |  Luschka). 


Fig.  581.    Pharyngeal  bursa  (Luschka). 


of  reflex  symptoms  in  various  parts  of  the  upper  air-tract.  His  views 
gained  some  adherents,  but  are  now  regarded  as  too  extreme.  He  considers 
the  bursa  as  a  normal  anatomical  structure,  but  Schwabach,  after  examining 
over  thirty  differenl  specimens,  denied  the  statement  that  the  bursa  was  a 
special  anatomical  formation.  It  should  rather  be  regarded  as  an  integral 
portion  of  the  pharyngeal  tonsil,  sharing  in  common  with  the  latter  all 
pathological  changes  (  Figs.  580,  581  ). 

The  heads  examined  by  Schwabach  -bowed   in  the  vault  of  the  pharynx 
a  series  of  irregular  cleft-  of  varying  depth  forming  intervening  ridges  of 
variable  breadtn.     The  older  the  child  the  less  distind  was  this  cleft-Forma- 
tion.    The  median  cleft  was  the  mosl   persistent.     The  bursa,  he  asserts,  is 


950      DISEASES  OF  THE  TONSILS,    I'M. ATI-:,  AND  PHARYNX. 

Dotbing  bul  a  remnanl  of  tbis  median  cleft.  Partial  or  complete  agglutina- 
tion of  its  edges  forms  a  Mind  pocket  or  pouch,  extremely  favorable  to  the 
ret<  otion  of  mucus,  which,  under  such  circumstances,  tends  to  become  puru- 
lent, and  a  cysl  results.  Such  inclusion-cysts  are  uncommon.  Their  epi- 
thelial lining  is  the  same  as  thai  of  the  surrounding  area.  The  columnar 
type  here  predominates,  shading  off  into  the  squamous  as  we  pass  down 
the  pharyngeal  wall  ;  l>ut  at  times  even  in  the  vault  the  latter  type  prevails, 
owing  to  irritating  secretions  or  the  attrition  of  inflamed  surfaces. 

Examination  of  tissue  removed  from  such  cases  shows  iirst  of  all  an  epithe- 
lial layer  with  a  range  in  structure  from  columnar  ciliated  to  squamous  cells. 
Underneath  are  lymph-nodes  embedded  in  a  mass  of  lymphoid  tissue,  which 
in  turn  presents  trabecular  of  scanty  connective  tissue.  The  usual  cryptic 
depressions  appear  on   the  surface  i  Figs.  582,  583). 


Ml 


F  i < ; .  582.    Lymph-follicle  from  naso-pharynx  (altered  from  Zarniko). 

Bosworth  has  pointed  out  the  difficulty  of  recognizing  the  relation  be- 
tween the  local  pathological  change  and  its  most  annoying  symptom — viz., 
increased  secretion.  There  is  no  increase  of  the  ordinary  muciparous  folli- 
cles, and  the  increased  secretion  must  therefore  come  from  the  surfaces  of  the 
clefts  and  ridges,  which  take  on  a  functional  activity  not  unlike  that  of  a 
mucous  gland.  The  mucus  being  itself  abnormal,  further  irritation  is  caused, 
and  thus  the  vicious  circle  is  perpetuated. 

Symptoms. — The  most  prominent  symptom  is  the  discharge  of  a  profuse, 
viscid,  yellowish  secretion.  It  may  adhere  to  the  surface  of  the  mucous 
membrane  or  flow  down  the  posterior  wall  and  be  removed  by  frequent 
hawking.  There  i-  often  the  sensation  of  a  pendant  drop  just  behind  the 
Bofl  palate.  We  must  suppose  that  this  secretion  is  perfectly  fluid  as  it  ap- 
pear- at   the  i ths  of  the  glandular  ducts,  and  that  its  inspissation  results 

from  the  abnormal  environment  it  there  meets,  [ts  consistency  varies  from 
time  to  time.  In  those  cases  where  there  is  an  inclusion  of  the  median  cleft 
tin'  discharge  ie  more  api  to  be  fluid.  The  cavity  apparently  fills  slowly  and 
then  becomes  a  Bource  of  sufficient  irritation  to  provoke  hawking  and  lead  to 
an  evacuation  of  the  bursal  contents.  During  the  day  the  natural  activity 
of  the  pharyngeal  muscles  keeps  the  discharge  from  clogging  up;  but  on 
waking  in  the  morning  the  acci ilation  of  the  oight-hours  begins  to  be  dis- 
lodged, causing  gagging,  nausea,  and  even  vomiting.  During  the  damp 
weather  and  at  the  Bea-level  the  severity  of  the  foregoing  condition-  i-  gen- 
erally increased. 

hoe-  this  form  of  catarrh  predispose  to  affections  of  the  lower  air-tract — 
the  larynx,  trachea,  and  bronchi ?  This  question  has  often  Inch  discussed. 
Probably  none  ni    the  detached   mucus  ever  goes  down   the   windpipe.     It 


DISEASES   OF   THE  X.\K< >- l>I I M;  Y XX .  951 

glides  along  the  post-pharyngeal  wall  into  the  esophagus.  It  is  Dot,  there- 
fore, the  carrier  of  contagion  to  the  laryngeal  mucosa.  Patients  who  suffer 
synchronously  from  naso-pharyngeal  and  laryngeal  catarrh  arc  probably  the 
victims  di'  abnormal  intranasal  conditions.  The  correction  of  the  latter  is 
the  only   rational  treatment  of  the  twofold  catarrhal   malady. 

Of  reflex  symptoms,  we  may  cite  asthma  and  headache.  The  middle-ear 
catarrh  sometimes  seen  in  naso-pharyngeal  cases  is  probably  due  to  intra- 
nasal trouble,  causing  improper  ventilation  of  the  pharyngeal  vault  and 
middle  ear.  It  may  at  times  be  due  to  direct  propagation  of  disease  of  the 
vault  along  the  lining  of  the  Eustachian  tubes. 

Diagnosis. — In  the  examination  of  a  given  case  we  musl  fust  ascertain 
whether  we  have  to  do  with  a  post-nasal  catarrh  pure  and  simple  or  with  one 
complicated  by  other  morbid  states. 

In  an  uncomplicated  case  the  small  mirror  will  enable  us  to  recognize 
either  the  broad  diffuse  hypertrophy  of  the  mucosa  or  the  enlarged  "bursa." 
The  latter  appears  as  a  cleft  of  varying  depth  with  lateral  rounded  lips, 
making  a  picture  which  a  French  writer  calls  with  greater  realism  than 
modesty  the  "  vulva  of  the  naso-pharynx."  An  accumulation  of  discharge 
here  may  result  from  syphilitic  changes;  but  other  evidences  of  the  latter 
trouble  will   make  the  diagnosis  easy. 

It  is  difficult  at  times  to  eliminate  as  factors  of  the  discharge  the  inflam- 
mation of  the  sphenoidal  or  post-ethmoidal  sinuses.  When  the  patient  reclines 
the  discharge  from  these  cavities  may  trickle  back  into  the  naso-pharynx, 
and  its  appearance  there  simulates  bursal  disease.  A  careful  examination 
made  during  the  day,  after  previously  cleansing  the  region,  will  generally 
determine  whether  or  not  serious  trouble  exists. 

Course. — Patients  have  generally  suffered,  in  a  mild  degree  at  least,  for 
many  years  before  coming  under  professional  care.  As  a  rule,  the  longer 
they  have  complained  the  more  quickly  they  seem  to  think  they  can  be 
cured.  Most  of  them  can  be  cured  if  they  will  follow  up  treatment  long 
enough,  but  at  the  outset  a  full  statement  of  the  continued  care  necessary 
should  be  laid  before  them. 

Treatment. — Any  underlying  diathesis  which  may  be  found  will  suggest 
its  own  appropriate  remedy.  Special  attention  must  be  paid  to  bathing, 
clothing,  foot-wear,  and  general  hygiene.  Alcohol  must  be  cut  off  in  all  its 
forms.  At  the  outset  tobacco  must  be  given  up,  but  later  a  mild  cigar  may 
be  taken  after  dinner. 

In  regard  to  diet,  no  special  rule  can  be  laid  down.  More  often  the 
stomach-condition,  if  annoying,  is  the  effect  and  not  the  cause  of  the  naso- 
pharyngeal trouble.     A   cure  of  the  latter  will  often    remove  the  former. 

As  to  local  treatment,  the  number  of  remedies  is  legion.  One  i-  probably 
as  good  as  another  if  thoroughly  applied.  Naso-pharyngeal  cleanliness  is 
the  foundation-stone  of  all  successful  care  of  these  cases.  From  two  to  four 
times  daily  the  vault  should  be  cleansed  with  some  one  of  the  solutions 
named  in  a  preceding  section  (boro-lyptol,  glyco-thymoline,  pyrozone,  lis- 

terine,  etc.),  all  in  the  proportion  of  one  to  two  teasp ifuls  in  four  ounces 

of  water.  Available  also  are  the  old-fashioned  Dobell's  solution  or  the  alka- 
line powder  (equal  part-  of  salt,  borax,  and  baking  soda  :  of  the  mixture, 
one  teaspoonful   to  the  pint  of  lukewarm  water). 

These  washes  may  be  snuffed  up  from  the  hand  or  used  in  the  nasal 
douche  cup  or  familiar  "  feeding-cup  "  <>('  the  sick-room.  ( Ordinary  atomizers 
spraying  through  the  anterior  nares  are  useless.  The  diseased  surface  must 
be  laved   with  a   certain   volume  of  alkaline  or  antiseptic  solution  at    body- 


952      DISEASES  <>r  THE  TONSILS,   PALATE,  AND  PHARYNX. 

temperature,  so  thai  all  the  adherenl  secretion  may  be  floated  up.  Of  course, 
too  forcible  manipulation  of  any  kind  should  be  avoided. 

After  the  parts  arc  thoroughly  cleansed,  some  alterative  application  may 
be  made  on  the  cotton-carrier,  such  as  the  glycerite  of  tannic  acid,  or  of 
boro-glycerin  or  a  solution  of  iodin  gr.  v,  potassium  iodid  gr.  xv,  carbolic 
acid  11]  'J  and  glycerin  j£j  ;  silver  nitrate  gr.  xxx-^j;  glacial  acetic  and  lactic 
acid-  in  varying  strengths.  All  have  their  advocates.  Such  applications 
should  be  made  three  times  weekly. 

The  nasal  douche  with  the  usual  reservoir  and  long  tube  has  not  been  ad- 
vocated, as  the  \\  riter  is  convinced  thai  bul  few  patient-  are  sufficiently  skilful 
in  it-  management  to  render  its  use  entirely  sale.  The  douche-cup  will 
suffice  for  every  case  if  it  is  faithfully  and  persistently  used.  It  can  do  no 
harm  it'  of  a  proper  shape  and  >ize.  In  office-practice,  the  long,  hard  rubber 
syringe  with  curved  tip  will  answer  every  purpose.  An  elaborate  air-spray 
apparatus  is  in  no  wise  necessary. 

1 1'  the  disease  be  more  pronounced  it  will  be  necessary  to  actually  destroy 
or  remove  the  diseased  tissue.  For  this  purpose  we  have  chromic  acid  and 
the  galvano-cautery.  With  the  latter  the  bursa  can  be  thoroughly  eradicated. 
Small  curettes  and  some  of  the  varieties  of  post-nasal  forceps  are  also 
available.  The  use  of  the  palate-retractor  and  post-nasal  mirror  are  neces- 
sary for  accurate  manipulation  of  these  instruments,  use  of  which  should  be 
preceded    by   cocain   on    the  cottoii-ca rrier  in   20   per  cent,   solution. 

lymphoid  Hypertrophy  in  the  Pharyngeal  Vault. — This  is  the 
familiar  condition  variously  known  as  hypertrophy  of  the  third,  pharyngeal 
or  Luschka's  tonsil,  adenoid  vegetations,  etc.  It  was  first  described  by 
Czermak  in  I860,  but  he  did  nol  appreciate  its  clinical  importance  as  we  under- 
stand it  to-day.  It  remained  for  the  late  Wilhelm  Meyer  of  Copenhagen  to 
accurately  portray  the  affection.  So  thorough  and  complete  was  his  exposi- 
tion of  the  subject,  that  no  one  ha-  keen  able  to  add  anything  essentially  new 
to  hi-  now    classical    paper  which  appeared    in   1870. 

It  i-  unfortunate  that  the  term  '•adenoids"  has  come  into  such  common 
use.  It  i-  in  this  connection  anatomically  incorrect.  It  was  formerly  sup- 
posed thai  the  hypertrophy  was  made  up  of  true  glandular  tissue,  hence 
adenoid  in  structure;  but  tin-  tissue  contains  no  true  secreting  glands.  Its 
fold-  and  fissures  may  at  time-  take  on,  so  far  as  the  elaboration  of  mucus  is 
concerned,  a  secreting  function. 

Causes. — The  condition  may  he  congenital.  Scrofula,  syphilis,  and 
tuberculosis  all  predispose  to  it.  It  seems  hereditary  in  some  families,  bul 
the  existence  of  several  cases  in  the  same  family  may  easily  be  referable  to 
the  same  diathesis  or  to  exposure  to  the  same  unsanitary  surroundings.  No 
race  or  climate  is  exempl  from  the  disease.  The  majority  of  case-  are  seen 
in  children  from  four  to  ten,  although  no  age  is  exempt.  Both  sexes  are 
equally  affected.  An  underlying  factor  exists  in  the  tendency  of  children 
to  "  lyiiiphaii-ni."  which  has  keen  described  in  a  previous  section.  The  ebb 
of  the  lymphatic  tide  cc -  aboul  the  time  of  puberty,  when  there  is  a  ten- 
dency of  the  lymphoid  structures  to  atrophy. 

A.ssociated  lesions  of  tic  malady  are  hypertrophic  rhinitis  and  especially 
enlarged  faucial  tonsils.  In  a  few  cases  the  nasal  mucosa  may  be  distinctly 
atrophic. 

Pathology. — The  lymphoid  masses  are  variously  arranged  in  the  naso- 
pharynx. Occasionally  they  are  pendant  from  the  vault;  km  more  fre- 
quently they  are  irregularly  distributed,  running  forward  to  the  edges  of  or 
even  into  the  choanse,  filling  the  fossae  of  Rosenmuller,  encroaching  upon  the 


/>/s/:.lS/:s  OF  THE  XASO-PHARYNX. 


953 


Eustachian  orifices,  and  extending  a  variable  distance  downward  upon  the 
posterior  and  lateral   pharyngeal  walls  (Fig.  582). 

Under  the  microscope,  the  tissue  is  seen  to  be  covered  with  stratified 
columnar  epithelium,  more  or  less  deprived  of  its  cilise.  Tlie  surface  is 
deeply  furrowed,  giving  the  mass  a  lobulated  appearance.  The  l>ull<  is  made 
up  of  lymphoid  cells  with  a  scanty  blood-supply.  These  cells  are  arranged 
in  the  usual  "node"  form,  with  internodal  areas  sparsely  supplied  with  a  low 
grade  of  connective  tissue  which,  however,  has  a  fairly  abundant  blood- 
supply  (sec   Fig.  583). 

These  lymph-nodes  resemble  in  every  respect  t\ic  solitary  follicles  of  the 
intestine,  and  have  the  same  relation  to  the  lymphatic,  system.  The  lymph- 
vessels  run  near  the  bottom  of  the  folds  into  which  the  surface  is  thrown. 
The  blood-vessels  are  for  the  most  part  atypical  in  structure.  Those  which 
are  at  the  bases  of  the  masses — i.e.  nearest  to  normal  tisstn — may,  however, 
show  a  more  typical  structure.  The  amount  of  connective  tissue  present 
does  not  bear  any  necessary  relation  to  the  age  of  the  patient.  As  a  rule,  the 
masses  arc  softer  in  young  children  and  harder  in  adults. 

It  must  be  remembered  that  this  lymphatic  formation  is  merely  an  over- 


£ ■J£&*~  '-V-StgiX; 


-       - 


V 


Fig  583.— Lymphoid    hypertrophy    in    the 
naso-pharyngeal  vault. " 


"'';-'i?'Y:''  ■ '.  ■    "'■,''«.''     ■"    -  *-  y\ 


-9£v^ 


Fig.  584. — Section  through  lymphoid  growth 
(altered  from  Zarniko  i. 


growth  of  a  normal  histological  element  of  the  mucosa  in  this  situation.  It 
is  not  an  adventitious  deposit.  Therefore,  those  who  speak  of  complete 
removal  use  a  term  which,  strictly  speaking,  is  not  correct,  for  absolutely 
complete   removal    would    mean   a    removal    of  the   mucosa    itself. 

The  relative  preponderance  of  the  cellular  elements  gives  to  the  growths 
their  soft  jelly-like  consistency,  and  the  furrowed  surface  liken-  the  feel  to 
the  examining  finger  to  that  (to  use  the  customary  simile:  of  "a  bag  lull  of 
earth-worms." 

It  musl  not  be  forgotten  that  in  adults  also  the  lymphoid  hypertrophy  is 
found  ;  but,  as  previously  noted,  the  consistency  of  the  deposits  is  firmer  and 
tiny  arc  aggregated  in  the  middle  of  the  vault,  at  the  site  of  the  so-called 
third  or  pharyngeal  tonsil.  The  condition  is  really  a  hypertrophy  of  the 
latter  structure  (see  Fig.  562). 

Small  cysts  are  occasionally  found  in  the  masses. 

\-  compared  with  enlargements  of  other  segments  of  the  tonsillar  ring, 
the  principal  difference  here  is  the  small  amount  of  connective  tissue.      The 


954      DISEASES  OF   THE  TONSILS,   PALATE,   AND  PHARYNX. 

growths  arc  largely  protected  from  those  irritative  influences  which  predispose 
to  connective-tissue  formation. 

Symptoms. —  Patient-  are  brought  to  the  physician  with  the  statement 
thai  the  nose  is  more  or  less  stuffed  up  and  at  times  discharges  muco-pus. 
The  children  breathe  through  their  mouths  and  snore  at  night.  The  voice 
has  a  peculiar  '•(lead"  quality  or  lack  of  resonance.  The  expression  is 
stupid  and  the  mental  condition  seemingly  often  below  par.  Deafness  is  not 
uncommon,  and  in  marked  cases  an  offensive  aural  discharge  exists.  Cough 
may  occur  and  occasionally  spasmodic  breathing.  Other  possible  features  are 
nose-bleed,  night-terrors,  nocturnal  enuresis,  aprosexia,  and  a  broadening  of 
the  bridge  of  the  nose. 

Night-sweats,  chest-deformities,  abnormal  formation  of  the  facial  and 
palatal   bones,  defective  development,  and   many  other  allied  condition-  have 

ml    |W 


.-"  ■>• 


Fig. 585.    Hypertrophy  of  the  pharyngeal  tonsil  (Seifert  and  Kahn). 

been  directly  attributed  to  lymphoid  vegetations  in  the  vault.  Many  of 
them  are  doubtless  more  properly  referable  to  the  underlying  dyscrasia  of 
which  the  vegetations  are  but  a  single  expression. 

Let   n-  analyze  the  foregoing  symptoms  somewhat  in  detail. 

The  profuse  nasal  discharge  is  the  result  (as  previously  stated)  not  of  an 
inflammation  of  the  true  acinous  glands,  but  of  the  surfaces  of  the  folds  and 
clefts  of  the  growth.-.  The  tissue  is  so  soft  and  pulpy  that  it  breaks  down 
under  the  examining  linger,  which  upon  it- withdrawal  is  covered  with  Mood, 
and  this  latter  facl  alone  evidences  an  abnormal  naso-pharynx.  The  mouth- 
breathing  comes  from  the  greater  or  less  obstruction  to  the  passage  of  air 
through  the  posterior  nares,  through  the  pharynx,  and  thence  to  the  lungs. 
'Ih"  snoring  ensues  upon  the  relaxation  of  the  .-oft  palate,  always  present  and 
naturally  accentuated  during  sleep. 

The  voice-tone  arises  from  the  interference  of  the  growths  with  the  ex- 
cursions of  the  sound-waves  transmitted  upward  from  the  larynx.  The 
"  sounding-board  "  function  of  the  pharynx  is  impaired.  " Spring,"  " ninety- 
nine,"  etc.  arc  pronounced  "sprig,"  " nidy-nid."  Deafness  and  aural  dis- 
charges arc-  sequences  of  rarefaction  of  air  in  the  naso-pharynx,  hyperemia 
of  the  lining  of  the  Eustachian  tubes  and  middle  ear,  and  retracted  drum- 
heads. There  may  be  eventual  ankylosis  of  the  ossicles  with  atrophy  of  the 
tympanic  membrane.  Sometimes  a  true  catarrhal  inflammation  is  set  up, 
changing  to  a  purulenl  form. 

Cough  is  referable  to  pharyngeal  irritation,  either  from  mouth-breathing 
"r  from   the  impact   of  secretion   detached   from   the  vault.     Night-terrors, 


DISEASES  OE  THE  XASO-PHAIIYXX.  955 

sense  of  choking,  enuresis,  etc,  arc  all  due  to  the  overloading  of  the  blood 
with  carbonic-acid  gas  and  the  resulting  nervous  explosion.  Gronbech  found 
enuresis  in  13  per  cent,  of  192  cases,  with  a  large  proportion  of  cures  of  this 
special  symptom  after  removal  of  the  vegetations.  He  admits  a  general  pre- 
disposition to  enuresis.  Otherwise,  he  says,  we  would  find  it  more  frequently 
in  hypertrophy  than  we  do. 

The  term  "aprosexia"  (from  a  Greek  derivation  meaning  literally  "nol 
to  hold  toward  or  to")  was  suggested  by  Guye  of  Amsterdam  as  a  proper 
designation  for  the  inability  which  many  of  these  children  manifest  to  con- 
centrate their  attention  upon  any  one  thing.  It  probably  arises  from  a 
sluggish  lymph-circulation  at  the  base  of  the  brain,  which  in  turn  affects 
the  functional  integrity  of  the  higher  centers.  Retzius  and  Axel-Key  have 
demonstrated  the  close  anatomical  relations  between  the  lymph-channels  of 
the  naso-pharynx  and  those  at  the  base  of  the  brain. 

Harrison  Allen  has  called  attention  to  a  condition  which  he  calls  " adenoid 
disease."  The  obstruction  is  here  due  to  a  congenitally  narrowed  naso- 
pharynx. It  does  not  excite  mischief  by  reason  of  its  influence  on  either 
respiration  or  acute  catarrh,  but  affects  directly  general  nutrition,  and  in  the 
opinion  of  the  author  quoted  is  allied  to  acromegaly  and  myxedema. 

Several  authors  report  cases  of  torticollis  coexisting  with  but  cured  by 
the  removal  of  the  lymphoid  vegetations,  and  the  same  is  true  as  regards 
epileptic  seizures. 

Diagnosis. — Many  of  these  cases  can  be  recognized  at  sight,  the  peculiar 
facies  and  open  mouth  at  once  suggesting  the  nature  of  the  trouble.  In 
tractable  children  the  small  mirror  enables  us  to  actually  see  the  deposits.  In 
intractable  ones  the  forefinger  of  the  right  hand  can  easily  be  slipped  up 
behind  the  soft  palate  and  the  situation  of  the  masses  accurately  located. 
Another  test  (not  diagnostic  of  this  particular  condition,  however)  is  the 
throwing  of  a  warm  antiseptic  or  oily  spray  through  one  anterior  naris.  If 
the  nose  and  naso-pharynx  are  clear,  the  fluid  will  escape  from  the  other  nos- 
tril with  practically  undiminished  force. 

It  is,  of  course,  possible  for  these  vegetations  to  be  of  a  sarcomatous, 
syphilitic,  or  tubercular  nature,  so  far  as  their  pathological  structure  is  con- 
cerned ;  but  unless  other  and  visible  evidences  of  these  respective  diseases  are 
present,  our  diagnosis  will  probably  fall  short  of  this  degree  of  refinement. 
Such  cases  have  come  to  light  mainly  from  the  microscopic  examination  of 
the  tissue  removed. 

Prognosis. — Parents  always  inquire  if  vegetations  will  do  any  permanent 
injury  if  left  alone.  Most  emphatically  they  will.  The  worst  cases  with 
their  train  of  symptoms,  called  in  general  "Catarrh,"  will  have  attracted  the 
parents'  attention,  and  they  will  consenl  to  operative  removal  of  the  offending 
tissue.  In  the  less  marked  cases  they  may  regard  an  operation  as  unneces- 
sary; but  it  must  be  pointed  out  to  them  that  even  if  there  seems  to  be  no 
immediate  danger,  there  is  great  danger  of  permanent  damage  to  the  organs 
of  hearing  and  of  the  perpetuation  of  an  intractable  post-nasal  catarrh  after 
puberty.  Immediate  dangers  are  the  increased  liability  to  any  contagion 
which  may  surround  the  child,  diseases  from  impaired  vitality  of  the  upper 
air-tract,  defective  mental  and  physical  development,  deformities  in  the  jaws, 
and  defective  dental  development. 

On  the  other  hand,  there  is  no  operative  procedure  in  the  whole  domain 
of  this  braneli  of  medicine  attended  l>v  happier  results  than  is  that  tor  the 
removal  of  lymphoid  hypertrophy  from  the  vault  of  the  pharynx.  The 
child   is   physically  almost    born   again.      Dull    intellects  brighten,  deal'  ears 


956      DISEASES  OF  THE  TONSILS,   PALATE,   AND   PHARYNX. 

are  unstopped,  phonatioo  becomes  clear  and  distinct,  mouth-breathing  dis- 
appears.     In  short,  the  child  is  a  new  creature. 

Does  such  tissue  recur  after  removal?  The  general  answer  has  been  in 
the  negative,  provided  thai  the  operation  has  be<  a  thorough.  F.  E.  Hop- 
kins,  who  has  investigated  this  question,  believes  thai  recurrence  may  happen 
even  after  the  mosl  thorough  removal.  This  possibility  of  recurrence  is  not 
■surprising  when  we  remember  that  the  lymphoid  elements  in  this  situation 
are  nol  mere  surface-deposits.  They  normally  infiltrate  all  the  layer-  of  the 
mucosa  down  to  the  periosteum.  Literally,  complete  removal  of  all  lym- 
phoid  elements    would    therefore    leave   hare   hone. 

Treatment. — The  existence  of  any  underlying  diathesis  musl  be  sought 
out  and  remedied.  For  general  tonics  cod-liver  oil  and  syrup  of  the  iodid 
of  iron  have  no  superiors.  The  latter  should  supplement  every  operative 
procedure.  Customary  direction-  should  be  given  in  regard  to  bathing, 
clothing,  foot-wear,  diet,  etc.  Especially  should  it  be  insisted  upon  that  the 
child    -hall   sleep   in   a  room   directly  open   to  outside  air. 

Little  value  resides  in  topical  sprays  and  applications.  They  may  afford 
temporary  relief,  but  it  is  only  temporary.  Can-tic  acids  and  the  galvano- 
cautery  have  their  advocates  as  destructive  agents,  but  such  measures  are 
difficull  to  follow  out  in  children.  By  exclusion,  therefore,  the  question  of 
treatmenl  practically  narrow-  itself  down  to  the  removal  of  the  vegetations 
by  some  cutting  or  scraping  method. 

In  children  over  twelve  and  in  adults,  cocain-anesthesia  will  suffice, 
[n  younger  patients  we  have  the  choice  between  ether,  chloroform,  nitrous 
o.xid.  and  ethyl  bromid.  if  ether  is  \\>vi\,  only  the  primary  degree  of  anes- 
thesia need  he  induced. 

(  )f  instruments  we  have  the  finger-nail  or  the  steel  nail  to  he  worn  over 
the  forefinger,  various  curette-  mid  forceps  almost  without  number.  These 
are  figured  and  all  operative  details  described  under  Operations. 


ATROPHIC  RHINITIS. 

By  \V.    PEYRE   PORCHER,    M.  D., 

OF   CHARLESTON,   8.  C. 


Synonyms.  —  Rhinitis  sicca  and  cirrhotica;  Con /.a  fetida;  Ozena,  etc. 

In  atrophic  rhinitis,  as  in  atrophy  of  other  organs,  atrophic  degeneration 
of  the  glandular  and  muscular  structures  is  found  in  one  form  or  another, 
whether  the  disease  occurs  in  the  young  or  the  old,  in  the  plethoric  or  the 
anemic.  Microscopical  research  amply  substantiates  this  fact,  as  shown  by 
the  investigations  of  Frankel,  Gottstein,  Krause,  Hartmann,  Bosworth,  and 
others.  Owing  to  the  various  phases  which  it  presents,  it  has  been  divided 
by  authors  into  several  varieties — namely,  mucous  or  simple  dry  rhinitis, 
muco-purulent  or  atrophic  rhinitis,  and  ozena  ;  but  the  typical  form  of  non- 
ulcerative atrophic  rhinitis,  attended  by  the  formation  and  retention  of 
crusts  in  the  nasal  fossae,  is  distinctive,  and  is  characterized  by  a  horrible 
stench,  which  once   inhaled  can  never  be  forgotten. 

The  odor  from  syphilitic  necrosed  bone  resembles  it  in  some  degree  and 
is  quite  as  objectionable;  but  the  fetor  of  atrophic  rhinitis  has  more  of  a 
musty,  graveyard  odor,  and  produces  a  sensation  which  is  unlike  anything 
else  to  which  it  can  be  compared.  It  is  generally  admitted  that  syphilis  is 
not  always  a  factor  in  the  etiology  of  typical  non-ulcerative  atrophic  rhinitis  ; 
but  syphilitic  ulceration  with  caries  always  results  in  atrophic  degeneration 
of  the  nasal  mucosa,  and  in  the  majority  of  instances  the  disease  will  be 
found  combined  either  with  syphilis,  struma,  or  tuberculosis. 

The  odor  varies  greatly  in  intensity  in  different  individuals,  a-  well  as 
the  crust-formation,  even  to  the  complete  absence  of  one  or  the  other  symp- 
tom ;  but  where  the  fetor  i-  marked  it  may  safely  he  depended  on  that  re- 
tained secretion  will  be  found  in  some  fossae  or  in  the  accessory  sinuses  ;  and 
where  the  amount  of  crust-formation  is  very  great  and  long  retained,  the 
fetor  will  usually  be  proportionately  intense.  I  .-peak  of  typical  non- 
ulcerative atrophic  rhinitis  because  one  of  the  most  common  fallacies  i>  that 
the  disease  i^  always  accompanied  by  ulceration.  There  is  never  any  ulcera- 
tion except  when  a  crusl  has  been  allowed  to  remain  so  Ion-  that  a  raw  sur- 
face i-  left  beneath  it.  or  where  the  septum  i-  excoriated  by  frequenl  picking 
with  the  finger-nail,  or  as  a  result  of  syphilitic  or  tubercular  degeneration. 
It  occasionally  happens  that  atrophic  degeneration  occurs  without  crusts  or 
odor;  but   these  cases  are   by  1 Leans  of  frequent   occurrence. 

Atrophic  rhinitis  i-  found  so  much  oftener  in  the  female  than  in  the  male 
that  it  has  been  held  by  some  to  be  purely  a  woman'-  disease,  a-  it  develops 
frequently  at  the  age  of  puberty  and  is  thought  to  be  uncommon  after  the 
menopause.  This  has  not  been  the  experience  of  the  writer,  however,  as 
many  of  the  worst  cases  which  have  come  under  my  care  have  been  in  old 

women  who  have  Ion--  passed  the  menopause  ;  and  it  ha-  occurred  quite  as 
frequently  in  men  a-  in  women.  Jusl  when  the  disease  begins  or  what 
is   the  immediate  cause,  ha-   always    been    difficult   t"  determine   from  the 


A  TROPHIC  RHINITIS. 

history  ;  as  in  most,  if  qoI  all,  cases  the  patients  arc  unaware  of  its  exist- 
ence until  it  has  become  so  well  established  and  has  made  such  inroads 
that  it  can  do  longer  be  overlooked,  cither  by  themselves  or  their  friends.  It 
may  be  found  at  any  age  from  extreme  youth  to  old  age;  but  in  the  former 
case  it  is  very  difficult  to  differentiate  it  from  the  syphilitic  manifestations 
with  whi.li  it  i-  so  often  combined  or  on  which  it  is  superinduced.  The 
poorly  nourished  <>r  those  whose  hygienic  surroundings  are  verv  had  are  the 
most  common  subjects  of  the  disease,  Because  of  the  repeated  catarrhal 
attack-  to  which  they  are  liable  and  the  prolonged  purulent  discharges  in 
which    these  attack-    result. 

Symptoms. — A  typical  case  of  atrophic  rhinitis  has  been  described  as 
follows:  The  patient  complains  of  great,  often  almost  choking,  dryness  in 
the  throat,  of  accumulation  of  mucous  crusts,  particularly  in  the  vault  of 
the  pharynx,  and  of  loss  of  the  sense  of  smell  ;  an  intolerable  sickening  odor 
mayor  may  not  be  present  in  greater  or  less  degree.  On  inspection  the 
mucous  membrane  is  found  to  be  dry  and  shiny,  and  the  turbinals  nearly 
or  entirely  destroyed  by  atrophy.  The  nasal  chambers  are  greatly  enlarged, 
so  that  tlie  pharyngeal  wall  can  lie  plainly  -ecu  by  anterior  rhinoscopy.  The 
surface  of  the  turbinals  i-  often  rough  and  irregular  from  unequal  degenera- 
tions; and  intense  congestion  from  crust-irritation  is  generally  present.  By 
posterior  rhinoscopy  the  pharyngeal  glandular  tissue  is  found  to  be  almost 
totally  destroyed,  and  the  vault  and  nasal  fossae  are  blocked  by  crusts,  often 
intensely  offensive,  which  may  be  cither  dry  or  soft  and  mucous  in  character, 
and  often  completely  occlude  the  Eustachian  tubes  and  posterior  nares.  The 
lower  pharynx  presents  a  mosl  peculiar  and  typical  appearance.  The  pos- 
terior wall  i-  dry,  often  puckered  from  lack  of  moisture,  and  intensely  con- 
gested. The  posterior  half-arches  appear  drawn  much  nearer  together  than 
in  their  normal  condition,  and  on  pressure  with  the  probe,  the  pharyngeal 
mucous  membrane  i-  found  to  be  practically  resting  on  the  bodies  of  the 
vertebra'.  Deeply  congested  and  frequently  abraded  tissues  are  found  on 
examination  with  the  laryngoscope,  and  the  trachea  and  bronchi  arc  often 
also  diseased. 

The  t'oid  breath  forms,  of  course,  the  mosl  obtrusive  symptom.  Owing 
to  the  atrophy  of  the  nerve-iilanients  in  the  olfactory  region,  where  the 
degeneration  generally  begins,  there  is  complete  anosmia,  so  that  the  patients 
are  entirely  unconscious  of  the  -tench  which  they  exhale;  but  they  gradually 
learn  to  shun  people.  Their  presence,  however,  is  often  only  too  apparent, 
even  when  they  are  at  a  distance,  unless  they  are  in  the  open  air  or  the  ven- 
tilation  of  the  apartment    i<  unusually  good. 

The  trouble  i-  generally  attributed  by  the  patient-  to  gastritis,  or  the 
complaint  is  made  that  they  never  have  occasion  to  blow  the  nose  from  one 
week  to  another.  When  the}  do,  however,a  large  crusl  is  generally  expelled. 
This  gives  greal  relief  to  the  sufferer  and  lessens  the  odor  for  a  short  time  ; 
but  it  recur-  with  full  intensity  a-  soon  as  the  crusts  re-form,  and  becomes 
more  penetrating  the  longer  they  are  allowed  to  remain.  The  color  of  the 
crusts  varies  from  brown  to  green  and  yellow,  and  they  arc  sometime-  even 
black  on  the  out-ide.  They  are  generally  hard  in  the  middle,  but  become 
softer  in  consistency  a-  tiny  approach  the  outside  edges. 

'I'he  eye-  and  ear-  are  often  involved.  The  mouths  of  the  Eustachian 
tube-  are  large  and  patulous,  and  not  infrequently  acute  suppurations  of  the 
middle  ear,  accompanied  by  verj  severe  pain,  are  caused  by  small  particle- of 
mucus  which  have  been  inhaled  or  driven  in  by  the  forcible  use  of  the  ante- 
rior or  posterior   nasal   douche.     When  the  abscess   is  complicated  with  or 


SYMPTOMS.  959 

dependent  upon  a  syphilitic  diathesis,  there  may  be  a  complete  absence  of 
pain,  and  this  forms  a  means  of  differential  diagnosis  between  an  abscess 
due  alone  to  atrophic  disease  and  that  dependent  upon  the  syphilitic  diathesis. 
Bosworth  maintains  "  that  in  a  given  number  of  eases  of  grave  impair  men  I 
of  hearing  the  number  due  to  hypertrophic  disease  outnumbers  those  due  to 
atrophic  disease  in  far  greater  proportions  than  the  comparative  frequency  of 
the  two  diseases."  This  is  a  most  rational  conclusion  for  many  reasons,  but 
especially  because  every  tendency  of  hypertrophic  rhinitis  is  to  occlude  the 
Eustachian  tubes,  whereas  in  the  atrophic  forms  the  tube-  are  open  and  patu- 
lous. Tinnitus  and  many  other  intractable  forms  of  ear-disease  are  sometimes 
distinctly  traceable  to  this  disease.  Many  affections  of  the  eyes  may  accom- 
pany or  result  from  atrophic  degeneration  of  the  nose,  notably  phlyctenular 
keratitis  and  conjunctivitis. 

Atrophic  rhinitis  frequently  dates  from  one  or  other  of  the  exanthemata, 
scarlet  fever,  measles,  or  diphtheria,  or  more  commonly  from  a  series  of  bad 
colds  in  the  head.  There  is  a  certain  facial  expression  that  is  almost  typical 
of  sufferers  from  ozena — the  low  flat  nose  with  the  large  open  nostrils.  In  old 
subjects  the  nose  generally  appears  to  be  almost  sunken  in  the  face.  There 
is  a  peculiar  dry  appearance  about  the  vestibule  and  anterior  naris.  There 
is  a  complete  absence  of  vibrissa?,  with  widely  distended  ahe,  as  though  the 
patient  was  suffering  from  want  of  breath.  This  must  unquestionably  be 
caused  by  the  large  plugs  of  mucus,  in  which  a  small  hole  is  often  found,  on 
which,  unless  they  resort  to  mouth-breathing,  the  patients  must  depend  for 
their  supply  of  air  until  the  plug  is  removed.  So  tightly  do  these  crusts 
become  impacted  in  the  nares  that  their  pressure  may  contribute  to  cause  the 
abnormal  roominess  found  in  the  nose,  the  turbinals  are  pressed  widely  apart, 
there  is  a  complete  collapse  of  the  erectile  tissue,  and  in  some  cases  the 
mouths  of  the  Eustachian  tubes  and  the  posterior  pharyngeal  wall  can  be  in- 
spected by  anterior  rhinoscopy.  The  mucous  membrane  is  conspicuously  pale, 
except  around  the  margins  of  ulcerations  or  in  localized  spots  of  inflamma- 
tion. In  the  incipiency  of  the  disease  the  mucous  membrane  will  generally 
be  covered  with  a  thick,  glairy,  white  secretion,  which  constitutes  a  most 
aggravating  source  of  annoyance  both  to  the  patient  and  to  the  practitioner. 
The  patient  keeps  up  an  incessant  coughing,  hawking,  and  clearing  of  the 
throat  in  the  effort  to  get  rid  of  it,  and  the  physician  finds  it  almost  impos- 
sible to  free  the  throat  and  nose,  even  with  the  most  persistent  washing  and 
swabbing  out  with  antiseptic  solutions,  etc.  It  is  the  belief  oi'  the  writer 
that  many  patient-  have  succumbed  to  this  disease  before  the  diagnosis  was 
ever  clearly  established.  The  continuous  cough  and  irritation  so  lowers  the 
vitality  of  the  patient  that  death  supervenes  directly  or  is  superinduced  upon 
~ome  intercurrent  malady. 

Epistaxis  not  infrequently  occurs  as  a  result  of  erosions  caused  by  dry 
incrustations  on  the  septum  and  elsewhere.  These  erosions  may  be  so  small 
that  the  point  from  which  the  hemorrhage  proceed-  can  only  with  difficulty 
be  detected.  The  hemorrhage  may  also  be  produced  by  a  perforation  through 
the  septum,  due  to  incessant  picking  of  the  nose  in  the  effort  to  get  rid  of  the 
crust-formation.  Hoarseness  is  often  present  and  the  vocal  function  is  always 
impaired.  In  the  later  stages  of  the  disease  the  crusts  break  up,  and  -mall 
particles  being  inhaled  set  up  violent  spasms  and  incessant  and  aggravating 
cough.  These  small  particles  are  often  -ecu  Limr  upon  the  vocal  cords  or 
other  parts  of  the  laryngeal  interior,  and  there  can  be  no  question  that  their 
presence  often  results  in  the  most  intractable  laryngeal  and  pulmonary  in- 
flammation. 


.1  TROPHIC  RHINITIS. 

Etiology. — Many  theories  have  liccn  advanced  ;i>  to  the  etiology  of  this 
disease.  Mackenzie  -ays:  "Thai  atrophic  rhinitis  always  appears  as  a  sequel 
of  a  pre-existing  catarrhal  inflammation  is  rendered  highly  probable  from  a 
number  of  clinical  and  pathological  facts.  It*  the  clinical  history  he  accu- 
rately taken,  it  will  point  to  pre-existing  catarrhal  process.  As  has  been 
indicated  above,  the  rapidity  with  which  the  hypertrophic  passes  into  the 
atrophic  form  of  rhinitis  is  proportionate  in  all  probability  to  the  possession 
of  some  constitutional  taint,  such  as  congenital  or  acquired  syphilis." 

Dr.  Bosworth  say-  that  " a  purulent  rhinitis  in  childhood  is  a  catarrhal 
process  in  the  first  year  and  a  catarrhal  process  always;  and  that  it  con>ists 
essentially  in  an  increased  secretion  of  mucus  in  the  earlier  stages,  together 
with  rapid  desquamation  of  epithelial  cells,  which,  running  its  course  as  a 
purulent  disease  in  from  live  to  ten  years,  develops  finally  into  what  is 
known  a-  atrophic  rhinitis.  The  disease,  in  fact,  is  the  first  stage  of  so-called 
dry  catarrh  or  ozena."  The  theory  that  a  purulent  inflammation  of  the  ac- 
cessory cavities  is  the  cause  of  atrophic  rhinitis  was  advanced  many  years 
ago  by  Michel,  ami  sphenoidal  and  ethmoidal  involvement  is  common. 

A  hypertrophied  mucous  membrane  may  he  found  in  one  nostril  with 
atrophic  degeneration  in  the  other;  but  that  does  not  prove  that  either  con- 
dition  i-  dependent   Upon  the  ot  her. 

One  of  the  interesting  theories  of  the  etiology  of  atrophic  rhinitis  is  that 
of  Lbwenberg,  who  attributed  it  to  micro-organisms. 

Amhe  and  Brindel ,  contribute  a  paper  to  the  bacteriology  of  atrophic  rhinitis 
which  confirms  the  observations  of  many  previous  students.  They  examined  twenty 
cases,  and  their  results  are  summed  up  :>s  follows: 

"1.  The  diplobacillus  of  Lbwenberg  has  been  demonstrated  in  all  the  cases  of 
atrophic  rhinitis  with  <>r  without  ozena  in  course  of  evolution.  It  was  not  found  in  old 
atrophic  coryzas  which  bad  apparently  been  cured.  It  is  not  the  pathogenic  agent  of 
ozena. 

••2.  The  pseudo-diphtheria-bacillus  was  found  eighteen  times  out  of  twenty  obser- 
vations of  atrophic  coryza  in  course  of  evolution.     It  was  met  with  twice  in  four  patients 

ted  with  old  atrophic  rhinitis  which  had  been  much  ameliorated.  It  is  not  the 
causative  agent  of  ozena.  It  is  very  probably  only  a  saprophyte  developed  in  the  nasal 
chambers  of  patients  affected  with  atrophic  coryza.  on  account  of  changes  in  the  secre- 
tions ot'  the  mucosa. 

■:;.  The  little  bacillus  of  Pes  and  Gradenigo  was  only   found   in  cases  of  ozena 

18tS  .  and   only  in   the    proportion  of  three   to   twenty. 

Electrolysis  produced  no  effeel  upon  the  microbial  flora  of  our  patient-." 
Ar-lan.'-'  after  the  bacteriological   examination  of  24  cases,  arrived  at  results  which 
are  equally  negative  so  far  as  concerns  the  discovery  of  an  organism  which  could  he 
aed  as  the  causative  agent  of  the  malady,  hut  he  is  disposed  to  he  rather  optimistic 

in  hi-  \iew-  a-   to  the   efficacy  ot'  the   serum-t  reat  incut  of  ozena.      He  treated  a    number 

of  cases  with  diphtheria-antitoxin,  hut  an  analysis  of  all  his  cases  does  not  seem  to  me 
to  warrant  the  hope  that  in  the  serum  we  -hall  lind  a  satisfactory  curative  agenl  for  this 
distressing  malady. 

Although  Gradenigo  ha-  recanted  his  firs!  favorable  opinion  of  the  method  and 
there  have  been  other  discouraging  reports,  tin -re  seems  to  he  considerable  interesl  ah  mini 
among  rhinologists  in  the  outcome  of  experience  with  the  method.  Moline"  reports 
having  cured  three  cases  of  advanced  ozenic  atrophic  rhinitis  by  the  repeated  injection-  ot 
10  cc.  of  Roux's  diphtheria-antitoxin.  He  reserves  his  decision  as  to  the  value  ol  the 
method  for  fuller  experience,  and  he  suggests  thai  the  curative  properties  may  reside  in 

ordinary  horse-e n.     Compaired  sums  up  his  experience  with  the  serum-treatment 

na  ;i-  follow- : 

1     \t  |.r.  -■  nt  i  hi-  procedure  is  one  which  furnishes  the  most  positive  results  in  the 
treatment  of  ozena. 

./,  laryngologie,  etc.,  No.  tl.  1897;  Wright,  .V.  )'.  Med.  Journal,  June 
' 

l     •  ma  ilalia.no  di  otologic,  vol.  vi.  fasc.  1,  2,  '■'< 
I  W  0       e,  etc.,  A  pril,  I  897 


ETIOLOGY.  961 

"2.  The  result  is  shown  subjectively  by  the  disappearance  of  the  fetor  after  the 
second  or  third  injection  of  5  or  ti  ec.  of  serum  recently  obtained  and  employed  accord- 
ing to  all  the  aseptic  and  antiseptic  rides;  and  objectivelj  by  the  absence  of  dryness  in 
the  nasal  fossae  with  diminution  of  the  crusts  and  the  increase  of  the  nasal  secretion. 

"3.  Objectively,  a  change  in  the  color  of  the  mucosa  is  noted,  becoming  redder, 
moist  at  times,  and  slightly  congested  and  hyperemic. 

"4.  The  crusts  are  less  bard,  dry,  and  extensive,  and  become  more  fluid,  according 
as  the  number  and  dose  of  the  injections  increase. 

"5.  The  quantity  of  10  cc.  proposed  by  Gradenigo  is  no!  free  from  danger,  and 
this  is  so  even  as  to  weaker  doses.  For  this  reason  it  is  neee-sar\  to  use  the  injections 
in  gradually  increasing  doses  with  great  care. 

'"  6.  The  treatment  in  question  otters  many  inconveniences  and  dangers,  but,  on  the 
other  hand,  it  furnishes  very  positive  results;  therefore  it  is  proper  that  the  study  of 
the  method  should  be  carefully  pursued." 

Notwithstanding  the  above  statement,  until  a  micro-organism  is  constantly 
demonstrated  in  the  superficial  layers  of  the  atrophied  mucous  membrane 
and  it  is  shown  that  inoculations  produce  the  disease,  we  must  he  satisfied 
with  believing  that  micro-organisms  are  responsible  only  for  the  characteristic 
odor  of  the  altered  secretions  of  atrophic  rhinitis,  in  which  they  find  a  suit- 
able medium  for  their  growth.  It  is  probable,  from  what  has  thus  far  been 
reported,  that  several  microbes  are  capable  of  producing  the  odor  when 
growing  in  the  secretions. 

Purulent  inflammation  originating  in  any  of  the  accessory  sinuses  or  result- 
ing from  a  simple  acute  inflammation  may  likewise  result  in  atrophic  degen- 
eration, with  more  or  less  complete  destruction  of  the  muciparous  glands 
and  follicles.  The  effect  of  pus  on  the  epithelial  and  glandular  structures. 
especially  in  the  nose,  need  not  be  dilated  on  here  ;  but  it  has  been  a  well- 
observed  fact  that  atrophic  degeneration  generally  begins  upon  the  middle 
turbinal  bodies,  and  it  has  also  been  noted  that  scabs  which  become  incrusted 
there  and  elsewhere  almost  always  contain  some  particles  of  pus  incarcerated 
on  the  under  surface  of  them.  Of  course,  it  may  be  said  here  that  atrophy 
may  result  from  the  simple  non-use  of  any  organ,  without  the  presence  of" 
any  inflammation,  simple  or  purulent,  to  produce  it.  Paradoxical  as  it  may 
appear,  it  is  nevertheless  true  that  the  nares  of  habitual  mouth-breathers 
or  those  to  whom  the  nose  is  little  more  than  an  ornament  of  the  face.  Instead 
of  becoming  larger  from  atrophy  of  the  mucosa,  become  narrower  and  more 
occluded,  almost  as  though  a  hypertrophic  instead  id'  an  atrophic  process 
had  been  established;  so  that  it  cannot  be  said  that  atrophic  degeneration  is 
in  any  case  due  to  simple  non-use  of  the  organ — first,  because  of  the  fact 
above  cited,  and  second,  because  the  worst  cases  of  atrophic  rhinitis  are 
generally  found  in  those  who  live  in  workshops  where  they  breathe  the  most 
foul  air,  sooty  emanation-,  etc. 

Atrophic  rhinitis  occurs  quite  often  at  a  very  early  age.  Large  green 
crusts  forming  complete  casts  of  the  nose  have  been  found  in  children  of' 
seven  years  and  younger.  In  these  cases  the  etiological  factors  of  hyper- 
trophy, dust-inhalation,  etc..  may  he  entirely  excluded.  This  was  notably 
the   case    in    a   child  of  six    or   seven  years  of  age  that    was  hrought    to  the 

* 

writer.  There  was  no  specific  taint  in  this  case,  and  hence  there  could  be 
but  one  cause  to  which  the  disease  could  possibly  he  attributed — namely,  a 
prolonged  rhinitis  resulting  from  an  acute  attack  which  had  been  left  to  run 
on  until  the  nasal   mucosa   was  almost  entirely  destroyed. 

Polypi,    malignant    growths,  etc.,   have   been   cited    a-   a    cause  of  ozena. 

Hereditary  abnormal   patency  of  the  nostrils  has  also  been  advanced  as  one 

of  the  causes  id"  ozena,   because  of  the  inability  of  the  patient   tit  tree  the 

nostril-  of*  accumulated  muco-pus.     This  is  too  hypothetical  to  he  relied  on  ; 

f.i 


962  ATROPHIC  RHINITIS. 

Itiit  there  is  do  doubt  that  t li<-  fetor  is  due  to  decomposition  and  fermentative 
products,  because  when  the  uostrils  are  cleansed  in  the  proper  manner  there 
j-  an  aimosl  complete  absence  of  fetor  for  many  hours  afterward.  The 
theory  thai  atrophic  degeneration  is  nothing  but  a  secondary  stage  of  the 
hypertrophic  variet)  has  been  refuted  time  and  again  by  many  of  the  most 
careful  clinical  observers,  because  it  affords  no  explanation  of  the  ozena  of 
early  childhood  ;  and  the  dry  rhinitis  of  later  life  is  not  always  preceded  by 
hypertrophy,  and  hypertrophy  does  not  always  terminate  in  atrophy.  The 
theory  of  Michel  that  the  disease  is  due  solely  t<»  purulent  discharges  flow- 
ing from  one  or  other  of  the  accessory  sinuses  met  with  much  favor  for  some 
time;  but  this  also  has  been  refuted,  because  in  some  instances  the  accessory 
sinuses  wen-  not  found  to  be  involved  or  any  discharge  flowing  from  them. 

Diagnosis. —  In  regard  to  diagnosis,  there  should  be  no  difficulty,  as 
the  intense  fetor  at  once  make-  itself  known,  and  in  the  cases  where  this 
symptom  is  reduced  to  a  minimum  the  large  roomy  nostril,  together  with  the 
characteristic  physiognomy,  at  once  proclaims  the  nature  of  the  malady.  I 
cannot  agree  with  the  authors  who  make  separate  subdivisions  of  simple 
vascular  collapse  of  the  turbinals,  mucous  or  simple  dry  rhinitis,  ozena,  etc. 
I  am  inclined  to  believe  rather  that  these  will  he  found  to  he  only  different 
stages  of  the  same  disease.  This  also  applies  to  ulcerations  which  are  found 
in  some  so-called  non-syphilitic  eases  and  not  in  others. 

The  ulcerations  will  generally  he  found  in  those  cases  in  which  there  has 
been  not  only  an  entire  neglect  of  treatment,  hut  in  which  the  patients  have 
had  no  relief  from  the  sources  of  irritation  which  originally  started  the 
disease,  and  in  which  the  crusts  have  been  retained  so  long  that  the  mu- 
cous membrane  ha-  broken  down  and   left   the  tissues  abraded. 

The  crusts  in  lupus  vulgaris  may  he  mistaken  for  those  of  atrophic 
rhinitis,  hut  lupus  generally  attacks  the  outside  of  the  nose  as  well  as  the 
inside;  and  when  the  inside  is  alone  involved  the  crusts  adhere  so  closely 
thai  they  cannot  he  removed  without  hemorrhages  and  the  fetor  is  never  so 
intense  as  it  i-  in  ozena.  In  ordinary  cases  of  atrophic  rhinitis  the  crust 
will  he  found  lining  the  mucous  membrane  of  both  mires.  It  may  com- 
pletely lill  the  nasal  chamber,  being  perforated  in  places  for  the  air  to  pass 
through  ;  and  when   blown  oul    it    will   show  a  complete  cast  of  the  interior. 

In  syphilitic  ulceration  the  ravages  of  the  disease  are  far  more  general 
than  in  lupus  and  the  sequestrum  rapidly  forms,  which,  together  with  the 
histon  of  the  case  and  the  peculiar  fetor,  may  make  the  diagnosis  very  clear. 
The  presence  of  rhinoliths  can  only  be  determined  with  the  aid  of  th<i 
rhino-cope  and  the  probe.  Tubercular  ulceration  may  be  mistaken  for  ozena, 
especially  in  the  incipiency  of  the  disease;  but  here  again  we  must  rely  on 
the  history,  the  general  appearance  of  the  patient,  and  the  microscopical 
examinat  ion. 

Pathology.  Opinions  vary  so  much  in  regard  to  the  pathology  of 
atrophic  rhinitis  in  accordance  with  the  various  theories  of  the  etiology  of 
the  disease,  thai  it  is  difficult  to  arrive  at  any  definite  conclusion  in  regard  to 
it.  It  i-  generall}  admitted  thai  it  is  similar  to  thai  of  atrophic  degenera- 
tion in  any  other  organ — i.  <..  a  gradual  wasting  away  of  the  differenl  layers 

of  miK -  membrane  and  the  conversion  of  their  individual  element-  into 

fibrous  connective  tissue.  The  walls  of  the  erectile  -pace-  are  converted  into 
dense  fibrous  bands,  which  in  contracting  obliterate  the  erectile  cavities.    This 

fibrous  degeneration    \  be  confined  to  the  deeper  layer  and  the  epithelial 

layer  be  intact;  or  the  epithelial  layer  ma\  be  destroyed,  while  the  deeper 
layer*  an   lesfi  involved.      I  he  limits  of  this  article  make  it  impossible  to  go 


TREATMENT.  963 

into  the  minute  microscopical  appearances  of  this  condition  ;  but  this  can  be 
found   in  any  of  the  text-books  on  the  subject. 

Prognosis. — It  is  beyond  question  that  this  disease  is  one  of  the  most 
intractable  to  deal  with  in  the  whole  field  of  medicine,  and  from  the  very 
nature  of  the  case  it  is  held  by  a  very  large  number  of  most  eminent  author- 
ities to  be  incurable.  'lucre  are  still  a  large  number,  however,  as  will  be 
seen  later,  who  believe  that  the  mucous  membrane  can  be  so  changed  by 
judicious  use  of  stimulants,  antiseptics,  constitutional  treatment,  etc.,  that  a 
virtual  cure  is  brought  about  ;  and  in  the  light  of  the  most  recent  investiga- 
tions it  is  the  opinion  of  the  writer  that  this  latter  conclusion  will  be  found 
to  be  correct. 

Treatment. —  It  is  apparent,  then,  as  has  been  stated  by  some  writers, 
that  atrophic  rhinitis  is  not  a  disease  per  se,  but  is  the  result  of  any  inflam- 
mation, acute  or  chronic,  specific  or  non-specific,  whether  excited  by  exposure 
to  cold  or  continuous  inhalation  of  irritating  dust,  vapors,  etc.,  which  ends 
in  a  purulent  discharge,  and  which  may  or  may  not  involve  the  accessory 
sinuses,  but  is  sufficiently  prolonged  to  wash  away  the  epithelium  and  destroy 
the  nasal  mucosa.  If  this  is  true,  what  measures  should  best  be  instituted 
for  the  relief  of  the  patient,  and  what  hope  have  we  that  the  formation  of 
scabs  may  be  stopped  ? 

In  response  to  an  article  by  the  writer,  this  subject  was  very  fully  dis- 
cussed at  the  meeting  of  the  American  Laryngological  Association  in  1896, 
and  again  it  was  made  the  special  subject  of  discussion  at  the  annual  meeting 
in  l<Si)7,  and  a  great  many  varieties  of  treatment  were  suggested.  The  fol- 
lowing resume  of  remarks  will  give  some  idea  of  most  advanced  views  of 
the  treatment  of  this  disease  (see  also  page  885)  : 

Dr.  C.  C.  Rice  expressed  his  belief  that  the  disease  was  intimately  de- 
pendent upon  some  constitutional  taint  or  unhealthy  occupation  or  manner 
of  living.  He  therefore  urged  the  necessity  of  giving  patients  out-of-door 
work  with  good  hygienic  and  sanitary  surroundings.  He  recommended  a 
combination  of  75  per  cent,  compound  stearate  of  zinc  with  boric  acid  and 
25  per  cent,  compound  stearate  of  zinc  with  alum.  This  powder  should  not 
be  used  after  the  discharge  has  been  stopped  and  congestion  controlled,  as  it  is 
too  drying.  In  the  markedly  congestive  forms  of  atrophic  rhinitis  seen  in 
immoderate  cigarette  smokers  and  alcoholic  drinkers  this  powder  is  a  valuable 
one.  It  goes  without  saying  that  we  should  not  promise  any  benefit  from 
any  form  of  treatment  unless  excessive  smoking  and  drinking  are  given  up. 

Dr.  Wright  recommended  mild  stimulation  with  a  weak  solution  of 
thymol. 

Dr.  Delavan  concurred  with  Dr.  Wright,  and  recommended  electricity  for 
the  -ami'  reason. 

Dr.  Vanderpoel  had  used  diphtheria-antitoxin  based  on  the  similarity 
between  the  Klebs-Loffler  bacilli  of  diphtheria  and  those  found  in  atrophic 
rhinitis,  and  in  one  case  there  was  no  return  of  the  crusts  which  the  patient 
had   had  before  the  attack  of  diphtheria. 

Dr.  Logan  laid  stress  on  the  necessity  of  establishing; free  drainage  from 
the  accessory  sinuses,  bo  as  to  stop  the  continual  discharge  of  pus  over  the 
middle  ami   upper  turbinals. 

Dr.  Casselberry  advised  that  patients  should  select  the  wanner,  moist,  and 
salubrious  climate  of  the  Southern  seashore  rather  than  tin  dry  regions  ol  tin 
West. 

Dr.  Mackenzie  recommended  weak  solutions  of  bichlorid  of  mercurj 
rather  than   -lion-  antiseptics.      A  for f  stimulation  in  the  shape  of   ma  — 


•.Mil  ATROPHIC  RHINITIS. 

has  been  strongly  recommended  by  Laker  of  Vtenna.  Massage  may  be 
applied  to  the  nose  either  by  the  aid  of  an  electrical  vibrator  or  simply  by 
titillating  the  parts  with  a  probe  armed  with  a  pledget  of  cotton. 

The  Germans  and  Italian-  recommend  bichlorid  of  mercury  strongly  on 
the  assumption  thai  the  disease  is  duv  to  the  presence  of  bacteria.  Koch 
and  Lowenberg  claim  greal  benefit  from  a  solution  of  1  :2000or  1:4000, 
applied  with  a  spray  or  brush.  ( !ardonne  of  Naples  and  Marano  also  advocate 
the  same  treatment.  Belfanti  has  used  the  diphtheria-antitoxin  with  great 
benefil  in  ozena  ;  and  other  observers  have  u>vd  the  same  treatment,  but  not 
u  iih  uniformly  good  results. 

Dr.  George  Stoker  of  London  warmly  recommends  the  use  of  oxygen-gas 
in  this  affection  and  chronic  aural  suppuration.  The  nose  or  ear  is  first 
thoroughly  cleansed  with  warm  water  and  the  gas  is  then  applied  from  four 
to  six  hours  daily,  with  intervals  of  one  half*  hour.  The  efficacy  of  this  plan 
of  treatment  is  beyond  question  where  free  outlet  is  given  to  all  pus-cavities 
and  free  ingress  of  oxygen  i-  allowed. 

Where  a  specific  element  is  present  mercury  should  he  pushed  to  the  extent 
of  moderate  salivation.  A  patient  recently  under  the  care  of  the  writer  he- 
came  severely  salivated,  with  the  result  that  the  formation  of  crusts  as  well 
as  the  severe  headaches  which  had  occurred  daily  before  the  treatment  lias 
ceased  entirely  and  the  patient  considers  himself  cured.  He  has  experienced 
no  ill  effects  whatsoever  from  the  salivation,  and  denies  absolutely  any  venereal 
infection  :  nevertheless,  the  atrophic  condition  has  undoubtedly  been  materially 
benefited.  He  u<vd  locally  also  a  spray,  as  follows:  K.  Glycerin  pur.,  §ij  ; 
sodii  bibor.,  3v;  aqua?  destillatae,  sj.  The  nose  was  thoroughly  sprayed  with 
this  solution  three  times  a  day.  The  use  of  the  galvanic  current  applied 
locally,  first  recommended  by  Shurly  of  Detroit  and  afterward  by  Delavan 
and  Ilartmann,  has  produced  excellent  result-. 

A  great  many  drugs  have  been  used  lor  their  irritating  and  stimulating 
effects.  Among  these  may  be  mentioned  iodoform,  iodol,  aristol,  salicylic  acid, 
camphor,  iodin,  perchlorid  of  iron,  tannin,  alum,  opium,  25  per  cent,  tri- 
chloracetic acid,  etc.  The  writer  has  used  with  much  success  a  solution  of 
iodin,  glycerin,  and  potassium  iodid  applied  on  a  cotton  pledget  high  up 
in  the  vault  of  the  oose.  This  produces  a  very  profuse  discharge  of  mucus, 
which  washes  away  the  crusts  and  after  a  time  appears  to  prevent  their 
formation. 

The  use  of  can-tic-,  the  electric  cautery,  chromic  acid,  etc.,  should  never 
he  indulged  in  because  of  their  injurious  effect  on  an  already  attenuated  mem- 
brane. Almosl  every  drug  in  the  Materia  Medica  has  been  tried  in  one  way 
or  another  to  cure  this  disease,  and  they  have  been  given  up  because  they 
proved  either  entirely  valueless  or  only  palliative.  Dioxid  of  hydrogen  was 
at  one  time  highly  extolled,  but  has  been  abandoned  because  it  leaves  the 
mucous  membrane  a-  dry  a-  ever.  <  )ilv  solution-  in  combination  with  various 
drugs  acl  as  excellenl  stimulants  and  protectives,  but  do  no1  accomplish  much 
in  the  way  of  cure. 

In  conclusion,  the  writer  would  suggesl  the  following  plan  of  procedure  : 
A  rigid  examination  should  first  be  made  to  determine  if  there  is  any  discharge 
of  pus  from  the  accessory  sinuses,  any  sign  <>r  possibility  of  specific  taint,  any 
history  of  tubercular  or  diphtheritic  disease,  and  the  general  hygienic  and 
sanitary  surroundings  of  the  patient  should  be  carefully  investigated.     Should 

a  pus  discharge  be  found  fr any  of  the  accessory  sinuses,  free  outlet  -I Id 

be  given  to  it  and  the  sinus  should  be  carefully  washed  oul  with  hydrogen 
dioxid    and   du-tcd  with    -oine  antiseptic  powder.       If  in  any  case  there  i-  the 


TREATMENT.  965 

least  likelihood  of  a  specific  complication,  mercury  and  opium  with  mercurial 
inunction  should  be  pushed  until  mild  salivation  is  produced.  It  has  been 
the  experience  of  the  writer  t hat  the  combination  of  mercury  and  opium  has 
a  much  more  rapid  and  satisfactory  effect  than  iodid  of  potash,'  even  when 
given  in  very  large  doses.  The  patient  should  be  ordered  to  keep  the  nose 
thoroughly  cleansed  always  with  Seller's  solution  or  a  spray  of  glycerin  and 
biborate  of  soda  or  some  other  mild  stimulant  used  three  times  a  day.  [f  the 
patient  has  had  diphtheria  or  the  crusts  still  persist,  diphtheria-antitoxin  may 
be  administered  and  a  solution  of  bichlorid  of  mercury  (1  :2000)  he  sprayed 
daily.  The  patient  should  he  directed  to  live  out  of  doors  as  much  as  pos- 
sible, and  his  general  health  should  be  built  up  with  tonics,  cod-liver  oil,  etc. 

The  limits  of  this  article  entirely  forbid  further  elaboration  of  this  sub- 
ject. Suffice  it  to  say  that  the  best  results  will  be  obtained  when  the  patient 
is  instructed  how  to  maintain  thorough  cleansing  so  as  to  promote  adequate 
nasal  respiration,  as  well  as  the  healing  of  all  ulcerations,  proper  drainage, 
and  the  restoration  of  the  normal  mucous  lining  membrane  as  far  as  possible. 
He  should  have  plenty  of  fresh  air  and  sunshine,  as  well  as  absolutely 
hygienic  surroundings.  In  some  instances  a  visit  to  the  seashore  or  some 
mineral  springs  will  exert  a  marked  influence  for  the  better.  J.  X.  Mac- 
kenzie advises  that  "as  little  liquid  nourishment  should  be  taken  as  is  com- 
patible with  the  comfort  of  the  individual." 

The  ingestion  of  large  quantities  of  liquids  is  to  be  deprecated,  as  well 
as  alcoholic  beverages  of  any  kind,  unless  taken  in  great  moderation. 
Healthy  out-door  exercise,  combined  with  the  observance  of  the  ordinary 
rules  of  health,  will  generally  so  moderate  the  worst  features  of  the  disease 
as  to  render  the  patient  comparatively  comfortable,  if  not  entirely  relieved. 

1  In  syphilitic  cases  ulceration  and  sequestrum-formation  may  be  furthered  by  the  mercurial, 
when  the  iodid  will  give  as  prompt  and  lasting  cure  without  such  loss  of  substance. 


DISEASES  OF  THE    ACCESSORY  SINUSES  OF  THE 

NOSE. 

r.v    ROBERT  CUNNINGHAM  MYLES,   M.D., 

"I     M  u     V/OBK    CITY. 


The  accessory  sinuses  of  the  nose  arc  cavities  in  the  hones  of  the  head 
and  face  that  conned  with  the  nasal  fossa'  by  one  or  more  narrow  apertures. 
There  are  three  bilateral  single  sinuses — the  antra  of  Highmore,  or  maxillary 
sinuses,  the  frontal  sinuses,  the  sphenoidal  sinuses,  and  two  bilateral  groups  of 
sinuses,  the  anterior  and  posterior  ethmoidal  sinuses. 


ANATOMY. 


The  maxillary  sinuses  are  situated  on  both  sides  of  the  face,  between  the 
c.rhit-  and  upper  teeth  (see  Fig.  545);  their  average  measurements  are  about  27 
millimeters  through  the  center,  both  vertically  and  antero-posteriorly.  They 
have  an  oblong  or  fissure- like  opening  into  the  middle  meatus  of  the  nose,  about 


ital  section  through  the  nasal  cavities  from  above:  i.  cm  itv  of  antrum  of  High- 
""•;'  acbrymal  duct  ;  3,  middle  turbinal     i.  Bphenoid  cell.     (See  also  Plate  \<> 

its  middle  third.  Accessory  openings  posterior  to  the  hiatus  are  common.  Oc- 
casionally the  roots  of  the  molars  project  like  small  cones  from  the  floor  of 
ili>  *inus,  and  frequently  there  are  partitions  and  membranous  bands,  one- 
fourth  to  one-half  an  inch  high,  dividing  the  floor  and  walls  into  compart- 


ANATOMY. 


967 


ments.  These  arc  often  regarded  by  observers  as  pathological  formations, 
but  I  believe  that  they  are  normal.  The  walls  of  the  canine  fossae  and  the 
inner  or  nasal  wall,  from  one-third  of  an  inch  above  the  floor,  are  very  thin, 
excepting  that  part  which  gives  an  attachment  to  the  inferior  turbinated  bone. 
Fluids  of  low  specific  gravity  will  sometimes  Mow  from  the  frontal  sinus, 
down  through  the  infundibulum,  into  the  antrum  of  Highmore.  This  is 
important,  as  it  shows  that  the  antrum  may  serve  as  a  pus-reservoir  for  the 
inflammatory  products  from  the  frontal  sinus  or  anterior  ethmoidal  cells.  The 
ethmoidal  cells  are  situated  between  the  nasal  process  of  the  superior  maxil- 
lary and  lachrymal  hones  and  the  frontal  sinus  in  front  ;  the  sphenoid  and 
palate  bones  behind  ;  the  sphenoid,  cribriform  plate,  and  frontal  bones 
above;  and  the  os  planum,  lachrymal,  sphenoid,  and  superior  maxillary 
bones  on   the  outer   side.       The  inner  side   is   bounded   by   the  space   from 


Fig.  587. — Horizontal  section  through  the  nasal  cavities :  1,  cavity  of  ant  ruin  of  Highmore  ;  2,  sphenoid 
cell ;  '■'<.  interior  turbinal  :  4,  septum. 

the  cribriform  plate  to  the  middle  third  of  the  middle  meatus  in  front  ami  to 
the  attachment  of  the  middle  turbinated  bone  behind.  (Fig.  543  shows  the 
ethmoidal  cells  partially  exposed.)  They  are  separated  by  an  unbroken  par- 
tition into  anterior  and  posterior  cells.  Sometimes  the  anterior  cells  commu- 
nicate with  the  infundibulum  or  frontal  sinus  direct.  The  anterior  cells 
drain  by  an  opening  in  the  median  wall  of  the  ethmoidal  bulla,  and  fre- 
quently by  another  opening  into  the  superior  meatus.  The  sphenoidal  cell- 
are  best  described  as  being  in  the  body  of  the  sphenoid  bone:  they  arc  sepa- 
rated from  the  posterior  ethmoidal  cells  by  a  common  wall,  and  discharge 
their  contents  through  an  opening  in  the  tipper  anterior  wall.  (Fig.  548  -how- 
right  and  left  cells  as  they  cross  the  median  line.  -  The  frontal  sinuses  are 
situated  in  the  frontal  bone,  above  the  inner  canthus  of  each  eye.  Their  wall- 
are  made  up  by  the  frontal  bone,  excepting  a  part  of  the  floor,  which  is 
formed  bv  the  ethmoidal  cells  and  the  projecting  portion  of  the  nasal  process 
of  the  superior  maxilla  (see  Fig.  547).  These  cavities  are  irregular  in  size: 
in  tiie  average  sinus  the  perpendicular  and  transverse  diameters  are  about  one 
inch  in  their  longesl  ;i\i-.  The  central  antero-posterior  diameter  measures  about 
three-eighths  to  one-fourth  inch;  it  is  not  uncommon  to  find  one  large  and 
one  very  small  cell  in  the  same  head.     The  large  cell-  usually  extend  toward 


DISEASES  OF  THE  ACCESSORY  SINUSES  OF  THE  NOSE. 

the  temporal  region,  from  one  to  three  millimeters  bejuond  the  orbital  notch, 
and  they  discharge  their  secretion  through  an  irregular  tortuous  canal,  the  in- 
fundibulum.  They  arc  divided  by  a  bony  wall,  which  is  rarely  central  and 
occasionally  perforated  (see  Figs.  544  and  <">48). 

PHYSIOLOGY. 

Although  the  physiology  of  these  cells  is  not  definitely  settled,  an  analysis 
of  their  function  points  to  the  conclusion  that  they  are  intended  to  supply 
warm  air  and  moisture  for  respiratory  purposes,  and  also  probably  to  act  as 
resonators  for  modifying  certain  qualities  of  the  voice.  When  we  consider 
that  aboul  LOO  cubic  inches  of  air  are  inhaled  per  minute,  which  should  be 
warmed  t<»  a  temperature  as  near  dS.?)0  F.  as  possible,  and  that  this  same 
air  should  be  charged  with  vapor  nearly  to  the  point  of  saturation,  I  cannot 
conceive  of  a  more  satisfactory  arrangement  than  these  cells  afford.  During 
respiration  the  apertures,  including  the  naso-lachrymal  duets,  have  a  tendency 
to  dilate,  while  during  expiration  they  partially  close.  At  the  beginning  of' 
inspiration,  the  partial  vacuum  produced  takes  a  part  of  the  latent  air  from 
within  the  cells,  and  the  velocity  of  the  inspired  current  further  draws  from 
them.  Toward  the  end  of  the  inspiratory  act,  new  air  enters  the  cells  to  fill 
the  partial  vacuum,  aided  by  the  natural  law  by  which  warm  air  is  displaced 
by  cold.  <  )n  expiration,  the  vis  d  tergo  pressure  partially  closes  the  cells. 
The  to-and-fro  currents  of  air  constantly  draw  the  tenacious  mucus  from  the 
cells,  overcoming  the  adverse  conditions  of  small  openings  and  the  laws  of 
gravity. 

EMPYEMA  OF   THE  MAXILLARY  SINUS. 

Htiology.  —  Distinguished  specialists  have  written  a  great  deal  within 
the  pasl  few  year-  concerning  the  cause  of  pyogenic  conditions  within  the 
antrum  of  Highmore;  and  they  are  aboul  equally  divided  on  the  question 
whether  disease  of  the  nose  or  the  teeth  is  the  more  frequent  causal  factor 
of  disease.  My  own  experience  in  the  chronic  cases  is  that  the  teeth  and 
nose  are  aboul  equally  responsible  for  the  purulent  condition.  Many  of  my 
worst  cases  were  caused  by  fillings  placed  in  teeth  with  very  large  cavities 
where  the  nerve-  were  either  e\ posed  or  dead.  Suppurat ion  had  evidently 
occurred  in  the  root-end  ;  the  pus  had  discharged  itself,  with  little  resistance, 
through  the  thin  hone  lying  between  the  top  of  the  alveolus  and  the  floor 
of  the  antrum,  and  from  thai  time  the  tooth  had  not  given  the  patient  any 
pain  nor  the  dentist  any  concern,  lint  the  patient  had  been  trying  nearly 
all  of  the  patenl  catarrh-remedies,  and  had  been  treated  by  different  special- 
ists for  nasal  and  post-nasal  catarrh.  A  few  case.-  seemed  to  be  caused  by 
alveolar  periostitis,  caries,  and  necrosis,  which  had  been  originally  started 
by  .i  decaying  tooth.  The  majority  of  the  cases  of  nasal  origin  began  with 
polypoid  degeneration.  In  some  of  my  patients  their  septa  were  so  far 
deflected  in  the  upper  middle  region  that  the  middle  turbinal  bodies  were 
pressed  firml)  againsl  the  hiatus;  the  secretions  had  been  retained  under 
putrefactive  and  fermentative  conditions,  and  hail  produced  chronic  inflam- 
mations of  the  membranes  and  hones,  and  probably  necrotic  areas.  Inllu- 
enza,  la  grippe,  or  acute  inflammations  of  almost  every  kind  appear  to  pro- 
duce  empyema  when  the  swelling  i-  30  'jre.it  .-i-  to  close  the  normal  opening, 
especially  by  pressing  the  upper  and  inner  valve-like  lip  of  the  hiatus  out- 
ward againsl  the  semilunar  partition.  Atrophic  rhinitis,  syphilis,  tuberculosis, 
tumors,  and  foreign  bodies  occasionally  cause  Buppuration  in  the  antrum. 


EMPYEMA   OF  THE  MAXILLARY  SINUS.  969 

Symptoms. —  In  cases  of  acute  empyema  with  complete  occlusion  the 
pain  is  extremely  severe,  ami  there  is  a  feeling  as  though  the  antrum  would 
rupture  from  the  intense  pressure.  In  four  <>i*  my  suppurative  cases  with 
complete  stenosis  the  pain  ceased  immediately  after  the  evacuation  of  the 
pus.  In  those  instances  where  the  acute  and  subacute  catarrhal  process 
either  occurred  simultaneously  with  nasal  cold  or  extended  into  the  antrum 
by  continuity  there  was  a  slight  fulness  and  a  sensation  of  stuffiness  in  the 
region  beneath  the  eye,  together  with  a  thick  muco-purulent  discharge  into 
the  middle  meatus  beneath  the  bulla,  which  usually  stopped  within  from 
three  to  six  weeks.  The  chronic  cases  all  had  the  symptoms  of  so-called 
post-nasal  catarrh,  and  in  the  majority  of  them  the  mucus  and  pus  were  dis- 
charged also  through  the  anterior  nares.  Certain  patients  complained  of  the 
fluid  running  downward  over  the  upper  lip  whenever  the  head  was  inclined 
forward;  others  complained  of  asthma,  tubal  stenosis,  tinnitus  annum,  and 
impairment  of  hearing,  which  were  relieved  after  an  operation  or  by  irriga- 
tion of  the  antrum.  In  my  series  of  cases  pain  was  the  most  irregular  and 
deceptive  symptom  of  all.  Frequently  it  Mas  entirely  absent  ;  at  other 
times  it  would  occur  in  either  the  frontal,  maxillary,  temporal,  or  occipital 
regions,  or  in  two  or  more  of  them. 

Pathology. — I  have  classified  the  usual  pathological  conditions  under 
eight  subdivisions,  as  follows,  representing  the  pathological  states  approxi- 
mately as  I  have  observed  them  in  my  cases : 

I.  Acute  catarrhal,  suppurative,  and  infectious  sinusitis,  without  complete 
stenosis  of  the  normal  outlet. 

II.  Acute  catarrhal,  suppurative,  and  infectious  sinusitis,  with  complete 
occlusion  of  the  normal  outlet. 

III.  Subacute  and  chronic  catarrhal  and  suppurative  sinusitis,  with  moder- 
ately obstructed  opening,  with  or  without  decayed  puro-mucoid  debris. 

IV.  Polypoid  degeneration. 

V.  Alveolar  periostitis  and  periodontitis,  attended  by  suppuration,  caries, 
necrosis,  or  other  pathological  changes  at  the  root-end. 

VI.  Atrophic  rhinitis. 

VII.  Tumors  and  foreign  bodies. 

VIII.  Syphilis. 

Acute  cases  without  stenosis  are  very  common.  The  mucous  membrane 
of  the  nose  and  cavity  is  usually  congested  at  first,  and  then  it  begins  to 
swell,  and  continues  to  do  so  until  it  is  several  time-  its  normal  thickness. 
At  tin-  stage  it  usually  throws  out  a  thick  muco-purulent  secretion  ;  the 
discharge  gradually  censes  within  from  three  to  six  weeks,  and  the  mem- 
brane is  left  a  trifle  thicker,  having  undergone  slight  hyperplasia.  In  the 
completely  stenosed  cases,  where  neither  nature  nor  surgery  relieves  them, 
necrosis  of  the  soft  tissue-  usually  occurs,  and  occasionally  the  bone  i- 
involved   in   the  same  process. 

In  the  subacute  and  chronic  catarrhal  and  suppurative  cases,  where  the 
opening  i<  moderately  obstructed,  the  mucus  frequently  becomes  partially 
inspissated  and  form-  a  lump,  which  enlarges  by  accretion  and  act-  a-  a 
foreign  ; i lt< ■  n t ,  causing  a  bacterial  development.  The  corroding  by-products 
of  this  frequently  destroy  the  surfaces  of  the  mucosa  and  -tart  -mall  ulcer- 
ated area-,  winch,  if  not  cured,  extend  in  time  to  the  periosteum,  and  often  to 
the  bone  itself. 

Polypoid  degeneration  extend-  from  the  ethmoid,  or  ha-  its  origin  upon 
tin-  antrum-membrane.  In  it-  early  stages  this  peculiar  condition  maybe 
classed   a-   watery  edema.      If  it   occurs  on  the   lateral  or  upper  wall-  of  the 


970     DISEASES  OF  THE  ACCESSORY  SINUSES  OF  THE  XOSE. 

cavity,  and  remains  more  or  less  Mat  or  mammillated,  there  isa  possibility  of 
its  returning  to  its  normal  state  under  favorable  conditions;  but  if  it  once 
becomes  pedunculated  it  seems  to  lose  this  power  of  self-restoration.  Caries, 
necrosis,  and  burrowing  periostitis  in  the  molar  or  bicuspid  roots  frequently 
extend  through  the  Boor  of  the  bone  and  burrow  in  a  fistulous  manner  be- 
neath the  periosteum,  elevating  it  and  frequently  leaving  the  entire  mem- 
branous floor  floating  in  muco-purulent  matter.  A  rupture  may  take  place 
through  this  membrane  at  a  distance  from  the  injured  bone  and  discharge 
itself  into  the  nose.  The  membrane  becomes  very  thick  and  granular,  and 
d6bris  from  the  mucus,  pus,  and  bone  degenerates  in  the  cavity.  The  atrophic 
process,  which  is  the  consequence,  in  my  opinion,  of  suppurative  rhinitis  in 
early  childhood,  invades  the  antrum,  frequently  destroys  the  epithelium  and 
the  serous  glands  of  the  membranes,  and  leaves  a  sclerosed  membrane  which 
secretes  a  semipurulent  matter  ;  this,  in  turn,  degenerates  in  the  warm  cell 
and  issues  through  the  normal  opening  into  the  nose,  where  it  is  formed  into 
crusts  by  the  inspired  air. 

Tumors,  especially  sarcomata,  may  form  in  the  antrum  and  simulate  em- 
pyema. Syphilis  usually  attacks  the  antruni-walls  by  the  formation  of 
gummata  ;  while  at  rare  interval-  the  germs  of  scarlet  fever,  measles,  tuber- 
culosis, and  diphtheria  invade  the  antrum,  as  do  aspergilli  and  other  fungi. 

Diagnosis. — A  unilateral  pus-discharge  from  the  nasal  cavity  is  by  far 
the  mosl  suspicious  symptom  of  empyema  of  the  maxillary  sinus.  On  rare 
occasions  this  unilateral  pus-  or  muco-pus-discharge  is  only  made  manifest 
posteriorly.  On  the  other  hand,  polypoid  degeneration,  which,  in  my  expe- 
rience, is  next  in  frequency  to  the  irritation  caused  by  decaying  teeth  in 
causing  antrum-trouble,  is  usually  bilateral.  The  classical  symptoms  as  laid 
down  in  the  older  book-  are  usually  wanting,  save  in  the  acute  stenosed  cases. 
The  frequency  and  urgency  of  diseases  of  the  antrum  have  led  us  to  abandon 

the  considerati f  a  greal  deal  of  the  circumstantial  evidence  upon  which 

formerly  so  much  stress  was  laid,  and  we  make  small  delay  in  trying  to 
obtain  positive  evidence  at  once.  This  is  usually  secured  first  by  inspection 
.,!'  the  middle  meatus.  If  pus  is  detected  beneath  the  bulla  ethmoidalis 
under  the  middle  turbinal  body  and  the  hiatus  semilunaris,  we  know  that 
one    of    the    three    cavities     i-    di-eased — the    anterior    ethmoidal    cells,    the 

frontal   sinus,  or  the  antr f  Highmore.     After  coeain   has  been  applied 

to  the  membrane  and  pus  is  found,  a  cotton-applicator  should  be  used  to 
wipe  it  away,  and.  if  pus  then  exude-  from  beneath  the  middle  turbinal 
body  and  on  the  lateral  side  of  the  bulla  ethmoidalis.  it  of  course  comes  from 
the  anterior  ethmoidal  cells.  If.  after  wiping  it  away  and  placing  the  patient 
on  :i  lounge,  with  the  top  of  hi-  head  near  the  Moor,  pus  comes  from  the  hiatus, 
the  evidence  is  almosl  positive  that  it-  source  i-  the  antrum.  In  those  cases 
in  which  the  pus  is  liquid  in  character  it  will  Mow  readily  into  the  nose  and 
will  have  a  more  or  less  offensive  odor.  I  f.  however,  the  pus  i>  very  thick  and 
much  intermixed  with  mucus,  il  will  sometimes  merely  protrude  through  the 
opening.  In  the  frontal  -inn-  cases  I  have  usually  been  able  to  detect  th< 
pus  at  the  very  uppermosl  anterior  part  of  the  hiatus.  Usually  it  is  well. 
after  the  pus  discharges  with  the  head  in  a  downward  position,  to  intro- 
duce a  curved  irrigation-tube  into  the  hiatus,  and  inject  warm  water  into  the 
cavity;  il'  this  is  successfully  done, we  are  almosl  invariably  rewarded  with 
the  evidence  of  pu-  in  the  returned  fluid.  In  those  obscure  form-  of  latent 
empyema,  the  firs!  evidences  of  their  existence  is  usually  shown  by  the  electric 
light  (Plate  Mi.  Uthough  this  procedure  is  not  infallible,  it  is  of  greal 
value  in  the  hand- of  one  who  know-  how   to  employ  it.      \    pus-discharge 


Plath  14. 


in. 


V 


Fig.  I.  Transillumination  of  both  maxillary  antra  by  electric  light  in  mouth,  and  of  both 
frontal  sinuses  by  Lights  under  the  orbital  margin 

Fig.  [I.— Failure  of  transillumination  of  antrum  and  frontal  sinus  on  the  left,  while  l>"tli  are 
lighted,  and  the  pnpil  also,  <>u  the  right. 

Fig.  QL— Failure  of  illumination  complete  for  frontal  and  maxillary  sinuses  of  both  —  i « *  •  - 

Fig.  IV.    Onlj  the  righl  maxillary  antrum  Is  illuminated,  while  both  frontals  remain  'lark. 


EMP  YEMA    0  F  THE  M.  I  XIL  LARY  SIS  US.  97  ! 

on  one  side,  with  a  dark  umbra  beneath  the  corresponding  eye,  is  almost  con- 
clusive evidence  ;  yet,  t<>  make  assurance  doubly  sure,  I  nearly  always  remove 
some  of  the  pus  from  the  antrum,  either  through  the  natural  opening  with  the 
silver  irrigation-tube  or  by  means  of  the  trocar  and  cannula  passed  through 
the  antrum-wall  in  the  middle  meatus,  just  below  and  posterior  to  the  hiatus. 
In  a  few  of  my  cases  even  these  tests  failed  to  demonstrate  positively  the 
pathological  state  within.  They  were  eases  in  which  the  ant  rum  was  full  of 
polyps,  and  in  most  of  them  there  was  a  thick,  tenacious  mucus  with  occa- 
sional hardened  lumps.  The  irrigation-fluid  simply  passed  over  the  polyps. 
Puncture  through  the  bone  of  the  canine  fossa  or  through  the  alveolus  of 
the  tooth  has  always  seemed  to  me  too  serious  a  procedure  to  he  justified 
for  merely  diagnostic  purposes.  The  small  trocar  and  cannula  (Fig.  588 
passed   through   the  middle  meatus,  below  the  posterior  end    of  the   hiatus, 


Fig.  588.— Curved  trocar  and  cannula  for  entering  the  maxillary  antrum. 

where  there  is  either  very  little  or  no  bone,  causes  but  little  pain  and  ap- 
parently no  after-disturbance.  Tenderness  on  pressure  and  dulness  of  per- 
cussion may  occur  from  periosteal  irritation  or  may  be  due  to  the  smallness 
of  the  antrum  ;  but  they  have  little  significance,  except  as  they  may  concur 
witli  a  train  of  symptoms,  to  make  the  diagnosis  by  exclusion. 

Prognosis. — Diseases  of  these  sinuses  rarely  cause  death  directly  ;  hut 
they  frequently  make  life  miserable.  The  dangerous  cases  of  antrum-trouble 
which  I  have  seen  have  been  those  in  which  the  orbital  plate  was  broken 
through  by  the  intense  pressure  of  the  confined  gases  and  fluids  ;  and  a  few- 
cases  are  reported  in  which  the  pus,  burrowing  through  the  orbit  and  ethmoid, 
has  extended  to  tiie  brain.  In  nearly  all  of  the  acute  and  subacute  cases 
resolution  takes  place  within  a  few  weeks,  li'  a  ease  has  existed  over  a  year 
with  a  history  of  constant  muco-purulent  discharge,  disclosing,  when  the 
cavity  is  opened,  carious  mid  necrotic  bone,  with  destruction  of  a  considerable 
area  of  the  mucosa,  the  prognosis  in  regard  to  an  early  cure  is  unfavorable,  as 
it  usually  takes  several  month-;  or  a  year  or  two  for  the  tissue  to  regain,  even 
approximately,  its  former  state.  I  have  found  cases  of  necrosis  of  the  septa 
of  the  superior  maxillary  hone  and  general  polypoid  degeneration  of  the 
mucous  membrane  of  the  cavity  the  most  obstinate  in  treatment  and  unfavor- 
able in  prognosis. 

Treatment. —  The  best  procedure  in  treating  these  cases  will  he  deter- 
mined by  the  pathological  state  and  by  the  history  of  each  case.  Acute  and 
subacute  cases,  not  of  dental  or  polypoid  origin,  can  usually  he  readily  cured 
by  restoring  the  nasal  mucous  cavities  to  their  normal  state,  and  by  irriga- 
tion of  the  -inn-  through  the  natural  openings,  [ncasesof  dental  origin  the 
offending  tooth  should  he  removed;  ami.  in  those  of  recent  date,  the  tissues 
should  he  let  alone  for  a  few  week-  in  order  that  they  max  have  an  opportu- 
nity to  resume  their  normal  condition,  the  causal  factor  of  disease  having 
been  removed.  If  the  trouble  has  existed  for  more  than  -i\  or  ten  months 
and  there  is  n  decided  odor  from  the  antrum,  with  evident  carious  and  necrotic 
trouble  at  the  root-end,  I  advise  immediate  penetration  liv  making  an  open- 
ing, about   5  or  <!  mm.  in  diameter,  through  the  alveolus-floor.      Irrigation 


972     DISEASES  OF  THE  ACCESSORY  SINUSES  OF  THE  NOSE. 


with  disinfectants  should  be  passed  through  with  the  regulation  tubes  and 
syringes.  If  the  internal  walls  appear  on  probing  or  curetting  to  he 
in  :in  extremely  degenerated  state,  with  serious  carious  and  necrotic  con- 
ditions of  the  bone,  I  think  thai  the  safest  and  most  effective  operation 
under  these  circumstances  consists  in  a  large  opening  into  the  antrum  through 
the  canine  fossa  and  the  anterior  lower  border  of  the  malar  ridge.1     This 


"l 


Removal  of  anterior  two-thirds  of  inferior  turbinal  to  gain  access  to  the  antrum  through  the 
OUter  nasal  wall. 


!  irainage-tubes   i"i  an 
tram. 


opening  should  he  from  K>  to  15  mm.  in  diameter;  the  cavity  should  be 
carefully  curetted,  and  in  certain  cases  a  counter-opening  (Fig.  589),  at  least  8 
to  H>  mm.  in  diameter,  should  be  made  through  the  inferior  meatns-wall  into 
the  nose.  I  have  operated  by  cutting  oil'  the  inferior  turbinal  and  tre- 
phining through  the  inferior  meatal  wall,  and  have 
C^mtmmmmxmmmmsr\  also  ent   into  the  lower  border  of  the  hiatus  in  the 

n  ,  |-rn     ,.  ,,      '  \  middle    meatus.      The  eases    in    which    I    did    this 

were  so  extensively  and  seriously  diseased  thai  I 
did  not  gei  a-  good  a  resull  a-  I  had  anticipated, 
chiefly  because  I  could  not  curette  the  walls  through 
this  intranasal  perforation.  The  after-treatment 
should  consisl  of  aseptic  and  antiseptic  irrigations, 
and  in  certain  cases  keeping  the  canal  open  by  means  of  rubber  (  Fig.  590)  or 
Bilver  tubes,  with  occasional  careful  curettage  of  the  necrotic  and  granular 
surfaces  and  ilir  insufflation  of  boric  acid  and  of  iodoform  in  certain  cases 
where  there  is  frequent  accumulation  of  foul-smelling  pus.  I  have  found 
thr  injection  of  a  drachm  and  a  half  of  liquid  albolene,  containing  ."»  to  10 
grains  of  iodoform,  hit  in  the  cavity,  to  afford  marked  and  decided  relief. 

<  i  188  [.—-The  cases  of  acuU   >i<t\u,-<   without  stenosis  are  very  common, 
and   usually  las!  from   three   to  six  weeks.     They  come  on  after  the  manner 

of  an    ordinary  cold    in    the    head,  followed    within    a    few    days    by   very  dis- 

agreeable  feelings  of  fulness,  oppression,  and  dulness  :  in  some  cases  a  certain 
amount  of  headache  exists,  or  toothache,  and  a  dull  feeling  is  present  in  the 
ears.     This  stage  is   relieved  by  a  copious  How    of  muco-pus.     During  the 
[The  operator  mn*l  be  prepared  for  Bevere  hemorrhage  in  rare  cases,     I  D  | 


EMP  YEM. I    OF  THE  M.  1 XIL LARY  SIN t  X  973 

course  of  these  cases  the  ordinary  treatment  for  a  severe  cold  is  the  best. 
MiH  individuals  who  are  subject  to  this  condition  have  from  two  to  four 
attacks  during  the  year.  The  rational  treatment  is  one  of  prophylaxis, 
which  consists  mainly  in  reducing  and  removing  the  intumescent  and 
abnormal  tissues  within  the  nose,  which  should  be  done  during  the  intervals 
of  the  attacks. 

Class  II. — Acute  Catarrhal,  Suppurative,  and  Infectious  sinusitis  with 
Stenosis. — These  cases,  besides  requiring  the  ordinary  treatment,  demand  the 
evacuation  of  the  retained  secretion  at  once.  A  limited  amount  of  a  satu- 
rated solution  of  cocain  should  be  applied  to  the  parts  around  the  natural 
opening,  and  a  persistent  effort  should  be  made  to  enter  the  cell  with  a  tube, 
or,  failing  in  this,  penetration  with  trocar  and  cannula  should  be  made,  and 
the  cavity  should  be  carefully  aspirated  and  irrigated.  As  soon  as  it-  patu- 
leney  is  restored  the  patient  recovers  rapidly.  These  cases  call  for  the  same 
treatment  during  the  intervals  as  that  described  for  Class  I. 

Glass  III. — Subacute  and  ('/ironic  Catarrhal  and  Suppurative  Sinusitis, 
with  Moderately  Obstructing  stenosis,  Thickened  Mucosa,  with  or  without 
Retained  Decaying  Puro-mucoid  Dibris. — This  class  of  cases  is  the  most 
fruitful  source  of  post-nasal  catarrh,  and  is  rather  difficult  to  diagnose 
accurately.  The  symptoms  rarely  indicate  the  latent  pathological  condition 
sufficiently  to  warrant  the  operative  procedures  necessary  for  a  proper  diag- 
nosis or  treatment.  In  these  cases  attempts  should  be  made  to  irrigate 
through  the  natural  openings.  In  certain  eases  removal  of  the  anterior  end 
of  the  middle  turbinal  facilitates  this  procedure,  and  frequently  we  are 
rewarded  with  a  cure  or  decided  relief.  It  is  taken  for  granted  that  in  all 
classes  of  eases  any  abnormal  intranasal  conditions  should  be  recti  lied. 
When  these  cases  resist  the  irrigation-treatment  and  are  of  sufficient  impor- 
tance, a  counter-opening  should  be  made  in  the  cell-walls  and  proper  curet- 
tage and  drainage  should  be  carried  out. 

Mrs.  C,  aged  thirty.  Acute  empyema;  sent  for  me  to  visit  her.  Complained  of 
great  pain  and  fulness  which  came  on  with  a  cold  in  the  left  jaw,  which  was  swollen 
and  tender.  The  hiatus  was  closed  by  tumefaction  of  all  the  tissues  near  the  part. 
After  applying  cocain-crystals,  I  washed  out  the  antrum  through  the  natural  opening; 
muco-pus  flowed  out  with  the  boric-acid  solution;  immediate  relief  from  the  severe 
pain  followed,  and  the  patient  gradually  recovered. 

Miss  L.,  aged  twenty-six,  had  been  suffering  for  several  days  from  severe  pain  and 
oppression  in  the  right  side  "f  the  tare,  with  a  sensation  as  though  the  face  and  orbital 
cavity  would  burst.  Her  septum  was  deflected  with  an  ecchondrosis ;  the  turbinals 
were  much  swollen,  and  transillumination  produced  an  umbra  under  the  right  eye.  I  re- 
duced the  intumescent  tissues  with  cocain,  and  found  the  tissues  about  the  r i lt  1 1 1 
hiatus  swollen  and  papillomatous  in  appearance.  On  introducing  one  of  the  smallest 
silver  tubes  the  confined  pin  escaped  with  the  irrigating  fluid,  which  gave  her  imme- 
diate relief.  I  removed  by  snare  a  (ungating  papillary  growth,  about  three  millimeters 
in  diameter,  from  the  internal  margin  of  the  hiatus.  Alter  several  irrigations  at  three 
days'  interval-  the  cavity  gradually  returned  to  a  normal  condition. 

Mr.  A.  \V\,  aged  fourteen,  consulted  me  in  May.  1892.  Complained  of  in  his  own 
words]  "Very  bad  discharge  from  nose  for  the  last  tour  or  live  years,  which  con- 
sists of  pure  matter.  Sometimes  there  i-  a  buzzing  noise  in  the  head  on  waking  in  the 
morning.  A  Wad  smell  from  the  nose."  There  had  been  a  muco-purulent  discharge 
with  unpleasant  odor,  mostly  from  the  righl  side,  for  the  pasl  three  or  four  years. 

Rhinoscopic  examination  showed  the  septum  deflected  to  the  left  with  an  ascending 
oblique  ecchondrosis.  The  septum  was  deflected  to  the  right  superiorly,  pressing  the 
middle  turbinal  body  outward;  pus  mixed  with  mucus  was  issuing  from  the  riidit 
hiatus.  He  had  excessive  hypertrophy  of  all  the  turbinal  tissues,  ami  also  of  the  third 
ami  faucial  tonsils.  The  electric  light  produced  a  lighl  spot  beneath  the  hit  eye  and 
an  umbra  beneath    the  right.     I  reduced  the  hypertrophy  of  tin'  turbinals  with  the 

electric  cautery  and  chromic  acid,  and  irrigated  the  righl  antrum  through  the  natural 
opening  two  or  three  time-  a  week  for  a  lew  months. 


974     DISEASES  OF  THE  ACCESSORY  SINUSES  OF  THE  NOSE. 

The  patient  gradually  improved,  pus  ceased  to  flow,  and  the  electric  light  produced 
the  light  spol  beneath  both  eyes. 

(  i  ^gg  [V. —  Polypoid  Degeneration. — This  class  furnishes  by  far  the 
majority  of  the  operative  cases.  Woakes,  Bosworth,  Casselberry,  and  others 
have  well  described  them  and  their  treatment.  Larue  counter-openings, 
packing,  careful  and  repeated  curetting,  good  drainage,  and  irrigation  are 
the  essentials  for  successful   treatment. 

Class  Y. —  Odontic  Periostitis  and  Periodontitis,  Sometimes  Terminating  in 
c<tr'i,s  ami  Necrosis. —  It  is  universally  conceded  that  the  offending  tooth  in 
this  class  of  cases  should  he  removed,  and.  it'  the  ease  he  of  long  standing, 
the  cavity  should  be  opened,  carefully  curetted,  and  dressed.  Formerly, 
following  the  advice  of  many  dentists  and  surgeons  in  these  extensively 
necrosed  cases,  after  the  tooth  had  been  extracted.  I  drilled  upward  through 
the  socket  ;  but  the  after-history  of  many  of  such  eases  has  caused  me  to 
regret  it.  The  principal  objectionable  features  are  :  the  distance  through  the 
bone  to  the  floor  of  the  antrum;  the  dense  thick  tissue  of  the  gum;  the 
difficulty  experienced  in  curetting,  the  long  walls  of  the  opening  preventing 
the  proper  play  of  the  handle  <.f  the  curette;  the  easy  entrance  of  food  into 
the  antrum,  and  the  necessity  of  plugging  the  tube,  when  one  is  worn  for 
drainage,  while  eating,  [take  it  for  granted  that  every  one  would  prefer 
the  lower  anterior  border  of  the  malar  ridge  for  penetration  in  all  cases 
where  the  first  molar  tooth  ha-  been  absent  for  some  time.  The  most  serious 
obstacle  which  1  have  met  with  is  the  decided  objection  of  the  patient  to 
losing  a  tooth. 

In  nearly  all  extensively  diseased  cases,  where  some  other  operation  was 
performed  in  place  of  the  one  through  the  malar  ridge,  the  patient  and 
myself  have  both  had  cause  to  regret  it.  On  the  other  hand,  a  great  many 
of  the  worst  types  of  cases  have  done  well  when  the  operation  was  properly 
made  through  the  point  of  election.  The  surgeon  has  complete  subsequent 
control  of  the  antr and  can  keep  it  open  and  curette  it  at  any  time  with- 
out inconvenience  to  himself  and  with  very  little  pain  or  annoyance  to  the 
patient.  The  canine  fossa,  when-  the  hone  is  very  thin,  is  the  next  point  of 
preference;  the  main  disadvantages  are  its  distance  up  under  the  cheek  and 
the  elevation  of  the  opening  above  the  floor  of  the  antrum.  The  history 
of  the  following  cases  presents  some  of  the  difficull  problems  of  this  cla-s 
..t'  cases. 

Mr.  C.  H.,  aged  twenty-five.  Presented  Por  treatment,  1891.  There  was  a  history 
iif  long-continued  catarrhal  discharge  from  the  nostrils,  anteriorly  and  posteriorly,  much 
greater  mi  the  righl  than  on  the  li  ft,  and  a  most  unpleasant  odor  in  the  expired  breath. 
The  nostrils  were  very  disagreeably  stenosed,  the  righl  more  than  the  left.  The  secre- 
tions were  rauco-purulent,  excessive  in  the  mornings,  al  times  decidedly  creamy  in  color 
and  consistence,  and  leaving  more  or  less  of  a  permanent  yellowish  stain  on  the  hand- 
kerchief. The  objective  Bymptoms  wire  a  moderately  "deflected  septum,  hypertrophy 
and  passive  dilation  of  turbinal  tissues,  which  I  reduced  with  electric  cautery  and 
chromic  acid.  <>n  certain  mornings  there  was  a  stream  of  muco-purulent  matter 
issuing  from  the  posterior  end  of  the  righl  hiatus  semilunaris,  and  continuing  its 
n  the  upper  Burface  of  the  inferior  turbinal  body,  to  the  naso-pharynx,  and 
not,  us   usual,   passing    over   the   inferior   turbinal   toward   the  floor  "t    the   nostril. 

r  reducing  the  general  hypertrophy,  I  diagnosed  empyema  by  placing  the  electric 
light  in  the  mouth,  showing  a  verj  dark  Bhadow  over  the  righl  antrum  and  brighl  spot 
under  the  left   eye;  and  besides  the  corroborating  evidence  of  pus  discharged   from 

.in  maxillaris,  I  passed  a    curved  needle  through  the  antrum-wall   in  the  inferior 

i    Mikulicz's  method   and  found  pus  in  considerable  quantity.     Irrigation 

■  it'  the  : 1 1 1 1 n 1 1 1 1  through  the  hiatus  gave  similar  results.     He  had  Bplendid  teeth,  but  on 

close  inspection  the   righl    Becond    molar  was   pale  white    in    color  and   appeared    as 

though  the  in  dead      This  tooth  had  been  filled  with  an  amalgam  four  years 


EMPYEMA    OF  THE  MAXILLARY  8IN US.  975 

previously  and  bad  given  no  disturbance  since.  I  proposed  removal  of  the  tooth  and 
trephining,  but  be  refused  an  operation  in  which  be  would  lose  a  tooth.  Subsequently 
I  sen!  bim  to  a  dentist,  who  removed  the  filling  and  found  some  purulent  secretion  and 
offensive  gas  in  the  palatine  root;  lie  treated  it  tor  sonic  time  with  the  hope  of  arresting 
the  trouble  above,  but  without  avail,  and  the  patient  finally  consented  to  have  the  opera- 
tion performed.  Under  gas  Drs.  Bradley  and  Dixon  removed  the  tooth  and  I  tre- 
phined a  space  about  6  millimeters  in  diameter  through  the  socket.  The  antrum  was  full 
of  the  most  offensive  pus  and  gas  it  has  ever  been  my  ill-luck  to  detect.  I  curetted 
from  the  cavity  a  great  deal  of  granulation-tissue  and  some  carious  bone,  and  after 
irrigating  the  cavity  with  an  antiseptic  solution,  packed  it  with  iodoform-gauze,  which 
remained  in  tor  a  tew  days.  Subsequently  I  packed  it  once  a  week,  and  there  was  very 
little  pus  or  odor  when  1  removed  the  gauze.  He  improved  steadily  tor  a  lew  months, 
wearing-  a  gold  tube  fitted  to  a  special  plate,  and  irrigated  the  cavity  regularly;  then 
the  hole  gradually  closed,  and  all  of  the  old-time  unfavorable  symptoms  reappeared. 
I  then  removed  a  part  of  the  external  wall  of  the  antrum  and  found  extensive  granu- 
lations and  carious  bone,  which  were  carefully  curetted.  He  wore  the  rubber  tube  for 
a  long  time  and  when  I  saw  him  last  was  in  a  very  good  condition,  the  irrigation 
bringing  away  daily  only  a  small    lump  of  mucus  about   as   large  as  a   pea. 

This  is  a  typical  case  due  to  the  filling  of  a  tooth  before  the  pathological 
state  in  the  root  had  been  relieved. 

The  results  in  the  cases  where  I  have  penetrated  through  the  walls  of  the 
meatus  have  not  been  so  satisfactory  as  those  reported  by  Grant  and  other 
European  writers.  I  have  noticed  that  many  eases  under  thorough  and  care- 
ful curetting  ultimately  did  better  than  those  which  were  extensively  or  over- 
curetted,  or  those  in  which  the  curette  was  used  too  moderately.  I  have 
found  the  greatest  benefit  from  recuretting,  at  intervals  of  about  one  month, 
until  all  bare  bone  is  covered  and  granulation-tissue  cicatrized. 

(  'lass  VI. — Atrophic  Rhinitis. — The  bacilli  of  atrophic  rhinitis  fre- 
quently find  a  permanent  home  in  the  sinuses.  Robertson  id'  Newcastle-on- 
the-Tyne  and  ( Jrunwald  have  done  some  original  and  efficient  work  in  this 
class  of  cases.  I  have  found  two  kinds  of  cases  apparently  caused  by  this 
affection  :  one  in  which  the  semi-solid  putrid  debris  is  confined  in  the  cavity 
and  remains  a  causal  factor  in  keeping  up  the  condition,  and  the  other  in 
which  the  tissues  have  undergone  degenerative  changes.  Irrigations  will 
frequently  relieve  the  first  ;  curetting  and  drainage  are  generally  necessary  to 
restore  the  latter. 

("lass  VII. —  'rumors. — -Tumors  occasionally  develop  in  these  cavities. 
Early  diagnosis  is  of  the  greatest  importance,  for  it  frequently  enable-  the 
surgeon  to  save  the  patient's  life  by  timely  removal,  and  rescues  him  from  a 
condition  of  intense  pain  and  distress.  Among  the  benign  tumors  mucoceles 
and  osteomata  are  the  most  important. 

Among  the  malignant  tumors,  sarcoma  (spindle-  and  round-celled)  and 
osteosarcoma  are  the  most  common.  The  prompt  removal  of  the  superior 
maxilla  in  a  patient  of  Dr.  Wyeth's  and  mine  has  apparently  cured  him  of 
an  otherwise  fatal  disease. 

The  patient  was  -en-  to  me  in  February,  L894,  by  Dr.  Wyeth  lor  my  opinion  con- 
cerning the  right  antr >f  Highmore.     He  had  been  troubled  with  a  diseased  tooth, 

pain  in  the  right  upper  jaw.  ami  with  an  extremely  unpleasanl  discharge  for  two  years. 
A  diseased  tooth  had  been  extracted.  In  August,  L892,  a  local  dentist  opened  the  antrum, 
but  the  pain  continued.  In  September,  L893,  Dr.  Wyeth  the  patient  being  under  ether) 
opened  and  curetted  the  antrum  through  the  tooth-socket,  but  little  relief  from  the  dis- 
charge was  experienced.  In  January,  1894,  Dr.  Wyeth  recuretted  the  antrum,  hut  the 
unfavorable  symptoms  conl  inued. 

In  passing  tin-  curette  over  the  antrum  I  noticed  a  thick  and  peculiar  linim_r  on  the 
antrum-walls,  which  produced  very  much  tie-  same  sensation  as  one  experiences  when 
scraping  a  raw  potato.  I  expressed  my  opinion  that  it  was  a  malignant  neoplasm,  ami. 
upon  l>r.  Wyeth'a  suggestion, a  specimen  was  senl  to  Mr.  Prudden,  who  reported  that  it 
was  a  large-celled  sarcoma.    In  March,  1894,  Dr.  Wyeth  removed  the  superior  maxillary 


976     DISEASES  OF  THE  ACCESSORY  SINUSES  OF  THE  NOSE. 

bone,  with  part  of  the  pterygoid  plate.  The  patient  recovered  from  the  operation,  and 
Beems  to  be  doing  very  well  with  an  artificial  jaw,  and  continues  in  the  practice  of  his 
profession  as  a  lawyer.  There  remains  one  unfortunate  result :  the  continuance  of  a 
constant  sweetish  and  extremely  disagreeable  taste  in  the  mouth.  There  is  a  little 
muco-pus  issuing  at  the  point  where  the  section  of  the  uaso-lachrymal  duet  was  made. 
1  -aw  the  patient  in  the  Bummer  of  1896,  and  there  was  no  recurrence. 

<  i  lss  VIII. — Syphilis. — Gummata  frequently  develop  in  the  nasal  walls 
of  the  antrum.  1  had  recently  under  observation  three  cases  of  gumma 
of  tin'  internal  wall  of  the  antrum  of  Highmore.  They  did  well  under 
iodid  of   potassium  and   occasional   scraping  of  the   necrosed  hone. 

An  illustrative  case,  .Mrs.  S..  aged  fifty,  applied  to  me  in  1894.  She  was  suffering  from 
such  severe  pain.-  in  the  left  side  of  her  head  that  she  had  only  slept  a  few  minutes  at  a 
time  for  several  nights  and  days.  I  removed  a  degenerated  gummatous  internal  wall 
of  the  antrum;  found  the  cavity  extensively  diseased  and  full  of  putrid  secretion  and 
tissue-d6bris.  Besides  local  measures  I  gave  her  iodid  of  potassium;  controlled  the 
pain  for  a  lew  days  with  morphin.  She  improved  rapidly,  and  in  two  months  was 
apparently   well. 

DISEASES  OF  THE  ETHMOIDAL  CELLS. 

The  large  number  of  tin-  ethmoidal  cells  and  the  peculiar  latency  of  their 
affections  make  it  difficult  t<>  determine  the  extent  of  their  pathological  condi- 
tions and  to  adopt  a  successful  line  of  treatment.  These  cells,  in  my  expe- 
rience, me  oftener  diseased  than  any  of  the  other  cavities.  Polypoid  degen- 
eration is  their  most  frequenl  affection.  The  bacteria  of  grippe  and  influenza 
invade  these  cavities  and  produce  alarming  and  distressing  symptoms.  In  tin1 
young  suppurative  rhinitis  nearly  always  terminates  in  atrophic  rhinitis,  and 
i-  a  frequent  cause  of  chronic  ethmoidal  empyema. 

Htiology. — Woakes  and  Thudicum  have  probably  done  more  than  any 
others  to  inaugurate  active  methods  of  treatment  of  these  cavities.  The 
mucosa  of  the  ethmoid  bone  seems  to  have  a  peculiar  proneness  to  watery 
infiltration,  which  if  not  relieved  will  terminate  in  a  polypoid  state.  This 
condition  seems  to  affecl  all  of  the  tissues,  including  the  periosteum  and  the 
1m, ne.  and  it  ultimately  render-  the  hones  soft  and  brittle.  Occasionally  the 
Beptum,  <»r  an  exostotic  or  ecchondrotic  growth  protruding  therefrom,  so 
presses  into  the  ethmoid  or  middle  turbinated  body  as  to  close  the  natural 
openings,  and  degeneration  take-  place  as  a  consequence.  In  a  lew  cases 
inflammatory  and  necrotic  processes  extend  from  the  antrum  to  the  ethmoid. 
In  other-  the  process  extends  from  the  frontal  sinus.  Cysts  occasionally  form 
in  one  of  the  cells  and  extend  backward  and  forward,  breaking  down  the 
intercellular  wall-,  and  finally  make  their  appearance  ahove  the  inner  can- 
thus  of  the  eve,  where  the  bone  i-  probably  thinnest. 

Again,  acute  catarrhal  inflammation  of  the  Schneiderian  membrane  is  fre- 
quently attended  h\    an  edema   which  continue-    SO    long   that    it    obstructs  the 

respective  openings  of  the  cells  for  several  days.  This  causes  putrefaction 
of  the  retained  secretions;  they  in  turn  irritate  or  destroy  the  mucous  lining 
of  the  cell-;  and  pu-  either  discharges  through  the  normal  outlet  or  force- 
it-  way  bj  pressing  through  it  (?)  or  through  an  artificial  opening.  If  the 
pressure  has  been  sufficient  to  produce  necrosis,  and  if  the  drainage  has  not 
keen  free,  we  have  n-  a  result  chronic  thickening  with  pus-production,  or 
watery  edema  or  polypoid  changes.  Syphilis  at  times  will  form  gummatous 
tumors,  which  in  breaking  down  present  the  appearances  of  polypoid  degen- 
eration. <  teteomata  and  malignant  minor-  in  thi-  region  are  occasionally  the 
cause  of  considerable  pain  and  a  discharge  of  broken-down  tissue-products. 


DISEASES  OF  THE  ETHMOIDAL   CELLS.  (.»77 

Symptoms. — The  most  c mon  symptoms  of  ethmoid  disease  are  muco- 
purulent discharges  through  the  rhino-pharynx  and  through  the  anterior 
nares,  with  dull  and  deep-seated  pain  around  the  orbit,  frontal  region,  or  in 
the  temporal  and  occipital  regions.  In  chronic  cases  the  pain  is  largely 
dependent  upon  the  retention  of  the  secretin  n-  and  the  amount  of  | » < ■  i  i •  ►  ~ t * • ; 1 1 
disease.  The  chronic  cases  with  free  drainage  usually  complain  of  muco-pus 
in  the  pharynx,  larynx,  and  bronchi.  Acute  cases  with  stenosis  complain  of 
profound  oppressive  pain  and  fulness  throughout  the  post-orbital,  frontal,  and 
temporal  regions,  and  usually  -how  some  mental  dulness — the  patients  com- 
plaining of  a  disinclination  to  mental  activity.  In  cases  of  mucocele  the 
symptoms  are  often  very  obscure.  The  pain  in  the  ethmoid  region  and 
behind  the  eye  is  rather  constant  and  severe;  and  the  nasal  walls  of  the 
ethmoid  rarely  bulge  or  protrude  sufficiently  to  awaken  our  suspicions, 
although  ultimately  the  orbital  plate,  just  above  the  inner  canthus  of  the  eye, 
gives  away  and    protrude-. 

Diagnosis. — In  eases  of  acute  inflammation  and  stenosis  of  the  ethmoidal 
cells  the  diagnosis  is  extremely  difficult,  save  when  it  is  inferred  from  the 
intense  subjective  symptom-.  The  subjective  symptoms  are  usually  those  of 
acute  and  infectious  rhinitis  :  rarely,  indeed,  do  we  have  sufficient  evidence  to 
warrant  us  in  penetrating  into  one  of  these  cells  when  a  condition  of  acute 
empyema  exists.  Frequently  in  cases  of  grippe  the  patient  implore-  the 
physician  to  cut  into  the  cells  to  relieve  the  distressing  and  almost  unbearable 
symptoms  of  pressure.  In  chronic  cases  with  discharge  the  diagnosis  i-  not 
difficult;  but  in  cases  where  abnormal  conditions  obstruct  the  view  there  i- 
some  difficulty  in  distinguishing  between  empyema  of  the  anterior  ethmoidal 
cells,  of  the  frontal  sinus,  and  of  the  antrum  of  Highmore.  In  those  cases 
where  the  muco-purulent  discharge  flows  from  the  septal  side  of  the  bulla 
ethmoidalis,  the  evidence  that  there  is  empyema  of  the  anterior  ethmoidal 
cells  cannot  be  disputed.  Pus  in  the  superior  meatus  can  mean  only  one  of 
three  things — posterior  ethmoidal,  or  sphenoidal  trouble,  or  subperiosteal  bone- 
disease.  Pus  issuing  from  the  posterior  ethmoidal  cells  must  pass  over  the 
posterior  end  of  the  middle  turbinal  body  ;  and  when  the  source  is  the 
.sphenoidal  cell  it  usually  passes  behind  the  tip  and  over  the  posterior  upper 
border  of  the  choana.  Occasionally  sneezing  or  forced  blowing  of  the  nos- 
tril  forces  muco-pus  into  the  upper  chambers.  In  such  cases  wiping  the 
mucus  away  and  awaiting  \\<  reappearance  will  decide.  The  posterior  rhino- 
scopic  mirror  is  most  valuable  in  demonstrating  muco-purulenl  secretions  in 
the  superior  meatus.  The  degree  to  which  the  pathological  state  hasextended 
can  be  determined  by  the  objective  appearance-,  especially  by  the  character 
of  the  pus,  muco-pus,  and  the  edematous,  polypoid,  and  sclerosed  states.  I 
have  been  able  to  confirm  my  suspicions  on  many  occasions  when  the  irriga- 
tion-tube had  Iteen  pa— ed  into  the  natural  opening.  The  probe  will  convey  an 
idea  of  the  diseased  state  of  the  membrane,  but  it  i-  frequently  deceptive  con- 
cerning the  bone.  The  periosteum  and  mucous  membrane  of  these  bone-  i- 
very  thin,  and  frequently  the  probe  fcr\<  as  if  it  was  <>n  bare  or  exposed 
bone  when  it  is  in  a  fairly  normal  state.  This  ha-  led  many  of  our  besl 
writers  into  controversy  on  the  diagnosis  of  diseases  "l   this  region. 

Treatment. — Although  we  have  done  much  in  the  treatment  of  eth- 
moidal disease,  many  questions  in  regard  to  the  best  methods  are  vet  to  be 
settled.  The  ethmoid  is  really  the  home  of  nasal  polypi  ;  the  majority  of  the 
serious  cases  are  the  cause  or  consequence  of  polypi,  ami  are  etiological 
features  in  the  deeper  degenerative  changes  of  tissue  ami  bone.  All  peduncu- 
lated polypi  should  be  removed  by  the  wire  snare,  and  I  have  found  the  B 

f,2 


978     DISEASES  OF  THE  ACCESSORY  SINUSES  OF  THE  NOSE. 

worth  snare  by  far  the  besl  for  this  purpose.  In  a  few  cases  it  is  well  to  pull 
out  the  polypi  after  the  wire  has  been  well  tightened  around  the  pedicle;  on 
the  other  hand,  it  i-  sometimes  better  to  cut  through  the  pedicle  and  afterward 
destroy  the  small  polypi  that  grow  around  the  base.  The  profound  symp- 
toms of  pain,  shock,  and  hemorrhage  thai  follow  tearing  away  greal  sections 
of  the  mucous  membrane  and  bone  by  traction  on  the  snare  should  contra- 
indicate  its  indiscreet  use.  A.fter  the  practise  of  these  methods  in  my  cases  I 
have  never  observed  the  recurrence  of  polypi  in  the  space  of  the  pedicle;  yet 
1  have  noticed  little  polypi  growing  around  the  parts,  and  thai  their  growth 
continues,  being  favored  by  the  absence  of  the  larger  ones;  those  should  be 
removed  l>v  some  excisor-forceps.  I  have  found  Jarvis's  to  be  the  best.  Jn 
nearly  all  serious  ethmoidal  cases  the  question  of  removing  a  part  or  all  of  the 
middle  turbinal  body  should  be  carefully  considered,  and  as  it  is  necessary 
in  most  cases,  it  is  well  to  decide  this  question  early.  1  do  not  believe  in  the 
method  of  tearing  this  bone  away  with  forceps,  as  advocated  by  some  earlier 
w  riters,  because  the  membranous  tissues  that  pass  through  the  cribriform  plate 


Dividing  the  middle  turbinal  before  sawing  off  the  posterior  half  to  gain  free  access  t"  !!"■ 

I  sinus. 


with  the  olfactory  nerve,  and  extend  downward  over  the  middle  turbinated 
bone,  are  quite  tough,  and  sometimes  they  are  torn  loose  from  the  bone  up  to 
the  plate  instead  of  breaking  off  where  the  middle  turbinated  body  joins  the 
ethmoidal  bone.  In  m\  experience  I  have  found  the  mosl  feasible  procedure 
to  be  thai  "I  making  a  section  with  nasal  dipper-  or  scissors  through  the 
middle  of  the  bone.  The  Boswortli  wire  snare  with  small  cannula  will 
remove  the  anterior  and  posterior  sections  readily  and  effectively,  with  little 
disturbance  to  the  membranes  of  the  parts  above.  Deflected  septa,  narrow 
nostrils,  and  hemorrhage  are  the  chief  difficulties  n>  be  overcome.  The  floors 
of  these  cells  can  be  penetrated  with  shoulder-protected  drills  and  trephines 
with  very  little  danger  to  the  neighboring  parts.     The  antero-posterior  nasal 


DISEASES  OF   THE   FRONTAL   SINUSES. 


979 


excisor-forceps,  a  cut  of  which  I  present,  has  been  extremely  valuable  for 
enlarging  these  openings  and  for  removing  the  floors  of  the  cells.  The 
patient  rarely  experiences  disagreeable  results,  save  in  the  cases  where  the 
cancellated  parts  of  the  ethmoid  bone  have  been  cut  into.  The  small  malle- 
able curettes  are  extremely  valuable  in  removing  pus,  polyps,  and  granulation- 
tissue.  When  the  holes  are  large  enough  the  cells  usually  drain  so  well  thai 
it  is  necessary  to  irrigate  them  at  stated  intervals  only.      When  the  process 


Fig.  592.—  Bosworth's  snare  in  position  for  making  the  section  of  the  middle  turbina]  (author's  specimen). 

extends  far  up  into  the  little  cells  above  the  orbital  cavity,  or  in  some  of  the 
recesses  under  the  cranium,  the  results  of  treatment  are  not  so  satisfactory.  I 
have  found  that  it  is  advantageous  to  freely  spray  the  nose  two  or  three  times 
a  day  with  a  preparation  of  liquid  albolene  4  oz.,  carbolic  acid,  eucalyptol,  and 
menthol,  ad  10  grains;  this  is  usually  very  soothing  and  beneficial.  In  the 
suppurative  cases  I  use  the  nasal  douche,  1  quart  of  warm  water,  1  teaspoon- 
ful  of  salt,  \  drachm  of  carbolic  acid,  applied  by  a  fountain-syringe  through 
the  narrower  nostril  ;  with  occasional  insufflations  of  boric  acid,  aristol,  and 
iodoform.  Bosworth  reports  most  remarkable  results  from  drilling  into  these 
cavities  with  an  ordinary  burr  and  breaking  down  the  intracellular  wail-  ; 
and  I  believe  that  he  accomplishes  this  entirely  by  the  sense  of  touch  and 
appreciation  of  distance-  and  direction-  from  the  anterior  oares. 

As  to  results,  regarded  from  the  standpoint  of  the  subjective  symptoms, 
about  three-fourths  of  my  ethmoidal  cases  are  apparently  well  :  but  on 
inspecting  them,  in  the  majority  of  cases,  a  small  quantity  of  pus  and  muco- 
pus  can  be  seen  either  in  the  nose  or  issuing  from  the  natural  or  artificial 
openings.  This  increases  in  winter,  and  is  very  much  diminished  in  the 
summer  time. 

DISEASES    OF    THE    FRONTAL    SINUSES. 

The  frontal  sinuses  develop  al t  the  age  of  puberty,  and  apparently  are 

the  extension  of  the  ethmoid  cells  into  the  frontal   bone.      I?hey  are  much 


980     DISEASES  OF  THE  ACCESSORY  SINUSES  OF  THE  .Vox/;. 

more  frequently  diseased  than  is  generally  suspected,  and  many  supra-orbital 
headaches  are  due  t<»  trouble  in  these  cavities.  Improved  methods  of  inspect- 
ing the  region  < » t*  the  opening  of  the  infundibulum  and  the  use  of  silver 
irrigation-tubes  have  thrown  a  great  deal  of  Light  upon  their  pathology,  and 
have  led  to  procedures  that  have  indisputably  relieved  the  nan-bid  condi- 
tions. 

Etiology. — Polypoid  or  myxomatous  degeneration  has  been  the  cause  of 
the  diseased  conditions  in  the  majority  of  the  cases  that  have  come  under  my 
observation.  Of  nine  frontal  sinuses  which  I  have  opened  externally,  seven 
had  polypi  within  the  cavity  and  one  had  fronto-ethmoid  necrosis.  I  have 
seen  a  great  many  cases  with  polypi  in  the  region  of  the  infundibulum,  and 
evidently  extending  np  into  the  frontal  sinus,  which  were  operated  upon  per 
nasi  and  carefully  treated.  These  cases  have  improved  under  drainage,  but  did 
not  seem  to  get  entirely  well.  I  have  had  one  case  of  osteoma.  I  have  seen 
a  few  cases  of  syphilitic  invasion  resulting  in  necrosis.  Parasites  sometimes 
invade  this  cavity, especially  in  the  southern  partsof  the  American  continent, 
as  by  the  screw-worm  or  larva  of  the  eompsomyia  mascellaria,  cases  of  which 
have  been  so  well  reported  by  Sir  Morel!  Mackenzie. 

Symptoms. —  Pain  above  the  eyes  and  through  the  frontal  bone  is  the 
almost  constant  subjective  symptom  of  frontal-sinus  disease;  this  is  fre- 
quently  made  worse  by  bending  the  head  forward  and  downward.  In  cases  of 
complete  stenosis  of  the  infundibulum  the  pain  is  very  great,  and  the  symp- 
toms of  oppression  and  suffering  are  profound.  In  the  chronic  cases,  where 
the  nose  is  nol  occluded  by  deflection  or  hypertrophy,  muco-pus  can  be  seen 
at  the  very  uppermost  end  of  the  lower  lip  of  the  hiatus  semilunaris,  rather 
anterior  to  the  bulla  ethmoidalis. 

Diagnosis. — The  diagnosis  can  frequently  be  inferred  from  the  constant 
pain,  tenderness,  and  discharge  in  the  region  of  the  middle  meatus,  but  the 
only  infallible  test  is  the  demonstration  that  pus  really  comes  from  the 
cavity.  The  silver  irrigation-tube  is  by  far  the  most  valuable  and  reliable 
means  of  attaining  this  evidence ;  although  I  think  that  we  are  justified  in 
operating  when  the  subjective  symptoms  indicate  frontal  sinus  trouble  and 
when  the  objective  condition-  demonstrate  that  there  is  pus  in  the  infundib- 
ulum and  the  anterior  cells.  Tenderness  to  dec])  pressure,  dulness  On  per- 
cussion,  and  failure  of  transillumination  (see  Plate  14)  furnish  auxiliary 
evidence. 

Prognosis. —  The  prognosis,  as  regards  the  relief  of  the  pain  and  the 
excessive  discharge,  is  very  good  indeed  if  we  secure  and  maintain  good 
drainage  from  the  cavity;  but  in  many  cases  life  is  jeopardized  on  account 
of  the  opposition  <>n   the   pari  of  the  patient    to  an  external  operation. 

Treatment. —  In  acute  cases  with  complete  stenosis  of  the  infundib- 
ulum  the    region   of   the    uasal    opening   of   the    infundibulum    should    be 

m  — (L^^ 


Irrigation-tube. 


thoroughly  cocainized  and  an  attempt  made  to  enter  the  infundibulum  with 
a  silver  irrigation-tube— a  cut  of  which  is  shown  in  Fig.  593.  In  several 
I  have  succeeded  in  dislodging  the  gas  and  pus  and  in  equalizing  the 
external  and  internal  atmospheric  pressure.  It  may  not  be  necessary  to 
'■in.  r   the  frontal   sinus   in   all  the  cases,  as  the  relief  Beems  to  be  secured 


DISEASES  OF  THE  FRONTAL  SINUSES.  981 

after  the  manner  of  that  produced  by  the  Eustachian  catheter  in  tympanic 
troubles.  The  following  case  illustrates  a  brilliant  result  obtained  l»v  this 
method. 

The  patient  sent  for  me;  I  found  him  almost  in  a  state  of  collapse  and  in  great 
agony.  He  bad  been  suffering  for  several  days  with  intense  pain,  together  with  a  full 
feeling  in  the  right  frontal  sinus.  1  sprayed  the  nostril  with  cocain  and  applied  it  on 
cotton.  The  hiatus  and  int'undibulum  were  very  much  swollen;  the  middle  turbinal 
body  was  moderately  so.  I  passed  a  tube  into  the  infundibulum  and  injected  gently 
but  firmly  a  borated  solution;  a  gush  of  pus  and  offensive  gas  followed,  with  immediate 
cessation  of  the  severe  symptoms.  The  muco-purulent  discharge  continued  for  a  few 
weeks,  but  the  patient  recovered  completely. 

When  relief  of  the  retained  pus  cannot  be  secured  through  the  nose,  and 
when  the  subjective  symptoms  are  profound,  an  external  opening  should  be 
made  without  delay  by  making  an  incision  extending  from  the  center  line  of 
the  forehead  and  on  a  level  with  and  through  the  eyebrow,  or  above  it,  out- 
ward to  within  two  millimeters  of  the  supra-orbital  notch.  A  small  hole,  6 
or  8  millimeters  in  diameter,  should  be  chiselled  through  the  bone  (Fig.  544), 
the  cavity  carefully  cleansed  and  inspected,  and  afterward  a  probe  or  bougie 
should  be  pa— ed  through  the  obstructed  infundibulum  into  the  nose.  If 
deemed  expedient,  one  of  the  silver  retention-tubes  can  be  kepi  in  and  the 
external  wound  closed.  Subsequent  irrigation  can  be  easily  carried  out 
through  the  tube  in  the   nose. 

The  two  chief  considerations  in  the  treatment  of  the   chronic  cases  are  : 

First,  the  removal  of  the  pathological  tissues  and  their    products.     See I. 

the  securing  and  maintenance  of  proper   fronto-nasal   drainage. 

<  )u  account  of  the  irregularity  in  the  size  of  the  frontal  sinus  and  infun- 
dibulum, the  procedure  that  would  be  successful  in  one  case  would  not  be  so 
in  another  with  the  same  pathological  conditions.  The  selection  of  a  place 
for  making  the  incision  and  chiselling  through  the  bone  is  a  very  important 
one,  and  the  more  I  operate  the  more  I  am  convinced  that  a  small  opening 
should  be  made  just  above  the  supra-orbital  ridge,  close  to  the  median  line; 
it  should  then  lie  extended  upward  and  outward  for  a  sufficient  distance  to 
make  an  aperture  about  8  to  10  millimeters  in  diameter.  The  direction  of 
the  chiselling  will  be  determined  by  the  position  of  the  dividing  wall  of  the 
sinuses.  If  none  of  the  ridge  is  removed  we  have  very  little  resulting 
depression;  and  tin-  great  advantage  i-  secured  of  being  able  to  trephine, 
chisel,  and  inspect  the  floor  of  the  -inns,  the  infundibulum,  and  the  anterior 
ethmoidal  cell-,  through  which,  in  my  opinion,  it  is  absolutely  necessary  to 
make  a  free  drainway  into  the  nose.  In  the  other  operation  which  I  have 
performed  quite  frequently,  and  which  seems  best  in  cases  where  the  wound 
i-  intended  to  be  left  open  and  packed  for  any  length  of  time,  it  i-  very 
difficult  to  chisel,  trephine,  and  properly  enlarge  the  infundibulum  through 
the  hole  in  this  below  the  supra-orbital  ridge-space;  although  in  a  few  cases 
I  have  removed  the  anterior  wall  down  to  the  nasal  process  of  the  superior 
maxillary  bone  and  succeeded  in  making  a  partially  satisfactory  ami  per- 
manent opening  into  the  nose  (Fig.  594).  Luc  ha-  evidently  grasped  the 
most  practical  idea  that  has  yet  been  presented — that  i-.  to  close  the  external 
wound  at  once  after  having  made  a  large  opening  through  the  fronto-nasal 
canal  and  inserted  :i  large  silver  drainage-tube.  The  after-treatment  of  these 
cases  consists  of  irrigat  ing  the  cavity  through  the  tube  for  three  or  four  weeks, 
and  then  until  the  discharges  cease,  continuing  the  irrigation  through  the  patu- 
lous canal  which  had  been  created  by  the  tube. 

In  seven  cases  with  severe  ami  prolonged  disease  of  the  frontal  -inn-  I 
opened  nine  of  the  sinuses.     One  of  the  sinuses  was  obliterated  l>v  packing 


982      DISEASES   OF   THE  M'CEssoliY  SINVSES  OF   THE  NOSE. 

for  nine  months,  bui  there  was  a  resulting  depression.  The  patient  is 
entirely  relieved  of  the  original  symptoms.  In  one  of  the  polypoid  cases 
the  frontal  sinus  was  opened   by  the  infra-orbital-ridge  method,  packed  and 

curetted  ;  tlie  necrosed  bone  was  -craped,  and  this  cicatrized  over.  The 
patient  made  a  complete  recovery,  and  the  sinus  lias  been  well  since  the 
closure  of  the  external  wound.  In  another  case  of  fronto-ethmoidal  abscess 
the  anterior  wall  of  the  ethmoidal  cells  was  drilled  and  chiselled  away  : 
almost  all  of  the  nasal    process  of  the  superior  maxillary  was   removed,  the 


Fig.  594. — Operation  beneath  the  supra-orbital  ridge,  before  upper  section  has  been  stitched :  intended 
for  external  drainage  (author's  specimen). 

cavity  was  scraped,  irrigated,  and  drained  with  a  tube,  and  the  sinus  seems 
to  have  been  in  good  condition  ever  since.  Some  of  the  cases  were  troubled 
with  acute  swelling  and  retention,  and  the  scar-tissue  was  reincised  with 
immediate  relief.  Three  of  the  cases  operated  upon  by  the  same  method 
remained  in  apparently  good  condition  up  to  six  months  or  one  year ;  hut  in 
each  one  of  them,  on  two  or  three  occasions,  extreme  pain  occurred,  with 
swelling  in  the  -intt-  ;  the  infundibulum  seemed  to  he  closed,  this  being  the 
result  of  acute  cold.  Silver  tubes  were  introduced  through  the  infundibuli 
and  the  accumulation  of  degenerating  mucus  and  pus  dislodged^  The 
patients  improved  at  once,  and  subsequent  irrigation  brought  away  only 
clear  fluid.  At  time-  these  patients  discharge  a  mucus  from  these  cavities, 
which  seems  to  be  of  a  catarrhal  and  transitory  nature. 


DISEASES  OF  THE  SPHENOIDAL  CELLS. 

Etiology. — Acute  inflammations  of  the  sphenoidal  cells  accompany  or  are 
consequenl  upon  acute  rhinitis,  especially  in  cases  due  to  infection.  Polypi 
are  frequently  the  cause  of  chronic  disease  within  the  cell.  Syphilis  com- 
monly affects  the  cell-wall  with  a  gummatous  deposit.  Ethmoidal  mucocele 
will  occasionally  break  through  the  dividing  wall.  Tumors  occasionally 
develop  in  or  extend   into  the  cavities. 

Symptoms. — The  subjective  symptoms  of  acute  inflammations  of  the 
sphenoidal  sinuses  are  headache  and  .-i  full,  heavy  feeling  over  and  behind  the 
eyes.  In  the  cases  of  chronic  suppuration,  the  subjective  symptoms  are  deep- 
seated  pains  in  the  orbital,  temporal,  mid  occipital  regions,  feelings  of  depres- 


DISEASES  OF  THE  SPHENOIDAL   CELLS. 


983 


sion  and  oppression,  discharge  <>t"  pus  or  muco-pus  over  the  anterior  surface 
of  the  sphenoidal  cell  at  the  posterior  extremity  of  the  middle  turbinal 
body,  and  disturbances  of  the  field  of  vision.  The  objective  symptoms  are 
hyperplastic  edema  of  the  nasal  mucosa  covering  the  cell,  discharge  of  pus, 
muco-pus,  polypi,  and  pharyngitis  sicca,  due  to  destruction  of  the  epithelium 
by  the  pus,  which  flows  constantly  over  the  post-pharyngeal  wall. 

Pathology. — -The  osseous  modification  and  changes  in  the  vitality  of  the 
hone  occur  in  those  sphenoidal  cases  in  which  the  mucosa  has  undergone 
polypoid  degeneration,  the  bone  becoming  brittle  and  losing  much  of  its 
cohesive  quality.  In  neglected  syphilitic  cases,  necrosis  of  the  hone  or  soft 
tissues  always  follows  the  gummatous  process.  The  chronic  suppurative 
cases  with  stenosis  of  the  normal  opening  are  usually  protracted  by  the  irri- 
tating  qualities  of  the  degenerating  products. 

Diagnosis. —  The  diagnosis  is  comparatively  easy  in  those  cases  where 
the  nasal  f'ossse  are  nut  seriously  obstructed  by  septum  deflections  and  the 
throat  is  tolerant  enough  to  permit  posterior  rhinoscopy.  The  obstruction  in 
many  cases  is  the  posterior  end  of'  the  middle  turbinal  body;  its  early 
removal  will  facilitate  matters  greatly.  Under  favorable  condition.-  the  pus 
can  he  seen  flowing  from  the  normal  opening,  which  is  situated  above  the 
superior  turbinal  body  in  the  uppermost  part  of  the  anterior  sphenoidal 
wall.  An  irrigation-tube  passed  through  the  opening  will  confirm  the  pro- 
visional diagnosis. 

Prognosis. — Since  surgeons  have  adopted  the  method  of  making  a  large 
opening  of  8  to  1<>  millimeters  in  diameter  into  this  sinus,  the  prognosis  is 
much  more  favorable. 

Treatment  of  Chronic  Empyema. — The  treatment  of  chronic 
empyema  is  essentially  surgical.  Much  annoyance  and  delay  in  the  favorable 
progress  of  these  cases  will  be  avoided  by  removing  the  posterior  half  of  the 
middle  turbinal  body  as  a  first  step  in  the  operation,  as  it  almost  always 
lies  in  the  direct  line  of  the  operative  field.  In  my  experience  the  most 
simple  and  satisfactory  procedure  for  the  removal  of  the  middle  turbinal 
body  is  carried  out  by  cutting  into  its  middle  section  with  the  nasal  clippers 
(Fig.  592),  placing  the  wire  of  the  Bosworth  snare  in  the  cut  and  over  the 
posterior  end,  and  by  firm  traction  removing  the  whole  posterior  half.      In 


Fig,  595. — Rongeur  for  opening  sphenoid  sinusi 

certain  cases  a  long  and   rather  -mall  silver  probe  can  be  passed  through  the 

normal    opening  of  the   -inn-,  and    this  can   be   followed    with  some   form  of 
gouge  <>r  curette.     Usually  it   is  besi   to  enter  the  sinus  about   \   to    ',  inch 


984      DISEASES  OF  THE  ACCESSORY  SINUSES  OF  THE  NOSE. 

below  the  normal  opening,  and  aboul  .'!  <>r  I  millimeters  externally  to  the 
septum.  The  wall  is  usually  thin  at  this  spot,  and  the  only  objection  is  the 
probability  of  wounding  the  oaso-palatine  nerve  and  the  spheno-palatine  artery, 

which  traverse  the  1 e  near  this  region.    Alter  the  opening  has  been  made,  it 

i-  well  to  pass  in  one  of  the  smallesl  size  antero-posterior  nasal  clippers  (Fig. 
595),  and  cui  out  the  wall  upward  and  laterally;  the  instrument  cuts  after 
the  manner  of  a  rongeur  forceps.  When  the  blood  is  wiped  away  the  sinus 
ean  lie  easily  observed  and  the  pathological  state  rather  definitely  determined. 
In  m\  experience  polyps  have  been  found  in  the  majority  (if  the  eases.  It 
i-  well  to  curette  them  away  very  gently  and  carefully,  for  any  tearing  of  the 
upper  wall-  mighl  bring  on  intracranial  trouble.  I  have  noticed  diseased 
condition-  rapidly  improve  under  simple  drainage  and  careful  attention.  The 
tendency  of  all  these  openings,  even  when  large  enough  to  admit  the  little 
finger,  i-  to  close,  and  it  is  very  remarkable  witli  what  rapidity  they  become 
occluded.  They  then  require  a  second  excision  of  the  contracting  membrane. 
'flu-  syphilitic  have  given  me  more  trouble  than  the  polypoid  cases,  because  of 
extension  of  the  necrosis  into  the  body  of  the  sphenoid  bone.  Tumors  occur 
sometimes  in  the  sphenoid  ;  but  they  usually  originate  in  the  fibrous  tissues 
of  the  rhino-pharynx  or  in  sarcomatous  degenerations  of  the  ethmoid,  and 
extend  through  the  wall  into  the  cell.  Certain  types  of  infectious  or  septic 
rhinitis  invade  this  cavity  ami  produce  a  diseased  state  of  the  mucosa,  which 
in  turn  generates  a  putrid  product,  and  this  product  acts  as  a  perpetual  nidus 
for  new  reinfecting  material.  Proper  opening  of  the  sinus  and  curettage, 
foil. .wed    by   antiseptic   irrigation,    usually   cures   the   case  or  affords  decided 

relief. 

Sphenoidal  Cases. —  In  two  of  my  sphenoidal  cases  the  symptoms  were 
so  Bevere  thai  death  was  anticipated.  The  anterior  walls  were  punctured,  and 
after  breaking  through  with  a  gouge  the  antero-posterior  clippers  were  used 
to  enlarge  the  opening.  The  cavities  were  curetted,  and  the  patients  im- 
proved :ii  "iice  and  steadily.  These  openings  gradually  closed,  and  at  the 
end  of  six  or  eight  months  had  to  be  re-excised;  this  brought  about  imme- 
diate relief  fr the  severe  symptoms  which  had  returned.      I  noticed  in  the 

fitter  cutting  of  the  bone  thai  it  had  become  much  harder  than  it  was  orig- 
inally. One  syphilitic  case,  which  is  under  observation  at  the  present  time, 
i-  apparently  well  in  ,-i  subjective  sense,  save  for  a  certain  amount  of  post- 
nasal  catarrh  ;  and  I  can  detect  dead  bone,  which  extends  from  the  rostrum 
of  the  vomer  into  the  sphenoid.  I  have  been  gradually  removing  this 
necrosed   bone  at    intervals  with  a  drill   which  excavates  laterally. 


ACUTE   AFFECTIONS  OF   THE    LARYNX  AND 

TRACHEA. 

BY    WILLIAM  E.  HOPKINS,   M.  I)., 

OF    SAN  FRANCISCO,  CAL. 

ACUTE  CATARRHAL  LARYNGITIS. 

Guer.sant  Hr.-t  clearly  described  the  simple  form  of  this  disease.  The 
•disease-process  consists  of  a  very  mild  non-dangerous  inflammation  of  the 
mucous  membrane  of  the  larynx,  not  absolutely  confined  to  any  age,  but 
usually  occurring  in  adults,  and  may  run  on  to  a  chronic  condition. 

Htiology. — It  may  be  primary  or  secondary,  idiopathic  or  the  result  of 
some  direct  and  known  irritation.  Its  principal  causation  is  the  process 
known  as  "catching  cold,"  grafted  upon  an  already  slight  and  possibly 
chronic  hyperemia  or  congestion  of  the  lining  membrane  of  the  larynx. 
Occurring  primarily  in  the  larynx,  this  disease  is  extremely  rare.  Indeed, 
Bosworth  considers  it  as  invariably  secondary  to  an  inflammation  in  some 
other  portion  of  the  upper  respiratory  tract.  The  irritation  caused  by  inhal- 
ing air  not  properly  warmed  and  moistened  or  tilled  with  particles  of  dust  ; 
irritating  vapors,  such  as  chlorin,  bromin,  sulphur,  ammonia,  tobacco-smoke, 
etc.,  predispose  to  chronic  change;  and  the  stimulus  of  cold  produces  the 
acute  condition.  In  early  life,  frequent  attacks  of  tonsillitis,  pharyngitis, 
and  the  hypertrophy  of  the  pharyngeal  tonsil  predispose  to  attacks  of  this 
disease;  while  in  later  life  some  chronic  process  in  the  nose  or  naso-pharynx 
i-  frequently  found.  On  account  of  the  greater  exposure,  it  occur-  mosi 
frequently  in   men. 

Pathology. — The  changes  in  this  disease  are  entirely  similar  to  those 
occurring  in  acute  catarrhal  inflammations  of  all  mucous  membranes.  There 
is  at  first  dilatation  with  engorgement  of  the  blood-vessels  and  arrest  of  secre- 
tion from  the  muciparous  glands;  later  there  follows  a  serous  and  mucous 
hypersecretion.  The  greatesl  -welling  i-  found  where  the  membrane  is  mosl 
lax — at  the  arytenoid  commissure  and  subglottic  region. 

Symptoms.  —Changes  in  the  voice  are  chiefly  noted.  It  may  be  hoarse, 
dulled,  or  entirely  lost ;  phonation  may  be  slightly  painful  and  labored  :  there 
may  be  slight  dryness,  roughness,  or  tenderness  of  the  throat,  accompanied 
by  a  tickling  sensation.  The  cough,  when  present,  is  dry,  harsh,  and  painful. 
Except  in  young  children  there  [g  rarely  any  interference  with  respiration. 

Diagnosis.— Changes  in  tin1  voice  and  the  metallic  cough  will  indicate 
the  -eat  of  disease.  The  laryngoscope  will  reveal  in  mild  cases  the  enlarged 
blood-vessels  scattered  over  the  mucous  membrane,  and  especially  noticeable 
on  the  cords,  commissure,  and  ventricular  hand-;  in  severe  cases  the  mem- 
brane may  he  pink  or  deep  \t<\  in  color,  and  there  ma)  he  -mall  localized 
hemorrhages.  When  swelling  is  noticeable  the  function  of  the  cords  may 
lie   interfered  with,  resulting  in  aphonia,      [nfiltration  of  the  muscles   inter- 


986      i'  i  TE  AFFECTIONS  OF  THE  LARYNX  AND   TRACHEA. 

feres  with  proper  adduction.  The  rise  in  temperature  is  very  slight,  rarely 
exceeding  100     V. 

The  disease  runs  a  course  lasting  from  five  to  ten  days  and  ends  in  reso- 
lution.    It  is  of  importance  chiefly  t<»  singers  and  public  speakers. 

Treatment. — The  whole  upper  air-tract  should  be  considered  in  treat- 
ing t lii—  disease.  In  the  early  stages  direct  local  applications  should,  perhaps, 
!),•  avoided.  The  inhalation  of  -team,  medicated  with  the  oil  of  pine,  com- 
pound tincture  of  benzoin  or  the  oil  of  eucalyptus,  with  the  wet  pack  locally, 
should  l>e  sufficient.  The  use  of  oil-sprays  is  of  unquestioned  set-vice. 
Later  in  the  disease  we  may  try  the  direct  application  of  astringents,  such 
a-  nitrate  of  silver  -  1  to  2  per  cent,  solutions),  menthol,  or  some  preparation 
of  tannin  or  iron.  To  relieve  the  cough  a  mild  dose  of  codein  may  he 
prescribed.  The  exhibition  of  large  doses  of  the  muriate  of  ammonia  (30  to 
40  grains)  will,  at  times,  very  rapidly  control  the  disease. 

ACUTE  CATARRHAL  LARYNGITIS  IN  CHILDREN. 

It  has  been  found  that  in  childhood  the  mucous  membrane  of  the  larynx 
possesses  a  greater  number  of  vessels  and  lymphatics  than  later  in  life,  and 
that  the  tissues  are  less  resistant  and  more  relaxed.  In  consequence,  there 
are  some  differences,  from  a  clinical  point  of  view,  in  the  disease  as  occurring 
in  childhood.  When  the  disease  develops  in  early  life,  certain  characteristic 
features  are  noticeable  in  relation  to  the  anatomical  region  attacked.  Ac- 
cording as  the  mucous  membrane  in  the  region  above  or  below  the  vocal  cords 
is  the  seat  of  the  disease,  it  naturally  follows  that  we  may  divide  the  disease 
for  clinical  study  into  supraglottic  and  subglottic  laryngitis.  We  may  meet 
either  of  these  conditions  up  to  about  fourteen  years,  although  a  very  large 
percentage  of  the  cases  will  be  encountered  before  the  fourth  year. 

Acute  Supraglottic  Laryngitis. — This  runs  a  course  very  similar 
to  that  of  the  simple  catarrhal  laryngitis  of  adults,  and  may  be  considered 
a-  identical  with  it.  There  i~.  indeed,  somewhat  greater  tenderness  over  the 
upper  part  of  the  larynx,  and  in  very  rare  cases  there  may  be  very  slight 
dyspnea.  There  is  the  usual  morbid  predisposing  cause  to  be  found  in  the 
naso-pharyngeal  region,  and  the  common  exciting  cause  of  exposure  and 
"taking  cold."  It-  course  is  short,  rarely  lasting  more  than  ten  days.  It 
i-  very  mild  in  character  and  resolves  naturally.  It  may  be  necessary  to 
differentiate  it  from  a  slight  croupous  laryngitis.  This  maybe  done  by 
observing  the  suddenness  of  the  onset  of  the  latter  disease  and  its  steadily 
progressive  course. 

Subglottic  Laryngitis  ;  False  Croup ;  Millar's  Asthma ;  Laryn- 
gitis Stridulosa. — The  entire  surface  of  the  larynx  i-  more  or  less  in- 
volved in  this  form  of  inflammation,  hut  the  intensity  of  the  process  is  much 
greater  in  the  tissues  below  the  vocal  cords.  The  mucous  and  submucous 
connective  tissue  becomes  infiltrated  and  swollen,  leading  to  more  or  less 
dyspnea. 

Etiology. — There  Beem-  to  he  a  constitutional  tendency  to  this  disease. 
Heredity  seems  to  be  associated  with  it.  Several  children  in  the  same  family 
or  families  closely  related  will  suffer  from  repeated  attacks.  Strumous 
children  are  predisposed  to  it.  and  those  with  an  abnormally  large  and  active 
lymphatic  system.     Gerhard!  insists  that  the  chief  predisposing  cause  will  be 

found    above,    iii    enlarged    tonsils   or   other   obstructions    in    the   air-pa-sa<_res. 

While  this  may  undoubtedly  influence  any  disease  of  the  larynx,  no  close 
causative  connection  can  he  found  associated  with  this  particular  form  of 


ACUTE  CATARRHAL  LARYNGITIS  IN  CHILDREN.         987 

laryngitis.  The  exciting  cause  is  practically  the  same  as  in  the  previous 
class. 

According  to  Sappey  (Anatomie  Descriptive,  1868,  vol.  ii.  p.  869),  the  very 
abundant  lymphatic  supply  found  in  this  region  in  children  explains  the 
marked  and  at  times  extreme  swelling  found  in  the  acute  stage  of  the  disease. 
The  pathological  condition  is  more  or  less  stenosis  from  the  crowding  forward 
of  the  congested  and  inflamed  mucous  membrane  by  the  engorged  lymphatics. 

Symptoms. — There  will  be  some  prodromal  symptoms  sufficiently  severe 
to  indicate  marked  systemic  disturbance — the  general  feeling  of  malaise,  severe 
or  slight  headache,  the  accelerated  action  of  the  heart,  and  the  temperature 
increased  to  100°  or  101°  F.  The  voice,  at  first  hoarse,  rapidly  becomes  shrill 
and  metallic,  and  phonation  may  be  very  painful.  A  croupy  cough  sets  in 
early,  and  is  of  a  harsh,  dry,  barking  nature.  Even  after  phonation  is 
entirely  suspended  this  cough  retains  its  characteristic  sound,  proving  quite 
conclusively  that  it  is  produced  by  the  dry,  swollen  tissues  below  the  cords. 
This  process  is  similar  to  inflammations  of  other  mucous  membrane-,  and 
after  a  period  of  variable  length,  usually  two  or  three  days,  the  mucous  secre- 
tion is  resumed,  the  cough  becomes  softer  and  less  irritating,  and  there  is 
some  little  frothy  expectoration.  During  the  day  the  symptoms  are  invariably 
less  severe,  while  at  night  exacerbations  occur  that  have  a  seeminglv  alarming 
import.  The  child,  somewhat  relieved  by  the  restful  day,  falls  into  a  calm  and 
easy  sleep.  This  may  continue  several  hours,  when  he  suddenly  awakens  in 
a  violent  and  agonizing  struggle  for  breath.  The  face  is  flushed,  the  lips 
purple,  the  nails  blue,  and  every  muscle  tense  and  contracted— all  of  the 
characteristic  symptoms  of  marked  dyspnea.  These  serious  symptoms  may 
continue  for  half  an  hour  or  longer;  finally  the  child  succeeds  in  coughing 
up  a  quantity  of  inspissated  mucus  and  the  attack  subsides.  A  period  of 
relief  and  rest  will  follow  for  a  few  hours,  when  the  child  again  wakens  in  a 
similar  paroxysm.  These  exacerbations  occur  only  at  night  and  separated  by 
periods  of  complete  remission  of  dyspnea.  Usually  there  will  be  from  four 
to  eight  of  these  violent  seizures  during  the  progress  of  the  disease.  The 
question  of  muscular  spasm  is  a  mooted  point.  That  true  spasm  of  the 
laryngeal  muscles  is  a  prominent  factor  in  these  seizures  is  asserted  by  Rilliet 
and  Berthez,1  D'Espine  and  Picot,2  J.  Lewis  Smith,''  and  Gottstein  ;'  while 
Bosworth,5  Rauehfuss,6  and  Dehio  claim  that  muscular  spasm  plays  no 
important  part,  and  if  it  occur  is  purely  incidental.  Probably  the  principal 
cause  is  the  swelling,  which  is  greatly  increased  by  the  presence  of  the  dried 
mucus  acting  as  an  irritant  foreign  body  ;  it  is  also  probable  that  the  same 
irritation  produces  a  certain  amount  of  spasm  of  the  laryngeal  muscles. 

There  is  a  persistence  of  more  or  less  difficulty  of  breathing  throughout 
the  attack,  but  only  at  night  do  the  paroxysms  become  sufficiently  severe  to 
occasion  distress.  During  the  remissions  a  slight  inspiratory  murmur,  higher 
in  pitch,  will  be  heard.  ( )n  succeeding  nights  the  paroxysm  will  recur  at 
about  the  same  hour  as  the  first,  although,  as  a  rule,  with  diminished  severity. 

Diagnosis. — Though  difficult  and  often  impossible,  an  effort  should  be 
made  to  examine  the  parts  with  the  laryngoscopic  mirror.  When  :i  view  is 
seemed  the  mucous  membrane  appears  inflamed  and  engorged,  while  pro- 
truding between  the  voc;d  cords  will  be  seen  the  rounded  swollen  masses  of 
the  subglottic  tissues.  These  are  of  a  deeper  red  than  the  cords  and  the  tis- 
sues above.     Differentiation  must  be  made  between  this  condition  and  mem- 

1  Maladies  des  Enfanto,  I  853,  p.  351.  '  Maladies  de  VEnfancic,  188  I.  p.  612, 

1  Diseases  of  Children,  Phila.,  1890,  p.  646.        *  Die  Krank.  des  Kehlkopfes,  1892,  p.  80. 

5  .Vo.se  a  tid  Throat,  p.  504,  '  Handbueh  dei   A    i       -A  u    ■    .  L878,  p,  L16. 


988     ACUTE  AFFECTIONS  OF  THE  LARYNX  AND   TRACHEA. 

branous  croup,  diphtheria,  foreign  bodies,  and  perichondritis.  In  both  mem- 
branous croup  and  diphtheria  there  is  much  greater  systemic  disturbance  : 
the  temperature  ranges  higher,  the  cough  is  less  marked  and  not  so  severe,  the 
disease  is  progressive,  and  is  not  characterized  by  nocturnal  exacerbations 
with  almost  complete  remissions;  also  the  false  membrane  can  generally  be 
seen  /'"  situ  or  attached  t<>  surrounding  tissues.  A  foreign  body  may  give 
rise  to  many  of  the  symptoms  of  acute  subglottic  laryngitis  ;  but  the  history, 

ther  with  an  examination  by  means  of  either  the  mirror  or  the  index 
finger,  will  generally  clear  up  the  diagnosis.  Perichondritis  of  the  cricoid 
cartilage  i-  more  difficult  to  exclude:  but  with  the  aid  of  the  laryngoscope 
the  irregular  nodulated  swellings,  generally  unilateral,  can  he  seen  and  easily 
recognized. 

The  disease  runs  a  course  of  from  six  to  twelve  days,  and,  as  a  rule,  is  not 
dangerous,  a   fatal   termination   being  very  rare. 

Treatment. — The  general  health  of  the  patient  should  he  considered. 
The  strumous,  lymphatic  child,  subject  to  attack-  of  croup,  should  he  toned 
up  with  syrup  of  the  iodid  of  iron  and  cod-liver  oil.  The  passages  above 
should  he  looked  after  with  care  and  relieved  if  found  in  an  unhealthy  con- 
dition. During  an  attack  the  child  should  he  confined  in  a  warm  and 
moisture-saturated  atmosphere;  the  bowels  should  be  acted  on  by  repeated 
-mall  doses  of  calomel  ;  while  internally  the  ammonias  and  small  doses  of  an 
opiate  should  he  administered  to  stimulate  the  secretion  of  mucus  and  to 
allay  the  irritating  and  exhausting  cough.  During  the  acute  paroxysms  at 
night  every  effort  should  he  made  to  soften  and  expel  the  dried  mucus 
and  to  moisten  ami  soothe  the  dry,  irritable,  and  inflamed  mucous  membrane. 
With  tin-  end  in  view  we  may  use  a  hot  bath,  steam-inhalations,  or  hot 
fomentations,  and  these  failing,  excite  free  emesis  by  tickling  the  fauces  with 
tin'  finger  or  a  brush;  or  by  administering  an  emetic,  such  as  ipecac.  If  the 
attack  is  extremely  severe  or  there  is  dangerous  dyspnea,  inhalations  of 
ether  or  amy]  nitrite  may  he  given,  the  O'Dwyer  tube  introduced,  or  the 
trachea    may  lie   opened. 

ACUTE  PHLEGMONOUS  OR  EDEMATOUS  LARYNGITIS. 

Much  confusion  in  classification  is  encountered  in  the  literature  of  this 
disease.  Cohen l  describes  edema  and  acute,  chronic,  infraglottic,  and  hem- 
orrhagic edematous  laryngitis  :  while  the  different  forms  of  the  disease  arc 
divided  byMackenzie2  into  typical,  contiguous,  and  consecutive  edematous 
laryngitis.  Ziemssen3  recognizes  only  one  form,  laryngitis  phlegmonosa; 
while  Grottstein  '  and  Schrotter5  describe  acute  and  chronic  submucous  laryn- 
gitis and  acute  ami  chronic-  edematous  laryngitis.  Browne6  acknowledges 
only  acute  :1ml  chronic  inflammati f  the  submucous  tissues. 

The  presence  or  absence  of  high  temperature  and  other  acute  inflamma- 
tory symptoms  render-  this  disease  clearly  divisible  into  two  general  forms — 
acute  phlegmonous  laryngitis  and  simple  edematous  laryngitis.  The  occur- 
rence of  either  form   ie   rare,  the  latter  especially  so. 

Acute  Phlegmonous  Laryngitis. — This  is  an  acute  inflammation 
of  the  laryngeal  mucous  membrane,  to  which  i-  added  edema  due  t"  serous 
effusion.     The  edema   here  follows  the  characteristic  course  of  inflammatory 

Diem*    oj  tfu    Throat  and  Vn  al  Pa     ■■:■  .  2d    I  d 
/'   ea  .    oj  tfu    Throat  and  Vb»e,    American  Ed.,  vol.  i.  p.  '-'77. 
'  '/  \ ni'  rican  Ed.,  vol.  vii.  p.  7'.'l . 

'  /'/•   Krankheilen  da  Kehlkopfi  .   1 —  Vo  lesnngen  uber  den  Krank.  dt   A'.////..  1887. 

/       /'■    .  \i  and  No  •  and  lh*  ■     I  >      ■        Id    Ed.    I  390. 


EDEMA    OF  THE  LARYNX.  989 

edema  in  other  tissues  and  exhibits  the  different  stages  of  serous,  sero- 
purulent,  and   purulent  edema. 

Etiology. —  In  addition  to  cold,  the  usually  assigned  cause,  there  is 
undoubtedly  exposure  to  some  septic  infection.  Such  an  authority  a-  Mac- 
kenzie states  that  he  never  encountered  a  case  except  of  ~« •  | >t  i< ■  origin. 
Virchow  considers  it  a  true  erysipelas  of  the  larynx.  It  is  indeed  usually 
found  among  hospital  physicians  and  nurses,  undoubtedly  the  most  exposed 
class  of  people.  It  is  very  rare  as  a  primary  condition,  being  found  gen- 
erally secondary  to  quinsy,  abscess  of  the  neck,  follicular  pharyngitis,  and 
tonsillitis,  or  complicating  an  attack  of  typhoid,  typhus,  variola,  or  diph- 
theria. It  may  develop  at  any  age,  but  is  usually  found  between  twenty 
and   forty. 

The  same  morbid  changes  are  found  as  in  inflammatory  edema  of  mucous 
membranes  elsewhere.  There  is  first  vascular  engorgement  followed  by 
serous  effusion,  the  swelling  being  most  marked  where  the  membrane  is 
most  relaxed — that  is,  in  the  aryepiglottio  folds,  ventricular  bands,  ami 
the  epiglottis  posteriorly.  At  first  serous,  the  effusion  gradually  becomes 
purulent. 

Symptoms. — A  slight  chill  accompanied  by  a  corresponding  rise  of  tem- 
perature is  rapidly  followed  by  decided  impairment  or  loss  of  voice,  with 
dyspnea  and  stridulotts  breathing.  The  condition  is  progressive,  the 
dyspnea  developing  within  twelve  hours,  growing  steadily  worse;  for  twenty- 
four  to  thirty-six  hours,  when  it  reaches  its  maximum.  There  is  pain  and 
soreness  on   pressure  or  swallowing,  and  cough  is  not  often  present. 

Diagnosis.— This  disease  can  only  be  confounded  with  the  presence  of 
a  foreign  body  or  an  attack  of  simple  edema.  The  history  of  the  case  and 
the  use  of  the  mirror  should  prevent  mistakes.  Vou  will  see  the  red,  tense, 
and  glossy  membrane  with  three  rounded  swollen  masses  of  tissue  above  the 
small  triangular  opening  of  the  glottis. 

Prognosis. — This  is  a  disease  of  rapid  development.  It  run-  a  shorl 
course  of  four  or  five  days,  the  extent  and  severity  of  the  symptoms 
varying  largely.  If  at  the  end  of  thirty-six  hours  the  dyspnea  has  not 
become  dangerous,  the  case  will  spontaneously  resolve.  Until  this  time. 
however,  it  should  be  closely  watched,  as  symptoms  sufficiently  alarming  to 
demand   surgical   interference   may  occur  at   any  moment. 

Treatment  is  at  first  the  use  of  the  ice-bag  or  Leber  coil  to  the  larnyx, 
with  local  depletion  (leeches)  externally,  and  free  and  frequent  scarification 
of  the  swollen,  inflamed  mucous  membrane  within.  The  atmosphere  should 
be  warm  and  saturated  with  moisture,  and  only  such  drugs  as  will  -timu- 
late  secretion  should  be  administered.  When  serious  symptoms  develop  so 
suddenly  as  to  prevent  tracheotomy,  the  introduction  of  a  -mall  laryngeal 
catheter  i-  advised  1»\    Macewen. 

EDEMA  OF  THE  LARYNX. 

Under  tin-  name  is  considered  that  morbid  condition  which  presents  a 
simple  edema  of  the  mucous  membrane  of  the  larynx,  without  inflammation, 
ami  which  is  certainly  secondary  to  a  more  serious  general  condition. 

Etiology. — Some  morbid  change  in  the  kidneys,  heart,  or  liver,  an 
obstruction  to  the  return  circulation  in  the  neck,  a  vaso-motor  paresis,  or  any 
general  or  local  condition  which  tends  to  produce  dropsical  effusion  may  be 
the  cause  of  tin-  disease.  There  is  an  escape  of  normal  healthy  serum 
into  the  submucous  tissues,   producing  general   swelling  ol     the  parts  and 


990    ACUTE  AFFECTIONS  OF  THE  LARYNX  AND   TRACHEA. 

noticeable  tumefaction  in  the  relaxed  portions  of  the  mucous  membrane,  the 
aryepiglottic  folds  on  each  side,  and  the  epiglottis  in  front  and  above. 

Symptoms. — The  onset  is  sudden.  There  will  be  loss  of  voice,  with 
great  difficulty  in  breathing,  inspiration  being  more  difficult  than  expiration. 
There  is  little  pain,  soreness,  or  cough. 

The  diagnosis  is  easily  made  by  the  history  of  the  ease  and  laryngo- 
scopy examination. 

The  prognosis  is  always  grave.  Death  from  the  laryngeal  stenosis  is 
liable  to  occur  and  very  quickly  :  but  even  should  this  he  controlled,  the 
genera]   condition   is  almost    invariably  of  an  organic  nature  and   incurable. 

Treatment. — Efforts  should  be  made  to  control,  at  least  temporarily, 
the  systemic  cause,  free  diaphoresis  or  catharsis  is  indicated,  while  local 
puncturing  of  the  swollen  tissues  freely  should  be  frequently  done.  This 
not  availing,   resort   should   be  had  to  tracheotomy. 

CROUPOUS  LARYNGITIS. 

Synonyms. — Croup  ;  Membranous  laryngitis. 

It  would  hardly  prove  profitable  to  enter  into  the  active  discussion  that 
has  been  carried  on  for  many  years  past  regarding  the  unity  or  duality  of 
croup  and  diphtheria.  Perhaps  the  weight  of  modern  evidence  tends  to  the 
belief  thai  croupous  laryngitis  is  a  local  affection  with  some  general  disturb- 
ance; while  diphtheria  is  a  general  systemic  disease  with  local  expression. 
It  i-  not  yet  demonstrated,  but  largely  a  matter  of  opinion  gained  from  per- 
sonal observation  and  experience.  The  literature  on  the  subject  is  most  con- 
fusing. Statistics  in  general  are  not  to  be  depended  on,  and  even  mortality 
statistics  are  unreliable  owing  to  frequently  varying  opinion.  While  there 
are  many  point-  of  similarity,  there  are  also  enough  elements  of  distinction 
to  warrant  the  consideration  of  croupous  laryngitis  as  a  disease  distinct  from 
diphl  heria. 

Etiology. — 'I 'hat  there  i-  at  least  some  similar  or  analogous  causative 
element  in  this  disease  to  diphtheria  cannot  be  denied.  In  diphtheria 
proper  it-  distinctive  germ  can  generally  be  detected  ;  while  although  the 
germ  of  non-diphtheritic  croup  ha-  not  vet  been  separated,  the  possibility 
and  probability  of  its  future  discovery  had  not  been  abandoned.  It  is  likely 
that  a  germ  find-  lodgement  in  the  pharynx,  tonsils,  or  larynx,  which  excites 
an  inflammatory  process  with  certain  well-marked  and  peculiar  characteris- 
tic-. The  disease  may  commence  above  in  the  pharynx  or  fauces,  progress 
downward,  and  attack  the  laryngeal  mucous  membrane  secondarily.  It  is 
selective,  and  age  and  susceptibility  play  important  parts.  True  croupous 
laryngitis  is  practically  unknown  in  adult  life,  while  it  is  most  common 
between  tin-  ages  of  one  and  nine  years,  rapidly  diminishing  in  frequency 
from   this  time  on. 

Pathology. — -The  membrane  consists  essentially  of  two  layers — a  super- 
ficial, consisting  of  the  epithelium  that  ha-  proliferated  and  undergone 
mucoid  degeneration,  ami  a  deeper,  composed  of  fibrinous  strata,  with  numer- 
oii-  leukocytes  -<  altered  throughout  it-  layers. 

Symptoms. — At  first  there  is  generally  slight  catarrh,  with  some  rise 
of  temperature  and  a  general  feeling  of  languor;  there  may  or  may  not 
bav<  been  a  chill.  Loss  of  appetite  and  persistent  thirst  accompany  painful 
deglutition.  The  pulse  ifi  full  and  the  skin  hot  and  dry.  After  a  few  hours 
there  i-  slight  hoarseness,  and  later  a  short,  dry,  shrill  couch;  the  voice 
I"  comes  more  impaired  and  assumes  a  w  hispering  character.     Then  interfer- 


DIPHTHERIA.  991 

ence  with  respiration  appears  and  there  is  some  laryngeal  stridor.  The 
mucous  membrane  is  bright  wi\,  and  may  show  some  patches  of  false  mem- 
brane. These  symptoms  usually  occupy  the  first  twenty-four  to  forty-eight 
hours  of  the  disease  and  are  followed  by  attacks  of  dyspnea.     The  voice  is 

lost,  the  face  is  red  and  anxious,  there  is  a  hoarse,  stilled  cough,  with  little  or 
no  expectoration.  The  attacks  at  first  last  hut  a  lew  moments  and  subside, 
although  the  stridor  remains.  The  pulse  increases  in  rapidity  and  is  irreg- 
ular. The  attacks  of  dyspnea  become  more  and  more  frequent  until  they 
are  practically  constant,  with  no  remissions  and  occasional  aggravation  of 
the  symptoms.  From  time  to  time  pieces  of  the  membrane  are  coughed  up. 
The  struggle  tor  Wreath  becomes  each  moment  more  painful  and  exhausting, 
and  finally  death  supervenes  from  suffocation. 

Diagnosis. — True  croup  must  he  differentiated  from  acute  catarrhal 
laryngitis  of  severe  form  and  from  diphtheria.  In  the  former  there  is 
absence  of  the  membrane,  frequent  cough,  the  attacks  come  on  only  at  night, 
and  there  are  absolute  and  prolonged  periods  of  rest  with  complete  absence 
of  dyspnea. 

For  the  differentiation  from  diphtheria,  see  the  article  on  that  disease. 

Prognosis. — This  is  a  most  serious  disease:  death  may  occur  at  any 
time   from   dyspnea. 

Treatment. — This  should  be  both  local  and  constitutional.  Internally 
the  preparations  of  mercury  should  be  administered.  They  can  he  given  in 
frequent  and  increased  doses.  The  salts  of  iron,  notably  the  tincture,  are 
most  valuable.  Locally  ice  may  be  used  in  the  form  of  the  pack,  and  small 
lumps  may  be  swallowed.  Sprays  of  lactic  acid  and  persulphate  of  iron  are 
also  valuable.  The  chief  danger  to  be  guarded  against  is  suffocation;  so 
everything  should  be  in  readiness  for  the  performance  of  intubation  or  tra- 
cheotomy, and  interference  when  demanded  should  not  be  delayed.  An 
expert  in  both  operations  will  generally  select  the  former  procedure  as  being 
simpler,  more  rapid  and  less  dangerous  in  itself,  knowing  that  should  intuba- 
tion fail,  the  trachea  can  then  be  opened. 

DIPHTHERIA.1 

This  is  an  acute  infectious  disease  having  local  manifestations  in  the 
upper  air-passages. 

It  has  been  known  and  studied  from  the  earliest  times,  but  no  absolute 
evidence  as  to  its  causation  was  produced  until  1868,  when  Oertel  made  the 
announcement  of  the  presence  of  a  micrococcus  in  the  exudate  that  is  charac- 
teristic of  this  disease  alone.  This  view  was  confirmed  by  many  other  inves- 
tigators, notably  Recklinghausen,  Prudden,  and  Wood  and  Formad,  who  carried 
on  many  elaborate  culture-experiments  ;  but  until  the  announcement  l>v 
Kleb-  and  Loffler  of  the  definite  microscopic  character-  of  the  bacillus  which 
i-  peculiar  to  this  morbid  process,  the  discussion  was  not  set  at  rest. 

Etiology. — A  diphtheritic  attack  is  undoubtedly  precipitated  by  a 
deposil  of  the  Klebs-Loffler  bacillus  upon  the  faucial  or  laryngeal  mucosa. 
There,  finding  a  favorable  culture-medium,  it  sets  up  its  peculiar  inflamma- 
tory process;  and  as  the  result  of  the  life-functions  of  the  bacilli  there  is 
generated  a  ptomaiii  that,  absorbed  by  the  capillaries,  enters  the  general  cir- 
culation and  produces  the  constitutional  symptoms.  Tin-  theory,  first 
advanced  by  Cheyne,  was  subsequently  confirmed  by  Brieger  and  Frankel, 
who   injected   in  rabbits  the  liltrate  id'  the  diphtheritic  membrane,  entirely 

page  1010.     Tin'  different  standpoints  <>t'  the  two  writers  3eem  to  justify  duplication. 


992    ACUTE  AFFEl  TIONS  OF  THE  LARYNX  AND   TRACHEA. 

separated  from  the  bacilli,  and  reproduced  the  genera]  disease,  Imt  without 
the  local  laryngeal  manifestations. 

A  very  large  majority  of  cases  occur  in  childhood,  and  at  least  seventy- 
five  per  cent,  prior  to  the  age  of  ten  years.  Cold  and  damp  climates  and  the 
periods  of  the  year  when  these  conditions  prevail  undoubtedly  predispose  to 
the  disease.  All  catarrhal  processes,  enlarged  tonsils,  the  presence  of  adenoid 
growths  or  diseased  nasal  fossae  render  one  more  liable  to  the  infection. 
Absence  of  sanitary  surroundings  is  an  important  element,  the  disease  having 
undoubtedly  a  filth-origin  and  the  bacillus  thriving  l>est  in  the  neighborhood 
of  sewers,  street-cuttings,  turned  earth,  and  locations  shut  oil'  from  sunlight. 
Diphtheria  i>  both  contagious  and  infectious;  it  may  attack  individuals,  it 
mav  develop  only  in  a  limited  community  from  some  special  local  origin,  or 
it  may  be  epidemic  and  spread  over  a  very  wide  area  ;  hut  wherever  and 
whenever  it  makes  its  appearance,  it  i-  without  doubt  (\\\v  to  the  presence  of 
it-  own  specific  organism. 

It  may  be  carried  in  clothes,  in  letters,  or  in  the  furnishings  of  railway- 
carriages  ;  while  drinking-water  and  milk  are  favorable  transportation- 
mediums.  It  is  a  disease  common  to  the  lower  animals,  and  a  pet  animal 
will  often  convey  it  to  it-  owner.  There  i-  no  question  as  to  the  vitality  of 
this  germ,  but  its  activity  must  be  somewhat  restricted.  ]t  will  be  found 
redeveloping  in  hospital-wards  years  after  their  abandonment  and  thorough 
disinfection  ;  but  the  area  of  it-  activity  must  be  limited  when  you  realize 
that  all  cities  and  large  towns  are  the  best  breeding-places  for  the  bacillus, 
and  yet  the  number  of  cases  occurring  each  year  represents  but  about  one  to 
every  thousand  of  population.  The  danger  of  breath-transmission  is  small, 
the  secretions  retaining  the  bacilli  ;  yet  small  particles  may  be  thrown  out  by 
coughing  or  sneezing,  and  these  deposited  on  some  mucous  surface  will  serve 
to  propagate  the  disease. 

Pathology. — The  bacillus,  finding  lodgement  on  the  mucous  membrane, 
reproduce-  it-elf  with  great  rapidity.  It  force-  its  way  into  and  through  the 
epithelial  layer-  into  the  mucosa,  causing  inflammation  of  that  membrane. 
There  is  dilatation  of  the  blood-vessels,  exudation  of  serum,  and  escape  of 
the  leukocyte-.  The  epithelial  cells  proliferate,  and  uniting  with  the  fibrin, 
which  coagulates  mi  exposure  to  the  air,  form  the  \\\\>c  membrane.  Thus 
will  be  -ecu  a  pathological  process  identical  with  croupous  inflammation, 
except  tor  the  presence  of  a  specific  organism  (Bosworth).    The  inflammatory 

process  is  so  energetic,  the  fibri i-  bands  contract  so  rapidly,  that  necrosis 

of  the  false  membrane, as  well  as  of  the  superficial  layer-  of  the  true  mucosa, 
will  take  place,  and  sloughs  will  form  and  be  thrown  off,  leaving  the  raw 
and  bleeding  surface  exposed.  The  membrane  quickly  re-forms  on  these 
spaces  "i'  resolution  takes  place.  In  mild  cases  the  false  membrane  is  very 
thin  and  superficial  and  penetrates  to  yen  little  depth;  while  in  malignant 
cases  the  entire  mucous  membrane  may  be  infiltrated.  A-  a  rule,  the  exudate 
first  appears  on  the  tonsils  or  faucial  arch.  It  may  extend  into  the  nasal 
-pan-  l.nt.  a-  a  rule,  it  passes  downward,  involving  the  pharynx,  larynx, 
trachea,  and  even  extending  into  the  bronchi.  When  in  the  lower  air-passages, 
the  false  membrane  assumes  more  the  croupous  form,  penetrating  but  slightly 
into  the  mucous  tissue.  Some  of  the  organs  sho\i  slight  changes:  the 
kidney- and  liver  may  be  somewhal  enlarged  and  minute  hemorrhages  may 

be  found  :    while  in  the   brain  and    spinal  cord  minute  extravasations  of  blood 

are  found  scattered  throughout  their  tissue. 

Symptoms.  -In  direct  contagion  the  period  of  incubation  is  very  -h<>rt. 
urn  more  than  thirt\--i\   hours  ;  where  the  infection  i-  conveyed,  it   mav  be 


DIPHTHERIA.  993 

much  longer,  varying  from  three  to  ten  days.    Experimental  inoculation  may 

develop  the  disease  in  twelve  hours.  In  a  typical  attack  of  the  disease  yon 
will  have  the  false  membrane  not  only  involving  the  tonsils  and  fauces,  but 
penetrating  the  larynx,  and  in  addition  the  serious  constitutional  disturbance 
caused  by  the  toxic  absorption.  There  may  be  the  general  prodromal 
symptoms  of*  malaise,  restlessness,  and  loss  of  appetite.  Souk  time-,  there 
is  vomiting  and  ureat  nervous  excitement,  even  convulsion.-.  The  direct 
onset  of  the  disease  is  marked  by  a  chill  or  chilly  sensation,  followed 
by  mild  febrile  disturbance,  dry,  Hushed  skin,  headache,  and  -canty, 
highly  colored  urine.  The  mental  processes  are  unusually  dulled,  and 
the  patient  often  lies  in  a  half-stupid  condition.  The  febrile  reaction  i-  not 
severe,  the  temperature  rarely  rising  above  1<>2°  F.  The  heart's  action  is  weak 
and  rapid.  Accompanying  these  symptoms  there  will  be  dryness  of  the 
throat,  some  pain  and  difficulty  in  swallowing,  and  soreness  and  tenderness 
in  the  tissues  of  the  neck.  At  the  end  of  twelve  hours,  if  the  throat  i- 
examined,  thin  circumscribed  patches  of  whitish  or  pearl-colored  membrane 
will  be  seen  on  the  tonsils  or  fauces;  and  at  the  end  of  twenty-four  hours 
these  patches  will  have  completely  covered  the  tonsils  and  assumed  the  char- 
acteristic yellowish  and  velvety  appearance.  The  mucous  membrane  is  in- 
tensely injected  and  somewhat  discolored.  Within  three  days  a  purulent  or 
muco-purulent  discharge  sets  in,  the  membrane  continues  to  spread,  the  edges 
become  ragged,  and  sloughing  begins.  If  the  membrane  progresses  upward, 
the  soft  palate  swells,  the  uvula  becomes  edematous,  and  the  nasal  passages 
become  occluded  by  a  mass  of  membrane  and  muco-purulent  secretions;  the 
tongue  becomes  dry  and  brown  ;  the  breath  fetid  from  the  necrotic  membrane 
and  decomposition  of  the  secretions.  About  this  time  the  serious  symptoms 
of  laryngeal  involvement  will  appear.  There  will  be  another  rise  in  tem- 
perature, the  voice  changes,  and  the  development  of  dyspnea,  as  shown  In- 
increased  inspiratory  effort,  the  subclavicular  depression,  and  the  fixation  of 
the  chest-muscles.  The  laryngeal  obstruction  is  due  to  the  narrowing  of  the 
passage  by  the  exudation,  and  perhaps  in  part  by  muscular  paresis.  In  the 
larynx  the  membrane!  is  more  characteristic  of  the  croupous  deposit,  except  in 
spots  (Prudden)  where  it  invades  the  mucous  tissue.  If  life  lie  prolonged 
for  two  or  three  days  the  membrane  may  become  separated,  and  at  time-  a 
membranous  cast  of  the  trachea  will  be  thrown  off.  Resolution  may  take 
place  as  in  the  upper  part  of  the  pharynx,  or  similarly  there  may  be  a  fresh 
exudate.  This  may  be  considered  as  a  description  of  a  case  of  moderate 
severity.  In  the  simpler  forms  there  may  be  very  slight  systemic  disturb- 
ances; and  the  false  membrane,  if  any,  thin,  almost  transparent,  and  consist- 
ingof  a  few  scattered  patches.  In  the  malignant  form  the  attack  will  be  charac- 
terized by  profound  symptoms  of  toxic  absorption.  The  usual  features  ot 
blood-poisoning  will  be  noticed  ;  and  indeed,  in  a  case  of  this  class,  the  vital 
powers  will  apparently  be  overcome  almost  from  the  onset  by  the  virulence 
of  the  poison.  Convulsions  or  low.  muttering  delirium  may  be  constant; 
there  will  be  absence  of  tendon-reflex  ;  rapid,  feeble,  and  irregular  pulse,  or  a 
condition  of  semi-coma. 

Diagnosis. — It  is  chiefly  sessary  to  make  the  distinction  between  this 

disease  and  membranous  croup.  In  the  early  stages  this  may  be  attended 
with  some  difficulty.  The  croupous  membrane  is  thin,  of  a  whitish  color. 
with  a  glazed,  shining  surface,  and  can  be  easily  wiped  away  without  irritating 
the  surface  beneath;  the  diphtheritic  membrane  i- thicker,  ha-  a  soft,  vel- 
vety appearance,  a  yellowi-h-brown  color,  and  i-  so  adherent  to  the  mucous 
tissue  that  it-  removal  is  not  easy,  and  will  leave  a  raw  and  bleeding  surface 
63 


ft!' I     ACUTE  AFFECTIONS   OF   THE   LARYNX  AND    TRACHEA. 

beneath.  Later  in  the  diphtheritic  process  there  will  be  fetor,  a  profuse 
iniim-purulent  discharge,  and  the  dirty  bluish-black,  ragged,  necrotic  mem- 
brane. The  croupous  membrane  undergoes  uo  change  until  the  end  ;  it  con- 
tinue- clean  and  white,  and  has  no  mucous  or  purulent  discharge.  In  recent 
times  the  true  scientific  method  for  determining  the  presence  of  the  diph- 
theritic process  lias  been  followed.  Knowing  with  what  rapidity  the  Klebs- 
Lbffler  bacillus  multiplies,  a  small  portion  of  the  exudate  is  transferred  from 
the  throal  to  a  properly  prepared  culture-tube  partly  rilled  with  peptone, 
bouillon,  or  blood-serum.  In  twenty-four  hours  colonies  of  the  bacilli  will 
form  that  can  be  recognized  by  the  naked  eye,  and  the  bacilli  can  be  demon- 
strated under  the  microscope.  This  plan,  so  simple,  safe  and  certain,  is  being 
rapidly  adopted  by  the  entire  profession  ;  and  mosl  of  the  large  cities  employ 
a  competent  bacteriologist,  a  large  part  of  whose  duty  it  is  to  make  these 
investigations. 

Prognosis. — Diphtheria  i>  rightly  regarded  as  one  of  the  most  fatal  of 
diseases.  The  mortality-rate  is  large,  and  there  are  many  complications  and 
sequela?.  Until  very  recently  the  mortality-rate  varied  from  40  to  <><)  per 
cent.  Under  the  influence  of  the  treatment  by  antitoxin  this  has  fallen  to 
from  1  2  to  20  per  cent.  Two  causes  are  active  in  producing  a  fatal  termina- 
tion, the  asphyxia  secondary  to  laryngeal  stenosis  and  the  overwhelming  of 
the  nerve-centers  and  organs  l>v  the  blood-poison.  The  toxic  effects  may  he 
marked  in  the  mildest  form  of  the  disease  as  well  as  in  the  most  virulent. 
There  may  lie  much  interference  with  the  cardiac  function,  due  to  the  action 
of  the  poison  on  the  nervous  centers  controlling  it,  or  there  may  he  instant 
cessation  of  the  heart's  action,  due  to  the  overwhelming  effect  of  the  poison 
upon  the  heart-muscle  itself.  Ajnong  the  most  important  complications  and 
sequelae  may  he  noted  albuminuria,  bronchitis,  changes  in  the  abdominal  vis- 
cera, purulent    infla lation  of  the  middle  ear,  and    paralysis  of  the  various 

muscles. 

Treatment. — The  two  point-  to  he  kept  in  mind  in  the  treatment  of 
diphtheria  are  to  prevent  the  spread  of  the  local  process  and  to  control  the 
systemic  effects  of  the  ptomain-poison.  In  consequence,  there  should  he 
systematic  local  and  constitutional  treatment.  Innumerable  preparations 
have  been  used  locally,  and  among  them  may  he  mentioned  solutions  of 
bichlorid  of  mercury,  even  a-  strong  as  1  part  to  500  (Sternberg),  carbolic 
acid  from  5  io  30  per  cent.  ( Ranlin  |,  lactic  acid  from  •"><>  to  oil  per  cent.  ( P>os- 
worth),  the  persulphate  or  perchloric!  of  iron  i  Bosworth),  the  nitrate  of  silver 
5  to  10  per  cent.  (Trousseau),  hydrochloric  acid,  nitrate  of  mercury,  chlorid 
of  zinc,  bromin  ( I  5  per  cent.),  solution  of  pancreatin,  trypsin,  and  other 
digestive  ferments,  the  officinal  aq.  calcis,  the  peroxid  of  hydrogen  by  spray 
and  inhalation — all  of  these  applications  have  their  advantages,  and  each  it> 
special  and  ardent  advocates.      The  application  should  he  made  only  under 

e I   illumination  and  with   the  greatesl  care.      The  objeel  of  various  local 

applications  is  to  destroy  the  pathogenic  organism  by  direct  action;  in  con- 
sequence, they  should  he  applied  directly  to  and  around  the  margins  of  the 
membranous  deposits.  Internal  medication  is  indicated  to  combat  the  effects 
of  the  poison  by  sustaining  the  resisting  power-  of  the  system.  The  prepa- 
rations of  alcohol  are  undoubtedly  besl  for  this  purpose,  and  whiskey  and 
brandy  should  he  freely  and  frequently  administered.  The  tincture  of  iron 
in  large  doses  is  most  important,  while  such  drugs  a-  digitalis,  strophanthus, 
carbonate  of  ammonia,  and  musk,  especially  support  the  heart's  action.  The 
mercurial  treatment  is  strongly  advocated  by  eminenl  and  experienced 
observers,  the    mild    chlorid,  the    corrosive  chlorid,  and    the    cvanid    each 


A  CUTE  PERICHOXh  R I TIS.  UU ■'> 

having  its  supporters.  Various  antiseptic  sprays  have  been  found  ex- 
tremely useful,  and  will  come  in  contact  with  diseased  tissues  beyond  the 
reach  of  direct  applications.  The  constant  use  of  steam,  l»<»th  in  the  atmo- 
sphere and  by  inhalation,  prevents  the  dissemination  of  the  germs,  keeps  the 
surface  of  the  tissues  moist,  and  enables  the  gangrenous  membrane  to  separate 
more  readily.  The  recent  introduction  of  antitoxin  in  the  treatment  of 
diphtheria  marks  an  important  advance.  It  is  too  early  as  yet  t<>  decide 
upon  the  ultimate  value  of  this  method.  It  is  claimed,  however,  thai  the 
mortality  has  been  so  greatly  reduced  by  its  use  as  to  remove  the  fear  here- 
tofore felt  for  this  dread  disease. 

After  every  effort  has  been  made,  every  method  tried,  a  very  large  pro- 
portion  of  cases  will  still  show  that  the  laryngeal  stenosis  is  progressing,  and 
without  surgical  interference  there  is  imminent  danger  of  suffocation.  We 
may  then  choose  between  opening  the  air-passages  or  introducing  an  intra- 
laryngeal  tube.  The  individual  experience  of  the  operator  will  decide  which 
method  to  follow  :  either  may  be  relied  upon  to  give  temporary  relief ;  but 
the  progressive  advancement  of  the  disease  will  overcome,  at  times,  every 
effort   made  (see  page  1029). 

LARYNGISMUS  STRIDULUS. 

Synonym. — Spasm  of  the  glottis. 

This  condition  is  more  a  symptom  than  a  disease.  It  is  a  spasmodic 
closing  of  the  glottis,  purely  neurotic  in  its  character. 

Htiology. — It  may  occur  at  any  age,  but  is  most  frequently  found  in 
children,  especially  if  they  are  ill-nourished  or  rachitic.  The  spasm  is  usu- 
ally brought  on  by  something  that  nervously  unbalances  the  child — loud  talk- 
ing, coughing,  teasing,  irritating,  or  perhaps  a  drop  of  water  or  milk  finding 
its  way  into  the  larynx  during  feeding. 

Symptoms. — There  are  two  or  three  labored  efforts  at  inspiration,  fol- 
lowed by  total  cessation  of  breathing.  This  may  pass  in  a  moment  and 
respiration  be  resumed.  The  spasm  may  continue,  the  glottis  never  relax, 
and  death  at  once  supervene.  There  may  be  but  one  attack,  or  there  may 
be  several  before  the  fatal  issue  ;  and  there  may  be  general  systemic  convul- 
sions. There  is  no  recognized  pathological  change  whatever.  The  disease 
is  instantly  understood  even  by  the  inexperienced. 

Treatment. — Sudden  shock,  slapping  the  sides  and  back,  dashing  cold 
water  on  the  naked  body  and  face,  the  application  of  strong  ammonia  or  amy] 
nitrite  to  the  nose,  or  forcing  a  catheter  or  intubation-tube  pasl  the  obstruction 
in  the  larynx. 

ACUTE  PERICHONDRITIS. 

Acute  inflammations  of  the  perichondrium  of  the  laryngeal  cartilages 
are  occasionally  met  with. 

Ktiology. — The  cause  may  be  idiopathic,  or  the  disease  maj  follow 
typhoid,  typhus,  diphtheria,  pneumonia,  or  any  <>f  the  exanthemata.  Syph- 
ilis is  a  very  prevalent  cause.  The  pathology  is  the  same  as  that  "I'  a  peri- 
chondritis in  any  location.  Increased  vascularity,  followed  by  swelling, 
effusion,  and  pus-formation,  separating  the  perichondrium  from  the  cartilage. 

Symptoms. — There  i-  usually  some  systemic  disturbance,  a  feeling  «»t' 
malaise,  chill,  etc.,  followed  by  a  slight  rise  of  temperature,  with  a  sense  of 
fulness  in  the  larynx,  soreness,  pain  on  -wallow  in-,  slight  dyspnea,  and  more 
or  less  loss  of  phonation.  The  local  symptoms  depend  largely  upon  the 
extent  of  inflammation  and  the  particular  cartilages  involved. 


996    ACl  TE  AFFECTIONS  OF  THE  LARYNX  AND    TRACHEA. 

When  the  cricoid  cartilage  is  the  seat  of  the  trouble  dyspnea  and  loss 
of  phonation  are  the  principal  symptoms.  There  may  be  cough.  In  affec- 
tion of  the  arytenoid  there  is  some  slight  dyspnea  and  impairment  of  voice; 
Win  interference  with  deglutition  is  the  principal  symptom. 

When  the  thyroid  i-  involved  it  is  usually  unilateral,  and  interference 
with  phonation  is  the  principal  symptom.  The  voice  is  never  entirely  lost, 
luit  becomes  very  hoarse.  There  may  !>e  a  purulent  discharge  through  a 
fistula   in   the   neck. 

Diagnosis. — This  is  often  made  with  very  great  difficulty.  Careful 
and  thoughtful  consideration,  with  frequent  examinations  with  the  laryngo- 
scope,  will  enable  one  to  detect  the  diseased  cartilage  or  exclude  the  diseases 
simulating  it.     These  are  croupous  laryngitis  and  acute  catarrhal  laryngitis. 

Prognosis. — -There  may  result  necrosis  of  the  cartilage,  with  fistulous 
passages  to  the  surface.  There  is  final  resolution  usually,  with  some  per- 
manent  voice-changes.     There  is  little  real  danger  to  life. 

Treatment  should  lie  the  administration  of  mercury  and  iodid  of  potas- 
sium, and  surgical  measures  may  be  called  for  from  time  to  time  to  curette  or 
scarify  the  tissues  internally  or  to  open  pus-sacs  or  fistulous  passages. 

HEMORRHAGIC  LARYNGITIS. 

Hemorrhages  into  the  larynx,  or  the  so-called  hemorrhagic  laryngitis,  is 
an  extremely  rare  condition,  unless  secondary  to  ulcerative  processes  such  as 
an-  found  in  syphilitic  or  cancerous  diseases.  Turek  cites  a  case  as  occurring 
from  syphilitic  ulceration  and  Mackenzie  describes  it  as  one  of  the  symptoms 
of  acute  laryngitis.  The  only  point  of  practical  importance  is  to  determine 
whether  the  bleeding  i-  from  the  larynx  or  the  bronchial  tubes;  as  in  the 
former  case  it  i-  of  little  consequence,  while  in  the  latter  it  is  an  indication 
of  probable  tubercular  changes. 

ACUTE  CATARRHAL  TRACHEITIS. 

Tin-  development  of  an  acute  inflammatory  process  localized  solely  in 
the  trachea  i-  indeed  of  v<  r\  rare  occurrence.  That  this  structure  take- 
part  in  every  severe  inflammation  that  involves  the  larynx  and  fauces  above 
and  the  bronchial  tubes  below  may  he  expected,  both  from  it-  direct  connec- 
tion and  similarity  of  structure.  That  acute  catarrhal  tracheitis  doe-  occur, 
however,  alone  and  idiopathically,  is  undoubtedly  true ;  and  it  runs  a  course 
parallel  to  and  of  the  same  character  and  intensity  as  diseases  of  like  nature 
in  the  tissues  above  and  below.  It  i-  almost  invariably  of  a  catarrhal  form, 
and  i-  followed  very  rapidly  by  an  extension  of  the  disease  to  the  larynx 
and  bronchi. 

Etiology. — The  causation  w  hen  it  develops  independently  is  the  same  as 
in  the  neighboring   structures.     There  i-  the  usual  predisposition  dependent 

upon  chronic  changes   in  the  hum s  tissues  above,  and  exposure  serves  to 

light  up  the  process.  It  i-  in  reality  almost  always  an  extension  downward 
of  ;i  laryngeal  catarrh  that  ha-  itself  extended  from  above.  In  youth  it  is 
gi  Derail}  consequent  upon  an  acute  rhinitis;  while  in  later  life  it  i-  secondary 
to  a  bronchial  catarrh.  It  may  occur  at  any  age;  and,  like  other  inflamma- 
tions of  the  air-tract,  it  i-  found  most  frequently  in  the  male,  dependent,  no 
doubt,  ii | ion  their  greater  exposure  to  the  exciting  causes — i.  e.,  sudden  climatic 
changes,  wet  clothing,  draughts,  and  dust. 

Pathology.  —  In  the  early  stage  there  is  the  usual  vascular  injection  and 


AVCT1-:  CATARRHAL    TRACHEITIS.  997 

turgescence  and  some  slight  swelling  from  serous  exudation.  The  surface 
will  he  dry  and  glazed.  Later,  when  mucus  secretion  i-  iv.-uincd,  the  .-well- 
ing subsides  and   resolution    follows. 

Symptoms. — A  dry,  irritating  cough,  caused  by  the  air-current  passing 
over  an  inflamed  surface,  and  a  constant  tickling  sensation  causing  a  con 
tinuous  efforl  at  clearing  the  throat,  hut  totally  devoid  of  expectoration. 
Ordinarily  there  is  no  dyspnea,  as  the  trachea  will  allow  of  gnat  encroach- 
ment on  the  caliber  of  its  lumen  without  interfering  with  the  normal  air- 
current;  but  in  very  severe  cases  there  may  be  slight  dyspnea.  A-  the  dis- 
ease run-  its  course  the  irritating  cough  gradually  subsides  and  expectora- 
tion increases.  Tin-  is  greater  in  quantity  than  in  catarrhal  laryngitis  and 
much  less  than  in  bronchitis.  If  the  stethoscope  is  applied  to  the  trachea 
there  will  be  heard  in  the  early  stage  a  harsh,  dry,  inspiratory  sound,  and 
later  on  an  abundance  of  large  moist  rales. 

Diagnosis. — An  acute  respiratory  disease  with  cough  and  expectora- 
tion, but  without  dyspnea  or  aphonia,  must  involve  either  the  trachea  or 
bronchi.  The  stethoscope  will  exclude  the  latter  region,  and  if  a  tracheo- 
scopic  examination  is  made  the  mirror  will  quickly  show  the  highly  injected, 
dark-red,  inflamed  mucous  membrane. 

Treatment. — The  local  application  of  the  wet  compress  or  counter- 
irritation  with  a  tampon.  The  inhalation  of  vapors  saturated  with  benzoin, 
eucalyptus,  or  some  of  the  essential  oils.  A  mild  expectorant-mixture  con- 
taining ammonia  may  be  given. 


CHRONIC  INFLAMMATORY  DISEASES  OF  THE 

LARYNX. 

By  r.  E.  de  .M.  SAJOUS,    M.  I>., 

OF    PHILADELPH1 \ 

CHRONIC  LARYNGITIS. 

A-  here  understood,  the  term  chronic  laryngitis  simply  moans  a  condi- 
tion of  the  larynx  brought  about  by  chronic  inflammation  affecting  cither 
the  superficial  or  deep  tissues  of  this  organ,  and  involving  either  a  restricted 
portion  or  the  totality  of  the  parts  concerned.  Syphilis  and  tuberculosis  of 
the  larynx,  sometimes  termed  "syphilitic"  and  "tubercular"  laryngitis,  are 
considered  elsewhere  in  this  volume. 

Etiology. — In  the  vast  majority  of  cases,  chronic  laryngitis  represents 
bul  an  anatomical  subdivision  of  :i  chronic  inflammatory  disorder  involving 
the  respiratory  tract,  the  nasal  cavities — anterior  or  posterior — the  pharynx, 
the  tonsil — post-nasal,  pharyngeal  or  lingual — the  trachea,  and  the  bronchi, 
representing  as  many  foci.      Indeed,  chronic  laryngitis  perse,  involving  no 

other  porti >f  the  respiratory  surfaces,  is  rarely  met  with,  except  in  persons 

such  as  singers,  clergymen,  public  speakers,  officers,  hucksters,  etc.,  who  are 
called  upon  to  use  their  voices  excessively  and  vigorously.  Occupations 
such  as  those  involving  arduous  labor  in  a  dusty  or  smoky  atmosphere  are 
also  capable  of  inducing  ;i  chronic  inflammation  of  the  larynx,  but  in  these. 
likewise,  the  vocal  organ  is  bul  a  part  of  the  area  involved,  the  nose.  naso- 
pharynx,  mid  pharynx  being  also  kept  inflamed  through  contacl  with  the 
extraneous  irritants.  Gastric  mid  hepatic  disturbances,  especially  those 
caused  by  the  abuse  of  alcoholic  drinks,  are  frequenl  causes  of  chronic  laryn- 
gitis, as  evidenced  by  the  hoarseness  of  drunkards  and  the  laryngoscopic 
image  presented  by  the  larynx  in  such  cases.  Here  again,  however,  the 
glottic  turgescence  and  hyperemia  but  represent  what  might  be  seen  along 
the  entire  mucous  surfaces — the  active  manifestation  of  a  general  vascular 
engorgement. 

Four  prominent  subdivisions  of  the  general  causative  factors  will  besl 
serve  to  dearly  ill  line  the  limit-  wherein  each  line  of  remedial  measures  will 
find  it-  most  effective  application.  Starting  with  the  source  of  congestion 
most  benign  in  giving  rise  to  local  manifestations,  we  hav< — first,  contact  of 
tin'  nine, ,n-  surfaces  of  the  larynx  with  a  du-t-,  -moke-,  or  fume-laden 
atmosphere  capable  of  eliciting  a  marked  hyperemia  of  the  parts.  In  this 
class  may  be  included  smokers  who  indulge  their  habit  immoderately  and 
who  spend  much  of  their  time  in  the  vitiated  atmosphere  of  bar-room-. 
smoking-cars,  etc.  In  these  cases  the  mucous  membrane  of  the  entire 
nine., n-  traet  i-v  .1-  it  were,  bathed  in  fresh  smoke  with  each  inspiration,  the 
respiratory  acl  thus  serving  to  maintain  tin  contacl  between  the  irritant  and 
the  mucous  surfaces.     The  constitutional  effeel  of  tobacco—  nicotism  -enter- 


CHRONIC  LARYNGITIS.  999 

but  slightly  in  the  causation  of  local  congestion.  The  local  irritation  pro- 
duced is  further  aggravated  in  smokers  who  expectorate  freely,  the  main 
factor  in  the  causation  of  the  congestion  being  an  abnormal  dryness.  In 
individuals  who  make  it  a  practice  to  inhale  smoke  deeply,  a  whistling  rale 
resembling  that  observed  in  mild  asthma  is  frequently  heard.  Singers, 
public  speakers,  etc.  often  sutler  from  hoarseness  after  a  long  railroad  nip, 
during  which  their  organs  of  phonation  and  respiration  have  been  exposed 
to  the  drying  and  irritating  influence  of  smoke  and  dust.  Workers  in 
tobacco,  weavers,  mill-hands,  etc.,  may  be  included  in  this  category  of  cases. 
That  deficient  lubrication  of  the  upper  respiratory  tract  plays  an  important 
part  in  these  cases  is  shown  by  the  thirst  which  attends  them.  Alcoholism 
is  thus  sometimes  engendered,  the  alcoholic  beverages  tending  in  turn  to 
aggravate  the  trouble. 

The  second  class  of  causes,  and  one  which,  as  already  stated,  furnishes 
by  far  the  greatest  number  of  cases  of  chronic  laryngitis,  is  represented  by 
all  disorders  of  the  nasal  cavities,  anterior  and  posterior,  which  interfere 
with  their  normal  physiological  functions.  To  allow  the  ingress  of  a  suf- 
ficient quantity  of  air,  to  warm  the  latter  and  rid  it  of  its  irritating  particles 
or  noxious  micro-organisms,  are  functions  which,  interfered  with,  promptly 
give  rise,  directly  and  indirectly,  to  morbid  processes  in  the  regions  which 
they  were  intended  to  protect.  Chronic  catarrhal  affections,  stenotic  or 
atrophic,  septal  deviations  or  tumors,  by  compromising  the  lumen  of  the 
upper  respiratory  passages  and  reducing  or  arresting  the  outpour  of  nasal 
mucus,  by  limiting  the  powers  of  the  ciliated  epithelium,  transform  parts 
which  formerly  acted  as  guards  above  the  larynx  into  centers  of  morbid 
changes.  These  may  exert  their  influence  directly  by  continuity  of  tissue 
and  the  irritating  action  of  muco-purulent  secretions  which  find  their  way 
into  the  larynx  ;  indirectly,  by  imposing  more  or  less  mouth-breathing — 
dusty,  unwarmed,  and  perhaps  septic  air  thus  coming  into  direct  contact  with 
the  larvngeal  mucous  membrane. 

The  third  class  includes  the  various  visceral  or  diathetic  disorders  fre- 
quently overlooked  as  causative  agents.  In  a  large  proportion  of  these  cases 
the  larynx  but  furnishes  the  most  salient  evidence  of  a  general  hyperemia 
of  the  mucous  membranes.  This  hyperemia  may  be  incident  upon  some 
disorder  compromising  the  functions  of  the  vascular  system,  either  by  caus- 
ing on  the  one  hand  changes  in  the  elements  of  the  blood  itself,  or  by  offering 
a  mechanical  impediment  to  its  circulation,  especially  in  the  capillaries,  the 
resuli  of  a  localized  engorgement.  The  liver  is  the  organ  of  predilection  in 
this  particular,  the  hepatic  engorgement  being  in  turn  frequently  secondary 
to  a  gastric  disorder.  Such  cases  commonly  suffer  also  from  hemorrhoids. 
A-  to  diatheses,  it  is  quite  certain  that  in  gouty  subjects  general  rreatmenl 
calculated  to  antagonize  the  effects  of  the  dyscrasia  act-  promptly  when  local 
treatment  will  utterly  fail.  A.S  regards  syphilis,  a  chronic  laryngitis  occur- 
ring in  an  infected  individual  will  be  materially  benefited  and  frequently 
cured  by  a  eourse  of  iodid  of  potassium  after  all  topical  measures  have 
proven  futile.  Again,  cod-liver  oil  and  iodin  will  do  more  to  cure  chronic 
laryngitis  in  lymphatic  children  than  any  direel  medication.  All  these 
undeniable  fact-  point  to  the  influence  of  general  affections  upon  laryngeal 
tissu< — a  point   too  frequently  overlooked  (see  also  page  875). 

In  excessive  professional  use  of  the  larynx,  coupled  with  faulty  methods 
of  tone-production,  we  have  the  fourth  variety,  and  the  mosl  pernicious 
etiological  factor  as  regards  local  anatomical  changes.  A  peculiar  feature 
<»f  these  can--  i>  that  they  d< I  always  pre-eiit  active  symptoms,  baritones 


1000      CHRONIC  INFLAMMATORY  DISEASES  OF  THE  LARYNX. 

and  bassos  frequently  showing  laryngoscopically  every  evidence  of  active 
inflammation — intense  redness  of  the  vocal  bands,  marked  thickening  of  the 
margins  of  the  glottis,  etc.-  without  suffering  from  the  least  hoarseness  to 
attract  attention  to  the  vocal  organ.  These  eases  point  to  the  effects  of  overuse 
— namely,  a  localized  engorgement  of  the  superficial  blood-vessels  caused  by 
intense  and  prolonged  muscular  contraction.  The  vessels  beneath  the  sur- 
face being,  as  it  were,  supported  by  surrounding  tissues,  the  superficial  capil- 
laries bear  the  bruni  of  the  undue  bloou-pressure,  owing  to  the  absence  of 
resistance  afforded  by  their  location,  and  become  inordinately  and  perma- 
nently dilated.  Years  are  doubtless  required  to  produce  this  varicose  condi- 
tion in  the  average  case,  but  an  undue  effort  at  a  time  when  a  singer  is  not 
in  his  usual  good  health  may  in  an  instant  cause  a  vascular  dilatation  pre- 
senting the  same  redness,  but  attended  by  all  the  phenomena  of  an  acute 
inflammation,  the  precursor  of  a  tedious  chronic  catarrhal  disorder  susceptible 
to  frequent  exacerbations. 

Chronic  inflammatory  disorders  of  the  larynx  are  more  frequently  ol>- 
served  in  men  than  in  women,  because  they  are  more  exposed  to  the  etiological 
factors  outlined  than  the  latter.  Smoking  and  drinking  are  prolific  indirect 
causes,  a-  stated,  and  these  halm-  are  mosl  generally  indulged  in  l>y  the  male 
sex.     Chronic  laryngitis  can  occur  at  all  ages. 

Symptoms. —  Impairment  of  the  voice  is  naturally  the  mosl  prominent 
symptom — one  hut  little,  if  at  all,  influenced  by  the  nature  of  the  primary  cause 
of  the  laryngeal  disorder.  A  sensation  of  rawness  or  tickling  gives  rise  to 
the  de-ire  of  hemming  or  hawking — a  voluntary  effort  to  rid  the  larynx  of 
a  supposed  offending  ma--  of  mucus.  The  hoarseness  may  not  be  continuous, 
hut  occur  only  after  the  voice  has  been  used  for  a  short  time.  In  some  cases 
the  voice  i-  at  first  quite  veiled  or  hoarse,  and  after  a  few  words  or  sentences 
have  been  spoken  it  becomes  temporarily  clear.  The  vocal  disability,  how- 
ever, i-  sometimes  shown  by  a  feeling  of  local  fatigue,  heat,  and  constriction. 
In  singers  all  these  symptoms  maybe  present  simultaneously,  the  least  effort 
at  singing  increasing  the  trouble.  The  voice  is  usually  lowered  in  pitch. 
Complete  aphonia  occasionally  occurs.  Pain  is  an  occasional  symptom,  de- 
noting the  probability  of  rheumatic  diathesis.  Cough  provoked  by  the  sensa- 
tion of  itching  already  alluded  to  i>  present  in  the  majority  of  cases  and  is 
occasionally  spasmodic.  The  expectoration  is  scanty,  however,  unless  tracheal 
«>r  bronchial  trouble  is  also  present. 

The  laryngoscopic  appearances  vary  considerably  and  are  proportionate  to 
the  degree  of  active  inflammation.  The  evidences  of  local  hyperemia  are 
nevertheless  always  present,  and  vary  from  a  slight  arhorescent  and  li^ht  pink 
tinge,  suggestive  of  congestion,  to  a  bright  red  hue,  indicative  of  violent  in- 
flammation. The  epiglottis  is  also  congested,  enlarged  vessels  coming  over 
it-  posterior  surface,  while  the  aryteno-epiglottic  folds  appear  thickened,  the 
tumefaction  involving  the  entire  larynx  in  marked  cases.  The  general  red- 
ness, however,  i-  not  so  marked  a-  in  some  cases  of  acute  laryngitis.  The 
vocal  hand-  are  also  more  or  less  congested  ;  the  congestion  may  either  he 
limited  in  a  -mall  portion  of  their  surface  or  involve  their  entire  area. 
Small  masses  of  stringy  cream-like  mucus  are  frequently  to  he  -ecu  forming 
film-    w  hen    the   glottis    i-   opened. 

Iii  some  cases  the  vocal  hand-  appear  relaxed  and  their  thickened  edges 

donol  seem  to  come  accurately  together,  an  elliptical  opening  being  occasionally 

observed  between  them.     This  want  of  parallelism  i-  due  to  muscular  paresis 

!  15),  affecting   usually  hut    one  side.     Shallow  abrasions   of  the 

epithelial  covering  are  occasionally    met   with,  especially  in  the   interaryte- 


CHRONIC  LARYNGITIS.  1001 

noid  space.  Deeper  ulcerations,  sometimes  leading  to  perichondritis,  have 
been  observed  by   various  clinicians. 

In  some  cases  the  secretion,  beside-  being  muco-purulenl  or  purulent,  is 
prone  to  adhere  firmly  to  the  mucous  surfaces  and  to  become  partly  desiccated 
in  this  situation.  The  dry  crusts  formed,  by  impeding  the  free  passage 
of  air,  give  rise  to  more  or  less  dyspnea.  Laryngoscopically  examined,  the 
larynx  appears  red  and  dry,  with  greenish  crusts  closely  adhering  t<>  parts 
adjoining  the  vocal  cords  either  above  or  below.  Owing  to  the  appearance 
of  dryness,  a  special  name,  laryngitis  sicca,  is  frequently  given  this  disorder. 
The  breath  expired  from  the  month  is  usually  very  fetid,  hence  another  name, 
ozena  laryngis,  given  it  by  observers  who  considered  the  disease  as  invariably 
associated  with  atrophic  catarrh  of  the  naso-pharynx.  It  is  probably  a  rare 
manifestation  of  chronic  laryngitis,  but  it  appear-  to  me  one  possessing  an 
insufficient  number  of  known  characteristics  to  warrant  for  it  a  special  position 
in  our  nomenclature 

Hemorrhage  of  the  larynx  sometimes  occurs  in  the  course  of  chronic 
laryngitis  in  connection  with  severe  cough  and  copious  expectoration.  In  a 
case  related  by  Michael  Pleskoffthe  expectoration  had  been  bloody  on  several 
occasions.  Laryngoscopy  revealed  the  ordinary  diffuse  redness  of  the  vocal 
bands  common  to  chronic  laryngeal  catarrh;  but  in  the  region  of  the  left 
vocal  process,  near  the  ventricle,  there  was  an  elongated,  submucous,  circum- 
scribed bloody  patch,  which  covered  half  the  breadth  of  the  vocal  band,  ami 
which  was  evidently  due  to  rupture  of  a  blood-vessel.  The  treatment  insti- 
tuted consisted  solely  in  suppression  of  the  voice,  and  gradual  absorption  of 
the  effused  blood  took  place  with  its  disappearance  in  three  week.-.'  Another 
marked  case  was  recently  reported  by  Compaired.2 

The  infraglottic  space  is  frequently  involved  in  the  inflammatory  process, 
and  the  mucous  membrane  of  it-  wall-  sometimes  project-  slightly  beyond  the 
margins  of  the  glottis,  especially  when  the  vocal  band-  are  abducted.  In  the 
so-called  laryngitis  sicca  this  region  is  one  of  predilection  for  the  formation 
of  crusts. 

Pathology.  —Whatever  the  primary  causative  factor,  the  main  patho- 
logical feature  of  these  cases  is  dilatation  of  the  vascular  supply,  the  vessels 
of  the  band-  reaching  in  some  cases,  as  already  stated,  a  condition  of'  varicosity. 
The  chronic  character  of  the  disease  is  mainly  due  to  paresis  of  the  vascular 
wall-  and  to  the  hyperplastic  character  of  the  chronic  inflammatory  process. 

In  mild  eases  it  is  probable  that  there  is  merely  deficient  lubrication, 
especially  when  an  atrophic  rhino-pharyngitis  represents  the  primary  cause, 
hyperesthesia  of  the  surface  taking  an  active  part  in  the  production  of  the 
subjective  symptoms. 

Prognosis. — Marked  cases  of  chronic  laryngitis  seldom  tend  toward 
recoverv.  In  cases  in  which  the  disorder  is  due  to  irritation  by  inhaled  irri- 
tating substances,  the  continued  use  of  the  voice  and  the  inhalation  of  dusl 
and  smoke  attending  everyday  life  are  as  many  condition-  tending  to  keep  up 
the  trouble,  if  not  to  aggravate  it.  These  sufferers  are  seldom  willing  or  per- 
haps able  to  give  up  an  occupation  in  order  to  counteract  a  disease  the  symp- 
toms of  which  do   not    involve   marked    suffering  or  danger  to   life.      This   is 

especially  the  case  in  patients  in  whom  the  voice  is  not  a  source  of  livelil 1, 

a-  it  i-  in  singers,  speakers,  etc.  In  the  great  majority  of  these  case-,  there- 
fore, the  chances  of  recovery  are  to  a  degree  compromised  by  circumstances 
beyond  the  physician's  control.      When  tiny  are  within  hi-  control,  the  prog- 

1  Mwiehener  "/•</.   ]('./-•/,..  I  >,,-.  i.  l s.S8. 

*  Annates  dea  Maladies  de  C  Oreille  etc.,  May,  I- 


1002      CHRONIC  INFLAMMATORY   DISEASES  OF  THE  LARYNX. 

oosis  is  :ii  "nee  modified,  appropriate  treatment  and  a  judicious  change  of 
occupation  Leading  to  recovery   in  many  uncomplicated  cases. 

Cases  of  chronic  laryngitis  in  which  the  primary  causative  agent  is  repre- 
sented   1>\    -Mm,,   disorder  of   the   naso-pharyugeal    tract   generally  resp I 

promptly  to  measures  capable  of  favorably  influencing  the  morbid  process. 
The  prognosis  of  these  cases,  therefore,  depends  upon  that  of  the  primary 
disease.  The  same  can  be  said  of  cases  in  which  visceral  or  diathetic  disorder 
plays  an  active  role  as  an  etiological  factor.  Hepatic  torpidity  added  to  gas- 
trie  insufficiency  arc  with  difficulty  overcome,  and  a  chronic  laryngitis  due  to 
these  condition-;,  while  yielding  t<>  judiciously  directed  measures,  frequently 
reappears  with  much  greater  suddenness  than  it  departed. 

The  prognosis  of  chronic  laryngitis  in  singers  is  often  a  question  of  trreat 
in. inn -iit.  a  brilliant  career  being  frequently  at  stake.  Fortunately,  advanced 
laryngeal  therapeutics  enable  us  to  satisfactorily  treat  even  the  worst  of  these 
cases,  provided  our  instructions  are  properly  carried  out. 

Another  question  of  importance  is  the  possibility  of  complications  during 
the  active  inflammatory  process,  and  particularly  the  likelihood  of  a  simply 
chronic  laryngitis  being  transformed  into  benign  or  malignant  growth's  or  into 
tuberculosis  of  the  larynx.  A.s  to  benign  growths  it  is  undeniable,  judging 
from  clinical  evidence.  Still  the  proportion  of  benign  neoplasms  as  com- 
pared to  that  of  eases  of  marked  chronic  laryngitis  is  so  small  that  the 
presence  of  a  concomitant  dyscrasia  capable  of  manifesting  itself  when 
hyperemia  is  prolonged  beyond  a  certain  limit  can  but  suggest  itself.  The 
same  might  be  -aid  of  malignant  growths  until  we  are  better  acquainted  with 
their  pathology.  A-  regards  tuberculosis  of  the  larynx,  no  case  so  far 
reported  warrants  the  assertion  that  a  catarrhal  inflammation  can  at  any  time 
give  rise  to  a  local  tubercular  process.  Indeed,  a  careful  clinical  study  of 
the  subject  ha-  led  me  to  <•< include  that  tuberculosis  of  the  larynx  is  primarily 
due  i<>  precisely  an  opposite  condition,  local  adynamia,  and  that  what  benefit 
topical  applications  afford  in  the  treatment  of  "tubercular  laryngitis,"  so- 
called,  is  in  a  measure  due  to  the  local  stimulation  produced. 

Treatment.— To  properly  treat  chronic  laryngitis  the  predominating 
etiological  factor  of  each  case  must  he  clearly  determined.  The  local  appli- 
cati( f  astringents  to  the  larynx  in  a  patient  in  whom  a  disordered  diges- 
tive system  plays  the  leading  pari  can  hut  finally  prove  ineffectual  ;  the 
relief  obtained  i-  soon  attended  by  a  return  of  the  symptoms.  To  treat  the 
larynx  alone  when  a  nasal  disorder  is  also  present  is  as  futile,  unless  the 
laryngeal  inflammation  he  a  mere  exacerbation  of  a  latent  catarrhal  process 
that  i-  -....n  to  yield  of  it-  own  accord.  In  other  words,  to  merely  treat  the 
larynx  without  seeking  for  the  primary  cause,  proximal  or  remote,  is  to  court 
d'l'.at  or  t"  accept  time  a-  an  ally  in  the  great  majority  of  cases.  In  tin- 
disease,  probably  as  much  as  in  any  other  that  could  he  named,  the  removal 
of  the  active  can--  i-  the  mosl  important  feature  of  the  treatment  ;  the  appli- 
cation of  topical  remedies  playing  a  secondary — although  important — role  in 
hastening  the  successful  issue.  Briefly,  in  cases  due  mainly  to  continued 
irritation  of  the  larynx  and  adnexa  l>v  such  extraneous  elements  ;i<  dust, 
smoke-fumes,  etc.,  a  change  of  halm  or  occupation  should  he  enjoined  ;  when 
the  laryngeal  disease  is  due  to  a  morbid  process  of  the  nose,  naso-pharynx, 
pharynx,  etc.,  this  morbid  process  should  lie  corrected;  when  a  gouty  or 
rheumatic  diathesis,  a  gastric  or  hepatic  affection,  etc..  i-  at  the  bottom  of 
the  trouble,  general  treatment  of  the  condition  i-  all-important;  when  in 
singers,  speakers,  etc.,  the  organs  of  phonation  are  improperly  and  exces- 
used,  the   paramount   indication   to  insure   success   is   to  corred   the 


CHRONIC  LARYNGITIS.  1003 

errors.     The  prognosis  of  the  case  depends  mainly  upon  the  perfection  with 
which  all  these  indications  can   be  carried  out. 

The  topical  measures  vary  but  little,  whatever  the  primary  cause  of 
the  local  trouble,  and  common  to  all  forms  is  the  maintenance  "1'  cleanliness, 
not  only  of  the  larynx  itself,  but  <»f  the  naso-pharyngeal  cavity  as  well. 
For  this  purpose,  a  drachm  of  bicarbonate  of  soda  dissolved  in  a  pint  of 
lukewarm  water  serves  an  admirable  purpose.  A  few  tablespoonfuls  of  this 
solution  being  placed  in  an  atomizer,  the  pharynx  and  larynx  are  freely 
sprayed  at  short  intervals  during  two  or  three  minute-.  The  balance  of  the 
solution  is  then  employed  to  cleanse  the  oaso-pharyngeal  cavities,  the  palm 
of  the  hand  being  used  as  a  dipper  from  which  the  liquid  is  inhaled.  The 
patient  should  do  this  morning  and  evening  and  on  reaching  home  from  work, 
if  his  occupation  happens  to  he  one  capable  of  causing  irritation  of  the 
mucous  tract.  After  using  the  warm  detergent  spray,  the  patient  should 
employ  in  the  same  manner  a   solution  of  resorcin,  5  grains  t<>  tin-  ounce. 

To  obtain  contraction  of  the  superficial  blood-vessels,  local  applications 
of  active  astringents  must  he  made.  The  most  satisfactory  of  these  is  still 
nitrate  of  silver,  employed  in  solutions  varying  from  10  to  Hit  grains  to  the 
ounce.  When  erosions  are  present  the  latter  solution  should  he  preferred 
and  applied  after  slightly  anesthetizing  the  laryngeal  surface  to  prevent  spas- 
modic contraction.  A  small  pledget  of  cotton  should  he  used,  and  after 
being  adjusted  in  the  grasp  of  the  forcepsand  dipped  in  the  solution  it  should 
be  lightly  squeezed  between  the  folds  of  a  towel  to  prevent  dripping. 
When  another  remedy  is  preferred,  a  solution  of  sulphate  of  copper,  ■".'  I 
grains  to  the  ounce,  may  be  employed.  In  cases  uncomplicated  by  erosions, 
etc.,  weaker  solutions  of  nitrate  of  silver  or  a  10-grain  solution  of  tannin  in 
glycerin  applied  every  other  day,  besides  the  measures  to  be  carried  out  at 
home  by  the  patient,  usually  suffice  to  bring  about  recovery,  provided  the 
original  cause  has  been  properly  treated,  important  in  this  connection,  especi- 
ally when  treating  people  who  use  their  voices  professionally,  is  always  to 
include  the  infraglottic  region,  the  portion  immediately  below  the  vocal  hand-. 

in  the  remedial  measures  adopted.    A  peculiarity  of  the  mucous  membrai f 

this  region  i-  to  form  creases  or  longitudinal  folds  when  the  bands  are  not  in 
extreme  adduction.  Upon  the  integrity  of  this  crease-forming  quality  greatly 
depends  the  character  of  the  voice.  In  the  treatment  of  singers,  local  appli- 
cations including  the  infraglottic  space  and  calculated  to  reduce  congestion 
and  irregular  traction  upon  the  a\'j:('<  of  the  vocal  bands  will  lie  found  to 
control  much  more  readily  a  case  of  hoarseness  due  to  an  acute,  subacute,  or 
chronic  disorder  than  when  the  same  application  i-  limited  to  the  upper 
laryngeal  cavity.  A-  soon  as  the  regular  formation  of  creases  is  interfered 
with,  the  tension  upon  the  vocal  band-  becomes  excessive  or  irregular,  and 
there  is  added  to  the  catarrhal  or  other  anomalous  local  condition-  present 
one  of  even  greater  mechanical   moment. 

These  cases  are  frequently  characterized  by  what  mighl  be  termed  a  sub- 
acute exacerbation.  Hie  benzoate  of  -odium.  5  grain-  every  three  hour-, 
usually  suffices  to  arresl  this  intercurrent  trouble,  [f  the  attack  is  a  -harp 
one,  the  patient  should  remain  at  home  and  inhale  every  hour  the  -team  of  a 

mixture  of  two  teas] nful-  of  the  compound  tincture  of  benzoin  and  a  pint 

of  boiling  water.      The  vessel  containing  the  water  should  1 vered  with 

a  towel  folded  into  the  shape  of  a  cone  ;  into  the  upper  opening  of  this  cone. 
the  patient  introduce-  hi-  nose,  month,  and  chin  to  better  confine  the  benzoin- 
laden  -team  inhaled  and  prevent  too  rapid  a  dissipation  of  the  heat. 

In   cases  of   long   standing    the   superficial   blood-vessels  are  sometimes 


1004     CHRONIC  INFLAMMATORY  DISEASES  OF  THE  LARYNX. 

permanently  dilated  to  twice  their  normal  caliber  and  are  increased  in  Length 
in  proportion.  Astringents  lure  are  useless.  The  only  measure  likely  to 
procure  a  return  of  the  voice  is  to  cauterize  the  varicose  vessels  of  the  sur- 
face of  the  vocal  bands.  Chromic  acid  is  the  best  agent  for  the  purpose. 
Alter  thorough  anesthetization  with  a  strong  solution  of  cocain,  the  acid, 
fused  by  heal  to  the  end  of  a  covered  probe,  is  applied  to  one  of  the  hands 
while  the  patient  in  his  effort  to  make  a  sound  brings  the  bands  in  apposition, 
and  thus  render-  accidental  cauterization  of  their  edges  impossible.  An 
abrasion  the  size  of  a  -mall  pea  is  the  result,  and  this  spot,  alter  healing,  is 
distinctly  whiter  than  the  surrounding  parts.  The  applications  are  to  be 
renewed  every  few  days,  each  hand  being  treated  alternately,  until  all  the 
area-  of  superficial  congestion   have  been  dot  roved. 

Krause1  of  Berlin,  in  stubborn  cases  occurring  in  singers,  recommends  a 
method  considerably  employed  in  the  United  States  many  years  ago — i.  e., 
minute  longitudinal  incisions  made  with  a  lancet-shaped  laryngeal  scarificator 
into  the  hyperplastic  tissues  of  the  hands.  The  bleeding  is  slight,  and  rapid 
improvement  ensues.  In  the  same  class  of  cases  Massei  <>f  Naples  recom- 
mends spraying  with  a  '1  per  cent,  solution  of  lactic  acid,  used  frequently, 
eight  to  ten  times  daily.  Hygienic  measures  and  tonics  form  important 
adjuvants. 

In  mild  chronic  laryngitis  frequently  attending  an  overworked  professional 
vocalist,  an  exacerbation  of  the  local  trouble  is  often  due,  as  already  stated,  to 
deficiency  in  the  lubrication  of  the  vocal  hands.  This  condition  is  success- 
fully combated  by  the  administration  every  two  hours  of  10  grains  of  ammo- 
nium chlorid  in  a  tumblerful  of  water,  and  the  topical  use  of  warm  sprays 
of  a  saturated  solution  of  potassium  chlorid  at  the  same  intervals.  The 
doses  are  SO  managed  that  the  last  one  should  be  taken  at  least  about  three 
hour-  before  :i  performance.  This  avoids  exposure  during  the  subsequent 
stage  of  perspiration.  A  lozenge  containing  one  grain  of  the  ammonium 
chlorid  taken  between  acts  is  of  benefit  in  some  instances,  mainly  owing  to 
it-  effect  upon  the  phar\  ox. 

<  )f  importance  in  these  cases  i-  the  question  of  rest.  This  is  always  indi- 
cated, especially  in  female  voices,  a  line  voice  being  always  endangered  when  it 
i-  used  during  a  more  or  less  grave  local  disorder.  ( )ur  recommendation  should 
be  framed  accordingly,  taking  the  severity  of  the  local  trouble  as  our  guide 
a-  regards  the  duration  of  the  resting  period  and  its  degree.  Unfortunately, 
rest  i-  rarely  possible  in  professional  singers,  and  as  long  as  a  vestige  of  voice 
remain-  they  insist  upon  a  continuance  of  their  work.  \\That  are  we  to  do  in 
these  cases?  Without  doubt  the  most  advantageous  plan  to  all  concerned  is 
frankly  to  disclose  to  the  patient  the  dangers  incurred;  to  recommend  aban- 
donment of  rehearsals;  limitation  to  the  smallest  degree  possible  of  the  part 
to  he  sung  or  spoken  ;  to  transpose,  when  possible,  all  high  notes,  or,  if  this 
i-  not  possible,  to  shorten  the  chest-register  a  couple  of  notes,  thus  changing 
to  the  head-tone-  without  having  to  throw  upon  the  larynx  the  strain  of  the 
two  highest  notes  of  the  chest-register;  in  other  words,  to  limit  as  much  as 
practicable  the  work  of  the  vocal  apparatus. 

Besides  the  local  measures  recommended,  these  cases  require  special  efforts 
to  overcome  the  muscular  fatigue  entering  for  a  great  -hare  in  the  subjective 
-ymptoin-.      Strychnia,  ,',,  of  :i    grain    every    three    hour-,  and    electricity   are 

usually  effective.     The  faradic  current   i-  most  effectively  employed  in  the 

following   manner,  which    introduces    water  a-   a    ( luctor    for    the    current, 

thus  avoiding   the  local  irritation  caused  by  contact  with  the  electrode,  and 
/.     iner  Win.   Woeh.,  \\>n\  Hi,  L894. 


NODULAR   LARYNGITIS,   OR   CHORDITIS   TUBEROSA.    1005 

doingaway  with  all  gagging:  The  patient  having  taken  what  is  usually  called 
a  mouthful  of  water — in  reality,  about  an  ounc< — is  told  to  throw  bis  head 
backward  and  to  open  his  mouth.  The  first  movement  of  deglutition  causes 
the  water  to  till  the  pharyngeal  cavity.  Lighl  being  thrown  in,  a  Mackenzie 
laryngeal  electrode  is  introduced  and  simply  immersed  in  the  water,  the  ex- 
ternal electrode,  thoroughly  wetted  to  secure  penetration  through  the  skin,  being 
placed  over  the  thyroid.  The  circuit  being  then  closed  by  pressing  the  button 
of  the  Mackenzie  electrode,  the  current  is  allowed  to  flow  as  long  as  the  patient 
can  hold  his  breath.  The  mouth-electrode  being  then  taken  out,  he  can, 
either  by  closing  his  month  and  bowing  his  head  forward,  bring  the  water 
forward  and  take  a  few  breaths  through  the  nose,  then  renew  the  firsl  move- 
ment, throwing  the  head  backward,  etc.,  or  take  another  mouthful  of  water, 
after  ridding  himself  of  the  first.  The  oftener  the  sittings — which  should 
last  at  least  fifteen  minutes — are  renewed,  the  better  ;  the  patient  may  even 
be  taught  the  procedure,  and  he  can  then  treat  himself  twice  or  three  times 
daily  at  home. 

When  there  is  a  tendency  to  the  formation  of  crusts,  as  in  "laryngitis 
sicca,"  the  benzoin-and-steam  inhalations  are  very  effective.  Iodid  of  po- 
tassium, five  grains  in  a  glass  of  water  after  each  meal,  has  given  me  the  best 
results.  Local  applications  of  a  30-grain  solution  of  nitrate  of  silver  usually 
prevent  a  return  of  the  trouble. 

NODULAR  LARYNGITIS,  OR  CHORDITIS  TUBEROSA. 

Etiology. — This  is  a  disorder  of  the  mucous  membrane  of  the  vocal 
bands,  consisting  in  the  development  of  small  nodules  on  the  surface  or  edge 
of  the  latter  as  a  result  of  chronic  laryngitis.  The  use  of  the  voice  while  an 
inflammatory  process  is  present  in  the  larynx,  a  faulty  method  of  singing, 
friction  of  the  free  edge  of  one  band  against  that  of  the  otherwhere  the  voice 
is  considerably  used,  are  the  main  primary  factors  to  which  this  disease  is 
attributed.  It  is  almost  always  observed  in  singers  and  public  speakers,  and 
more  frequently  in  sopranos  and  tenors  than  in  baritones  and  bassos.  Ac- 
cording to  Moure,1  this  affection  is  frequently  met  with  in  children  from 
seven  to  ten  year-  of  age. 

Symptoms. — The  most  prominent  symptom  is  hoarseness,  or  an  irregular 
production  of  the  voice,  characterized  by  the  escapeof  air  simultaneously  with 
the  emission  of  sound.  In  some  cases  there  is  aphonia  when  the  normal 
vocal  effort  is  made  in  .-peaking,  while  sound  is  emitted  dining  vigorous 
enunciation.  In  others,  again,  complete  aphonia  exists.  There  is  usually  do 
dyspnea,  and  in  fact  no  evidence  of  local  trouble  other  than  the  mild  chronic 
laryngitis  which  is  usually  present  in  such  case-. 

The  nodules  may  be  situated  upon  either  band.  In  the  few  cases  I  have 
had  occasion  to  treat  they  were  situated  on  the  i'vrr  edge  of  the  left  band — a 
mere  coincidence,  doubtless.  In  one  case  there  was  evident  irritation  of  the 
same  spot  on  the  other  band,  caused  by  the  friction  of  the  nodule.  In  this 
manner  secondary  nodule-  are  thought  to  be  produced,  as  they  are  frequently 
symmetrically  located.  The  growths  are  usually  the  size  of  a  pin-head:  in 
one  of  my  cases,  however,  the  growth  had  reached  at  least  four  times  thai 
size.  The  nodule-  arc  usually  pinkish-gray,  an  areola  of  red,  from  winch 
arborescent  venules  sometimes  project,  surrounding  the  base.  They  are  said 
to  sometimes  disappear  spontaneously  or  to  become  changed  into  laryngeal 
growths  of  another  variety. 

1  I;,  i  a.  ,l,  Laryngologie,  Feb.  8,  1896. 


1006      CHRONIC  INFLAMMATORY  DISEASES  OF   THE  LARYNX. 

Pathology. — The  nodules  are  the  resuH  of  inflammatory  action.  The 
hyperplasia,  al  first  limited  to  the  epithelium,  finally  implicates  the  tissues 
beneath,  the  changes  consisting  mainly  in  cellular-tissue  hypertrophy.  The 
epithelial  elements  are  also  largely  increased. 

Treatment. —  I  am  inclined  to  believe  that  the  nodules  reported  as  re- 
moved by  the  local  applicati f  -non-  solutions  of  nitrate  of  silver  or  of 

iodin  wcic  not  really  nodules,  bu1  merely  ampullae  or  tortuous  blood-vessels, 
such  as  those  occasionally  observed  in  chronic  laryngitis  of  old  standing.  In 
bona  fidt  cases,  the  only  measures  found  of  real  service  in  my  cases  were 
chromic-acid  crystals,  the  silver  nitrate  in  its  solid  form,  and  the  galvano- 
cautery.  Either  of  the  former  two  agents  may  be  fused  upon  the  end  of  a 
protected  probe  and  applied  to  the  nodule- alter  anesthetizing  the  laryngeal 
surfaces.  Of  the  remedies  mentioned,  chromic  acid  has  served  the  best  pur- 
pose, applied  in  the  manner  described  in  the  section  on  chronic  catarrhal 
laryngitis.  Nitrate  of  silver  and  the  galvano-cautery  leave  a  sear-like  tissue 
which  might   ultimately  compromise  a  fine  voice. 


PACHYDERMIA  OF  THE  LARYNX. 

Although  this  affection  is  not  always  considered  as  a  morbid  entity,  its 
pathological  features  are  nevertheless  such  as  to  warrant  its  classification 
among  the  special  complications  of  chronic  laryngitis. 

Ktiology. —  Pachydermia  of  the  larynx  is  a  disea-e  consisting  of  sym- 
metrically elongated  swellings  of  oval  shape,  most  frequently  observed  near 
the  posterior  extremities  of  the  vocal  hand-,  especially  the  region  of  the  vocal 
processes.  It  occurs  especially  a-  a  result  of  the  chronic  laryngitis  observed 
in  persons  addicted  to  the  excessive  use  of  alcohol  and  tobacco,  and  is  some- 
time- ascribed  to  tuberculosis  and  syphilis.  Judging  from  the  cases  so  far 
observed,  it  occurs  most  frequently  in  men  between  thirty  and  forty-five 
year-   of  age. 

Pathology.— In  a  series  of  fifteen  larynges  affected  with  pachydermia 
examined  microscopically,  1  laherinann  '  found  connective-tissue  changes  in 
the  mucosa  ami  submucosa  of  the  vocal  cord-  and  ventricular  hands,  extend- 
in-  occasionally  into  the  thyro-arytenoid  muscle  involved  (Fig.  596).  In 
some  spots,  especially  the  vocal  processes  and  the  posterior  wall  (the  inter- 
arytenoid  space),  individual  papillae  had  developed  into  papilloma-like growths. 
The  cup-like  prominence-  due.  a-  thought  by  B.  Fran kel,  to  pressure  exercised 
by  the  vocal  processes  upon  one  another  during  phonation,  were  present  in  the 
majority  of  cases,  the  central  depression  corresponding  to  the  point  of  the 
hyaline  process.  Connective-tissue  strands  radiated  in  all  directions  from  the 
surface  of  the  papilla?.  The  erosions  and  ulcer-  found  occurred  most  fre- 
quently on  the  vocal  processes,  about  equally  on  each  side,  less  often  on  the 
free  border  of  the  vocal  hand-.  Nothing  was  found  to  indicate  that  these 
ulcerations  were  due  to  either  tuberculosis  or  syphilis.  The  association  of 
pachydermia  and  ulceration  with  diseases  which  cause  general  congestion, 
pulmonary  emphysema,  cirrhosis  of  the  liver,  etc.,  was,  however,  confirmed. 

Symptoms. — The  symptoms  vary  according  to  the  situation  of  the  local 
thickening,  but  a-  a  rule  the  disease  run-  it-  course  unattended  by  any  great 
<\<^ti<>>\'  discomfort.  The  firsl  symptom  huskiness — is  usually  ascribed  to 
a  cold,  and  i-  accompanied  by  frequenl  de-ire  to  clear  the  throat,  owing  t"  a 
sensation  resembling  thai  caused   by  the  presence  of  a  foreign  body.     Slight 

/  Heilkunde,  Bd.  \\i..  1895,  and  Journal  of  Laryngology,  Oct.,  1896, 


PACHYDERMIA    OF  THE  LARYNX.  1007 

dyspnea    is  sometimes  experienced  ;    this  is  perhaps  due  to  the  diminished 
abduction  observed  in  these  cases. 

Examined  laryngoscopically,  the  larynx  appear-  more  or  less  congested 
according  to  the  intensity  of  the  catarrhal  process  that  may  be  present.  In 
some  cases  the  laryngeal  surfaces,  except  the  sites,  of  the  growths,  appear 
normal.  On  the  vocal  hands,  however,  and  almost  always  over  the  vocal  pro- 
cesses, two  pink  or  red  swellings,  oue  on  each  side,  and  someti s  involving 

the  posterior  wall  of  the  larynx,  may  be  seen.     One  of  these  growths  is  much 
larger  than  the  opposite  one.      In  a  case  seen  by  Dundas  Grant  the  larger 


:■':•'•  ■'■'■':.;  ;-S:' '.'''/.■> . 

■     .  -.  -  ■'  '    ' 


Fig.  596.— Section  of  mucosa,  showing  pachydermia  of  the  larynx.  The  hypertrophied  papilla 
covered  with  greatly  thickened  epithelium  (a  .  and  the  infiltrated  submucosa   d)  shows  gaping  vascular 
channels        seifert  and  Kahn). 

tumor  had  reached  the  size  of  a  shirt-button.  The  smaller  thickening  on  the 
opposite  side  shows  an  excavation  or  depression  at  its  apex,  precisely  where 
the  growth  of  the  other  side  comes  in  contact  with  it  during  approximation 
of  the  vocal  hand-.  This  cup-like  depression,  as  already  stated,  is  due  to  the 
pressure  exerted  by  the  tumor  of  the  one  side  upon  the  corresponding  tumor 
of  the  other.  There  may  be  but  one  excre-ccn.r.  however,  and  indentation 
of  the  opposite  be  formed  at  the  expense  of  the  tissues  of  the  vocal  hand 
proper. 

Prognosis. — The  prognosis  of  this  affection  mainly  rests  upon  the  possi- 
bility of  transformation  from  a  benign  to  a  malignanl  growth.  Klebs1  con- 
sider- pachydermia  laryngitis  as  a  possible  primary  stage  of  cancer;  but 
this  view  has  no!  been  generally  sustained,  and  the  prevailing  opinion  is  thai 
degeneration  into  malignancy  is  ao1  to  be  feared.  Chondritis  and  peri- 
chondritis, however,  have  been  observed;  hut  as  a  rule  the  affection  is  < - 

sidered  a  benign  one,  offering  no  special  danger  to  life.  A-  regards  the 
voice,  permanent  impairment  is  likely  unless  the  case  be  seen  -\ni\  properly 
treated  in   its  early  stages. 

Treatment.  The  measures  recommended  for  the  treatment  nf  nodular 
laryngitis  are  probably  the  best  to  adopt,  especially  the  local  application  of 
1  DeutotJu  med.  IIV/,.,  p.  :,:;:.  i  - 


1008      CHRONIC  INFLAMMATORY  DISEASES  OF  THE  LARYNX. 

chromic  acid.  The  internal  administration  of  i< »« 1  i*  1  of  potassium  has  been 
found  beneficial  in  some  cases  owing  to  the  frequent  association  of  the  disease 
with  syphilis.  The  local  measures  indicated  for  the  treatment  of  chronic 
laryngitis  may  also  prove  of  value.  A  spray  of  a  3  per  cent,  solution  of 
chlorid  of  sodium   has  been  especially   recommended. 

Removal  with  forceps  followed  by  local  cauterization  has  been  advocated 
by  Gougenheim  ;  while  Mull  states  that  he  has  obtained  prompt  results  from 
electrolysis,  a  double  needle  and  a  current  of  5  milliamperes  being  employed. 

CHRONIC  SUBGLOTTIC  LARYNGITIS. 

Htiology. — -This  is  a  rare  form  of  chronic  laryngitis  in  which  the  Intuit 
of  the  inflammatory  process  is  located  in  the  tissues  beneath  the  vocal  hands, 
giving  rise  in  this  situation  to  more  or  less  rapid  hypertrophic  changes. 
The  nature  of  this  disease  has  remained  obscure  owing  to  its  rarity,  but  it  is 
thought  to  be  associated  with  the  so-called  scrofulous  habit,  syphilis,  tuber- 
culosis, and  rhino-scleroma.  According  to  Gordon  Holmes,1  the  causes  of 
this  disease  are  nearly  always  well  defined.  Exposure  to  wet  and  cold, 
straining  efforts  of  the  voice,  and  excessive  indulgence  in  spirituous  liquors 
are.  in  his  opinion,  almost  exclusively  the  sources  of  the  disease.  It  is  also 
allied  to  certain  occupations  in  which  the  vocal  organ  is  used  with  vigor. 
Of  17  cases  seen,  30  were  males.  Reports  of  cases  seen  by  other  authors 
would  indicate,  however,  that  the  disease  occurs  more  frequently  in  females 
than  in  male-.  It  occasionally  presents  itself  as  a  complication  of  typhoid 
fever.2 

Pathology. — An  analysis  of  the  microscopical  examinations  reported 
by  Wedl,3  Sokolowski/  and  Kuttner  '  tends  to  show  that  the  disease  consists 
mainly  of  a  chronic  cell-proliferation,  not  only  in  the  mucous  and  submucous 
cellular  tissue,  but  also  in  the  underlying  muscular  layer,  the-  epithelial  lining 
sinking  into  the  submucous  tissue  in  various  places.  This  process  progress- 
ing insidiously,  a  dense  indurated  mass  is  gradually  developed,  which  occa- 
sionally includes  the  edges  of  the  vocal  bands  and  the  neighboring  tissues. 
It  would  seem  that  besides  a  dyscrasia,  lymphatism,  syphilis,  etc,  the  disease 
requires  some  exciting  organism,  especially  the  typho-bacillus  and  that  of 
rhino-scleroma,  for  it>  development.      No  bacillus  special  to  the  disease  has 

as    vet     been    (blind. 

Symptoms.  —The  earliesl  symptom  is  hoarseness,  which  is  generally 
attributed  to  n  cold.  The  voice  is  muffled  and  labored,  and  is  sometimes 
completely  lost.  This  complete  aphonia  is  more  likely  to  occur  in  females 
than  in  male-.  The  patient  sometimes  experiences  a  sensation  of  weight  in 
the  throat,  due  probably  to  the  impediment  offered  by  the  more  or  less  solidi- 
fied subglottic  tissues  to  the  movement  of  the  vocal  bands.  Pain  is  seldom 
i  sperienced,  but  there  i-  often  :i  sensation  of  pricking  that  causes  the  patient 
to  frequently  " hem "  to  clear  his  larynx  of  a  small  mass  of  mucus  which 
may  have  collected  over  the  diseased  area.  Such  a  patient,  who  may  perhaps 
experience  a  slighl  difficulty  in  breathing  during  exertion,  may  all  at  once, 
without  the  leasl  warning,  become  the  prey  of  intense  dyspnea,  and  pa>s  away 
mile--,  immediate  relief  be  at  hand,  the  subjective  manifestations  being  such 
as   to  suggest   other  disorders,  cardiac  or   vascular,  as  the  cause  of  death. 

/    ,..-.  November  I  s<i;. 

\    Sokolowski,  Archivfur  Laryngologie,  Bd.  ii.  II.  1,  l-'.'l 
Wedl,  in  Turck'a  Klinikda   I  n  det  Kehlhrpf  ,  y.  203,  L866. 

lowski,  Op.  cit.  'Kuttner,  Archivfur  Laryngologie. 


<  IIR  ONK '  TR  AC  11 E.  \L   A  I  I  l-J  II  <>  NS.  1 009 

Several  such  eases  have  been  reported;  others  have  been  saved  h\  timely 
tracheotomy.  The  subglottic  enlargement  on  each  side  can  usually  be  seen 
laryngoscopically,  especially  when  the  vocal  hand-  are  abducted,  appearing 
as  more  or  le>-  rounded  bulging  masses  varying  from  the  dull,  variegated 
pink  tint  of  catarrhal  hyperemia  to  the  vivid  ved  hue  of  active  inflamma- 
tion. In  acute  attacks  the  latter  color  prevails  and  the  glottic  lumen  i- 
almost  occluded.  When  edema  is  a  prominent  factor  of  the  case,  the  gray- 
ish-white color  of  the  projecting  mass  suggests  the  presence  of  polypi  such 
as   those    found    in    the   nasal   cavities. 

Prognosis. — As  may  he  surmised,  the  prognosis  of  such  a  case  i-  not 
encouraging,  tracheotomy  or  laryngotomy  becoming  obligatory.  Even  then 
the  patient  frequently  perishes  from  gradually  increasing  debility  unless  an 
intercurrent  disease  such  as  pneumonia  should  carry  him  off.  It  is  probable, 
however,  that,  discovered  early,  the  trouble  might  he  arrested  by  antagoniz- 
ing any  condition,  occupation,  overuse  of  the  voice,  etc.,  capable  of  inciting 
local  trouble,  or  by  counteracting  the  pathogenic  influence  of  any  dyscrasia 
that   may  be  present. 

Treatment. — Change  of  climate,  to  avoid  acute  exacerbations  so  fre- 
quently caused  by  damp  cold,  is  indicated,  with  cessation  of  vocal  effort  and 
any  other  occupation  or  habit  acting  as  exciting  cause.  Gordon  Holme-,' 
who  has  obtained  some  cures,  states  that  relief  may  be  obtained  from  the  use 
of  cold  spray  inhalations,  of  solutions  of  perchlorid  of  iron,  sulphate  of 
copper,  etc.,  between  paroxysms,  but  that  during  the  exacerbations  warm 
soothing  inhalations,  impregnated  with  opium,  conium,  or  stramonium,  are 
preferable.  Local  applications  by  the  attending  physician  of  a  solution  of 
perchlorid  of  iron — two  drams  to  the  ounce  of  water — directly  to  the  byper- 
trophied  region  are  of  value  in  mild  eases.  In  advanced  cases  strong  solu- 
tions of  nitrate  of  silver  are  recommended.  Cauterization  of  the  parts  with 
the  galvano-cautery  has  been  highly  recommended  by  Voltolini  ;  while  Mack- 
enzie advised  scarification.  Sokolowski  recommends  laryngofissure  and 
thorough  extirpation  of  the  hypertrophied  tissues. 

CHRONIC   TRACHEAL   AFFECTIONS. 

Unless  of  a  neoplasm,  the  trachea  may  be  said  never  to  be  independently 
the  seat  of  a  chronic  affection,  merely  sharing  in  those  which  extend  into  it 
from  the  larynx  above  or  from  the  bronchi  below.  Separate  discussion  i- 
therefore  needless. 

1  Loc.  tit.,  ]>.  868. 

64 


DIPHTHERIA  OF  THE  AIR-PASSAGES. 

By  J.   H.   McCOLLOM,    M.  D., 

OF    BOSTON,    MASS. 


Definition. — The  term  diphtheria,  derived  from  the  Greek  word  dupdepa, 
meaning  skin  or  leather,  should  l>e  applied  only  to  those  eases  of  sore 
throat  in  which  a  membrane  is  found,  and  in  which  a  culture  taken  from  this 
membrane  or  near  it  shows  the  presence  of  the  bacilli  of  diphtheria,  or  in 
those  cases  in  which  there  is  a  profuse  nasal  discharge,  a  culture  from  which 
shows  the  presence  of  these  organisms.  In  cases  of  laryngeal  stenosis,  al- 
though no  membrane  is  visible  and  the  cultures  are  negative,  the  existence  of 
this  membrane  has  been  proved  by  autopsies  and  by  the  fact  that  membrane 
ha-  been  coughed  up.  The  term  membranous  croup  is  a  misnomer  and  is  a 
relic  of  past  ages.  No  such  disease,  as  distinguished  from  diphtheria,  exists, 
and  the  term  should  lie  erased  from  the  nomenclature.  Laryngeal  stenosis 
in  children  in  the  vasl  majority  of  instances  is  caused  by  the  presence  of  a 
membrane  which  i<  the  result  of  the  growth  of  the  bacilli  of  diphtheria. 
Streptococci  may  cause  the  appearance  of  a  membrane  in  the  air- pas  sages, 
but  thi~  membrane  is  not  sufficiently  thick  and  tough  to  impede  the  respi- 
ration. 

History. —  It  is  generally  supposed  that  diphtheria  is  a  disease  of  modern 
times,  but  A.reta?us,  a  Greek  physician  of  Cappadocia,  wrote  a  description  of 
a  disease  similar  to  diphtheria  in  111  a.  i>.  In  the  sixteenth  century  the 
disease  was  prevalent  to  ;i  greater  or  less  extent,  according  to  written  state- 
ment- of  the  physician-  of  that  time.  In  1S21  Bretonneau  wrote  the  first 
full  and  elaborate  accounl  of  the  disease.  After  that  time  until  1847  diph- 
theria did  not  seem  to  attract  much  attention  among  the  physicians  of  the 
Continent.  In  is  17  an  outbreak  of  diphtheria  occurred  in  England,  which 
was  traced  to  it-  origin  al  Boulogne  and  was  known  as  the  "  Boulogne  -ore 
throat."  Since  that  time  diphtheria  ha-  been  more  generally  recognized  and 
more  carefully  studied  ;  and  for  tin-  reason,  although  the  disease  is  somewhat 
more  prevalenl  at  the  present  time  than  formerly,  yet  the  apparent  increase 
is  due  in  :i  measure  to  it-  better  recognition. 

Diphtheria   was  first   recognized   in   Boston,   Massachusetts,  in   1859,  in 

which  year  there  were    |!l   dentil-    from  this   cause    reported.       From    what    is 

known  of  the  disease  to-day,  it  seems  reasonable  to  suppose  that  if  1!)  deaths 
from  a  so-called  new  disease  were  reported,  there  musl  have  been  many  cases 
of  the  -nine  disease  thai  were  nut  recognized.  The  following  vear  there  was 
only    one   death    from    this   cause    reported    in    Boston.      Since    that    time   the 

death-returns  have  shown  :i  gradual  increase  in  the  number  of  deaths.  In 
1863  nid  1864,  in  Boston,  with  a  population  of  186,526,  there  were  353  and 
287  deaths,. respectively.  From  1865  to  [874  there  were  very  few  deaths 
from  diphtheria.  In  bs7o  the  number  of  deaths  from  this  disease  increased 
to  an  alarming  extent.  In  1881  there  \\:i-  quite  a  severe  epidemic  of  this 
disease  in  this  city,  the  deaths  for  that  period  numbering  802,  giving  a  rate 
nun 


ETIOLOGY. 


Hi]  1 


per  1000  of  the  living  of  2.178.  Since  1881  the  number  of  deaths  from 
diphtheria  has  varied  from  285  to  878  eacli  year.  The  number  of  case-  re- 
ported in  1«S!»4  was  3019,  with  878  deaths,  making  the  death-rate  from  this 
disease  per  1000  of  the  living  for  1894,  1.803,  while  thai  of  1893  was  1.1  15. 
The  most  marked  increase  in  the  cases  of  diphtheria  in    1894,  as  compared 


-$06U- 

4 

* 

4 

re 

4 

4- 

V 

^ 

*• 

5$ 

A 

4 

700 

\* 

r 

650 

-\ 

/ 

600 

\ 

550 

\ 

500 

450 

WO 

350 

300 

Fig.  597.— Chart  of  the  total  number  of  cases  of  diphtheria  in  Boston,  by  months,  for  live  years. 


with  1893,  occurred  in  the  last  six  months  of  the  year.     The  ratio  of  deaths 
per  1000  for  1895  was  1.173,  and  that  for  1896  was  0.980. 

In  England  the  increase  of  the  mortality  from  diphtheria  has  been  much 
more  marked  in  the  larger  towns  than  in  the  rural  districts.  In  London  this 
has  been  more  particularly  noticeable. 

Etiology. — The  discovery  by  Klebs  of  the  bacillus  of  diphtheria  in 
1883  and  the  investigations  by  Loffler  a  year  later,  placed  the  etiology  of 
diphtheria  upon  a  scientific  basis.  The  result  of  these  researches  shows  con- 
clusively that  diphtheria  is  distinctly  a  contagions  disease;  that  it  never 
originates  spontaneously;  that  it  is  a  local  disease;  and  that  the  constitu- 
tional symptoms  are  due  not  to  the  presence  of  the  organism  in  the  blood. 
but  to  the  toxin  caused  by  the  growth  of  the  bacillus. 

It  is  now  generally  conceded  that  imperfect  drainage  and  unsanitary  con- 
ditions should  not  be  considered  important  factors  in  increasing  the  frequency 
of  this  disease.  Twenty  years  ago  diphtheria  was  considered  to  be  a  tilth- 
disease,  but  careful  investigation  of  the  course  of  epidemics  in  various  cities 
and  towns  has  shown  conclusively  that  diphtheria  is  no  more  prevalent  where 
unsanitary  conditions  exist  than  where  the  general  sanitation  is  good. 

The  influence  of  mild  cases  of  diphtheria  in  the  public  schools  has  a 
marked  effect  on  the  prevalence  of  the  disease.  The  accompanying  chart, 
which  gives  the  number  of  cases  of  diphtheria  reported  in  Boston,  Massachu- 
setts, by  months,  for  five  years,  shows  that  when  the  schools  are  in  sessiou  the 
number  of  cases  is  much  greater  than  during  vacation-time,  in  the  months 
of  July   and    August. 

Cows  may  have  diphtheria,  and  when  suffering  from  the  disease  may  be  a 
source  of  infection.  Klein,  in  a  report  to  the  Local  Government  Board  of 
London,  traced  an  epidemic  of  the  disease  to  milk  from  cow-  that  gave  un- 
mistakable evidence  of  being  ill  of  diphtheria.  Small  areas  of  false  mem- 
brane were  found  on  the  teats  of  these  cow-.  Cultures  made  from  these 
lesions  contained  the  diphtheria-bacillus.     Cats  fed  on  the  milk  from  these 


1012  DIPHTHERIA    OF  Till-:  AIR-PASSAGES. 

cows  contracted  diphtheria.  While  there  is  no  positive  evidence  that  the 
milk  in  the  udder  contained  the  germ  of  the  disease,  there  is  every  reason  to 
believe  that  the  milk  was  contaminated  by  the  hands  of  the  milkers. 

One  factor  in  the  spread  of  diphtheria  is  the  existence  of  this  disease 
in  cats  and  dogs.  Diphtheria  manifests  itself  in  cats  ami  dogs,  not  by  the 
presence  of  marked  membrane  in  the  throat,  but  by  the  condition  of  the  lungs 
simulating  pneumonia.  The  animal  has  a  peculiar  strident  cough,  has 
anorexia,  and  loses  flesh  rapidly.  If  children  are  allowed  to  play  with 
animals  suffering   from   this  disease,   they   may   contract  it  from   them. 

The  area  of  infection  of  diphtheria  i-  not  as  or  eat  as  that  of  scarlet  fever, 
but  that  it  is  a  distinctly  contagious  disease  must  he  admitted.  The  dis- 
charge from  the  nose  ami  the  secretions  from  the  month  may  he  the  carriers 
of  the  contagium,  hence  the  importance  of  burning  or  disinfecting  all  articles 
-oiled  by  these  discharges.  Kissing  frequently  conveys  the  germs  of  the 
disease  from  one  person  to  another. 

Morbid  Anatomy. —Diphtheria  must  be  considered  a  local  disease  at 
the  outset  :  and  the  symptoms  that  occur  later  are  tin.'  result  of  the  toxin 
caused  by  the  growth  of  the  bacilli.  The  growth  of  these  organisms  causes 
the  formation  of  false  membrane,  which,  according  to  Weigert,  as  stated  by 
Councilman,1  is  due  to  a  necrosis  of  the  epithelial  surfaces.  The  exudation 
from  the  vessels  beneath  coming  in  contact  with  the  necrosed  tissue  coagulates 
and  forms  fibrin.  Wagner1  says  the  presence  of  the  membrane  is  due  to  hyper- 
emia and  inflammation  of  the  tissues  beneath,  ami  that  there  is  a  fibrinous 
metamorphosis  of  the  epithelial  cells.  Heubner1  found  that  in  the  beginning 
of  the  disease  membrane  was  formed  in  the  most  superficial  layers  of  the 
epithelial  cells  and  gradually  extended  to  the  deeper  ones.  The  appearance 
of  the  membrane  during  the  first  twelve  hours,  as  compared  with  its  appear- 
ance forty-eighl  hour-  later,  is  explained  by  this  view  of  Heubner.  The 
membrane  in  diphtheria  i-  generally  of  ;i  grayish-white  color,  and,  as  a  rule, 
cannot  be  easily  detached  ;  but  this  is  not  universally  the  case,  as  frequently 
it  i-  white,  and  appears  only  in  small  circumscribed  patches  easily  detached. 
The  membrane  sometimes  early  in  the  disease  assumes  a  gangrenous  appear- 
ance, which  i-  ai ten  of  very  grave  import.  Nasal  diphtheria  is  character- 
ized by  a  profuse  nasal  discharge,  and  it  is  the  exception  that  any  membrane 
can  be  detected  without  a  rhino-epic  examination.  Diphtheria  of  the  eye, 
often  caused  by  the  transmission  of  the  germs  of  the  disease  from  the  nose, 
is  of  frequenl  occurrence.  There  is  great  swelling  of  the  lids,  intense  con- 
gestion of  the  conjunctiva?,  and  frequently,  but  not  always,  the  formation  of 
a  false  membrane.  Frequently  the  pharyngeal  inflammation  extends  through 
the  Eustachian  tube  and  causes  an  inflammation  of  the  middle  ear.  The 
membrane  may  extend  into  the  larynx,  giving  rise  to  marked  dyspnea. 
Below  the  voc.d  cords  the  membrane  is  not  very  firmly  attached  to  the  sub- 
jacent tissues  ami  i-  frequently  coughed  up.  Fig.  598  represents  membran- 
ous casts  of  the  trachea  coughed  up  by  a  patient  ill  with  diphtheria.  Casts 
of  the    right    and    left    bronchi    can    be   clearly  seen. 

Membrane  may  extend  into  the  various  ramification-  of  the  bronchi. 
The  heart  may  be  of  i  grayish-yellow  color,  and  when  death  occurs  late  in 
the  disease,  may  -how  evidences  of  fatty  degeneration.  The  kidneys,  as  a 
nde,  are  enlarged  ;  and  on  section  the  cortex  is  found  swollen  and  the  region 

<•('  the  convoluted  tube-  opaque.  When  death  occurs  late  in  the  disease, 
during  apparent  convalescence,  there  are  no  characteristic  macroscopic  lesions 
found,  a-  a   rule,  nt   the  autopsy.     Microscopical  examination,  however,  of 

'  Boston  Medical  and  Surgical  Journal,  exxxiu.,  la,  p  231. 


I'ltorilYI.A.XIS. 


1013 


the  nerves  shows  in  the  majority  of  instances  marked  degeneration  of  the 
nerve-tissue. 

Prophylaxis. — The  importance  of  isolating  every  case  of  doubtful 
sore  throat  cannot  be  overestimated,  and  it  is  also  equally  important  to  isolate 
every  child  who  has  a  profuse  nasal  discharge,  until  the  diagnoses  can  be 
definitely  made  by  means  of  a  bacteriological  examination.  It  is  a  trite 
saving-,  hut  nevertheless  true,  that  mild  eases  of  contagious  disease  are  much 
more  dangerous  to  the  public  health  than  the  severer  ones.  The  writer  has 
investigated  quite  a  number  of  outbreaks  of  diphtheria  which  could  be 
definitely  traced  to  mild  cases  of  the  disease,  eases  so  mild  that  no  physician 


i';(,    593     Casts  of  the  trachea  and  branch 


saw  them.  Too  much  emphasis  cannot  be  laid  upon  the  danger  of  per- 
mitting children  with  profuse  nasal  discharges,  loaded  with  the  bacilli  ol 
diphtheria,  to  mingle  with  others.  The  careful  medical  inspection  ol  schools, 
in  order  that  children  suffering  from  mild  attacks  <»!'  diphtheria  may  be 
isolated  at  their  horn.-,  is  a  very  important  factor  in  prophylaxis.  When  a 
patieni  i-  taken  ill  with  diphtheria,  he  should  be  placed  in  an  upper  room 
of  the  house.  All  hangings,  stuffed  furniture,  and  carpets  should  beremoved 
from  the  sick-room,  [f  possible,  only  one  person  should  attend  upon  the  patient, 
and  she  should  wear  cotton  gowns,  which  should  be  frequently  changed  and 
disinfected.    All  discharges  from  the  patient  should  be  disinfected  by  corrosive 


1014  DIPHTHERIA    OF  THE  AIR-PASSAGES. 

sublimate,  1  part  to  500,  or  by  a  solution  of  carbolic  acid,  1  part  to  20.  No 
handkerchiefs  should  be  used,  1  > 1 1 1  in  place  of  them  pieces  of  old  cotton-cloth 
should  be  employed  to  receive  the  discharges  from  the  nose  and  mouth.  These 
pieces  of  cloth  should  be  burned.  All  utensils  should  be  sterilized  in  boiling 
water  or  l«v  washing  with  a  solution  of  corrosive  sublimate,  care  being  taken. 
however, to  thoroughly  wash  them  after  the  immersion  in  corrosive  sublimate. 
The  room  should  be  well  ventilated  and^  if  possible,  should  have  a  sunny 
exposure.  An  abundance  of  sunlight  in  the  room  of  a  patient  is  of  very 
great  importance.  The  germicidal  properties  of  sunlight  have  Keen  very 
clearly  demonstrated  by  v.  Esmarch.  In  his  experiments  he  proved  con- 
clusively that  the  bacilli  of  diphtheria  in  culture-tubes  and  on  cloth  were 
destroyed  in  from  four  to  five  hours.  Pure  air  and  plenty  of  sunlight  are 
Nature'-  most  effective  germicides.  Burning  sulphur  in  a  room  where  a 
patimt  i-  ill  i-  a  most  reprehensible  practice.  It  not  only  fails  to  do  any 
good,  Inn  i-  ;i  source  of  very  greal  annoyance  to  the  patient  and  nurse.  The 
nurse  should  always  carefully  disinfect  her  hands  with  corrosive  sublimate 
after  any  manipulations  of  the  patient,  and  it  is  well  to  frequently  wash  the 
month  with  Dobell's  solution,  1  part  to  3.  The  physician,  when  making  his 
visit,  should  wear  a  cotton  gown,  and  should  be  particularly  careful  to  wash 
hi-  hand-  in  a  solution  of  corrosive  sublimate  after  his  visit.  Careful  atten- 
tion to  these  various  details  diminishes  the  chance  of  spreading  the  disease. 

After  the  recovery  or  death  of  the  patient,  the  mattresses  and  blankets 
should  be  sterilized  by  superheated  steam.  The  floors  and  woodwork  should 
be  washed  with  a  solution  of  corrosive  sublimate,  1  part  to  500.  The  walls 
of  the  room,  if  painted,  should  be  washed  in  a  similar  manner.  It'  papered, 
the  paper  should  be  removed.  The  ceiling  should  be  whitened  or  tinted. 
All  washable  material-  should  be  boiled  for  an  hour.  Books  and  toys  had 
better  be  burned,  a-  there  is  no  way  of  disinfecting  these  article-  properly. 
The  experiment-  of  Koch  in  1888  proved  conclusively  that  sulphurous  acid 
gas,  in  the  manner  in  which  it  was  usually  employed,  was  useless  and  that 
tin-  method  of  disinfection  was  misleading.  It  has  been  shown  in  the  labor- 
atory that  various  micro-organisms  exposed  under  a  bell-glass  to  the  fumes 
of  sulphurous  acid  gas  for  twenty-four  hours  have  been  destroyed,  vet  this 
i-  no  proof  that  sulphurous  acid  gas  is  an  efficient  disinfectant  for  apart- 
ments.    The  condition-   in  the   r n-  of  a   house  are   entirely  different  from 

those  under  a  bell-glass.  It  i-  impossible  to  make  a  room  in  a  house  air- 
tight, and  for  tin-  reason  sulphurous  acid  gas  cannot  be  considered  a  reliable 
disinfectant  in  these  cases.  For  the  purpose  of  investigating  the  true  germi- 
cidal value  of  sulphurous-acid-gas  disinfection,  a  few  experiments  were  made 
by  the  writer.  Six  test-tubes,  containing  each  about  10  <•.<•.  of  the  water  from 
the  tap.  colored  slightly  with  rosolic  acid  and  plugged  in  the  usual  wav,  were 
exposed  to  the  fumes  ol  sulphurous  acid  gas  for  six  hours  in  a  room  when- 
there  hail  been  a  case  -»f  diphtheria.  The  cotton  plugs  from  three  of  the 
tube-  were  ivi n o \e,  1  j 1 1 -t  b.  fore  the  room  was  closed  and  replaced  as  soon  as 
the  room  was  entered.  It  was  found  that  the  color  of  the  rosolic  acid  was 
discharged  by  the  sulphurous  acid  gas  in  all  of  them,  proving  that  the  gas 
had  penetrated  into  the  interior  of  the  tubes.  Cultures  on  gelatin-plates 
made  from  all  the-e  tub.-  showed  a  growth  of  the  common  organisms  found 
in  drinking-water.  The  number  of  colonies,  however,  that  developed  in  the 
gelatin-plates  was  not  so  greal  as  that  which  developed  in  the  plate-  used  for 
the  control-experiment.  In  the  second  experiment  six  test-tubes  -one  of 
which  contained  a  pure  culture  of  the  diphtheria-bacillus  on  cotton  cloth; 
a   second,  containing  a  pure  culture  of  the  spirillum  of  Asiatic  cholera  pre- 


PROPHYLAXIS.  1015 

pared  in  a  similar  manner;  a  third,  a  culture  of  the  diphtheria-bacillus  in 
bouillon;  a  fourth  tube,  containing  a  culture  in  bouillon  of  the  spirillum 
of  Asiatic  cholera,  of  the  diphtheria-bacillus,  and  of  the  bacillus  pyo- 
cyaneus;  a  fifth  tube,  containing  a  pure  culture  of  the  diphtheria 
bacillus  on  blood-serum,  and  a  sixth  tube,  containing  the  water  from 
the  tap — were  used.  These  tubes,  plugged  in  the  usual  way  and  the  con- 
tents colored  slightly  with  rosolic  acid,  were  exposed  to  sulphurous  acid 
gas  for  six  hours  in  the  presence  of  moisture.  As  in  the  previous  experi- 
ment, the  plugs  were  removed  from  three  of  the  tubes.  The  color  was  found 
to  be  discharged  from  the  rosolic  acid  in  all  of  them.  Culture-  made  from 
these  tubes  were  found  to  contain  all  the  organisms  with  which  the  initial 
tubes  had  been  inoculated,  with  one  exception,  that  of  the  tube  in  which 
there  were  three  organisms.  In  this  tube  the  spirillum  of  Asiatic  cholera 
was  not  found.  The  growth  was  not  very  abundant  in  the  inoculations  made 
from  these  tubes.  It  therefore  seems  evident  from  this  limited  investiga- 
tion that,  while  sulphurous  acid  gas  may  possibly  inhibit  the  growth  of 
pathogenic  organisms,  it  certainly  does  not  destroy  them.  Chlorin  gas,  when 
evolved  in  the  presence  of  steam,  is  one  of  the  most  efficient  disinfectants, 
but  the  objection  to  it  is  the  fact  that  it  ruins  all  metal  with  which  it  comes 
in  contact.  Fischer  has  proved  by  his  experiments  that  if  the  spores  of  the 
anthrax-bacillus  were  exposed  in  moist  air  to  chlorin  gas  they  were  destroyed 
after  an  exposure  for  one  hour.  The  disinfectant  known  as  electrozone, 
which  is  made  by  the  decomposition  of  sea-water  with  a  current  of  elec- 
tricity, contains  a  large  proportion  of  chlorin  with  a  .-mall  quantity  of  iodin 
and  bromin.  Recent  experiments  prove  that  this  agent  possesses  powerful 
antiseptic  and  germicidal  properties.  There  can  be  no  doubt  regarding  its 
deodorizing  powers. 

Steam  under  pressure  is  now  considered  to  be  the  only  proper  method  of 
disinfecting  mattresses,  wearing-apparel, and  carpets.  It  is  important  to  take 
the  precaution  of  removing  all  leather  and  horn  buttons,  as  these  materials 
will  not  stand  the  high  temperature.  There  are  various  forms  of  -team 
disinfecting  apparatuses  manufactured  abroad,  and  those  made  in  this  country 
are  modelled  on  the  same  plan.  Geneste  and  Herscher  of  Pari-  manu- 
facture a  stationary  and  a  movable  apparatus.  The  stationary  one  consists 
of  a  large  iron  cylinder  capable  of  sustaining  a  pressure  of  twenty  pounds 
to  the  square  inch.  At  each  end  of  the  cylinder,  which  is  placed  in  a 
horizontal  position,  arc  cast-iron  heads  moving  on  hinges  and  adapted 
with  screw  bolt-,  so  that  they  can  be  tightly  closed.  A  tight  partition-wall 
separates  the  ends,  so  that  there  can  be  no  communication  between  the  room 
where  the  infected  articles  are  put  in  and  that  from  which  the  disinfected 
article-  are  removed.  At  the  bottom  is  a  coil  of  closed  steam-pipes  for  the 
purpose  of  heating  the  interior  of  the  cylinder;  at  the  top  i-  a  set  oi  per- 
forated pipe-  for  introducing  -team.  An  appliance  for  exhausting  the  air  to 
increase  the  penetrating  power  of  the  superheated  steam  i-  attached  to  the 
apparatus.  The  movable  one,  the  prinicple  of  which  is  the  same  as  that  of 
the  stationary,  i-  mounted  on  wheels  and  weighs  aboul  a-  much  as  a  fire- 
engine.  The  steam  i-  generated  by  a  fire-box  at  the  lower  part  of  the 
cylinder.  Henneberg  of  Berlin  manufacture-  a  similar  movable  apparatus, 
which  has  some  slighl  improvements  over  that  of  Geneste  and  Herscher.  Lnese 
movable  disinfecting  cylinders  can  be  used  with  great  advantage  in  sparsely- 
settled  districts,  but  are  riol  adapted  for  use  in  a  thickly-settled  locality. 
Numerous  experiments  Bhow  conclusively  that  a  temperature  oi  about  212 
F.  for  one  hour  will  destroy  all   micro-organisms,  and,  therefore,  where  beat 


1016 


DIPHTHERIA    OF  THE  MR- PASSAGES. 


can  be  properly  applied  without  injury  to  the  articles,  it  is  the  very  best 
method  of  disinfection.  In  disinfecting  by  heal  in  one  of  these  steam- 
cylinders  it  is  important  to  raise  the  temperature  to  250°,  which  means  a 
steam-pressure  "t"  fifteen  pounds  to  the  square  inch,  tor  an  hour,  in  order  that 
the  heat  may  penetrate  into  the  interior  of  mattresses  and  rolls  of  blankets. 
The  besl  method  of  disinfecting  upholstered  furniture  is  an  open  question. 
The  only  available  method  of  accomplishing  this  end  is  by  immersion  in 
boiling  naphtha  lor  two  or  three  horns.  Although  there  are  no  reliable 
bacteriological  experiments  on  this  point,  yet  as  most  of  the  coal-oil  products 
are  disinfectants  of  greater  or  less  value,  and  as  it  has  been  definitely  settled 
that  the  thermal  death-point  of  many  organisms  is  about  160°  F.,  it  seems 
reasonable  to  suppose  that  this  method  of  disinfection  for  these  articles  is  of 
practical  use.  The  vapor  of  formaldehyd,  judging  from  the  results  of  the 
experiments  of  Vaillard  and  Lemoine,  is  a  germicide  of  some  value.  The 
apparatus  required  is  inexpensive  and  its  use  not  difficult.  More  extended 
experiments,  however,  are  necessary  before  the  efficacy  of  this  mode  of  dis- 
infection  can  be  absolutely  accepted. 

Symptomatology. — The  period  of  incubation  of  diphtheria  is  from  two 
to  three  days.  The  disease  i-  ushered  in  by  a  slight  chill  and  a  general  feel- 
ing of  malaise.      In  children  the  onset  in  certain  instances  may  commence 


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>99     Temperature-chart  In  diphtheria  without 
antitoxin. 


Fig.  600. — Temperature-chart  in 
diphtheria  with  anl  itoxin. 


with  a  slight  convulsion.  There  is  a  feeling  of  pain  and  soreness  in  the 
throal  :  dysphagia  is  not  a  prominent  symptom  at  the  commencement  of  the 
attack.  There  is  a  peculiar  dark-red  appearance  of  the  mucous  membrane 
of  the  mouth  which  is  characteristic  of  the  disease,  and,  although  not  always 
3een,  yel  it  is  sufficiently  common  to  be  classed  as  one  of  the  symptoms.  At 
the  end  of  twelve  to  twenty-four  hours  a  small  patch  of  membrane  of  a 
grayish  or  dirty-white  color  appears.  This  membrane  may  extend  very 
rapidly,  so  that  in  the  course  of  twenty-four  hours  the  tonsils  and  uvula  may 
be  covered  by  it.  Sometimes  the  membrane  becomes  gangrenous  and  there 
is  .in  extremely  disagreeable  fetid  odor  from  the  patient.  At  this  stage  a 
profuse  nasal  discharge  may  appear;  and  if  the  membrane  extends  and  the 
patient  becomes  septic,  spots  of  ecchymosis  appear  on  various  parts  of 
the  body.  These  3pots  of  ecchymosis  are  of  very  grave  import,  few 
in  which  these  Bymptoms  appear  recover.  The  difficulty  of  swallowing 
now  increases;  the  patient  is  in  a  listless  condition  or  may  be  delirious. 
Delirium  of  an  active  type  is  not  :i  common  symptom  in  diphtheria,  although 
it  sometimes  occurs.    An  eruption  resembling  scarlet  lexer  may  appear  in  the 


DIAGNOSIS.  1017 

later  stages.  Hemorrhages  may  occur  from  the  oose  and  mouth.  The  tem- 
perature, as  a  rule.  is  not  much  elevated,  but  in  certain  instances,  on  the 
second  or  third  day  of  the  attack,  may  rise  to  104  I'.  The  accompanying 
charts  (Figs.  599,  600)  give  the  temperature  in  diphtheria  without  antitoxin 
and  with  antitoxin.  In  some  instances  the  temperature  may  be  subnormal. 
A  subnormal  temperature  is  greater  cause  for  anxiety  than  a  moderately  ele- 
vated one.  The  pulse  is  rapid  and  weak  and  do.-  not  always  bear  anv 
relation  to  the  temperature.  Sometimes  the  pulse  i-  very  slow;  and  when 
this  occurs  it  is  an  indication  of  the  profound  impression  of  the  toxin  of 
diphtheria  upon  the  nervous  centers.  There  is  anorexia  and,  frequently, 
nausea  and  vomiting.  Diarrhea  is  frequent,  but  it  is  not  a  constant  symptom. 
In  the  laryngeal  eases  it  is  the  exception  rather  than  the  rule  that  any  mem- 
brane i>  visible  in  the  mouth.  There  is  marked  stenosis  of  the  larynx,  char- 
acterized by  a  cyanotic  hue  of  the  face  and  by  marked  retraction  just  below 
the  xiphoid  cartilage.  Supraclavicular  retraction  is  also  a  prominent  symp- 
tom, more  marked  in  older  children  and  young  adults.  The  patienl  i-  rest- 
less, is  constantly  opening  his  mouth  in  the  vain  attempt  to  get  air  into  the 
lungs.  In  adults  retraction  of  the  thoracic  walls  is  not  a  very  marked  symp- 
tom. Attack-  of  dyspnea  may  occur  very  suddenly  in  the  course  of  a  mild 
attack  of  the  disease.  A  peculiar  harsh,  brassy  cough  is  a  symptom  of  very 
frequent  occurrence  in  laryngeal  diphtheria.  These  attack-  of  suffocation  are 
sometimes  relieved  by  the  expulsion  of  large  pieces  of  membrane. 

In  the  acute  stage  of  diphtheria  death  is  caused  by  either  laryngeal  stenosis 
or  by  the  toxin  generated  from  the  growth  of  the  bacilli.  In  the  later  stages 
of  the  disease  or  during  convalescence  a  fatal  is.-ue  i>  due  to  the  action  of  the 
toxin  on  the  nervous  centers.  Pneumonia  and  broncho-pneumonia  are  very 
frequent  complications  in  the  course  of  diphtheria.  A  streptoooccous  infec- 
tion, abscess  of  the  cervical  glands,  and  a  purulent  inflammation  of  the  joint- 
may  occur.  Inflammation  of  the  middle  ear  not  mfrequeutly  is  observed. 
In  the  later  stage-  or  during  apparent  convalescence  paralysis  very  frequently 
appears.  Palatal  paralysis  is  frequently  seen,  characterized  by  a  nasal  voice 
and  by  the  passage  of  fluids  through  the  nose  during  the  act  of  .-wallowing. 
This  form  of  paralysis  may  be  so  marked  that  there  is  inability  to  -wallow  a 
sufficient  amount  of  food,  and  the  patient  is  in  danger  of  dying  from  inanition. 
Ocular  paralysis  also  frequently  occurs,  characterized  by  inability  to  read, 
dilated  pupil,  and  also  in  certain  instances  by  double  vision.     There  may  also 

be  a  general  paralysis,  in  which  the  patient  lies  in  a  listL tate  in  bed,  unable 

to  raise  his  head  or  to  move  bis  arm-  and  legs  beyond  a  limited  extent.  There 
is  sometimes  a  peripheral  neuritis,  in  which  the  pain  and  discomforl  are  very 
marked.  Paralysis  of  the  pneumogastric  nerve,  characterized  by  obstinate 
vomiting  and  failure  of  the  action  of  the  heart,  is  a  frequenl  cause  of  death 
during  apparent  convalescence  from  the  disease. 

Diagnosis. — The  discovery  of  the  bacillus  of  diphtheria  by  Klebs,  in 
1883,  and  the  further  study  of  tin-  organism  by  Loftier,  have  given  us  a 
ready  method  of  diagnosis  by  the  aid  of  bacteriology.  Much  ha-  been  said 
regarding  laboratory  diphtheria  and  clinical  diphtheria:  clinician-  having 
claimed  that,  in  certain  cases  where  the  membrane  in  the  fauces  had  the 
characteristic   appearance  of  n    diphtheritic    membrane,  the    bacteriologists 

failed     to    detect     the     -pecilic    o|^  ;i  | ,  j -|  n    of    tile    di-ea-e.         A-     a     matter  (if    fact, 

from  personal  stud}  "I'  something  over  3000  cases  of  diphtheria,  both  clinically 
and  bacteriologically,  il  seems  to  me  thai  the  failure  to  deteel  the  organism 
ha-  occurred  so  seldom  that  it  does  not  invalidate  the  accuracy  of  a  bacterio- 
logical diagnosis.     If  the  culture-  are  taken  properly,  if  tin  culture-medium 


L018  DIPHTHERIA    OF  THE  AIR-PAS8AGES. 

i<  in  a   suitable  condition,  and  if  the  staining  is  done  secundum  artem,  the 

failure  to  detect  the  organism  very  rarely  occurs.  A  very  greal  source  of 
error  is  the  fact  that  when  taking  the  culture  the  swab  or  the  platinum  needle 
i-  rubbed  over  the  surface  of  the  membrane  in  the  very  position  where  the 
organisms  are  most  Likely  to  die.  The  edge  and,  if  possible,  the  under  sur- 
face  of  the  diphtheritic  membrane  are  the  proper  places  from  which  to  take 
the  culture-.  It  i-  also  well  to  take  a  second  culture  from  the  secretions  of 
the  mouth.  In  nasal  diphtheria  where  no  membrane  is  visible,  the  profuse 
secretion  from  the  nose  is  invariably  found  to  be  loaded  with  the  bacilli.  A 
id  source  of  error  i-  the  use  of  an  antiseptic  gargle  a  short  time  before 
the  culture  is  taken.  Practical  experience  has  shown  that  when  this  is  done 
the  bacilli  of  diphtheria  are  not.  a-  a  rule,  found  in  the  culture-medium, 
although  other  organisms,  such  as  cocci  and  streptococci,  may  be  present. 

The  organism  that  causes  diphtheria, not  only  in  human  beings  but  in  the 
lower  animals,  is  a  small   bacillus,  straight  or  slightly  curved,  with   rounded 


•-,/.%  fir      j* 
kx 


**Jfr 


.? 


Fig.  601.     Bacillus  diphtherias,  from  a  culture  upon  M<  "»1  -serum;  x  1000  I  Frankel  and  l'fcififer). 

end-,  having  a  diameter  of  <  1.5  to  0.8/i  and  from  2.5  to  '\u  in  length  (  Fig.  601  ) ; 
or,  in  other  word-,  the  length  of  this  organism  is  about  one-half  that  of  the 
diameter  of  a  red  blood-corpuscle.  This  organism  requires  a  peculiar  stain, 
which  i-  known  as  Loffler's  methylene-blue,  consisting  of  a  saturated  alcoholic 
-olut  ion  of  methylene-blue  (30  c.c),  and  <>f  a  watery  solution  of  can -tic  potash, 
1  part  to  10,000  ( 100  c.c.).  Hunt's  differential  stain  is  of  great  assistance  in 
doubtful  cases.  This  stain  is  composed  of  a  watery  solution  of  methylene-blue, 
a  10  per  cent,  watery  solution  of  tannic  acid,  and  a  dilute  watery  solution  of 
methyl-orange  as  a  counter-stain.  When  the  bacillus  of  diphtheria  is  stained 
by  thi-  method  the  pole  granules  are  brought  out  with  great  distinctness, 
while  the  body  of  the  organism  i-  of  a  lighl  greenish-yellow  color.  So  far 
a-  i-  known,  no  other  organism  presents  this  peculiar  appearance  when  stained 

in  this  way.  The  bacillu-  of  diphtheria  i-  an  aerobic,  non-motile,  non-lique- 
fying  organism.  It  does  not  form  3pores,  which  ha- an  important  bearing  on 
the  subject  of  disinfection.  Although  this  organism  grows  on  all  the  usual 
culture-media,  the  growth  is  more  characteristic  on  Loffler's  mixture,  which 
i-  composed  of  •">  part-  of  blood-serum  and  1  part  of  bouillon  containing  I 
per  cent,  of  peptone,  l  per  cent,  of  grape-sugar,  and  one-half  of  1  per  cent. 


PBOGNOSIS.  1019 

of  -odium  chlorid.  ( )n  this  culture-medium,  ;it  the  temperature  of  the  blood, 
the  growth  is  very  abundant,  so  that  at  the  end  of  twenty-four  hours  small, 
round,  elevated  colonies  of  a  grayish-white  color  and  dry  appearance  will  be 
seen.  In  laryngeal  cases  of  diphtheria  where  no  membrane  is  seen,  cultures 
from  the  mouth  invariably  give  a  negative  result.  If  the  case  requires 
operation,  cultures  from  the  intubation-tube  or  from  the  tracheotomy-tube, as 
a  rule,  show  the  presence  of  the  bacillus.  The  fact  that  in  these  laryngeal 
cases  a  negative  result  is  obtained,  has  led  many  to  throw  discredit  upon  this 
method  of  diagnosis;  but  a  consideration  of  the  anatomy  of  the  parts  must 
lead  one  to  the  conclusion  that  we  should  not  expect  to  find  the  organism  in 
these  case-,  for  the  false  membrane  is  situated  so  far  down  in  the  larynx  that 
it  is  impossible  to  reach  it.  Another  point  of  interest  that  has  been  proved 
by  clinical  experience  is  the  fact  that  these  laryngeal  cases,  unless  associated 
with  nasal  diphtheria,  are  not  particularly  infectious. 

The  statement  has  been  made  that  diphtheria-bacilli  may  be  found  in  the 
throats  of  healthy  individuals  who  have  been  exposed  to  diphtheria  ;  and  while 
this  is  true  in  certain  instances,  it  is  so  rare  that  very  little  weight  should 
be  given  to  it.  The  result  of  the  examination  of  the  throat-  of  thirty  nurses 
on  duty  in  the  diphtheria-wards  of  the  South  Department  of  the  Boston  City 
Hospital  proved  the  presence  of  this  organism  in  only  one  instance.  The  ex- 
istence of  an  organism  resembling:  the  bacillus  of  diphtheria  found  in  healthy 
throats,  and  known  as  the  pseudo-diphtheria-bacillus,  has  been  used  as  an  argu- 
ment against  the  accuracy  of  this  method  of  diagnosis  ;  but  this  organism  is  so 
seldom  found  that  it  is  not  a  very  important  factor.  It  has  also  cultural 
peculiarities  which  assist  in  its  differentiation  from  the  true  diphtheria- 
bacillus.  Abbott  has  made  a  bacteriological  study  of  53  case-  of  simple 
sore  throat,  and  in  only  4  of  these  was  a  bacillus  found  which  resembled 
that  of  diphtheria.  The  examination  of  cultures  from  130  non-diphtheritic 
throats,  made  by  the  writer,  showed  that  the  existence  of  this  bacillus  was  not 
sufficiently  frequent  to  be  an  element  of  error  in  bacteriological  diagnosis. 
In  the  cultures  from  these  130  throats,  bacilli  of  many  varieties  wen-  found  : 
but  in  no  instance  was  an  organism  seen  that  with  care  would  be  likely  to  be 
mistaken  for  the  bacillus  of  diphtheria. 

The  bacilli  of  diphtheria  may  be  present  a  long  time  after  recovery,  and 
when  this  occurs  the  individual  must  be  considered  a  source  of  danger,  unless 
it  has  been  shown  by  repeated  experiments  on  guinea-pig-  thai  the  organisms 
are  non-virulent.  The  length  of  time  that  the  bacillus  continue-  after  the  dis- 
appearance of  the  membrane  varies  in  each  case,  [nstances  are  reported  in 
which  positive  culture-  were  obtained  sixty  days  after  the  disappearance  of 
the  membrane.  The  organism  remains  much  longer,  as  a  rule,  in  nasal  cases. 
The  average  length  of  time  i-  about  ten  days,  as  proved  by  an  analysis  of 
\UJ-J.  cases  treated  at  the  South  Department  of  the  Boston  City  Hospital. 

Prognosis. — Diphtheria  must  be  considered  an  extremely  fatal  disease, 
the  percentage  of  mortality  in  severe  epidemics  being  as  high  as  50.  In 
Boston,  from  1878  to  1894,  the  highest  death-rate  of  cases  reported  to  the 
board  of  health  in  any  one  year  w  a-  ■)'>.!  per  cent.;  the  lowesl  death-rate 
for  anyone  year  was  2<>.44  per  cent.,  with  an  average  of  30.7  per  cent. 
As  these  figures  are  based  on  24,813  cases,  the  fatality  of  the  disease  is  evi- 
dent. The  prognosis,  even  in  mild  cases,  must  always  be  guarded.  W  hen 
there  is  extensive  membrane,  profuse  nasal  discharge,  and  marked  septic 
odor,  the  prospect  of  recovery  is  very  Blight.  A  gangrenous  membrane  is 
cause  for  an  unfavorable  prognosis.  The  laryngeal  cases  that  come  to  oper- 
ation, in  certain  instances  succumb  to  broncho-pneumonia ;  in  other-,  death 


L020  DIPHTHERIA    OF  Till.   MIS- PASSAGES. 

is  caused  by  extension  of  the  membrane  into  the  bronchi  ;  the  prognosis, 
therefore,  in  these  cases,  mn-i  be  doubtful.  The  paralysis  that  occurs  as  a 
late  symptom,  if  the  muscles  of  respiration  arc  not  affected,  generally  ends 
in  recovery.  Failure  of  the  action  of  the  heart,  characterized  by  a  slow 
pulse,  is  a  very  grave  omen  ;  few  cases  of  this  nature  recover.  Degeneration 
of  the  pneumogastric  nerve,  characterized  by  persistent  vomiting,  irregular 
respiration,  and  a  slow  and  irregular  pulse,  renders  death  certain.  Spots  of 
ecchymosis  arc  very  unfavorable  symptoms,  and  epistaxis  is  of  the  graves! 
import.  Sepsis,  both  in  the  operative  and  non-operative  cases,  is  the  fore- 
runner of  death.  At'icr  apparent  convalescence  has  commenced,  the  liability 
to  failure  of  the  action  of  the  heart  must  be  considered.  Convalescence  is 
always  slow  and  tedious  in  the  severer  cases. 

Treatment. — As  diphtheria  is  a  depressing  disease,  alcoholic  stimula- 
tion should  be  commenced  at  the  outset.  The  quantity  of  alcohol  that  a 
young  child  will  take  with  positive  benefit  in  a  severe  attack  is  surprisingly 
large.  Wniskey  or  brandy  must  be  given.  It  is  well  to  commence  in  severe 
cases,  in  a  child  from  one  to  two  years  of  age,  with  a  dose  of  from  one  to 
two  dram-  every  four  hours,  watching  carefully  the  effect  on  the  ptdse  and 
on  the  general  condition.  Digitalis  should  also  be  administered  in  appropri- 
ate doses  early  in  the  disease.  Strychnia  may  be  given  in  the  later  stages  if 
there  are  indications  of  commencing  heart-failure.  When  there  is  a  great 
collection  of  mucus  in  the  air-passages,  atropia  sometimes  proves  to  be  of 
great  benefit.  In  cases  of  collapse  the  use  of  nitro-glycerin  sometimes  gives 
marked  relief.  Mercuric  chlorid  in  small  doses  has  been  given  apparently 
with   advantage   in   a   certain   number  of  cases. 

Antitoxin,  however,  i-  the  most  important  agent  in  the  treatment  of 
diphtheria,  and  must  be  administered  early  in  the  disease.  The  healing- 
serum  ha-  been  in  general  use  some  three  years,  and  the  results  obtained 
from  it  are  as  favorable  to-day  as  they  were  when  the  attention  of  medical 
men  was  first  called  to  it.  The  animals  that  are  to  furnish  antitoxin  are 
rendered  immune,  so  thai  the  diphtheria-toxin  has  no  effeel  on  them.  The 
toxin  i-  prepared  by  cultivating  virulent  diphtheria-bacilli  in  bouillon  for 
one  month  at  a  temperature  of  :'>7    ( '.,  or  98.5°  F.,  so  that  the  poison  may 

accumulate.     Before  « imencing  to  prepare  the  toxin   the  virulence  of  the 

diphtheria-bacilli  must  be  tested  by  it-  effect  on  guinea-pig-.  A  procedure 
requiring  less  time  has  been  advocated  by  MM.  Rous  and  Yersin.  This 
method  consists  iii  growing  the  cultures  in  a  current  of  moist  air.  It  must 
lie  borne  in  mind  that  in  the  preparation  of  antitoxin  the  bacilli  of  diphtheria 

:iiv  not  used  ;  but  the  toxin  caused  by  their  growth,  the  specific  poison 
caused  by  them,  is  used.  Toxin  thus  prepared  should  be  of  such  virulence 
thai  one-tenth  of  a  cubic  centimeter  should  kill  a  guinea-pig  weighing  500 
grams  in  from  twenty-four  to  forty-eighl  hours.  Frankel  firsl  rendered 
guinea-pigs  immune  to  diphtheria  by  injecting  pure  culture-  of  the  diphtheria- 
bacillus  which  had  been  sterilized  :n  70'  < '.  Since  then  Behring  has  recom- 
mended a  mixture  of  toxin  and  Gram's  solution  of  potassic  iodid. 

Burger  and  Wasserman  arrived  at  satisfactory  results  by  growing  a  cul- 
ture of  the  diphtheria-bacillus  in  ;i  bouillon  made  from  the  thymus  gland, 
flii-  culture  had  been  exposed  to  a  temperature  of  from  65°  to  70°  ('.,  dur- 
ing ;i  quarter  of  an  hour.  The  method  which  has  given  the  besl  results  is 
that  used  by  Roux  ami  Vaillard  in  their  researches  on  tetanus.  This  con- 
sists of  the  addition  of  three  parts  of  Gram's  solution — consisting  of  iodin 
one  part,  potassic  iodid  two  parts,  and  water  •'!<><>  parts — to  one  part  of  the 
toxin.      The  injection  i-  to  be  repeated  after  a  few  days,  and  either  the  dose 


TREATMENT.  1021 

of  the  mixture  must  be  increased  or  the  proportion  of  Gram's  solution 
diminished.  A  little  later  the  toxin  can  be  given  pure  It  i-  sometimes 
necessary  to  omit  the  injection  for  a  time  if  the  animal  is  losing  in  weight. 

Dogs  have  been  rendered  immune  to  diphtheria  by  many  experimenters, 
among  the  number  Bardach  and  Anm-on.  Sheep  and  goats  are  quite  sensi- 
tive to  the  action  of  the  diphtheritic  poison.  The  immunization  of  milk- 
animals,  such  as  cow-  and  goats,  is  of  particular  interest  from  the  facl  thai 
the  milk  of  thc~e  animals  has  a  certain  antitoxic  power.  Of  all  the  animals 
capable  of  furnishing  great  quantities  of  the  antidiphtheritic  serum,  the 
horse  is  the  most  easily  rendered  immune.  He  hears  the  toxin  much  better 
than  any  of  the  animals  to  which  allusion  has  just  been  made.  By  injecting 
gradually  increasing  doses  of  the  toxin  at  various  intervals  the  horse,  in  two 
months  and  twenty  days,  is  rendered  immune — that  is,  he  can  receive  from 
200  to  300  c.c,  according  to  his  weight,  of  toxin  of  definite  strength  with- 
out disturbance.  The  serum  from  this  animal  has  a  certain  protective  power, 
which  must  be  determined  by  experiments  on  guinea-pigs  before  it  i-  ready 
for  use. 

The  curative  action  of  antitoxin  has  not  been  satisfactorily  explained  ; 
but  it  appears  from  numerous  experiments  that  this  agent  does  not  destroy 
the  toxin,  but  that  its  remedial  power  is  due  to  stimulation  or  some  other 
special  action  on  the  tissue-cells.  If,  however,  the  cells  have  become  so 
damaged  by  the  action  of  the  toxin  of  diphtheria  that  they  cannot  respond 
to  the  stimulation  of  the  antitoxin,  the  remedy  fails  to  accomplish  good. 
This  is  a  powerful  argument  in  favor  of  the  early  administration  of  the 
healing-serum.  The  remedial  power  of  antitoxin  is  also  restricted  to  a  cer- 
tain degree  by  its  inability  to  combat  the  streptococcous  infection,  broncho- 
pneumonia, and  other  complications  referable  to  secondary  infection.  In 
some  of  the  experiments  made  for  testing  the  action  of  antitoxin,  diphtheria 
was  caused  in  female  guinea-pigs  by  rubbing  pure  cultures  of  the  diphtheria- 
bacillus  on  the  excoriated  surface  of  the  vulvae.  In  these  cases  the  pigs 
recovered  if  the  serum  was  injected  before  the  inoculation,  otherwise  they 
died.  A  membrane  was  formed  at  the  point  of  inoculation,  but  there  was 
very  little  constitutional  disturbance.  After  the  second  day  the  false  mem- 
brane became  detached  and  repair  of  the  mucous  surface  commenced.  In 
these  experiments  the  protected  animals  received  one  five-thousandth  part 
of  their  weight  of  the  serum.  Other  experiments  were  those  in  which 
guinea-pigs  were  inoculated  in  the  fauces  with  pure  cultures  of  the  diphtheria- 
bacilli.  Guinea-pigs  inoculated  in  this  way  died  in  three  days  if  not  pro- 
tected by  the  serum. 

In  February  of  1894,  after  the  beneficial  effects  of  antitoxin  on  animals 
had  been  proved,  as  the  preceding  brief  remm&  show-,  the  treatmenl  "I  diph- 
theria by  this  method  was  commenced  in  the  Children's  Hospital  in  I'ari-. 
During  the  years  from  \>>{M)  to  IS!*:',,  inclusive,  in  this  hospital  3971  cases  of 
diphtheria  were  treated,  with  a  death-rate  of  51.7]  percent.  From  Feb- 
ruary to  July  24,  1894,  148  cases  were  treated  by  antitoxin,  with  a  death- 
rate  of  -\  per  cent.,  a  diminution  of  more  than  one-half.  It  should  be  -aid 
that  all  the  cases  treated  by  this  method  were  extremely  severe  in  their 
nature.  It  must  also  be  borne  in  mind  that  in  many  of  the  cases  there  wa- 
in addition  to  the  diphtheria-infection  a  streptococcous  infection  which,  as  has 
been  -how  n,  has  a  nullifying  effect  on  the  benefit  of  the  antitoxin.  The  effect 
on  the  local  lesions  in  the  throat  was  similar  to  that  observed  in  the  experi- 
ments on  guinea-pigs. 

It  has  been  claimed  by  the  opponents  of  antitoxin  that  diphtheria  has  oi 


L022  DIPHTHERIA    OF  THE  M 11- PASSAGES. 

late  years  assumed  a  less  viruleni  type,  and  thai  many  cases  arc  now  recog- 
nized by  a  bacteriological  examination  which  were  not  so  classed  a  few  years 
ago.  Baginsky,  director  of  the  Emperor  and  Empress  Frederick  Children's 
Hospital  of  Berlin,  state-  emphatically  that  it  is  untrue  that  since  the  intro- 
duce  f  tin'  serum-treatmenl  diphtheria  lias  assumed  a  less  virulent  type. 

On  th.'  ether  hand,  he  says  the  most  malignant  forms  have  been  treated  by 
him  successfully  with  the  healing-serum.  He  says  tor  the  six  months  ending 
June,  1896,  the  percentage  of  mortality  (excluding  moribund  cases)  was  8.22, 
;i-  compared  with  a  mortality  of  40  to  50  per  cent,  a  few  years  ago.  Bagin- 
sky also  states  that  between  March  15,  L894,  and  March  15,  1895,  the  death- 
rate  in  his  service  in  cases  treated  by  antitoxin  was  15.6  percent.,  and  that 
during  the  time  when  the  supply  of  serum  gave  out  in  the  months  of  August 
and  September,  in  the  same  hospital,  the  death-rate  rose  to  48.4  per  cent.  It 
has  Inch  noticed  by  many  observers  that  during  the  warmer  months  diphthe- 
ria, a-  a  rule,  does  not  assume  so  virulent  a  type  as  during  the  colder  months; 
and  the  fact,  therefore,  thai  in  the  former  period,  when  antitoxin  was  not  used, 
the  death-rate  was  nearly  three  times  as  great  as  when  it  was  used,  seems  to 
l»e  a  sufficienl  answer  to  the  statemenl  that  antitoxin  statistics  are  unreliable 
because  based  on  mild  forms  of  the  disease.  Korte  says  that  there  was  an 
increase  from  :;:;.l  per  cent,  when  the  serum  was  used  to  53.8  per  cent,  when 
it  was  not  used.  Ganghofner  noticed  an  increase  from  12.7  percent,  with 
serum  to  53.2  per  cent,  without.     Heim  found  that  the  mortality  rose  to  65.6 

per  cent,  without   serum  as  < ipared  with  22  per  cent,  with   serum.      Iti  an 

epidemic  at  Trieste  the  fatality  rose  to  50  per  cent,  when  the  supply  of 
serum  failed,  a-  compared  with  Is. 7  per  cent,  when  it  was  used.  As  these 
statistics  are  based  upon  cases  occurring  in  the  same  epidemics,  the  argument 
that  antitoxin-statistics  are  unreliable  because  based  upon  the  mild  forms  of 
diphtheria  i-  untenable. 

In  the  Boston  City  Hospital,  from  February,  1891,  to  February,  1894, 
when  antitoxin  was  nol  used,  there  were  1062  cases  of  diphtheria  treated, 
with  193  deaths,  giving  a  percentage  of  46.  As  this  embraces  a  period  of 
three  years,  the  type  of  the  disease  might  change  considerably.  In  the  South 
Departmenl  of  the  Boston  City  Hospital,  for  a  period  of  thirteen  months, 
from  September,  1895,  to  October,  1896,  there  were  1H72  cases  treated  with 
antitoxin,  and  of  these  1706  were  discharged  well.  266  died,  giving  a  per- 
centage of  mortality  of  L3.4.  If  the  deaths  of  the  70  patients  who  were 
admitted  in  a  moribund  condition  are  eliminated,  it  would  bring  the  death- 
rate  down   to    1<>.:;   per  cent. 

Mackenzie  give-  the  death-rate  in  cases  of  laryngeal  stenosis  without 
operation  a-  !»n  percent.  Alt] gh  these  cases  are  not  stated  to  he  diph- 
theria, yet  it  i-  safe  to  conclude,  in  the  lighl  of  our  present  knowledge,  that 
nearly  all  of  them  musl  have  been  diphtheria.  Of  260  cases  of  diphtheria 
with  marked  laryngeal  stenosis  treated  with  antitoxin  at  the  South  Depart- 
ment of  the  Boston  '  iiy  I  [ospital,  60  were  relieved  of  this  symptom  withoul 
operation;  two  died.  The  cause  of  death  in  one  case  was  broncho-pneu- 
monia, and  in  the  other  cardiac  failure.  In  addition  to  the  use  of  anti- 
toxin, some  of  these  cases  were  placed  under  -team-  and  others  had  calo- 
mel-fumigation. While  the-,,  measures  relieved  temporarily  the  urgency 
of  the  symptoms,  the  permanenl  relief  vras  due  to  antitoxin,  judging  by 
the  experience  in  pre-antitoxin  days.  In  cases  of  intubation,  antitoxin  has 
I. eeii  ,•!'  very  greal  benefit  Waxham,  of  Chicago,  in  hi-  monograph  on 
intubation,  states  thai  of  L50  cases  collated  by  him.  previous  to  the  use  of 
antitoxin,  the  percentage  of  recoveries  was  '-'7.:;:;.     O'Dwyer,  of  New  York, 


TREATMENT,  102:; 

the  originator  of  intubation,  reports  in  the  Medical  Record  of  October  29, 
1887,  50  cases  with  1  _!  recoveries, giving  a  percentage  of  24.  As  these  cases 
occurred  in  private  practice,  it  is  reasonable  to  suppose  that  the  operation  was 
performed  early,  a  condition  that  does  not  always  occur  in  hospital  practice, 
because  patients  are  sent  to  a  hospital  as  a  last  resort.  In  the  Boston  City 
Hospital,  for  the  year  ending  January  31,  1895,  there  were  89  intubations 
and  7-1  deaths,  giving  a  percentage  of  recoveries  of  16.8.  These  cases  did 
imt  have  antitoxin.  In  the  South  Department, for  the  thirteen  months  ending 
October,  1896",  there  were  200  intubations  where  antitoxin  was  administered, 
with  a  percentage  of  recoveries  of  4(5.5.  If  the  percentage  of  recoveries  in 
cases  occurring  in  private  practice  where  antitoxin  was  not  used  i-  compared 
with  that  of  hospital  cases  at  the  Smith  Department  where  antitoxin  was  used, 
it  will  be  seen  that  the  percentage  of  recoveries  in  the  hospital  cases  is  con- 
siderably larger  than  that  occurring;  in  private  practice.  If  hospital  cases 
before  the  days  of  antitoxin  are  compared  with  hospital  cases  after  the  use 
of  this  agent,  it  will  be  seen  that  the  percentage  of  recoveries  ha-  been  in- 
creased from  16.8  to  46.5.  In  intubation  cases  the  use  of  antitoxin  has 
shortened  the  length  of  time  that  it  is  necessary  to  wear  the  tube. 

The  question  of  conferring  immunity  on  individuals  who  have  been  ex- 
posed to  diphtheria,  by  injection  of  antitoxin,  is  a  very  interesting  and  im- 
portant one.  The  results  thus  far  obtained  seem  to  prove  that  an  attack  of 
the  disease  may  be  prevented  by  the  early  administration  of  the  healing 
serum.  In  an  outbreak  of  diphtheria  occurring  in  institutions,  the  immuniza- 
tion of  all  persons  exposed  to  the  disease  should  be  strongly  advocated.  The 
time  that  immunity  can  be  conferred  is  short,  being  about  thirty  days.  A 
small  dose,   200  to  300  units,   is  required. 

Injurious  Effects  of  Antitoxin. — Eruptions  of  various  kinds  following 
the  use  of  antitoxin  have  been  observed.  These  eruptions  can  be  classified 
as  urticaria,  erythema,  a  papular  eruption,  and  an  ecchymotic  eruption,  which 
must  be  distinguished  from  the  spots  of  ecchymosis  occurring  as  an  early 
symptom  in  severe  cases  of  diphtheria  ;  a  punctiform  eruption  resembling 
scarlet  fever,  and  an  eruption  resembling  that  of  measles.  The  first  four 
eruptions  are  sufficiently  characteristic  not  to  present  any  very  great  difficul- 
ties in  diagnosis;  but  the  last  two  so  closely  resemble  eruptions  of  scarlet 
fever  and  measles  that  the  most  careful  examination  is  required  to  make  a 
definite  diagnosis,  and    in   some   instances  it   is  absolutely   impossible. 

In  the  scarlatinal  form  of  eruption,  the  absence  of  vomiting,  a  normal 
temperature,  no  hardness  of  the  palms  of  the  hands  or  the  tip-  of  the  fin- 
gers, the  fact  that  the  papillae  of  the  tongue  are  not  enlarged,  and  the  absence 
of  any  eruption  in  the  throat,  are  the  cardinal  points  on  which  the  differential 
diagnosis  must  be  made.  In  the  measles-like  eruption  the  diagnosis  must  be 
based  upon  its  transient  character;  that  there  is  no  rise  in  temperature;  that 
the  eruption  appears  first  on  the  extremities;  that  there  i-  nocoryza;  that 
there  is  no  cough  ;  no  eruption  in  the  mouth  ;  no  eruption  behind  the  ear-. 
In  a  small  number  of  cases  joint-pains,  resembling  articular  rheumatism,  have 
been  noticed.  These  joint-pains,  although  a  source  of  considerable  discom- 
fort to  the  patient,  have  not  been  sufficient  to  cause  any  greal  amount  of 
anxiety  and  have  been  followed  by  no  serious  results.  In  a  very  few  in- 
stances abscesses  have  occurred  after  the  injection  of  antitoxin  ;  but  the 
number  is  so  small  that  it  is  hardly  worthy  of  consideration,  being  do  greater 
than  would  follow  a  large  number  of  subcutaneous  injection-  ot  morphia.  It 
ha-  been  stated  that  albuminuria  is  caused  by  the  use  of  antitoxin,  bul  the 
observers  who  have  made  these  statements  have  l<>-t   sight  of  the  tact   that 


1024  DIPHTHERIA    OF  THE  A  IB-PASSAGES. 

albuminuria  very  frequently  occurs  in  the  course  of  diphtheria  ;  and  they 
also  have  nol  appreciated  the  well-recognized  fact  that  the  toxin  of  diph- 
theria may  cause  albuminuria,  as  is  proved  by  the  condition  of  the  kidneys 
of  guinea-pigs  that  have  died  from  injections  of  pure  cultures  of  the  diph- 
theria-bacilli. Of  the  H'Tl*  patients  treated  with  antitoxin  at  the  South 
Department  of  the  Boston  City  Hospital,  674,  or  34.1  per  cent.,  had  albu- 
minuria, which  proves  that  antitoxin  does  not  increase  the  frequency  of  albu- 
minuria, as  this  i-  not  as  large  a  percentage  as  occurs  in  cases  not  treated 
with  antitoxin.  In  173  cases  the  urine  was  examined  before  and  after  the 
administration  of  antitoxin.  Of  these  17-">  case-,  it  was  found  that  in  !>!> 
instances  albumin  was  absent  both  before  and  after  the  administration  of 
antitoxin,  which  was  without  doubt  due  to  the  fact  that  the  healing  serum 
was  administered  before  the  diphtheritic  membrane  had  increased  sufficiently 
to  generate  toxin  enough  to  cause  albuminuria.  In  33  cases  the  albumin 
was  about  the  same,  in  25  the  albumin  was  diminished,  which  seems  a  suffi- 
cient  answer  to  the  claim  that  antitoxin  causes  albuminuria.  In  16  cases  the 
albumin  was  increased,  hut  not  to  a  sufficient  extent  to  cause  any  special 
anxiety.  Antitoxin  has  no  influence  on  the  later  symptoms  of  diphtheria 
caused  by  the  action  of  the  toxin,  such  as  paralysis,  cardiac  failure,  and  nerve- 
degeneration,  hut  it  does  have  a  marked  effect  in  preventing  the  formation 
of  toxin  and  the  < •< .i i -. ■. 1 1 1 <  1 1 1  appearance  of  these  symptoms.  In  Pepper's 
"Theory  ami  Practice  of  Medicine,"  published  in  1893,  the  percentage  of 
post-diphtheritic  paralysis  in  a  lar<>;e  number  of  cases  is  given  as  40.  In  the 
Homerton  Hospital,  England,  of  1071  cases  treated  without  antitoxin, 
paralysis  occurred  125  times,  giving  a  percentage  of  11.6.  Of  the  1972 
cases  treated  with  antitoxin  at  the  South  Department  of  the  Boston  City 
Hospital,  paralysis  occurred  in  about  LI 5  instances,  5.8  per  cent.  The  con- 
clusion,  therefore,  that  antitoxin  does  not  cause  paralysis,  as  has  been  asserted, 
i<  justifiable. 

In    < slusion,   then,   it   can    be   confidently  asserted  that  antitoxin   is  a 

remedial  agent  of  great  value  in  the  treatment  of  diphtheria  ;  that  its  use 
does  not  cause  albuminuria  ;  that  it  does  not  predispose  to  paralysis,  and  that 
the  eruptions  and  the  joint-pains  that  sometimes  follow  its  administration 
are  not  of  sufficient   importance  to  preclude  its  use. 

The  dose  of  antitoxin  has  been  variously  stated  by  different  observers. 

The   quantity   must    depend    u] the  number  of  antitoxin-units   that   the 

specimen  used  contains.  A.s  an  initial  dose,  from  2000  to  3000  units,  de- 
pending upon  the  age  of  the  patient,  should  be  given.  If  there  is  not  a 
marked  improvement  in  the  appearance  of  the  throat  and  in  the  general 
condition  of  the  patient  at  the  end  of  eight  hours,  a  second  dose  should 
be  given.  If  at  the  end  of  twenty-four  I rs  the  membrane  has  not  com- 
menced to  roll  up  at  the  edges,  if  the  swelling  of  the  cervical  eland-  i-  not 
diminished,  if  there  i-  a  profuse  nasal  discharge  with  a  septic  odor,  a  third 
dose  should  lie  given,  and  in  certain  cases  a  fourth,  or  even  a  fifth,  dose  may 
be  required.1 

The  method  employed  l>\  Behring  and  Ehrlich  in  testing  the  strength  is 
the  one  now  in  general  use  in  Germany.  In  the  Boston  Medical  and  Surgical 
Journal  of  December  17.  ism;.  Behring's  method  of  testing  the  serum  is 
thus  described  : 

••  Diphtheria-toxin  i-  injected  subcutaneously  into  a  series  of  guinea-pigs 

1  Experience  has  much  increased  the  concentrated  potency  of  the  serum  while  proving  its 

innocuousneae    and  ii   i-   recognized   thai   r  results  in  the  past  were  often  due  to  the  timid 

and  tardy  use  of  inadequate  doses.     Better  results  are,  therefore,  t<>  \n-  hoped  for. 


TREA  TMENT.  1025 

to  determine  accurately  the  smallest  quantity  of  toxin  which  is  fatal  to  the 
guinea-pig.  When  this  has  been  determined  the  toxin  becomes  the  test- 
toxin.  A  given  quantity  of  serum  to  be  standardized  is  mixed  with  ten 
times  the  minimum  fatal  dose  of  the  test-toxin  and  injected  subcutaneoush 
into  guinea-pigs  of  nearly  the  same  weight  as  those  used  in  standardizing  the 
toxin,  [f  no  local  edema  nor  infiltration  appears,  if,  in  other  words,  the 
guinea-pig  i>  completely  protected,  the  quantity  of  serum  used  contain-  one- 
tenth  of  an  antitoxin-unit.  This  is  best  illustrated  by  an  example  ,  the  test- 
toxin  has  been  standardized  and  found  of  such  strength  that  0.039  c.c.  is 
the  minimum  fatal  dose.  The  serum  to  !><•  tested  is  diluted  with  sterile 
normal  salt  solution  until  1  c.c.  contains  0.001 6f  c.c.  of  serum.  The  serum 
and  0.39  c.c.  of  toxin  are  mixed  and  injected  subcutaneously.  If  the  guinea- 
pig  remains  permanently  well  and  .-how-  no  edema  at  the  place  of  injection, 
0.0016-|  e.e.  contains  at  least  one-tenth  of  an  antitoxin-unit.  One  «•.<•. 
would  contain  at  least  <i<>  units — that  is,  enough  serum  to  completely  protect 
600  guinea-pigs  from  ten  times  the  fatal  dose  of  toxin.  The  antitoxic  unit 
may  thus  he  defined  as  being  contained  in  ten  times  that  quantity  of  any 
given  serum  which  is  required  to  neutralize  ten  time-  the  minimum  fatal 
dose  of  diphtheria-toxin  when  mixed  with  the  latter  and  injected  subcutane- 
ously into  a  guinea-pig." 

Prof.  H.  C.  Ernst  employs  the  following  method  in  testing  the  antitoxin 
which  he  prepares.     This  methi  d  is  described  by  him  as  follows  : 

"A  normal  toxin  i-  one  of  such  a  strength  that  .1  c.c.  injected  subcutane- 
ously in  a  guinea-pig  weighing  500  grams  kills  the  animal  in  forty-eight 
hours;  in  other  words,  kills  5000  times  its  weight  of  guinea-pig.  We  call 
a  normal  antitoxin  a  serum  of  such  a  strength  that  .1  e.e.  injected  at  the 
same  time  subcutaneously  in  ;i  500-gram  guinea-pig  with  1  c.c  (ten  time-  the 
fatal  dose)  of  normal  toxin  produce-  no  effect  :  in  other  words,  protects 
50,000  time-  it-  weightof  guinea-pig,  and  is,  therefore,  of  a  strength  of  1  to 
50,000.  This  is  a  serum  that  for  practical  purposes  is  marked  "dose  lOc.c," 
or  approximately  sufficient  to  protect  1<»(»  pound.-.  When  we  find  the  serum 
tested  in  the  -ante  way  of  a  strength  of  1  to  100,000  or  over,  we  mark  it 
"dose  5  c.c.."  an  amount  approximately  sufficient  to  protect  the  same 
weight." 

Many  places  have  been  -elected  for  the  site  of  the  injection — the  outer 
aspect  of  the  thigh,  the  abdomen,  the  hack,  and  the  upper  part  of  the  thorax 
near  the  posterior  axillary  line.  After  trying  these  different  place-,  experi- 
ence has  shown  that  the  last-mentioned  situation  i-  the  most  desirable,  because 
here  the  tissues  are  lax.  there  i-  no  danger  of  entering  a  vein,  and  the  patient 
can  lie  on  the  back  or  on  one  side  without  bringing  any  pressure  on  the 
inoculated  place.  If  an  abscess  forms  there  i-  no  danger  of  burrowing  of 
pus,  a-  might  he  the  case  in  the  thigh  and  hack.  The  technique  of  the 
injection  i-  a-  follows:  The  part-  are  thoroughly  sterilized  by  washing  with 
a  solution  of  corrosive  sublimate;  a  portion  of  the  -kin  i-  pinched  tip  and 
the  needle  plunged  deeply  into  the  subcutaneous  cellular  tissue,  the  antitoxin 
is  then  -lowly  injected.  The  puncture  made  by  the  needle  is  sealed  by 
sterilized  gauze  and  collodion.  It  i-  very  important  that  the  needle  and 
syringe  should  he  carefully  sterilized  by  boiling.  It  is  advisable  to  pour  the 
antitoxin  through  sterilized  gauze  into  the  barrel  of  the  syringe,  rather  than 
to  attempt  to  draw  it  through  the  needle. 

There  are  many  different  kind- of  syringes  in  the  market.  \\  illiam-  - 
syringe,  which  ha-  an  asbestos  packing  ami  is  made  of  glass,  is  the  one  in 
use  at  the   hospital,  and   it    ha-  proved  to  he  well  adapted  for  it-   purp 


1026 


DIPHTHERIA    OF  THE  .  1  /  R- 1  \  1  ss.  I  < ;  AX 


Liter's  syringe,  which  has  a  ground-glass  piston  accurately  fitted,  is  a  very 
satisfactory  instrument.     Koch's  syringe  is  a  very  good   instrument   to  use. 


Antitoxin-syringes 


Iii  selecting  a  syringe,  it    is  well  to  choose   one  that  lias   the  noodle  con- 
ceded  with   the  barrel   by   rubber  tubing.     It  makes  very   little  difference 


f^l- 


what  kind  of  a  syringe  in  used  if  the  different  part-  arc  made  of  materials 
that  can  be  sterilized  b}  heal  withoul  injury.     A  comparatively  small  needle 


Tin: A  TMENT. 


1 1  >■_' 


should  always  be  used.     Figs.  602  and  <J< >-"i  represent   the  two  syringes  in 

general  use. 

In  the  treatment  <>t'  moderate  laryngeal  stenosis  occurring  in  diphtheria, 

recourse  may  lie  had  to  the  inhalati< I'  steam.     A  tent   can   he  made  over 

the  bed  and  the  -team  generated  in  the  ordinary  croup-kettle.      In  hospitals 

a   special   apparatus  for  this   purpose   is  connected    with   the   steam-supply. 

Medicated  -team    sometimes   seems   to  afford  relief.     The  following  mixture. 

in  the  proportion  of  one  ounce  to  a  pint  of  water,  may  he  used  with  advantage 

in  the  croup-kettle  : 

Apothecary.  M<  I 

R.     Olei  eucalypti,  ...j  30 

Aeidi  carbolici  liq.,  .V)  30 

( )lei  terehinthinie.  §viij  240. — M. 

Only  a  moderate  amount  of  steam  is  required.  The  debilitating  effect 
tit'  a  continued  -team-hath  i-  very  great,  and  this  is  always  to  lie  avoided  in 
the  treatment  of  diphtheria.  The  air  in  the  canopy  musl  lie  simply  saturated 
with   steam,  not  oversaturated,  as  is  frequently  the  case.     The  sublimation 


I.-,,,  ,  tent  with  sides  raised,  Boston  Citj  Hospital,  South  D 

of  calomel  often  gives  relief.  A  .-mall  alcohol-lamp,  surrounded  b)  wire 
gauze  or  perforated  tin,  with  a  pan  on  the  top  tor  the  recepti f  the  calo- 
mel i-  the  apparatus  \\-><\.  Five  to  ten  grains  of  calomel  are  placed  in  tin 
p;in,  ;m,l  t|M.  quantity  is  repeated  every  thirty  minute-  for  two  or  three  tune-. 


1028 


DIPHTHERIA    OF  THE  AIR-PASSAGES. 


depending  on  the  urgency  of  the  symptoms.  Care  must  be  taken,  however, 
not  to  continue  this  treatment  for  too  long  a  time,  as  there  is  danger  of  caus- 
ing salivation.  Small  doses  of  the  syrup  of  ipecac,  in  addition  to  the  meas- 
ures jusl  described,  sometimes  prove  of  benefit.  Emesis,  however,  must  nol 
l>e  caused. 

Caustic  applications  to  the  throat  have  been  advised,  hut  their  use  is  of 
doubtful  advantage.  The  less  the  throat  of  a  patient  ill  with  diphtheria  is 
irritated,  the  better.  The  experiment-  of  Roux  and  Yersin  show  that  the 
bacilli  of  diphtheria  do  not,  as  a  ride,  grow  on  sound  mucous  membrane, 
and.  therefore,  when  the  epithelium  is  removed  by  caustics  and  irritant-,  a 
fertile  soil  is  prepared  for  the  growth  of  these  organisms.  Irrigation  with 
hot  normal   salt   solution,  or  with  a   solution  of  mercuric  chlorid,    1    part  to 


Apparatus  for  calomel  sublimation,  Boston  City  Hospital,  South  Department. 


•sum  i.  or  with  ;i  weak  solution  of  chlorinated  soda,  every  four  hours,  frequenl  ly 
gives  much  relief  to  the  patient.  Thi-  irrigation  can  be  given  by  means  ot 
the  fountain-syringe,  with  the  patient  either  in  the  horizontal  or  vertical 
position.  In  nasal  diphtheria  the  douche  is  of  great  advantage.  By  the 
irrigation  .-ill  the  loose  membrane  is  removed,  contributing  much  to  the  reliei 
•>f  t he  patient. 

When   there  i-  marked  dysphagia,   spraying    the    throal    with  a    '1   to    I 

per  cent,   solution   "f  -1111.  a   shorl    time  before   find    and   stimulants   are 

administered,   i-  often   of  marked    benefit,   enabling  the   patienl    to  lake   his 
treatment    with  a  certain  degree  of  comfort. 

Painting  the  throal  with  ;i  mixture  of  salicvlie  ai  id,  twenty  grains  to  the 
ounce  "t'  glycerin,  is  sometimes  of  advantage.  The  application  of  bydrogen- 
dioxid  i-   sometimes  beneficial.      It   there  is  much  membrane,  a  strong  sol u- 


TREA  TMENT. 


1029 


tion  is  required.  The  application  should  be  made  with  a  mop.  The  nose 
can  be  sprayed   with   weak   solutions  of  one,   two.  or  five   volumes. 

In  order  to  cause  the  disappearance  of  the  bacilli  after  the  membrane  has 
disappeared,  many  things  have  been  tried,  but  the  results  have  nol  been  very 
satisfactory.  Spraying  the  throat  with  lemon-juice  or  with  a  5  per  cent. 
solution  of  antipyrin,  or  with  a  weak  solution  of  mercuric  chlorid,  or  with 
a  ten-volume  solution  of  bydrogen-dioxid,  can  he  tried. 

In  laryngeal  stenosis,  characterized  by  greal  restlessness,  a  marked  cyan- 
otic line  distinct  clavicular  and  sternal  retraction,  operative  interference  is 
demanded.  The  choice  lies  between  intubation  and  tracheotomy.  O'Dwyer's 
tithes  for  intubation  are  in  general  use  in  this  country.  The  apparatus  con- 
sists of  five  tubes,  suitable  for  children  from  oik-  year  to  twelve  years 
«>f  age;  the  gag,  the  introducer,  the  extractor,  ami  a  scale  indicating  the 
tube  to  l»c  used  for  a  particular  age.  These  tubes  are  plated  with  gold. 
The  upper  end  of  the  tube  has  a  head  that  rests  on  the  ventricular  bands 
and   prevents  the  tube  from  slipping  into  the  trachea;  in   the  middle  there  i- 


Fig.  606.— Showing  the  scale,   tin-  gag,  tin-  introducer,  tin-  extractor,  a   tube,  the  obturator,  and  thi 

introducer  \\  ith  ;i  tube  attached. 

a  fusiform  enlargement  hv  which  the  tube  is  retained  in  tin'  larynx.  On 
the  right  side  of  the  head  i-  a  small  hole  for  the  reception  of  a  loop  of 
silk.  Thi-  loop  of  silk  is  to  prevent  the  swallowing  of  the  tube,  if  the 
first  attempt  at  intubation  i-  not  successful.  Each  tube  is  fitted  with  an 
obturator,  which  is  screwed  to  the  introducer.  The  introducer  consists  of 
a  handle  and  a  shank  ;  on  the  handle  i-  a  hint  on.  by  pushing  which  the  jaws 
at  the  end  of  the  -hank  an'  pressed  forward  and  the  obturator  disengaged 
from  the  tube.  The  extractor,  which  i-  curved,  ha-  at  the  distal  endjawa 
which  are  opened   by   pressing  on  the  lever  in  the  handle. 

Fig.  606  show-  a  tube  attached  to  the  introducer  ready  for  use, a  detached 
tube,  the  extractor,  scissors  for  cutting  the  -ilk.  the  gag,  and  the  scale. 

Intiihation  i-  performed  in  the  following  manner  :  The  patient  is  wrapped 
firmly  in  a  blanket,  so  that    he  cannot   move  hi-  arm-,  and  then   placed  in  a 


L030 


DIPHTHERIA    OF  THE  AIR-PASSAGES. 


horizontal  position,  with  the  head  slightly  raised.  The  mouth  is  held  open 
by  the  gag,  with  its  jaws  resting  on  the  molar  teeth.  Care  must  be  taken 
not  to  have  the  cheek  injured  by  the  gag,  and  special  care  must  be  taken  to 
prevent  its  slipping.  The  head  must  be  steadied  by  the  assistant  who  holds 
the  gag.  The  operator  take-  the  introducer  in  the  right  hand,  with  the  index- 
finger  around  the  hook  on  the  under  surface  of  the  handle;  the  loop  of  silk 
passing  over  his  little  finger  and  his  thumb  resting  on  the  button  on  the 
upper  surface  of  the  handle.  The  index-finger  of  the  left  hand  is  then 
passed  down  to  the  epiglottis,  which  is  hooked  forward;  the  tube  is  passed 
into  the  mouth,  with  the  handle  well  down  on  the  chest  of  the  patient  ;  when 
the  epiglottis  is  reached  by  the  point  of  the  tube,  the  handle  should  be  given 
an  abrupt  turn,  so  .1-  to  bring  the  tube  into  a  vertical  position.  As  soon  as 
the  tube  is  well  in  the  larynx  the  button  on  the  handle  should  be  pushed 
forward,  disengaging  the  obturator,  which  must  now  be  removed,  and  the 
tube   pushed   into  position    by  the  index-linger.     The  loop  of  silk   is  passed 


tntubal 


aboul  the  ear  and  the  gag  removed.  If  the  tube  is  in  the  larynx,  the  patient 
will  immediately  commence  to  cough  with  a  peculiar  sound,  which  to  be 
appreciated  must  be  heard.  If  the  breathing  becomes  easier;  if  the  cyanotic 
hue  disappears;  if  the  retraction  of  the  thoracic  walls  diminishes;  if  the 
loop  of  silk  does  not  shorten,  one  may  rest  assured  that  the  tube  is  in  the 
larynx.  After  be< ing  satisfied  thai  the  operation  has  been  properly  per- 
formed, the  gag  is  inserted  ;i  second  time,  the  index-finger  placed  on  the  head 
"fil"'  tube,  and  one  strand  of  the  silk  loop  cut  so  thai  it  can  be  removed. 
Remember  thai  the  finger  of  the  operator  musl  be  :i  continuation  of  the  pos- 
terior wall  of  the  larynx;  remember  to  make  the  abrupt  turn;  remember 
'I';"  no  force  musl  be  used.  If  the  tube  is  in  the  esophagus,  no  cough  will 
be  heard;  there  will  be  no  relief  in  the  breathing ;  the  silk  loop  will  com- 
mence to  shorten  as  the  tube  passes  down  the  esophagus.  In  certain  instances 
intubation  does  not  give  relief,  and  tracheotomy  musl  !><■  done.  If  the  tube 
becomes  clogged  by  membrane,  a-  i-  sometimes  the  case,  it  musl   be  immedi- 


TBEA  TMENT.  1031 

ately  removed.  The  firsl  steps  of  an  extraction  are  similar  to  those  of  an 
introduction.  The  extractor  i-  passed  into  the  lumen  of  the  tube  and  the 
lexer  on  the  handle  pressed  so  as  to  open  the  jaws,  and  the  tube  extracted  1>\ 
a  reverse  of  the  movements  in  introduction.  Sometimes  there  is  considerable 
difficulty  in  extraction,  but  by  patience  and  gentleness  the  end  can  be  accom- 
plished. If  the  child  coughs  up  and  swallows  the  tube,  the  accident  may 
cause  considerable  annoyance  tit  the  physician,  yet  it  is  uol  of  serious  import, 
for  experience  lias  shown  that  the  tube  is  passed  by  the  rectum  in  from 
twenty-four  to  forty-eight  hours,  without  causing  discomfort.  No  definite 
rule  can  be  given  regarding  the  length  of  time  thai  the  patient  should  wear 
the  tube.  It  is  well  to  remove  it  at  the  end  of  the  third  or  fourth  day,  hut 
it  i-  frequently  necessary  to  immediately  re-insert  it.  In  some  instances 
three  or  four  extractions  and  introductions  may  We  required.  The  mosl 
favorable  eases  are  those  in  which  the  child  coughs  up  the  tube  at  the  end 
of  the  third  day  and  does  not  require  re-intubation. 

The  operation  of  tracheotomy  is  fully  described  in  the  article  on  Opera- 
tions and  in  works  on  surgery. 

In  regard  to  the  relative  merits  of  tracheotomy  and  intubation,  a  few- 
words  maybe  said.  It  seems  to  me  that  intubation,  in  the  majority  of  cases, 
is  the  better  operation:  First,  because  there  is  comparatively  little  .-hock; 
second,  because  there  is  no  open  wound  to  become  infected  ;  third,  because 
the  air  in  intubation  enters  the  lungs  through  the  natural  channels,  thereby 
diminishing  the  chance  of  broncho-pneumonia  ;  and,  lastly,  because  recovery 
is  much  more  rapid  after  intubation  than  after  tracheotomy,  there  being  no 
granulating  wound  to  heal.  In  adult  life,  tracheotomy  is,  perhaps,  the  better 
operation.  Bourdillat  gives  the  following  statistics  of  recoveries  after  trache- 
otomy, by  years:  Under  two  year-,  3  per  cent.;  between  two  and  two  and 
one-half  years,  \'l  per  cent.;  two  and  one-half  to  three  and  one-hall'.  17 
per  cent.  ;  three  and  one-half  to  four  and  one-half,  30  per  cent.  ;  four  ami 
one-half  to  five  and  one-half.  35  per  cent.  ;  over  five  year-  of  age.  39.5 
per  cent. 

Waxham,  in  his  collation  of  1072  cases  of  intubation,  give-  as  the  per- 
centages of  recoveries  after  intubation,  by  year-,  as  follows  :  I  under  two  years, 
L5.62  per  cent.  ;  between  two  and  three  year-.  19.  1'i  per  cent.  ;  between  three 
and  four  years,  30  per  cent.  ;  between  four  and  five  year.-.  32.65  per  cent.  ; 
between  five  and  six  year-,  33.92  per  cent.  :  over  sis  year-.  13.33  per  cut. 
It  will  be  seen,  therefore,  that  under  two  years  of  age  the  percentage  of  re- 
coveries after  intubation  was  live  times  as  great  a-  after  tracheotomy  ;  ami 
that  in  only  one  instance  was  the  percentage  of  recoveries  higher  after  tra- 
cheotomy than  after  intubation,  and   then  the  increase   was   very   slight. 

It  has  been  claimed  that  an  intubed  child  could  not  take  sufficient  nourish- 
ment, that  he  suffered  from  the  lack  of  liquids,  and  to  obviate  this  condition  of 
things  various  measures  have  been  suggested,  such  as  rectal  alimentation,  the 
use  of  soft  solids  for  food,  and  by  what  i-  known  as  the  <  'asselberry  method  ol 
feeding,  which  consists  in  placing  the  child  on  it-  back  and  lowering  the  head, 
so  thai  the  pharynx  is  on  a  lower  plane  than  the  larynx.  \\  hen  the  child  is 
placed  in  this  position  he  can  take  a  certain  amount  of  food  with  comparative 
comfort.  Nasal  feeding,  however,  is  by  far  the  besl  method  of  introducing 
food  into  the  stomach  of  an  intubed  child.  It  is  nol  a  painful  procedure  ;  it 
i-  not  specially  difficull  to  perform,  and  one  ha-  the  satisfaction  of  knowing 
just  how  much  food,  how  much  stimulation,  and  what  drugs  are  introduced. 
After  the  second  or  third  introduction  of  the  tube,  a-  a  rule,  the  child  do*  - 
not  struggle  ami  doe-  nol  exhibit  any  indication  of  discomfort.     'I  he  appara- 


1032 


/>//7/77//;A'/.l    OF    Till:   .  I //,'-/'.  I. VX.U//.X 


tu-  iii  use  :ii  the  hospital  isists  "I"  a  sofl  rubber  catheter,  in  which  is  in- 
serted a  short  glass  tube,  which  in  nun  is  attached  to  n  rubber  tube,  and  the 
rubber  tube  is  connected  with  a  glass  funnel.  The  catheter  having  been  well 
lubricated   is  slowly   and  carefully,   without   any   force,   passed   through   the 

anterior  uaris  down  into  the  esophagus.  The  funnel  is  elevated  and  about 
two  ounces  of  water  are  poured  into  it.  and  then  the  requisite  arnounl  of  milk, 
stimulants,  and  whatever  drug  may  he  deemed  advisable  to  administer,  fol- 
lowed by  an  ounce  or  two  of  water.  The  catheter  is  then  removed  quickly 
hut  gently.  If  the  catheter  is  removed  slowly  its  passage  may  cause  vomit- 
ing, therefore  it  i-  important  to  remove  it  quickly.     The  condition  of  intubed 


tus  I''  'r  nasal  feedin 


children  fed  in  this  way  is  very  gratifying  as  compared  with  those  l\-d  in  any 
other  way.  Nasal  feedin-  i-  also  of  very  greal  advantage  in  cases  of  post- 
diphtheritic palatal  paralysis,  and  there  is  no  doubt  that  lives  have  been 
saved  by  adopting  this  procedure  when  it  was  impossible  lor  the  child  to  take 
food  in  the  natural  way.  Many  cases  might  he  cited  in  which  death  might 
have  resulted  either  from  inanition  or  from  pneumonia  caused  hv  the  intro- 
duction of  food  into  the  air-passages,  if  this  method  of  feeding  had  not  been 
used 

In  diphtheria  of  the  eye.  the  chief  reliance  must  be  placed  on  antitoxin, 
which  should  he  administered  heroically.  The  pupil  musl  he  dilated  with 
:i tropin.  The  eye  should  be  irrigate  d  every  two  hours  with  a  l'  to  I  per  cent. 
solution  of  boric  acid.      In  some  instances  the  following  ointment  has  seemed 

to    lie    (,('    U-, •  : 

.,         ,,,,•,        i  Apothecary.  Mi  - 

u .     I  lyar.  mdn!  rub.,  gr.  i  .065 

( locainse  muriatis,  gr.  iv  .260 

Atropi;e  sulphatis,  gr.  iv  .260 

Petrolati,  gj  30.     M. 


TREATMENT.  1033 

A  portion  of  this  ointment  the  size  of  a  small  pea  should  be  put  in  1 1 1  *  - 
eve  every  eight  hours.  The  treatment  of  the  later  effects  of  diphtheria  on 
the  eye  belongs  rather  to  the  province  of  the  oculist  than  to  that  of  the  general 

practitioner.  The  action  of  antitoxin  on  the  diphtheritic  process  in  the  eye 
is  very  marked,  and  the  results  following  its  use  are  very  gratifying.  The 
greatest  attention  should  he  given  to  keeping  the  eye  clean.  If  only  one  eye 
is  affected,  the  other  must  he  protected  with  a  watch-glass,  h  must  lie  borne 
in  mind  that  the  object  of  treatment  is  to  prevent  the  extension  of  the  mem 
brane  and  to  cause  its  early  disappearance  ;  therefore  all  irritation  of  the  con- 
junctiva i>  to  he  avoided.  A  patch  of  membrane  that  in  the  throal  would 
not  be  of  importance,   in  the  eye  might   cause  blindness. 

The  administration  of  food  in  the  treatment  of  diphtheria  must  receive 
careful  attention.  Milk  is  the  best  article  of  diet,  and  should  he  given  in 
quantities  as  large  as  the  patient  can  he  induced  to  take.  Soups  and  broths 
may  also  he  given.  Soft  solids  are  frequently  grateful  t<>  the  patient. 
In  the  later  stages  of  the  disease,  cod-liver  oil  and  iron  should  he  given. 
Paralysis  can  he  treated  with  strychnia,  massage,  and  electricity.  In 
the  treatment  of  diphtheria,  care  must  he  taken  not  to  exhausl  the  strength 
of  the  patient  by  over-zealous  attempts  to  induce  him  to  take  food.  The 
practice  of  giving  food  and  drugs  to  a  patient  ill  with  an  exhausting  disease, 
every  ten  or  fifteen  minutes,  is  productive  of  much  harm,  and,  therefore, 
cannot  be  too  strongly  censured. 


TUBERCULOSIS  OF  THE  AIR-PASSAGES. 


B\   K.  L.  SHURLY,   M.  D. 

OF    DETROIT,    MICH. 


LARYNGEAL  TUBERCULOSIS. 

Ti  berculosis  of  the  larynx  consists  of  an  ulcerative  inflammatory  pro- 
cess depending  upon  the  presence  and  alterations  of  tubercular  material  in 
the  sofl  tissues  of  the  larynx.  This  material  may  appear  as  granular  or 
nodular  deposits,  or  as  a  more  or  less  diffuse  infiltration.  There  are  two 
typical  forms  usually  described:  (a)  An  acute,  inflammatory  affection,  de- 
scribed by  [samberl  and  Friedliinder  as  " acute  tuberculous  sore  throat  ;"  and 
by  other  observers  a-  localized  laryngeal  tuberculosis.  (6)  A  chronic  process 
characterized  more  by  infiltration  and  softening  than  by  inflammation  of  the 
tissues.  The  former  class  has  been  by  many  authors  considered  a  primary 
laryngeal  affection,  in  the  belief  that  the  morbid  process  may  originate  and 
possibly  remain  in  the  larynx.  Professional  opinion,  however,  has  been 
divided  upon  this  point  on  account  of  the  very  frequent  or  almost  constant 
implication  of  the  lungs;  although  in  rare  instances,  according  to  J.  Solis- 
Cohen,  no  lesions  have  been  found  upon  post-mortem  examination  in  other 
organs  of  the  body.  The  more  chronic  form  is  often  denominated  "second- 
ary," because  usually  occurring  subsequently  to  tuberculous  disease  of  the 
lungs  or  other  organs  of  the  body.  Between  these  two  types  there  arc  many 
gradations  according  to  the  constitutional  and  local  physical  peculiarities— 
which  also   variously  modify  the  course  and   character  of  the  disease. 

Htiology. — According  to  the  consensus  of  professional  opinion  at  the 
present  time,  the  essential  cause  of  laryngeal  tuberculosis  or  laryngeal  phthi- 
sis in  all  of  it-  phases  (as,  indeed,  of  all  other  form-  of  tuberculosis)  is  the 
invasion  of  the  tissues  by  the  tubercle-bacillus  of  Koch;  and  to  the  action 
of  this  micro-organism  is  ascribed  the  whole  pathogenesis  of  the  disease. 
Although  the  numerous  well-known  and  carefully-accepted  laboratory  exper- 
iments, besides  other  faithful  work  of  reliable  bacteriologists  on  this  subject, 
leave  little  doubl  concerning  the  accuracy  of  this  doctrine,  yet  it  does  not 
supply  to  the  clinician  an  adequate  explanation  of  all  the  etiological  or 
clinical  fiat ure- of  this  sometimes  complex  disease.  While  various  vagaries 
in  the  vitality  and  growth  of  this  micro-organism  are  soughl  to  be  demon- 
strated in  the  field  of  pathological  histology  in  explanation  <>f  the  diverse 
clinical  effects  ascribed  to  it-  presence,  there  -till  remain-  the  knowledge  of 
ii-  notable  failure  to  infeel  the  larynx,  except  in  from  aboul  H>  per  cent,  to 
In  per  cent,  (according  n>  various  author-)  of  the  cases  of  pulmonary  phthi- 
sis, where  certainly  the  conditions  would  seem  exceedingl}   favorable. 

The   i le  of  invasion    is   supposed    to   be  either  from   without    through 

abrasions  of  the  mm -  membrane  (exogenetic  .  or  from  within  through  the 

lymph-  or  blood-channels  (endogenetic).     J.  Solis-Cohen   believes  that    the 


LARYNGEAL    TUBERCULOSIS.  1035 

invasion  is  from  without,  and  infers  thai  generally  "an  acute  laryngitis  with 
some  desquamation  of  epithelium  affords  an  inlet  to  the  germ."  Bui  if  this 
wore  so,  almost  every  case  of  pulmonary  tuberculosis  would  be  accompanied 
by  laryngeal   infection  for  obvious   reasons  ;   and,   moreover,   the   laryngeal 

disease  would  be  apt  t :cur  anywhere  about  the  structure,  instead  of  (as  we 

observe)  in  selected  places;  while  the  constant  application  of  infected  sputum 
to  a  continual  succession  of  abrasions  would  prove  an  infallible  method  of 
infection.  The  comparative  immunity  of  the  larynx  has  been  accounted  for 
in  two  ways.  One  is  that  tubercle-bacilli  are  slow  in  developing  and  need 
not  only  a  suitable  nidus  but  quiescence,  conditions  which  the  larynx,  from 
its  exposed  situation  and  constant  movement  in  respiration,  phonation,  and 
coughing,  doe-  not  afford  :  and  the  other  is,  that  the  abrasions  of  the  mucous 
membrane  of  the  larynx  are  so  quickly  protected,  cither  by  exudate  or  gran- 
ulations— each  of  which  i-  known  to  he  if  not  quite  bactericidal,  at  leasl 
very  resistant — that  a  proper  foothold,  so  to  speak,  for  the  micro-organism  can 
only  with  difficulty  he  obtained.  As  to  the  first  explanation  we  may  remark 
that  when  the  laryngeal  membranes  are  in  the  least  degree  swollen,  there 
must  be  numerous  abrasions  from  friction  of  the  parts,  for  according  to 
Rice  and  Hodgkinson  there  is  continual  friction  between  the  ventricular 
band-,  the  walls  of  the  ventricle-,  and  the  vocal  cords.  Regarding  the  ques- 
tion of  a  resting-place,  there  is  probably  no  place  more  attractive  to  micro- 
organisms for  quiescence  than  the  laryngeal  ventricles,  where  even  particles 
of  dust  will  remain,  when  mixed  with  leukocytes  or  secretion,  perhaps  for 
days,  and  where  (being  rich  in  lymphatic  tissue)  the  region  would  furnish 
abundant  pabulum  for  the  growth  of  tubercle-bacilli.      Yet   it   i-  immune. 

(  'oticerning  the  second  explanation  there  is  little  to  be  -aid.  except  that 
the  defensive  effect-  of  the  reparative  process  in  this  situation  arc  probably 
no  more  active  and  effectual  than   in   similar  tissues   in  other  localities. 

A  few  years  ago  Dr.  Gibbes  and  myself  scarified  the  pharynx  and  epi- 
glottis of  several  healthy  monkeys  and  applied  thereto  sputum  from  tuber- 
culous patients,  without  producing  in  any  instance  local  tuberculosis.  We 
al-o  scarified  in  like  manner  the  pharynx  and  epiglottis  (and  possibly  the 
membrane  covering  the  arytenoids)  of  two  monkey-  suffering  from  pul- 
monary tuberculosis,  without  the  production  of  local  infection.  In  this  con- 
nection I  might  relate  that  a  patient  of  mine  suffering  from  pulmonary 
tuberculosis  accidentally  suffered  from  the  lodgement  of  a  piece  of  chicken- 
bone  in  the  pyriform  sinus  of  the  larynx.  In  hi-  effort  and  that  of  others 
to  dislodge  the  foreign  body  the  pharynx  was  considerably  wounded,  a-  was 
al-o  the  aryepiglottic  fold  and  the  covering  of  the  arytenoid  and  supra- 
arytenoid  cartilages.  It  was  with  some  difficulty  that  I  was  able  to  remove 
the  bone,  owing  to  the  impaction  of  some  of  it-  spiculae  beneath  the  surface 
of  the  mucous  membrane.  A-  he  came  from  a  distance,  considerable  time 
had  elapsed  (about  ten  hours)  between  the  period  of  the  accident  and  the 
period  at  which  I  saw  him.  and  in  consequence  there  was  considerable  tume- 
faction of  the  region.  I  fully  expected  a  development  of  secondary  laryngeal 
tuberculosis  on  account  of  tin-  accident,  but  no  such  phenomenon  occurred. 
The  man  lived  about  eighteen  month-  after  tin-  accident  and  was  under 
my  observation  more  or  less  of  the  time,  but  never  presented  any  tubercular 
lesion  of  the  larynx  or  pharynx  that  could  be  detected  by  the  laryngoscope 
or  by  the  observation  of  subjective  symptoms.  I  regret  to  -ay  that  no  post- 
mortem examination  of  the  case  could  be  obtained  in  order  to  verify  micro- 
scopically this  assumption.  Therefore,  it  would  -cm  that  the  moderate 
degree  of  invulnerability   of  the    larynx    to   tuberculosis,   or    the    invasion 


;  TUBERCULOSIS  OF  THE  A  IB-PASSAGES. 

and  ravages  of  the  tubercle-baeilli,  if  you  please,  mu-t  depend  for  ex- 
planation upon  some  other  hypothesis  or  facts  than  can  be  ascribed  to  either 
the  latent  or  oblique  behavior  of  the  tubercle-bacillus,  or  to  the  mere  abra- 
sion of  tlic  laryngeal  mucous  membrane  under  the  circumstances  usually  set 
forth.     While]    would  not   unjustly  underestimate  the  property  of  latency 

nerally  recognized  as  belonging  to  tubercle-bacilli  (Bollinger  lias  shown 
thai  tubercle-bacilli  may  remain  latent  in  bronchial  glands  for  twenty  years 
without  losing  their  vitality l),  nor  the  modifying  effects  upon  their  growth 
of  "tissue-reactions,"  yet  I  believe  with  Unterberger  not  only  thai  the  rdle 
of  the  tubercle-bacilli  in  spreading  disease  is  overstated,  but  that  the  inde- 
pendent powers  ascribed  to  them  have  also  been  overestimated. 

Neither  will  the  addition  of  the  "  tubercular  tendency  "  ("  congenital  ten- 
dency *'■  serve  to  supply  completely  the  missing  etiological  link,  because  there 
are  so  many  cases  of  chronic  laryngeal  catarrh  observed  in  persons  who  pos- 

the  tubercular  tendency  who  go  through  life  without  becoming  subjects  of 
laryngeal  tuberculosis;  while  on  the  other  hand,  in  a  considerable  number  of 

-  of  tubercular  disease,  uo  tubercular  or  "scrofulous"  family  history,  nor 
event  of  exposure  to  other  cases,  nor  history  of  previous  severe  disease  can 
be  elicited.  'The  accession  of  this  disease,  therefore,  must  await  some  definite 
bio-chemical  or  nutritional  alteration  of  the  part,  of  a  more  or  less  local  char- 
acter, before  its  particular  pathogenesis  can  be  established.  Undoubtedly, 
as  Cohen  says,  "it  is  not  improbable  that  certain  bacillary  element-  exist 
normally  in  the  tissues  of  the  healthy  individual,  which  under  certain  con- 
ditions undergo  conversion  into  tubercle-bacilli." 

Gibbes,  Mittendorf,  and  others  describe  forms  of  tubercular  tissue  differ- 
ing in  histological  character-  from  one  another.  The  second  author  indeed 
asserts,  upon  the  basis  of  numerous  bacteriological  and  histological  examina- 
tion-, that  tubercular  tissue,  called  technically  "  crude  "  or  "  healthy,"  is  very 
frequently  devoid  of  tubercle-bacilli. 

Regarding  tin-  so-called  secondary  variety  there  can  he  no  doubt  that  the 
toxic  agent  arrive-  at  the  larynx  through  the  lymph-channels,  and  depends 
for  it-  local  development  upon  the  continuous  and  enduring  alteration  of  the 
cellular  element-  either  created  or  maintained  by  the  lympho-cellular  met- 
abolism which  belongs  to  the  general  disease,  whether  the  tubercle-bacilli  or 
-.mi,-  specifically  depraved  cellular  or  protoplasmic  element- he  regarded  as 
the  initial  ferment  or  not.  In  the  light  of  recent  investigation  upon  the 
nature  and  power-  of  the  various  proteids  of  the  animal  body  in  health,  as 
well  a-  iii  disease,  it  is,  of  course,  very  diflficull  to  understand  the  early  steps 
in  the  development  of  any  general  disease  of  an  infectious  or  septic  character; 

es) ially  a-  the  exact   relation  of  the  microphytic  ferments  to  the  various 

proteids  upon  which  they  are  supposed  to  operate  ha-  not  yet  Keen  definitely 

-ettled. 

■•The  effect  on  the  body-cells  of  the  presence  and  growth  of  tubercle- 
bacilli  varies  considerably  and  depends  upon  the  number  and  virulenci  of  the 
germs  present,  the  character  of  the  tissue  in  which  they  lodge,  and  the  vul- 
nerability of  the  individual"  (Prudden  and  Delafield). 

Ever  since  VinTou  pointed  out  the  wonderfully  independent  and  special- 
ized functions  of  the  cellular  element-  of  the  body,  both  physiology  and 
pathology  have  made  important  progress  ;  hut  a-  yel  the  real  mutation-,  both 
in  health  and  disease,  of  these  incessantly  working  components  have  escaped 
positive  or  complete  detection.  Their  exact  source  and  manner  of  regenera- 
tion are  a-  yet  unknown,  a-  well  ;1-  the  definite  chemical  composition  of  all 
■  i;   ■    Med.  ./..„,„.,  <  i,t.  17.  1896,  p  64. 


LARYNGEAL    TUBERCULOSIS.  L037 

their  various  protoplasmic  contents;  while  their  relation  to,  and  influence 
upon,  the  body-fluids,  such  as  l»l 1  and  lymph,  are  -till  to  a  great  extent  sub- 
jects of  speculation.  Ilenee.  until  further  progress  is  made  in  this  direction, 
we  shall  be  unable  to  say  whether  chemical  changes  in  tJu  m  precede  or  follow 
the  presence  and  operation  of  bacteria;  in  other  words,  whether  toxins  or 
bacteria  constitute  the  initiation  of  morbid  processes,  and  whether  the  defen- 
sive or  immunizing  agency  resides  altogether  in  the  mobile  or  fluid  tissue 
(blood  and  lymph),  or  partially  or  essentially  in  the  formed  tissues  and  secre- 
tions of  an  apparatus  or  organ. 

( )f  predisposing-  causes  of  the  so-called  inflammatory  varieties,  the  mosl 
striking  are  undoubtedly  frequent  attacks  of  acute  and  chronic  laryngitis. 
Consequently  such  cases  show-  much  variation  in  their  course,  according  to 
the  circumstances  of  the  previous  disease  and  the  amount  and  extent  of  local 
inflammation  of  the  larynx.  The  local  disturbance,  of  course,  is  very  much 
aggravated  if  accompanied  by  miliary  tuberculosis  (in  which  event  it  is  apl 
to  be  very  rapid  and  extensive);  also  if  connected  early  with  pulmonary 
lesions  of  even  limited  area,  such  as  localized  broncho-pneumonitis  (Cohen) 
or  broncho-pulmonitis.  But  with  the  latter  class  of  cases  the  march  of  the 
local  disease  is  usually  .-lower  and  milder. 

Tuberculosis  of  the  pharynx  or  tongue  may  in  rare  cases  extend  to  the 
larynx.  The  larynx  may  also  become  infected  from  tuberculosis  of  the 
tonsils,  which  it  is  said  (Hans  Ruge)  occurs  much  more  frequently  than  is 
supposed,  and  is  difficult  to  demonstrate  clinically  because  ulceration  is  so 
often  absent.  An  extension  to  the  larynx  from  the  cervical  lymphatic  glands 
may  occur — although,  perhaps,  not  frequently — also  from  tuberculous  caries 
of  the  teeth.  Schatz  has  reported  cases  of  tuberculous  caries  of  the  teeth 
with  involvement  of  the  cervical  glands  where  tubercle-bacilli  were  found  in 
the  cavities  of  the  teeth,  while  their  floors  showed  microscopically  granular 
tissue  containing  giant  cells. 

Constitutional  syphilis  and  the  excessive  use  of  alcohol  are  common  deter- 
mining factors  in  the  origin  of  laryngeal  tuberculosis.  Indeed,  the  former 
disease  may  occur  concurrently   with   it. 

Inordinate  and  improper  use  of  the  voice  is  also  a  common  predisposing 
factor. 

Age. — Laryngeal  phthisis  is  generally  observed  in  persons  between  the 
ages  of  eighteen  and  thirty-five  years.  It  may  occur,  however,  in  infancy 
or  childhood  (Cohen,  Beverly  Robinson,  Bosworth),  or  rarely  in  old  age 
(Bosworth)  as  a  primary  affection. 

Sex. — Male-  arc  more  liable  than  female-  to  suffer  from  the  disease;  a 
fact  so  striking  in  relation  to  the  occupation  and  domestic  or  social  history 
of  the  two  sexes  in  general,  that  one  i-  led  to  place  even  additional  emphasis 
upon  the  exogenetic  over  the  hemogenetic  or  endogenetic  sources  ot  the 
morbid    process. 

Occupation. — Vocations  requiring  the  use  of  the  voice  in  the  open  air 
(peddler-,  etc.),  exposure  to  noxious  or  dust-laden  air.  or  frequently  alterna- 
ting variations  of  temperature,  or  confinement  in  close  rooms,  offices,  or 
shops  are  predisposing  causes. 

Pathological  Anatomy. — The  earliest  appearance-  in  the  so-called 
inflammatory  varieties  are  those  of  hyperemia.  The  capillaries  are  enlarged 
and  more  or  less  stuffed  with  blood-corpuscles  (Gibbes).  Into  the  surround- 
ing tissue  there    is    soon    effused  an   abundance  of  leukocyte-  and  -mall   round 

cells,  while  the  mucous  -land-  an-  swollen  with  serum  and  the  same  cellular 
products,  -o  that  their  acini   become  either  obliterated  or  distorted  by  pi 


TUBERCULOSIS  OF  THE  AIR-PASS  AGES. 

mv.  Here  and  there,  after  the  disease  has  progressed,  may  be  seeD  tuber- 
cular granula  in  the  stroma  without  necrosis  (Delafield  and  Prudden),  either 
coalesceni  or  more  or  less  discrete  ;  and  distinct  nodular  formations  of  gran- 
ula. perhaps  with  reticulated  surroundings,  may  supervene  as  a  result  of  pro- 
ductive inflammation  or  tissue-reaction.  There  become  manifesl  in  places 
attempts  at  organization  instead  of  necrosis,  or  viae  versd  :  the  latter  process, 
however,  finally  occurs  from  the  subsequent  obliteration  of  vascular  supply 
through  turgescence  of  lymph-channels  and  capillaries.  According  to  Wright, 
productive   inflammation  and  the   formation  of  depraved  granulation-tissue 

are  apt  to  pi- ide  the  necrosis  in  most  instances.     The  mucous  glands,  which 

at  first  are  excited  to  yield  extra  secretion,  arc  soon  compressed  from  without 
or  invaded  by  infiltration  products.  The  productive  inflammation  may  lead 
to  the  formation  of  a  granulation-tissue,  which  in  -pot-  will  endure  for  quite 
a  rime  :  but  the  majority  of  such  patches  ultimately  break  down — ulcerate. 
Gianl  cell-  may  not  he  found  in  the  granulation-tissue  in  some  eases;  and, 
excepting  in  the  undoubted  ••miliary"  forms,  where  extensive  ulceration 
or  caseation   rapidly  supervene-,  tubercle-bacilli   may  also  he  absent. 

When  the  morbid  process  i<  localized,  the  surrounding  tissue  shows  an 
active  formation  of  connective  and  fibrous  tissue  with  increasing  vasculariza- 
tion— Nature's  attempt  undoubtedly  to  throw  out  a  harrier.  The  zone  of  tissue 
nearesl  the  -eat  of  disease  i-  well  filled  with  small  round  cells  and  leukocytes 
in  rather  compacl  order.  The  pathological  process  is,  as  a  rule,  at  first  con- 
fined to  the  subepithelial  layers,  hut  soon  involves  the  submucosa  or  even  the 
deeper  tissues.  When  softening  occur-  it  i>  usually  from  below  toward  the 
surface,  resulting  in  ulceration.  The  confinement  of  the  caseation  products, 
so  as  to  produce  what  may  he  termed  abscess,  hut  rarely  occurs ;  although 
after  solution  has  taken  place  more  or  less  pus  together  with  mucus,  may 
he  seen  in  the  tissues  a-  well  as  upon  the  surface.  The  epithelial  layers  of 
the  mucous  membrane  suffer  greatly  and  are  entirely  changed  in  their  his- 
tological characters,  both  a-  to  -hap"  and  dimensions. 

!  n  the  in  tilt  rat  ion  form  (see  Fig.  613)  there  is  a  state  of  anemia,  the  capil- 
laries are  qoI  increased  either  in  number  or  caliber,  hut  the  lymph-channels 
.ire  enlarged  and  filled  ;  the  mucous  glands  are  also  tilled  with  serum  and 
lymphoid  edl-.  which  form  the  basis  of  the  so-called  tubercle-granula,  as 
well  as  round  cells,  which  also  fill  the  interacinous  -pace-.  The  epithelial 
layer-  are  thinned  and  uneven  from  distention — perhaps  more  marked  in  the 
arytenoid  region  and  epiglottis,  where  distention  may  he  greater.  At  or  near 
the  -lie-  <>f  ulceration  the  epithelial  layers  arc  either  lost  or  merged  into  one 
heterogeneous  layer.  Softening  may  quickly  occur  ami  the  tissue  break  doM  □ 
rapidly  to  the  surface  of  the  perichondrium,  even  involving  that  structure; 
although  it  i-  apt  to  li«'  checked  by  attempts  at  repair  through  the  formation 
of  granulation-tissue.  The  detritus  from  the  ulcer-  usually  shows  an  abun- 
dance of  tubercle-bacilli,  pus,  mucus,  altered  epithelial  cells,  and  epithelioid 
hod! 

The  regions  usually  firsl   affected  are  the  arytenoids,  posterior  wall,  ary- 

epiglottic  told-,  and  the  epiglottis,  altl gh  the  ventricular  and  vocal  bands 

may  be  simultaneously  involved.  The  ulterior  ravages  of  the  disease,  if  the 
patienl  lives  long  enough,  may  include  any  of  the  cartilages  of  the  larynx 
I  i'j.  61  5). 

Symptoms. — The  early  local  symptoms  are  usually  such  as  belong 
to  persistent  chronic  laryngeal  catarrh,  and  are  of  -low  accession,  unless,  of 
course,  the  type  of  the  disease  be  acute  or  it  be  a  concomitant  of  general 
miliary  tuberculosis.     These  -ympt -  consisl  of   more  or  less  hoarseness, 


/. .  I  /,'  VNQ  /:.  I  L    77  li  ERCl  Los  is.  [039 

sense  of  uneasiness  or  dryness  referred  to  the  larynx,  varying  degrees  of 
tenderness,  and  short,  hacking,   laryngeal  cough.     A.s  the  disease  progres 
there  is  soon  added  more  or  less  pain  in  deglutition  (odynophagia),  and  -till 
later  difficulty  of  deglutition  (dysphagia)  and  painful  and  difficult  phonation 
(dysphonia),  or  extinction  of  the  voice  (aphonia). 

The  severity  of  these  clinical  signs  varies  greatly,  of  course,  according  '" 
the  extent,  progress,  and  seat  of  the  morbid  process;  since,  for  instance,  lim- 
ited and  unabraded  infiltration  or  nodules,  as  a  rule,  give  rise  to  less  pain 
than  more  extensive  and  ulcerated  lesions.  Lesions  of  the  epiglottis  and 
arytenoids  produce  pain  and  embarrassmenl  of  deglutition  much  earlier  than 
those  situated  at  the  aryepiglottic  folds,  vocal  bands,  or  posterior  wall  of  the 
larynx.  Considerable  infiltration  of  the  interarytenoid  region  may  exisl 
without  giving  rise  to  much  discomfort.  The  degree  of  suffering  experienced 
will  be  according  to  the  amount  of  ulceration  and  swelling  of  the  larynx  and 
the  involvement  of  the  neighboring  lymphatic  tissue,  and  may  reach  such  a 
condition  that  the  patient  will  dread  to  swallow,  cough,  or  speak.  We  some- 
times meet  with  odd  cases,  however,  which  show  a  comparatively  anomalous 
degree  of  insensibility  of  the  parts  throughout  the  whole  course  of  the 
process.     These  cases  are  usually  secondary   to  pulmonary   tuberculosis. 

In  the  type  of  eases  characterized  by  extensive  infiltration  and  anemia  of 
the  tissues,  the  local  subjective  symptoms  are  less  marked — excepting,  per- 
haps, dysphonia  or  aphonia — owing  undoubtedly  to  the  lesser  degree  of  in- 
flammation present.  The  sensibility  of  the  laryngeal  tissues  may  lie  some- 
what obtunded  in  many  of  these  cases.  There  is,  however,  a  marked  degree 
of  embarrassment  of  the  vocal  function  and  often  mechanical  obstruction  to 
respiration.  In  any  case,  when  the  vocal  bands  escape  implication,  the  change 
in  the  voice  is  of  a  less  decided  and  progressive  character. 

If  the  pharynx  be  involved  the  distress  and  pain  in  deglutition  is  aggra- 
vated— the  pain  extending  to  the  ear-  and  perhaps  to  the  face  and  teeth. 
Patients  often  complain  of  a  sharp  pain  over  the  pectoral  region  of  the  chest, 
on  the  side  corresponding  to  the  most  affected  side  of  the  larynx.  This  is 
probably  due  to  the  connection  of  the  short  thoracic  nerve  with  the  laryngeal 
through  the  central  sensory  centers. 

The  cough  is  often  of  a  peculiar  stridulous  or  rattling  character,  and 
when  causing  much  pain  is  repressed  as  much  as  possible  by  the  patient. 
The  amount  of  expectoration  varies  greatly,  according  to  whether  there  i- 
much  softening  or  ulceration  of  the  tissues  going  on  ;  but  after  the  lir-t 
stages  there  is  usually  considerable  expectoration  of  mucus  and  saliva — often 
mixed  with  more  or  less  pus  and  streaked  with  blood.  A  certain  degree  of 
immobility  of  the  larynx,  a-  a  whole,  is  usually  observed,  which  may  be  dm' 
to  infiltration  of  the  lymphatic  eland-  in  the  neighborhood  of  the  muscles  or 
through  the  unconscious  effort  of  the  patient  to  escape  the  pain  attending  it- 
movement.  The  suffering  of  a  patient  with  extensive  ulceration  of  the 
laryngeal  structure-  i^  excruciating,  and  toward  the  last,  even  the  act  of 
breathing,  as   well   as   speaking  and   swallowing,  may   amount    to   torture. 

The  constitutional  disturbance  in  the  acute  varieties  take-  place  early,  so 
that  even  before  the  appearance  of  marked  laryngeal  diseast — debility,  slighl 
emaciation,  more  or  less  insomnia,  limited  anorexia,  hyperpyrexia,  a  rapid 
pulse,  and  frequency  of  respiration  may  be  observed.  Indeed,  so  insidious  is 
the  attack  sometimes  that   the  serious  import  of  the  hemming,  hacking,  and 

throat-uneasiness,  < pled   with   poor  appetite,  restless  nights,  debility,  etc., 

may  go  unrecognized  for  quite  a  while,  especially  when,  a-  is  often  the  case, 
the  complexion  and  display  of    personal  ambition  of   the   patient   seem   to 


1040 


TUBEBcrLosis  or  Tin:  mii-i>assages. 


remain  unchanged.  I  have  known  several  cases  of  this  sort  in  whom  ambi- 
tious tyros  have  mutilated  the  turbinals  in  the  belief  that  these  unoffending 
adnexa  were  obstructing  respiration  and  otherwise  preventing  the  well-being 
of  the  patient. 

In  one  such  case  brought  to  me  for  consultation  alter  severe  sanguinary 
surgical  attacks  had  been  made  upon  the  turbinals  and  nasal  septum,  there 
were  no  subjective  symptoms  of  laryngeal  disease  worth  noting;  and  yet 
laryngoscopical  examination  showed  a  considerable  infiltration  of  the  left  ary- 
tenoid region  with  corresponding  infiltration  at  the  apex  of  the  left  lung. 

Another  case  worth  alluding  to  briefly  was  that  of  a  young  girl  of 
eighteen  years,  of  ruddy  complexion  and  plump  appearance,  who  had  been 
complaining  for  about  two  months  of  debility,  slight  dyspepsia,  anorexia, 
and  a  very  moderate  hacking  cough  with  soreness  of  throat,  and  whoso  voice 
was  but  very  slightly  altered.  Examination  showed  slight  swelling  of  the 
arytenoid  region  and  very  slight  evidences  of  condensation  at  the  upper 
right  lung.  Further  infiltration  and  ulceration  of  the  larynx  rapidly  super- 
vened, and  she  died  lour  mouths  after.  Such  cases  are  also  treated  some- 
times as  "  malaria  !  " 

The  anemic,  diffuse,  infiltrating  type  of  the  disease  is  usually  preceded 
for  a  considerable  time   by  constitutional  symptoms  of  unmistakable  signifi- 


w 


Fig.  609. — Red,    infiltrated    larynx-    with 
ventricular  bands  swollen  almost  into  con- 
ding  the  righl  cord  and  most  of  the 
left,  the  base  of  which  is  covered  by  a  nodule 
>.ii  the  arytenoid  (Griinw 


Fig.  610.— Early  tuberculous  nodules  oi 
the  epiglottis  and  arytenoids  with  a  paretic 
righl  cord  and  an  injected  margin  of  the 
left  (Griinwald). 


cance,  although  exceptionally  these  cases  may  have  been  long  preceded  by 
symptoms  of  pharyngo-laryngeal  catarrh  only,  without  showing  much  sys- 
temic disturbance.  A.s  before  remarked,  there  are  many  gradations  of  sever- 
ity giving  rise  to  corresponding  modifications  in  the  symptomatology.     But 

too  much  ifidence  -t    uot    be  placed   in   the  apparent  mildness  of  the 

Bymptoms  a-  a   basis   for  prognosis. 

Besides,  a  large  number  of  these  cases  -how  exacerbations  and  remissions 
which  greatly  alter  both  the  subjective  and  objective  symptoms  from  time  to 

ti A.s  a  rule,  however,  when  a   patient  exhibits  persistent  alterations  of 

voice,  with  cough  and  other  symptoms  relating  to  the  larynx,  together  with 
nocturnal  elevation  of  temperature,  frequenl  pulse,  and  otherwise  unaccount- 
able debility  and  malnutrition,  the  actual  advent  of  laryngeal  phthisis  may 
be  suspected,  whether  the  physical  signs  elicited  from  an  examination  of  the 
chesl  are  corroborate  e  or  not. 

In  a  large  proportion  "I  cases,  especially  if  advanced,  the  tubercle-bacilli 
may  be  found  in  the  sputum  :  1  > 1 1 1  early  in  the  disease,  especially  when  more 
or  less  localized,  this  micro-organism  will  very  often  not  be  found,  however 
carefully  '  he  search  may  be  made. 


LA  Ii  YNGEAL   TUBERCULOSIS. 


ion 


Objective  Symptoms. — The  laryngoscopical  appearand  belonging  to 
laryngeal  phthisis  or  tuberculosis  may,  for  purposes  of  description,  be  pre- 
sented in  five  groups.  The  firsl  (see  Fig.  609)  includes  those  cases  which 
resemble  chronic  laryngeal  catarrh  somewhat,  and  are  characterized  by  more 
or  less  diffuse  hyperemia,  inflammation,  and  swelling  of  the  mucous  mem- 
brane. The  intensity  of  the  hyperemia  and  swelling,  however,  is  generally 
confined  to  either  the  base  of  the  arytenoid  bodies  and  interarytenoid  space 
the  epiglottis,  <>r,  exceptionally,  to  the  aryepiglottic  folds,  ventricular  and 
vocal  band-.  'The  latter,  however,  are  not  affected  to  so  greal  an  extent  by 
tumefaction,  on  account  of  their  anatomical  character.  The  tumefaction  is 
not  at  all  evenly  distributed,  but  preponderates  in  one  region  or  another. 
The  more  acute  as  well  as  localized  varieties  show  this  appearance  very  soon 
and  small  roundish  ulcers  appear  sometimes  over  the  vocal  cords  near  the 
posterior  vocal  processes  first,  or  upon  the  epiglottis  or  toward  the  bases  of 
the  arytenoids  very  soon.  They  may  be  many  in  number  or  only  two  or 
three. 

The  second  group  of  cases  is  marked  also  by  hyperemia  ('see  Fig.  610), 
but  more  localized ;  and   the   tumefaction   may  affect   either   the  epiglottis  or 


Fig.  611. — Infiltrated  larynx  with  injected  ventric- 
ular bands,  the  left  cord  nodular  and  the  riidit  appa- 
rently divided  by  an  ulcer  along  its  entire  margin.  I 'y  in- 
form tubercular  swelling  of  the  arytenoids  (Griinwald). 


Pig.  612.— Tuberculous  infiltration  with 
tumor-formation  betv>  een    the    pj 
arytenoids  and  cm  the  right  cord(Grun- 
wald). 


the  arytenoids,  generally  the  hitter  region  particularly.  These  parts  appear 
as  pyriform  or  "club-shaped"  swellings  of  brownish-red  color,  with  the 
deeper  tint  toward  the  base.  The  vocal  bands  are  usually  a  grayish-  or 
brownish-white.  The  infiltration  of  the  tissues  may  not  lie  extensive,  at  first 
affecting  mostly  the  arytenoids  and  aryepiglottic  folds.  The  tumefaction 
gives  to  the  parts  in  the  laryngoscopical  image  a  rather  tense, smooth  appear- 
ance, of  a  yellowish-red  or  salmon  color,  until  ulceration  supervenes,  when 
the  color  may  grow  even  paler,  with  reddish  blotches.  The  epiglottis  may 
be  the  part  most  affected  in  such  cases,  and  is  never  so  intensely  colored 
as  adjacent  parts. 

The  third  group  (see  Fig.  612)  comprises  those  cases  which  are  slow  and 
attended  with  exacerbations  and  remission-.  The  color  of  the  mucous  mem- 
brane varies  from  a  salmon  to  :i  dark  red  or  brick  red.  while  the  tumefaction 
presents  it -elf  in  rugae,  folds,  or  projections  (tumors).  <  me  or  the  other  ary- 
tenoid body  is  more  or  less  fixed  in  position  and  usually  bounded  b\  ragged  or 
papilla-like  projection-.  The  vocal  band- are  thickened,  roughened  on  their 
edges  or  surface,  and  of  a  dirty-gray  or  brown  color.  Many  vegetations 
simulating  papillomata  may  jut  out  from  around  the  base  of  one  or  the  other 
arytenoid  body,  or  from  the  interarytenoid  -puce,  the  epiglottis,  or  the  vocal 
bands.     The  edges  of   the   latter   may   appear   notched,  either   from   actual 

66 


1042 


TUB  E RCULOS IS  OF   I'll  E  AIR-PA  ss.  |  ( ,•  /•;*. 


ulceration  or  from   the  effects  of  former  ulceration,  granulation,  or  cicatriza- 
tion of  the  same. 

The  fourth  group  includes  cases  of  diffuse  tubercular  inflammation  (see 
Fig.  613).     The   mucous   membrane  appears   in  the   image   pale,   bloodless, 


Fig.  613.-  Diffus  -,  of  the  posterior 

wall  of  the  larynx,  hiding  all  configuration  of 
lids   ami    the   subjacent    structures 
(( Iriinwald). 


Fig.  614.-  Pale  larynx  with  swollen  anil 
roughened  posterior  wall  and  cicatricial 
changes  aboul  the  lefl  vocal  cord,  while 
destruction  is  still  advancing  on  the  right 

(( ii'iiim  aid  . 


swollen,  and  glistening.  The  tumefaction  varies  in  degree  and  extent,  and 
like  other  forms  it  may  he  more  marked  at  the  arytenoid  bodies,  which  will 
then   show  the   "clubbed"  appearance,  (if  at  the   epiglottis,  which  will   then 


n  behind,  showii  >  the  cricoid  with  ossified  sequestrum  and 

il  structures.    The  ulcerated  tracheotomy-opening  is  conspic 

-how  the  "  turban -like  "  appearance  (see  Figs.  613,  *il  1 1.      The  swelling  mav 
he  go  -rent  as  n.  give  the  appearance  of  edema,  ami  may  entirely  obscure  the 


LARYNGEAL    TVBERi  ULOSIS. 


1043 


view  of  the  interior  of  the  larynx.     The  ulcerations  are  likewise  small,  and 

may  be  numerous,  close  together,  or  scattered  ;  they  are  r dish  or  lenticular 

in  shape  until  the  deeper  structures  become  involved,  when  they  assume  vari- 
ous shapes  with  ragged  edges.  When  situated  on  the  edge  of  the  epiglottis, 
that  appendix  appears  as  it'  gnawed  or  "  worm-eaten." 

Group  five  (see  Fig.  615)  shows  the  results  of  extensive  ravages  in  the 
advanced  stages  of  the  disease.  After  the  destructive  process  has  reached 
the  deeper  parts,  such  as  the  submucous  connective  tissue,  perichondrium,  or 
even  the  cartilages  themselves,  necrosis  of  the  cricoid,  arytenoid,  or  thyroid 
cartilage  may  be  present.  The  ulceration  in  such  an  event  is  irregularly 
serpentin<  .  deep,  and  extensive,  with  borders  surrounded  by  granulations  and 
scar-tissue,  while  the  floors  consist  of  sloughing  dark-gray  or  greenish  mass  -. 
more  or  less  bathed  with  pus  and  sputum.  The  intervening  mm s  mem- 
brane is  thickened  and  irregular  in  contour,  of  dark  color,  and  in  patches 
consists  of  little  more  than  granulation-tissue. 

There  are,   of  course,   gradations   between   these  types  of   local    dig     - 
which  give  varying  and  sometimes  quite  anomalous  pictures.      For  instance, 

the  hyperemia,  -welling,  or  ulceration   may  he  limited  to  just  i  arytenoid 

body,  or  one  aryepiglottic  fold,  or  one  side  of  the  epiglottis  :  or  the  infection 
may  be  almost  confined  to  one  side  of  the  larynx,  especially  when  the  pr< 


^ 


/ 


f 


¥u,.  616.— Tuberculous  tumor-formation  on 
the  posterior  wall  with  pale  ri<_'i'l  infiltration 
of  the  ventricular  bands  and  edematous  swell- 
ing of  the  arytenoids  (Griinwald). 


Fig.  617.-  Bard  raspberrj  masses  of  tul  - 
Ious  infiltration  without  ulceration,  almost  lill- 
ing  the  larynx  (Griinwald  . 


first  take-  place  in  the  deeper  tissues  ;  while  in  other  cases  there  may  be  the 
appearance  of  considerable  inflammation  or  hyperemia  of  one  part,  with  an 
anemic  infiltrated  appearance  of  another  part.  There  are  also  great  varia- 
tions in  the  distribution  of  the  ulcerations.  They  may  be  confined  to  the 
laryngeal  surface  of  the  epiglottis  or  its  very  edge;  or  the  posterior  wall 
may  be  the  seat  of  undetected  ulcerations.  It  is  therefore  advisable  in  many 
cases  to  resort  to  Killian's  method  of  examining  this  wall  (see  page  872  in 
order  to  ascertain  it-  condition.  There  may  be  only  two  or  three  nicer-  vis- 
ible, and  those  situated  on  the  vocal  bands  only  :  or,  on  the  other  hand,  small 
ulcers  may  be  scattered  over  the  epiglottis,  ventricular  bands,  arytenoid  bodies, 
or  vocal  bands  respectively,  as  if  sprinkled  into  the  vestibule  of  the  larynx. 
\,  crosis  and  ulceration  of  the  tissues  will  surely  take  place  more  or  less  exten- 
sively in  the  natural  course  of  events.  Bui  either  under  appropriate  treat- 
ment or  spontaneously,  in  the  cases  of  slower  march,  a  retrogression  and 
I,,, Jin-  of  ulceration  may  occur.  When  this  event  transpires,  granulation 
and  cicatrization  with  their  attendant  contraction  will  mark  the  retrogression  of 
the  disease.     The  cicatricial  tissue  is  nol  nearly  so  abundant  as  in  syphilis  or 


lull  TUBERCULOSIS  OF  THE  AIR-PASSAGES. 

Lupus,  because  the  patient  doc-  not  usually  live  long  enough  to  recover  from 
extensive  destruction  of  the  tissues  in  tuberculosis.  Yet  there  may  be 
enough  found  to  cause  at  least  uncomfortable  if  nol  dangerous  interference 
with  respiration  from  stenosis  or  enough  to  produce  troublesome  aphonia. 
The  vegetative  proliferations  al>o  may  become  threatening,  requiring  removal, 
tor  sometime-  they  amount  to  tumors  of  considerable  size  (Figs,  616,  til"). 
These  vegetations  are  sometimes  ejected  spontaneously  (J.  Solis-Cohen). 
A.gain,  the  function  of  the  larynx  may  be  compromised  by  hypertrophied 
(reparative)  tissue  (superior  and  inferior  hypertrophy)  organized  in  folds  or 
ridges  (as  seen  in  Fig.  618), or  the  action  of  the  vocal  hand-  may  be  impaired 
by  adhesions.  When  ulceration  begins  the  parts  are  usually  freely  bathed 
with  muco-pus,  which  is  more  or  less  adherent  to  the  roughened  surfaces, and 
-how-  usually  in  the  image  a-  partially  desiccated  or  coagulated  clumps,  or  as 
stringy  bands  or  threads.  The  interarytenoid  space  is  nearly  always  so 
covered  :  while  the  posterior  wall  of  the  larynx,  as  well  as  the  walls  of  the 
trachea,  may  l>e  plastered  with  chimp-  of  sputum. 

Diagnosis. —  Laryngeal  tuberculosis  is  often  difficult  to  differentiate 
from  chronic  laryngeal  catarrh,  syphilis,  lupus,  and  sometimes  certain  forms 
of  epithelioma  :  and.  as  Schech  says,  may  baffle  differentiation  in  some 
instances.  When  ;i  clear  and  satisfactory  history  of  the  patient  can  he 
obtained,  the  difficulties  are  very  much  lessened,  if  not  removed.  There  are 
numerous  instances  on  record  of  a  mixture  of  these  diseases  taking  place; 
a-,  for  instance,  syphilis  becoming  implanted  upon  a  subject  suffering  from 
laryngeal  tuberculosis  (see  Fig.  622),  in  which  case  the  difficulty  of  diagno- 
sis i-  great.  It  i-  often  confounded  with  ordinary  hypertrophy  of  the  laryn- 
geal mucous  membrane  accompanying  chronic  catarrhal  laryngitis  or  syph- 
ilitic laryngitis.  Syphilis  of  the  larynx,  however,  is  usually  preceded  not 
only  by  its  own  peculiar  clinical  history,  hut  by  the  occurrence  of  the  local 
disease  somewhere  in  the  upper  structures  of  the  throat,  such  as  the  soft 
palate,  pharynx,  tonsils,  or  the  nasal  septum.  This  i-  especially  true  of 
the  tertiary  form,  which  shows  preferably  in  the  -oft  palate;  whereas  the 
Lesions  of  laryngeal  tuberculosis  usually  begin  and  remain  in  the  larynx  :  hut 
in  the  advanced  stages  the  local  appearance  of  this  affection  frequently  ^in- 
itiate- tertiary   syphilis,   lupus,  or    epithelioma.      In   secondary  syphilis   the 

ulcers  are  of  a   si what  different   character — being  deeper,  kidney-shaped, 

or  irregular,  with  sharp-CUt,  evened  edges,  hut  they  may  he  situated,  a-  ill 
laryngeal  phthisis, on  the  epiglottis  or  aryepiglottic  folds,  vocal  or  ventricular 
hand-.  The  tumefaction  of  the  surrounding  tissues  is  generally  much  less 
than  in  tuberculosis,  and  the  inflammatory  areola  about  the  ulceration  is 
usually  present  and  characteristic.  The  parts  are  generally  less  painful  than 
in  laryngeal  tuberculosis.  In  tuberculosis  the  ulcers  are  commonly  shallow, 
of  lenticular  shape,  with  smoother  edges,  and  with  less  disposition  to  imme- 
diate   sloughing    than    syphilis.      Syphilitic    ulceration    i-   attended    with    less 

tumefaction,  and  i-  in  preference  located  on  the  epiglottis  or  vocal  cord-; 
whereas  tubercular  ulcerati sually  appear-  first  in  the  region  of  the  aryte- 
noid cartilages  or  interarytenoid  -pace,  and  is  attended  with  tumefaction.1 
The  grayish  or  yellowish  tubercular  spots  sometimes  described  1>\  authors 
a-  visible  just  beneath  the  surface  of  the  mucous  membrane  (miliary  deposits) 

are   very  rarely  observed,  ah  I gh  sometimes  a    mottled   appearance  does 

accompany  the  early  stages  of  tubercular  infiltration.  In  lupus,  while  the 
nodular  growth  i-  not  a-  plain  a-  if  occurring  on  the  -kin  (see  Lupus,  page 

I    e  rough  rule,  "anterior    lesions  are  syphilitic;    posterior,  tuberculous,"  often   holds 


la  it  yx<u:al  rrni:n<ri.osis. 


L045 


1060),  yet  the  papillomatous  or  granular  appearance  is  well  enough  marked. 

Its  course  is  very  slow,  and  after  softening  has  taken  place  the  ulcerations 
soon  coalesce  to  form  a  few  discrete  plaques,  the  everted,  red,  granular,  rag- 
ged or  papular  edges  of  which  are  characteristic.  Outside  of  these  spots 
may  be  seen  zones  of  thickened  papillomatous  membrane  of  varying  hues  of 
red.  Besides,  the  parts  arc  not  painful  to  the  touch,  aor  i-  there  much  pain 
in  swallowing.  Pyrexia  is  usually  absent,  and  during  remission  the  cica- 
tricial tissue  is  prominently  visible.  In  the  so-called  secondary  form  of 
tubercular  laryngitis  (Fig.  618),  the  peculiar  paleness  of  the  mucous  mem- 
brane, with  characteristic  swelling  of  the  arytenoid  bodies,  known  as  the 
"clubbed  appearance,"  will  serve,  when  present,  to  settle  the  diagnosis  al 
once,  even   without  the  presence  of  pulmonary  symptoms. 

Epithelioma  usually  invades  the  larynx  from  the  lateral  wall  of  the 
pharynx,  the  tongue,  or  the  esophagus,  very  rarely  occurring  as  a  primary 
affection  in  the  larynx  unless  preceded  by  some 
benign  neoplasm  or  lupus.  It  is  of  slow  growth 
and  without  much  constitutional  disturbance. 
When  it  doesoccur  in  the  larynx  it  is  usually 
in  the  deeper  regions  of  the  organ,  and  will  be 
found  as  a  mass  of  tissue  raised  above  the 
surface  of  the  mucous  membrane.  It  will  be 
of  a  very  deep-red  color,  of  velvety  contour, 
with  fissured  and  sinuous  channels  bordered  or 
filled  by  sloughs  coursing  through  the  mass 
here  and  there.  It  presents  no  definitely  bor- 
dered ulceration,  but  irregular  pockets,  and 
readily  bleeds  upon  being  touched.  It  con- 
veys the  idea  of  an  excrescence  from  the  first. 
The  cervical  glands  are  usually  very  early  enlarged  and  hard.  Sarcomatous 
tumors  of  the  larynx  are  more  rare  than  the  myxo-sarcomatous.  Their 
growth  is  rapid  and  presents  the  smooth  appearance  and  contour  of  a  vas- 
cular tumor  or  polyp.  The  growth  is  prone  to  bleed  upon  the  slightest 
provocation,  and  does  not  present  a  tabulated  appearance  nor  any  of  the 
characteristic  ulcerative  details  of  cither  syphilis  or  laryngeal  tuberculosis. 
It  appears  as  if  independent  of  the  surrounding  tissues — not  blended  with 
them.  Besides,  there  are  no  constitutional  signs  presented,  al  least  for  a 
time,   if  we  except  the  cachexia. 

Glanders  and  leprosy  sometimes  simulate,  in  their  local  manifestations 
and  appearance,  laryngeal  tuberculosis;  but  the  history  of  the  case  and  the 
preceding  lesions  of  the  skin  or  lymphatic  glands  in  lepros)  .  and  of  the  nose 
or  mouth  in  glanders,  will  serve  to  distinguish  these  affections  from  each 
other.  In  the  advanced  stages,  when  the  destruction  of  tissue  has  been  con- 
siderable   and    perichondritis   or   cicatrization    has    been    com itant,    it    is 

often  very  difficult,  from  appearances  alone,  to  distinguish  syphilis  or  lupus 
from  laryngeal  tuberculosis ;  especially  is  this  true  of  the  former  affection. 
Yet,  generally  by  an  exploration  of  the  chest,  taken  together  with  the  clinical 
history  of  the  case,  one  may  clear  up  all  doubt. 

Prognosis  and  Course. — The  prognosis  i-  always  grave.  The  form 
described  as  acute  tuberculous  laryngitis,  or  inflammatory  tuberculous  larj  a- 
gitis  (tubercular  infiltration),  oiler-  practically  no  hope,  because  it  is  mereh 
a  local  manifestation  of  a  general  miliary  tuberculosis  which  may  possibly 
be  affecting  any  or  all  of  the  glandular  organs  of  the  body.  Hiis  form  oi 
general   infection   sometimes    attacks   persons   in   apparently    robtisl    health, 


Fig.  618.— Nodular,  lupus-like  infil- 
tration of  tin-  epiglottis,  true  aud  false 
cords,  P inning  small  tumor-mi  - 
tin-  arytenoids,  and  causing  total  apho- 
nia (( rrunwald). 


1046  TUBERCULOSIS  OF  THE  MR-PASSAGES. 

whom  «>nr  would  think  from  their  appearance  would  be  able  to  resist,  for  a 
time  at  least,  any  sorl  of  general  infection  or  sepsis.  In  such  persons,  how- 
ever, its  course  may  be,  au.l  indeed  usually  is,  as  rapid  as  with  those  appear- 
ing more  delicate.  The  larynx  soon  presents  evidences  of  great  inflamma- 
tion, and  it-  tissues  soon  break  down.  We  meet  with  eases,  however,  which 
mighl  properly  be  classified  as  acute,  in  which  the  disease  becomes  limited 
and  retrogresses  for  a  time,  even  though  there  may  be  well-marked  physical 
signs  of  involvement  of  the  lungs.  I  have  met  with  several  such  cases 
which,  contrary  to  expectation,  have  remained  passive  for  a  long  time.  In 
the  more  chronic  forms,  manifested  by  pale,  anemic  mucous  membranes,  the 
disease  usually  run-  a  -lower  course,  but  is  almost  always  fatal.  These  cases 
are  frequently  accompanied  by  systemic  infection  of  the  bronchial  lymph- 
nodes  or  spleen.  Such  cases  may  run  an  inactive  course,  however,  usually 
unaccompanied  by  cither  the  intense  odonphagia  or  dysphonia  of  other 
forms;  vet  the  voice  is  nearly  always  more  or  less  impaired.  The  limited 
forms  of  the  disease  usually  respond  to  appropriate  treatment  and  regimen, 
and,  excepting  for  exacerbations  of  acute  laryngitis — the  result  of  attacks 
of  influenza,  etc. — may  be  kept  more  or  less  passive  for  years,  if  not  per- 
manently checked. 

Treatment. — The  treatment  of  this  affection  is  generally  classified  as 
general  and  local.  The  general  treatment  may  be  considered  as  climatic, 
hygienic,  specific,  and  symptomatic;  and  the  local  treatment  may  be  discussed 
under  the  following  captions — local  medication  by  inhalation,  sprays,  or 
insufflations,   and   surgical   treatment. 

The  influence  <>f  climate  in  modifying  all  of  the  tuberculous  diseases  is 
well  known  and  need  not  be  discussed  at  length.  However,  in  no  form  of 
phthisis  is  it  more  disappointing  than  in  that  of  active  laryngeal  tuberculosis. 
I  Fsually  a  warm  moist  climate  is  the  most  beneficial  to  the  majority  of  cases, 
provided  it  is  nut  too  enervating,  such  as  a  tropical  or  subtropical  one.  The 
dry  warm  climate-,  such  as  those  of  Arizona,  New  Mexico,  and  some  parts  of 
California,  do  not  seem  to  suit  many  of  these  cases,  perhaps  on  account  of  the 
dryness  of  the  air,  for  in  many  instances  the  laryngeal  symptoms  seem  to  grow 
worse  after  entering  such  localities.  When  a  dusty  or  windy  feature  is  char- 
acteristic of  the  climate  of  the  locality,  the  discomfort  and  distress  is  sure 
in  he  increased  i  [ngalls).  With  regard  to  altitude,  it  may  be  pointed  out  as 
a  rule  thai  only  a  moderate  elevation  is  well  tolerated  by  many  subject-.  A 
large  majority  of  those  who  dwell  above  3000  feet  are  apt  to  suffer  extra 
distress,  if  not  exacerbations  of  inflammation  of  the  larynx  ;  this  is  espec- 
ially true  of  the  well-marked  inflammatory  cases.  There  are,  however, 
many  exceptions,  especially  when  the  local  lesion  is  in  a  primitive  state,  or 
when  much  infiltration  or  ulceration  i-  present.  Strange  as  it  may  seem, 
cases  showing  bul  little  involvemenl  of  the  lung  are  not  a-  much  relieved  as 
those  in  which  there  is  notable  involvement  of  the  lungs,  such  as  commencing 
softening  or  excavation.  A  cold  dry  climate  with  plenty  of  sunshine  has 
been  found  even  more  generally  beneficial  than  a  highly- elevated  dry  or 
dusty  one.  Sometimes,  however,  when  the  cold  is  very  intense,  the  laryn- 
geal mucous  membrane  seems  to  he  irritated  thereby,  especially  if  there  be 
much  hyperemia.  In  short,  according  to  experience,  a  windy,  dusty  locality 
i-  not  suitable  tor  cases  of  laryngeal  phthisis,  except  when  there  is  more  or 
less  ulceration  of  the  larynx  or  caseation  of  the  lungs  going  on.  A  moist 
warm  climate  or  ocean-voyages  would  therefore  seem  preferable  as  a  rule. 
< >f  course,  it  will  be  understood  that  the  individual  and  the  individual  cir- 
cumstances may  furnish  valid  exceptions  to  any  rule. 


LARYNGEAL   TUBERCULOSIS.  L047 

The  hygienic  treatment  consists  for  the  mosl  pari  in  proper  clothing,  not 

too  frequent  bathing,  and   the  administration  of  i rishing  bui    digestible 

food  ;  out-door  life  as  far  as  possible  during  the  day,  with  a  cool  (bui  not  too 
cold)  sleeping-apartment.  Patient-  with  this  disease  should  be  very  careful 
about  exposure  to  coal-gas  for  any  length  of  time.  The  use  of  tobacco, 
either  chewing  or  smoking,  ought  to  be  prohibited,  also  the  too  frequenl  use 
of  eold  and  hot  drinks  in  close  alternation,  such  a-  ice-water  and  hot  tea  or 
coffee  at  nieal-times.  The  full  quota  of  sleep  each  twenty- four  hours  should 
be  obtained.  Patients  should  be  enjoined  to  spare  the  voice  as  much  as  pos- 
sible in  conversation  ;  singing  and  public  speaking  ought  to  be  prohibited. 
I  have  known  several  instances  where  patients  in  the  early  stages  of  laryngeal 
phthisis,  presenting  certainly  good  prospects  for  at  leasl  temporary  recovery, 
have  been  thrown  into  almost  a  fatal  exacerbation  by  the  strenuous  use  of 
the  voice.  One  of  these  eases,  I  may  briefly  state,  was  that  of  a  clergy- 
man who  was  making  an  apparently  good  recovery.  He  had  been  away 
for  some  months  from  his  duties  and  had  returned  to  his  residence  in  a 
district  containing  a  great  many  friends  among  the  congregation-  of  sev- 
eral churches  where  he  was  well  known.  About  the  time  of  his  return 
there  was  considerable  church  activity  and  public  agitation  on  special  moral 
questions  concerning  the  district  in  question.  As  he  had  been  a  popular 
and  efficient  pulpit-orator,  lecturer,  and  worker,  he  was  persuaded  to  take  an 
active  part  in  these  events.  After  making  three  prolonged  and  rather  vehe- 
ment orations  in  three  adjacent  towns  during  a  period  of  a  week  or  so,  he 
contracted  a  violent  inflammation  of  the  larynx,  which  renewed  the  exuda- 
tion into  the  tissues,  and  ulceration — affecting  permanently  the  integrity  of 
the  larynx  and  necessitating  his  immediate  removal  to  the  South,  where  lie 
expired  in  about  nine  months.  A  similar  effect  occurred  in  the  case  of  a 
prominent  lawyer  who  was  a  patient  of  mine  and  whose  case  bade  fair  to 
end  in  recovery.  He  was  induced  to  return  from  a  needed  sojourn  in  the 
West  Indies  (where  he  was  sent)  to  take  part  in  some  important  cases  that 
he  had  been  engaged  for,  and  after  finishing  this  task  a  severe  inflammation 
of  the  larynx  with  extreme  tubercular  infiltration  followed.  Many  other 
like  instances  could  be  given  to  show  the  necessity  of  rest — as  absolute  as 
may  be — in  the  management  of  laryngeal   phthisis. 

The  specific  treatment  of  laryngeal  tuberculosis  has  not  yet  arrived  at 
the  perfection  which  we  would  wish.  A  great  many  agents  have  been 
brought  forward  from  time  to  time  which  have  undoubtedly  been  attended 
by  a  modicum  of  good  results;  but  owing  to  numerous  failures  they  have 
been  gradually  put  aside.  The  seekers  of  truth  in  this  field  of  discovery 
are  numerous,  however,  and  we  may  with  reason  hope  that — guided  by  pas! 
failures  and  partial  successes — the  right  series  of  therapeutic  measures  may 
yet  be  reached.  Among  the  more  modern  agents  of  supposed  specific  value 
may  be  mentioned  creosote, guaiacum,  tuberculin  and  its  various  modifica- 
tions, dog-serum,  horse-serum — plain  and  tuberculized — nuclein,  chloricl  of 
gold  and  -odium,  eantharidid  of  potassium,  ehlorin  water  with  chlorid  ol 
sodium,  oil  of  cloves,  cinnamon  and  other  essential  oils,  chlorid  of  zinc,  the 
formates,  iodin,  etc.  There  are  many  eases  on  record  of  moderate  and  even 
brilliant  results  following  the  use  of  each  of  these  agents,  both  in  laryngeal 
and  pulmonary  tuberculosis;  but.  a-  -aid  above,  the  effects  have  been  short 
of  general  utility.  I  am  led  to  the  conviction,  from  my  own  experience 
with  these  several  agents,  that  they  are  perhaps  less  useful  in  a  specific  sense 
in  laryngeal  tuberculosis  than  in  pulmonary  tuberculosis.  These  agents 
have  all  been  used  in  the  general  belief,  of  course,  thai  ;ill  cases  of  laryngeal 


1048  TUBERCULOSIS  OF  THE  AIR-PASSAGES. 

tuberculosis  were  simply  the  expression  of  ;i  genetal  infection.  But  un- 
doubtedly some  of  the  cases  reported  to  have  been  cured  have  been  aggra- 
vated forms  of  ordinary  chronic  inflammation  of  the  larynx  ;  while  some 
may  have  been  cases  of  chronic  laryngitis  complicated  by  syphilis.  1  have 
myself  been  deluded  once  in  a  while  by  such  erroneous  diagnoses,  and  un- 
doubtedly other.-  have  met  with  the  same  misfortune.  These  remedies  have 
been  used  both  hypodermatically  and  per  os.  While  the  hypodermatic 
use  of  such  remedial  agents  is  manifestly  more  desirable,  the  attendant 
pain  and  difficulty  of  properly  carrying  out  this  plan  of  medication  ren- 
der its  general  adoption  of  doubtful  practicability,  especially  in  private 
practice. 

I  am  still  of  th  i  opinion  that  among  these  agents  iodin,  when  conjoined 
with  some  proteid  substance,  furnishes  the  best  results  so  far  as  specific 
medication  is  concerned.  It  seems  to  make  some  difference  in  the  ulterior 
effects  whether  the  drug  is  administered  in  connection  with  iodid  of  potas- 
sium, glycerin,  and  water,  without  some  proteid  material  or  not,  for  I  have 
found  repeatedly  in  the  same  patient  that  the  administration  of  the  drug, 
either  hypodermatically  or  by  the  mouth,  in  a  mixture  with  sterilized  bouillon 
will  produce  more  lasting  benefit  than  when  given  otherwise;  so  that  we  have 
adopted  the  habit  in  hospital  practice  of  administering  it  in  bouillon  or  milk. 
It  may  also  be  given  advantageously  in  combination  with  glycerin  and 
extract  of  malt.  I  have  also  used  creosote  and  guaiacol  in  the  same  way 
with  apparently  better  effects  than  when  given  alone;  and  we  may  therefore 
be  pardoind  for  the  suggestion  thai  perhaps  the  majority  of  remedies  admin- 
istered tor  constitutional  effects — if  there  are  no  chemical  contra-indications 
would  he  more  efficacious  when  so  combined.  Whether  a  chemical  combina- 
tion actually  takes  place  between  these  agents  and  sonic  unknown  proteid 
of  the  animal  fluid  used,  I  am  unable  to  say  ;  but  possibly  at  some  future 
time  this  point  may  he  satisfactorily  demonstrated.  Guaiacol  and  oil  of 
cloves  are  both  very  useful  when  administered  in  an  emulsion,  in  suitable 
doses,  three  or  four  time-  daily,  or  (sometimes  a  better  way)  in  very  small 
doses  repeated  every  hour  for  a  certain  number  of  times,  according  to  the  tol- 
erance of  the  patient.  The  former  agent  as  "  benzosol  "  has  given  very  good 
results.  In  the  more  chronic  cases  characterized  by  anemia  of  the  mucous 
membrane,  phosphorus  administered  in  solution  with  olive  oil  in  capsule  is 
highly  beneficial.     This   combination    maybe  found   on    the   market    in    the 

form   of  capsules  containing  from   on le-hundredth   to  one-thirtieth  of  a 

grain  of  phosphorus  in  10  or  l5minimsof  oil.  It  should  be  administered 
always  ju.-t  after  food  has  been  taken,  and  if  irritation  of  the  stomach, 
urticarious  eruption,  or  aphrodisiac  effects  follow  its  use,  the  dose  must  be 
materially  modified  or  the  administration  of  the  drug  -topped.  A.rsenic, 
especially  the  arsenate  of  icon,  chlorid  of  gold  and  sodium,  salicin,  and 
strychnin  are  very  valuable  tonic  agents.  Strychnin  and  salicin  are  among 
the  mosi  useful  agents  for  general  effects.  When  there  is  much  hyperpyrexia, 
salol  "i-  sodium  salicylate  may  be  substituted  I'm-  salicin.  For  the  temporary 
repression  of  temperature,  acetanilid,  or  aconite,  or  judicious  bathing  may 
be  resorted  to.     The   somewhal    prevalenl    practice  of  combining  either  of 

these  agents  with  other  thin- ometimes  not  synergistic — is  certainly  a  bad 

Of  < r-e.  thi-  criticism  doe-  not  apply  to  mixtures  containing  seda- 
tives, such  as  codein  or  hyoscyamus.  But,  as  a  rule,  it  i-  preferable  to  ad- 
minister :dl  drugs  designed  for  temporary  effect,  alone.  The  use  of  alcoholic 
beverages  in  this  disease  ie  fraught  with  perplexity:  for  while  in  many  in- 
stances alcohol  in  one  form  or  another  i-  indicated*,  vet   the  condition  of  the 


/. .  1  R  )  \\G  /.\  I  /,    77  />•  Eli  <(L  OS  IS. 


1049 


throat  may  be  such  as  to  prohibil  it,  either  on  account  of  the  local  pain 
attending  its  deglutition,  or  on  account  of  its  decided  and  directly  deleterious 
effects  upon  the  diseased  larynx.  It  will  lie  found  better  generally  to  selecl 
the  malt  beverages  and  preparations,  rather  than  the  spirituous.  The  admin- 
istration of  a  little  rectified  spirit  with  milk,  however,  will  be  found  useful 
when  large  draughts  of  whiskey,  brandy,  rum.  etc.,  cannot  lie  consumed 
without  distress  or  evil  effects. 

The   symptomatic  treatment   of    laryngeal   tuberculosis    can    scarcely    be 
formulated,  and   will   depend   upon   a    variety  of  circumstances   which    will 

indicate  the  agents  to  be  -elected  for  each  individual   case  i der  to  allav 

cough,  pain,  hyperpyrexia,  diarrhea,  mental  perturbation,  etc.  A-  laryngeal 
tuberculosis  when  advanced  is  perhaps  one  of  the  mosl  painful  affections  to 
which  flesh  i.s  heir,  the  practitioner  may  be  sorely  taxed  to  meet  the  constanl 
demand  for  relief  without  incurring  other  mischief.  However,  opium  and 
its  -alts,  for  internal  medication  in  such  cases,  .-till  retain  their  popularity — 
codein,  morphin,  or  the  powdered  drug 
seems  best.  Cough  may  be  mitigated  by 
the  milder  anodynes,  such  as  codein,  tinc- 
ture of  opium,  hydrochlorate  of  cocain, 
hydrate  of  chloral,  etc.,  together  with  the 
various  expectorants  and  balsams  (see 
Formulary).  Care  should  be  taken  that 
syrups  are  not  used  too  freely,  lest  nau- 
sea, vomiting,  and  anorexia  be  favored. 
Chlorid  of  ammonia  and  other  chlorids 
may  cause  severe  pain  when  the  mucous 
membrane  is  ulcerated,  otherwise  they 
may  be  used.  Sleep  may  be  secured  by 
the  administration  of  sulfonal,  trional, 
chloral,  the  bromids,  or  some  preparation 
of  opium,  alone  or  in  combination  with 
one  of  the  other  anodynes  mentioned. 

The  local  treatment  consists  of  in- 
halations of  gases  or  medicated  air, 
sprays,  and  powders.  Inhalations  of 
medicated  air  arc  of  little  permanent 
benefit  excepting  in  the  early  stages,  or 
when  there  is  an  unusual  amount  of 
salivary  or  other  expectoration.  There 
are  a  number  of  suitable  inhalers  in  the 
market,  from  which  volatile  substances 
may  be  inhaled  either  with  or  without 
the  aid  of  hot  water.  A  simple  instru- 
ment may  be  made  of  tin.  with  a  per- 
forated  receptacle  at    it-   distal   end    for 

containing  a  piece  of  sponge,  upon  which  may  be  dropped  preparations  ol 
creosote,  carbolic  acid,  menthol,  camphor,  creolin,  tinct.  ben/,, in.  tinct.  mj  rrh, 
etc.,  combined  with  chloroform,  ether,  alcohol,  or  spirits  of  ammonia.  Hiese 
agents  may  also  be  dropped  into  hot  water  contained  in  a  hot-water  inhaler. 
These  instruments  can  be  used  by  the  patient  several  time-  a  day.  with  some- 
times very  good  effeel  in  the  early  stages  of  disease.  When,  however,  this  form 
of  inhalation  increases  the  sensation  of  "dryness,"  "  stiffness," or  pain  referred 
to  the  throat,  they  should  bedis< ti id.     A  preferable  method  of  inhalation 


ibe  in! 


1050  TUBERCULOSIS  OF  THE  AIR-PASSAGES. 

in  general  is  accomplished  by  spraying  the  medicament  into  the  throat  from 
either  a  steam  or  a  hand-ball  atomizer.  The  spray  may  be  projected  directly 
into  the  throat,  or  it  may  be  projected  (especially  if  it  be  oleaginous)  into  a 
globe  inhaler  (see  Fig.  619),  from  which  it  can  then  he  inhaled  through  a  face- 
shield  which  will  completely  enclose  the  nose  and  month.  This  is  a  much 
more  thorough  method  of  'local  treatment  in  laryngeal  phthisis,  especially 
when  iIm'  agent  is  in  the  form  of  an  oleaginous  solution.  All  such  agents  as 
creosote,  camphor,  menthol,  carbolic  acid,  guaiacol,  creolin,  phenol,  oil  of 
eucalyptus,  etc.  may  he  dissolved  in  a  pure  fluid  petrolatum  or  olive  oil  and 
projected  into  the  inhaler,  whence  they  can  be  carried  into  the  larynx  by  the 
ordinary  process  of  respiration.  Although  this  means  of  local  medication 
may  fail  in  many  instances  of  producing  radical  change,  it,  nevertheless, 
affords  a  very  practical  and  efficient  method  of  relief.  The  watery  solutions 
are  besl  used  by  spraying  directly,  as  near  as  possible,  upon  the  parts.  In 
this  manner  there  may  be  used  with  tolerable  efficiency  solutions  of  formate; 
of  soda,  biborate  of  soda,  alum,  boric  acid,  carbolic  acid,  cocain,  morphin, 
hydrochlorate  of  coniin,  tannic  acid,  sulphate  of  iron,  sulphate  of  zinc, 
nitrate  of  silver,  chlorid  of  zinc,  etc.  These  chemicals  may  he  used  in  vary- 
ing quantities  according  to  the  requirements  of  the  ease  (see  Formulary). 
Insufflations  of  powders  upon  the  larynx,  although  of  great  value,  especially 
when  ulceration  has  taken  place,  are  sometimes  not  well  tolerated  on  account 
of  the  desiccation  of  the  secretions  or  the  prolonged  and  distressing  paroxysms 
of  cough  which  they  produce.  A.mong  the  agents  most  useful  as  insuffla- 
tions in  laryngeal  tuberculosis  may  he  mentioned  iodoform,  iodoform  with 
boric  acid  or  bismuth,  uaphthalin,  aristol,  europhin,  boric  acid,  tannic  acid, 
amnion,  citrate  of  iron  and  potassium,  stearate  of  zinc  or  alum,  subnitrate 
or  tannate  of  bismuth,  morphin  with  gum  acacia,  etc.  The  insufflations 
should  always  he  preceded  by  a  thorough  spraying  of  the  parts  with  some 
detergent  solution,  such  as  biborate  of  soda  or  phosphate  of  soda  ;  and  care 
should  be  taken  that  the  amount  of  powder  propelled  upon  the  larynx  is  not 
ton  great,  otherwise  distressing  spasm  and  cough  may  supervene,  lasting  a 
considerable  length  of  time  and  producing  not  only  extra  congestion  and  irri- 
tation of  the  parts,  but.  perhaps,  vomiting  and  exhaustion.  It  is  often  desir- 
able to  apply  directly  with  a  brush  or  pledget  of  cotton  certain  medicaments, 
in  the  form  of  pigments,  to  ulcerations.  This  may  be  done  preferably  by 
using  the  Wagner  laryngeal  brush  or  a  pledget  of  absorbent  cotton,  either 
held  by  forceps  or  wound  around  the  roughened  end  of  a  probe  or  applicator. 
In  this  way  Btrong  solutions  of  nitrate  of  silver,  chloracetic  acid,  lactic  acid, 
carbolic  acid,  chlorid  of  iron,  chlorid  of  zinc,  formaldehyd,  creosote,  formate 
of  sodium,  etc.,  may  be  carried  to  the  part. 

The  range  of  surgical  measures  lor  the  relief  of  this  disease  is  necessarily 
limited.  The  papillomatous  excrescences  which  sometimes  accompany  pro- 
gressive ulceration  may  have  to  In-  removed  by  evulsion,  snaring,  or  eschar- 
otics.  Especially  is  this  the  case  when  such  protuberances  occur  aboul  the 
vocal  cords  or  ventricular  band-,  and  by  their  presence  obstruct  respiration 
or  produce  great  mechanical  irritation  of  contiguous  parts.  A  few  years  ago 
Dr.  Heryng  adopted  -0111  promulgated  the  plan  of  thoroughly  curetting 
tuberculous  ulcers  and  afterward  applying  to  the  surface  so  abraded  lactic 
acid    in   the   proportion   of    •_'(>.  .",0,  or  50  per  cent,   solutions,  or  stronger, 

a< rding   t<>  effects.     This   met  with  considerable  favor  for  the  treatment  of 

soup  There  b  no  doubt  that  it  may  be  n  very  efficient  and  practicable 

measure  in  cases  of  isolated  ulcerations  in  the  upper  part  of  the  larynx  ;  but 
for  m  large  proportion  of  cases  of  laryngeal  tuberculosis  presenting  no  limited 


LARYNGEAL    TUBERCULOSIS.  1051 

lesions, but  a  simultaneous  breaking  down  of  many  .-pot-  separated  IV each 

other,  this  plan  of  treatment  will  necessarily  be  limited  in  its  application. 
Besides  this,  many  times  the  lesions  will  be  found  out  of  reach.  Then,  too, 
there  are  individuals  in  whom,  for  some  reason,  these  parts  are  too  ph\  sicalh 
sensitive  for  interference  of  that  sort,  even  under  the  influence  of  cocain, 
■without  exciting  a  general  disturbance  which  is  not  easily  allayed.  This 
was  my  experience  in  two  favorable  eases,  when  I  was  obliged  to  desist  after 
early  manipulation.  The  application  of  lactic  acid  withoul  the  curettement 
is  generally  well  borne  and  efficient.  Scarification  of  the  larynx  in  the 
chronic  form  is  a  measure  of  relief  which  is  not  practised,  perhaps,  as  often 
as  it  ought  to  be.  The  writer  called  attention  to  this  plan  of  relieving  the 
tension  of  the  parts  some  twelve  years  ago;  and  many  practitioners  who 
have  adopted  the  plan  have  reported  good  results  from  it.  It  ought  not, 
however,  to  be  indiscriminately  adopted,  because  the  objection  urged 
against  the  practice,  that  it  opened  up  the  deeper  tissues  to  probably  further 
infection,  holds  good  in  many  instances.  However,  as  ulceration  in  any 
event  is  inevitable,  especially  after  great  infiltration,  it  will  be  found  that  the 
anticipation  of  nature's  step  in  this  direction  by  scarification  will  greatly 
modify  the  subsequent  necrosis  of  the  tissues,  and  at  the  same  time  enable 
the  practitioner  to  meet  the  prospective  condition  by  more  thorough  medica- 
tion. I  would  therefore  still  advise  in  some  cases  of  inordinate  effusion — 
even  though  it  be  not  considered  edematous — a  reasonable  amount  of  scar- 
ification over  the  tumefied  parts,  whether  it  be  the  arytenoid  cartilages,  inter- 
arytenoid  space,  ary-epiglottic  folds,  or  epiglottis. 

Hypodermatic  injections  of  creosote  or  other  agents  into  the  laryngeal 
mucous  membrane  have  been  in  my  hands  very  disappointing. 

It  must  be  confessed  that  local  treatment  in  many  cases  is  of  little  value, 
excepting  for  the  palliation  of  pain  and  other  phases  of  distress,  mainly, 
perhaps,  because  the  lesions  are  more  or  less  out  of  reach  and  too  deep  in  the 
mucous  membrane.  On  the  other  hand,  in  some  of  the  slower-going  cases, 
characterized  by  limitation  and  accessibility  of  the  lesion,  a  judicious  local 
treatment  constitutes  our  principal  means  of  assisting  nature  to  resist  the 
progress  of  the  disease.  We  must  agree  with  Gleitsman  that,  theoretically, 
the  thorough  removal  by  surgical  means  of  the  diseased  tissues  and  the 
induction  of  a  healthy  reparative  process  is  the  ideal  desideratum  ;  but, 
unfortunately,  there  are  as  yet  no  practical  ways  of  successfully  carrying  out 
such  laudable  aims.  So  we  are  still,  as  it  were,  obliged  to  drift  along 
empirically,  without  any  exact  principles  of  therapy  to  follow  in  the  man- 
agement of  this  disease.  It  will,  therefore,  be  impossible  to  lay  down  any 
rules  for  the  application  of  this,  that,  or  the  other  agent  or  preparation  ;  and 
the  question  of  the  selection  of  topical  medication  must  be  left  to  the  >Uill 
and  experience  of  the  practitioner.  It  may  be  added,  however,  in  conclusion, 
that  of  all  agents  for  general  use,  perhaps  none  surpasses  iodoform,  aristol, 
resorcin,  tannogen,  or  mercury  protochlorid,  \\>vA  either  by  insufflation  or  in 
solution  or  in  mixture  with  petrolatum  oil.  Next  in  value,  especially  when 
ulceration  has  begun,  may  be  ranked  lactic,  chloracetic,  and  carbolic  acids; 
and  after  these,  chlorin  water,  sodium  formate,  silver  nitrate  zinc  chlorid, 
mercury  bichlorid  and  biniodid,  creosote,  and  oil  of  eucalyptus.  I  he  inhala- 
tion from  a  face-shield  inhaler  of  1  ounce  of  solution  of  mercuric  chlorid  (  I  : 
3000),  immediately  followed  by  an  inhalation  of  from  2  to  I  ounces  of  a  solu- 
tion of  (1  to  2  per  cent.)  iodoform  in  petrolatum  oil,  will  oftentimes  prove 
highly  beneficial  to  a  large  number  of  cases.  The  inhalation  of  chlorin  water 
combined  with  a  solution  of  -alt  in  water  is  also  very  efficient  when  it  do,- 


1052  TUBERCULOSIS  OF  THE  AIR-PASSAGES. 

nol  cause  much  pain  or  coughing.  Usually  from  $  to  1  ounce  of  cue!]  (mixed) 
i-  as  much  as  ought  to  be  given  at  a  seance. 

One  of  the  leading  therapeutic  indications  is  toward  the  assuagement  of 
pain  and  laryngeal  distress.  For  such  purposes  we  must  resort  preferably  to 
the  local  application  of  either  cocain,  coniin  hydrochlorate,  bromoform,  mor- 
phin  formanilid,  atropin,  aconitin,  chloroform,  menthol,  ethyl-bromid,  creolin, 
or  similar  agents.  These  substances  are  besl  used  in  the  form  of  spray  or 
pigment,  excepting  ethyl-bromid  and  chloroform,  which  arc  volatile  (see 
Formulary  . 

In  cases  where  much  soreness  is  generated  from  a  more  or  less  continued 
muscular  action  of  the  pharyngo-laryngeal  muscles,  coniin  hydrochlorate, 
menthol,  or  ice  (held  in  the  month  until  melted)  will  be  found  beneficial. 
For  promoting  an  antagonistic  effect  against  the  burning  and  rawness  often 
complained  <»f.  either  aconitin.  atropin.  or  hyoscin  will  he  found  useful  in 
addition   to  other  treatment. 

Cocain  hydrochlorate  or  morphin  alone,  or  in  combination  with  either 
iodoform,  aristol,  naphthalin,  or  carbolic  acid,  will  he  found  to  he  the  "sheet 
anchors"  for  the  relief  of  pain.  The  frequent  cleansing  of  the  throat  with 
sprays  containing  peroxid  of  hydrogen,  boric  or  carbolic  acid,  when  well 
home,  is  a  good  practice  and  one  which  greatly  promotes  the  comfort  of  the 
patient,  to  say  tin1  least.  The  formulae  for  the  use  of  these  several  agents 
are  appended. 

Formulary. 
Sprays. — 

li  Zinc  chlorid,  1-3$;    2)  Zinc  sulphate,  1-4$;  (3)  Mercuric  biniodid,  0.2%,  and 
Potassium  iodid,  \  ■      in  glycerin  ami  water. 
Sodium  formate,  2-3%;  (5)  Coniin  hydrochlorate,  0.2$  :  (6)  .Mercuric  bichlorid, 
n.'_'\  .  and  Hydrogen  dioxid,  16$ — in  water. 

(7)  Alumnol,  2  -  ,  ami  Cocain  hydrochlorate,  1% — in  peppermint-water. 

(8)  Oil  of  eucalyptus,  3$  :  CM  Menthol,  1  %  ,  ami  Camphor,  1%;  (10)  Creolin,  1.5%, 

and  Alcohol,  0.2-0.5  $  — in  liquid  petrolatum. 
Pigments.— 

(11)  [odin,0.4%,  and  Potassium  iodid.  1$  ;   (12)  Formaldehyd,  10$  :   (1:'.)   Pyok- 

tanin  (blue),  -'>  ,  ami  Acacia,  2',  — in  water. 
(14)  Hyoscin    hydrobromate,    2%;    (15)  Aconitin.   0.2$  ;    (16)   .Morphin    sulphate. 

1   .  .  and  Antifebrin,  2%— in  glycerin  and  water. 
(17  i  Lactic  acid,  20   I1'  i,  in  water.     (18)  Carbolic  acid,  12.5%,  in  glycerin. 
Insufflations. — 

L9    Tannic  acid,  6 % ;   Powdered  starch,  19%;  and  Bismuth  subnitrate,  75%.     (20) 
Resorcin,  50$  .  and  Powdered  starch,  50$  . 
(21)  Aristol,  50$  .  and  Powdered  March.  50$  .     (22)  Silver  nitrate.  1-2$  .  and  Talc 
powder,  98  99%.     (23)  Tannic  acid.  3%;  Cannabin  tannate,  7%;   Bismuth 
subnitrate, 45 % ;  and  Powdered  starch, 45%.     (24)  Silver  nitrate, 3$  ;  Acacia 
powder,  '■'•'-■;    and   Bismuth  subnitrate,  65%.     (25)  Armenian   bole,  25%. 
Sugar,  25%;   and  Sodium  biborate,  50%.      (26)  Morphin  sulphate,  0 
Mild  mercuric  chlorid,  20%;  Sugar,    I11     :    and   Bismuth  subnitrate,    1" 
27    Morphin  sulphate,  3 %,  and  [odoform,97     .      28)  [odoform,  11%;  Boric 
acid.  34%;  Naplitalin.  55%;  and  Oil  of  Bergamot,  a  sufficient  quantity. 
fial  Mt  dicafion. — 

Compound  solution  of  lodin  (Lugol's  solution),  15  cc,  and  Glycerin,  L5  cc. 

Ten  drops  in  milk-  every   lour  hour-. 
Syrup  of  ferrous  iodid,  30  cc,  and  Compound  syrup  of  the  bypophosphites, 
30  cc. 

Tablespoonful  three  times  a  day. 
Salicin,  Igra. ;  Calcium  liypophosphite,  6  gm. ;   Whiskey,  150  cc";  and  Fluid 

■  racl  of  Malt,  2]u  cc.     Two  to  tour  teas] ufuls  three  times  a  day. 

-odium    salicylate,   H2  gm.;    Cinnamon-water,   li!<»  cc;   and  Water,  1-"  <<■ 

Two  teas  noon  fula  three  times  a  day. 
Powdered    hone.  8   12   gm. ;    Glycerin,  30   cc;    and    Cinnamon-water,  90  cc-. 
•  ml  three  times  a  day. 


TUBERCULOSIS  OF  THE  NASAL    PASSAGES.  1053 

TUBERCULOSIS  OF  THE  NASAL  PASSAGES  AND  THE  PHARYNX. 

The  Nasal  Passages. — Tuberculosis  confined  to  the  nasal  passages  ex- 
clusively or  primarily  occurring  then'  is  extremely  rare  (Cohen,  Bosworth, 
Chiari,  Hajek,  Risdel,  Kafeman,  Schaffer).  The  disease  is  more  often 
observed  in  connection  with  pulmonary  phthisis  of  an  advanced  stage,  or, 
according  to  Kafeman,  in  case-  of  latent  tuberculosis.  This  author  states  thai 
the  reported  cases  of  primary  tuberculosis  of  the  nose,  pharynx,  or  larynx, 
without  pre-existing  tuberculosis  or  latent  foci  elsewhere,  should  be  received 
with  a  great  deal  of  skepticism.  Authoritative  statistics  derived  fr autop- 
sies are  cited  in  support  of  this  statement. 

The  more  common  site1  for  the  development  of  the  disease  is  in  the  region 
of  the  cartilaginous  septum  of  the  nose,  although  Chiari  observed  thai  in  his 
six  eases  other  parts  as  well  as  the  septum  were  affected  ;  in  one  the  maxillary 
sinus  being  involved.  Kaschier  distinguishes  a  form  of  the  disease  which 
particularly  affects  the  bony  framework.  Lermoyez  cite-  cases  of  the  occur- 
rence of  tuberculous  vegetations  at  the  vault  of  the  pharynx.  There  are  a 
few  cases  on  record  in  which  tuberculosis  of  the  naso-pharynx  seemed  to 
follow  operations  for  the  removal  of  adenoid  vegetations  in  patient-  who  were 
previously  free  from  either  tubercular  disease  or  hereditary  tendency.  A 
few-  such  cases  have  been  reported  by  Kafeman  and  others,  one  or  two  of 
which  were  followed  by  tubercular  meningitis.  It  is  sought  to  accounl  for 
the  occurrence  of  this  latter  class  of  case-  upon  the  supposition  thai  the 
wound  of  the  operation  offered  an  opportunity  for  the  entrance  of  tubercle- 
bacilli,  carried  there  either  by  inspired  air.  food,  the  instruments  or  finger 
of  the  operator.  Some  writers  believe  that  in  all  such  cases  either  the  bacilli 
or  some  tubercular  formation  is  already  present  in  the  glandular  tissue.  I 
have  never  observed  a  case  of  primary  nasal  tuberculosis,  although  having 
-eeti  several  cases  occurring  in  the  course  of  advanced  pulmonary  phthisis. 
Cases  have  been  reported  in  which  the  disease  began  in  the  form  of  a  few 
papilloma-like  prolongations  from  the  mucous  membrane  at  intervals  along 
the  septum — tubercular  tumors,  as  it  were.  These  cases  are  notable  for 
their  slow  march.  The  lesions  oftener  occur  just  at  the  vestibule  of  the 
nose. 

Etiology. — The  majority  of  observers  believe  that  the  only  cause  of  the 
disease  in  this  situation,'  as  elsewhere,  i-  the  implantation  of  tubercle-bacilli, 
and  that  these  micro-organisms  may  be  conveyed  to  the  pari  either  from 
without  by  contact  of  sputum  during  act-  of  coughing  or  vomiting;  by 
means  of  the  finger,  as  in  picking  the  nose;  by  the  inspiration  of  bacilli- 
laden  air;  or  from  within  through  conveyance  from  some  remote  focus  by 
either  the  blood  or  lymph  (Kafeman.  Chiari).  The  well-known  ubiquity 
of  the  tubercle-bacillus  and  the  frequency  of  catarrhal  affections  of  the 
nose  entailing  abrasions,  etc,  are  relied  upon  in  explanation  of  these  modes 
of  origin.  Chiari  believes  that  the  infection  generally  takes  place  b\  the 
inoculation  of  some  abrasion  or  fissure  of  the  epithelium  with  tubercle- 
bacilli  conveyed  there  by  the  finger.  Although  adopting  the  idea  of 
primal  bacillary  infection',  he  uevertheless  states  that  he  found  tubercle- 
bacilli  in  four  only  of  hi-  -i\  cases.  Kafeman,  who  published  two  interest- 
ing caseg  0f  .,,_(.;i||(.,l  primary  nasal  tuberculosis,  and  who  likewise  beli< 
in  the  bacillary  origin  of  nl!  tubercular  di-ea-e,  found  no  tubercle-bacilli  in 
either  of  hi-  cases,  bul  in  one  of  them  some  stray  specimens  of  the  Langhans 
bacillus.  This  author  attributes  the  maladj  in  hi-  cases  to  :i  probable  infec- 
tion  through   abrasions  of    the   mucous   membrane   by  bacilli-laden   air,   as 


in:,  I  TUBERCULOSIS  OF  THE  AIM-PASSAGES. 

neither  of  his  subjects  were  tubercular  nor  of  a  tubercular  tendency.  The 
signal  immunity  of  the  nasal  passages  from  tuberculous  disease,  when  so 
constantly  exposed  to  abrasion  and  invasion  by  tubercle-bacilli,  has  been  a 
subjeci  of  much  perplexing  speculation.  Lately,  however,  experimental 
researches  of  the  bacteriology  of  the  nasal  passages  have  led  to  some  con- 
clusions which  may  account  for  the  hitherto-observed  immunity  mentioned. 
Clausen  found  thai  the  nasal  passages  of  rabbits  were  apt  to  contain  quanti- 
ties of  pyogenic  bacteria.  Von  Besser,  Fernier,  Lerrnoyez,  and  others  found 
thai  the  human  nasal  passages,  pharynx,  and  larynx  contained  numerous 
bacteria,  such  as  the  diplococcus  pneumoniae,  streptococcus  pyogenes  aureus. 
tubercle-bacillus,  etc. ;  while  St.  (lair  Thomson,  Hewitt,  and  others  found 
that  healthy  nasal  passages  were  bacteria-free.  Fernier  and  Bretschreiber 
also,  making  similar  investigations  with  varying  results,  concluded  that  the 
nasal  passages  were  only  quasi-aseptic,  due  conclusions  of  Thomsen  and 
Hewitt  were  to  the  etl'ect  that  the  normal  secretions  of  the  nasal  passages 
and  throat  were  bactericidal,  and  hence  neutralized  immediately  the  virulence 
of  any  superimposed  micro-organisms.  From  all  these  observations,  and 
from  the  negative  result-  of  clinical  experience,  it  is  fair  to  infer  that 
perhaps  some  of  these  cases  of  so-called  primary  nasal  tuberculosis  were 
really  of  doubtful  character.  Those  observers  (Storck,  Thost,  Heryng)  who 
really  believe  that  fissures  or  abrasions  of  the  mucous  membrane  invite  the 
origin  and  development  of  the  disease,  confess  that  there  must  he  some  par- 
ticular change  in  the  cell-life  of  the  part  in  order  to  consummate  the  estab- 
lishment of  the  malady.  Strauss  has  found  that  the  nasal  passages  and  pharynx 
of  health)  persons  who  spend  much  time  in  the  presence  of  phthisical 
patients,  or  in  rooms  where  phthisical  patients  are  confined,  contain  large 
numbers  of  tubercle-bacilli.  The  question  as  to  the  power  of  tubercle- 
bacilli  to  penetrate  sound  epithelial  tissue  is  yet  an  unsettled  one.  A  further 
discussion  on  the  etiology  of  this  subject  will  he  found  in  the  section  on 
Tuberculous   Laryngitis. 

Symptomatology. — The  early  symptoms  consist,  for  the  most  part,  of 
a  mild  coryza  and  frequent  attempts  at  sneezing,  with  a  sensation  of  fulness 
and  uneasiness  within  the  nasal  passages.  The  discharge,  which  is  at  first 
of  a  mucous  character,  gradually  becomes  more  serous  or  muco-purulent, 
hut  i-  not  apt  to  l»e  very  profuse.  After  a  while  the  nasal  passages  become 
more  or  less  plugged  with  exfoliating  crusts,  which  accumulate  just  Inside 
of  the  nostril  and  cause  considerable  itching,  burning,  and  other  irrita- 
tion. There  i-  rarely  much  odor  to  the  discharge,  such  as  we  meet  with  in 
ozena.  There  may  he  slighl  swelling  of  the  skin  of  the  nose,  redness  and 
marked  soreness.  Very  little  pain  i-  complained  of,  however,  unless  the 
internal  parts  he  touched.  The  disease  i-  usually  confined  to  the  mucous 
membrane  covering  the  cartilaginous  septum,  although  after  a  time  ulcera- 
tion of  the  turbinals  maj  he  observed.  The  ulcerations  are  usually  -mall,  with 
red  rim-,  and  discrete,  although  in  places  there  may  he  confluence  of  them, 
and  they  are  not  disposed  to  heal.  Slow-growing  perforation  of  the  car- 
tilaginous septum  i-  -in-''  to  take  place,  ami  in  some  cases  this  may  he  the 
firsl  symptom  to  excite  the  alarm  of  the  patient.     The  perforation  gradually 

nd-.  by  a  molecular  dissolution  of  the  edges,  until  nearly  the  whole  of  the 
triangular  cartilage  disappears.  When  the  disease  takes  an  exacerbation,  as 
sometimes  occurs,  it-  extension   may  become  quite  rapid,  covering  more  or 

of  the  whole  line  of  the  Beptum  and  even  extending  to  the  pharynx. 
I  he  local  symptoms  in  this  evenl  are,  of  course,  very  much  aggravated.  In 
all  cases  pain,  coryza,  and  lachrymation  may  make  the  patient  very  miserable, 


TUBERCULOSIS  OF  Till:  PHARYNX.  1055 

aside  from  more  or  loss  constitutional  disturbance.  II'  the  lungs  or  other 
organs  arc  also  the  scat  of  the  tubercular  process,  the  constitutional  symptoms 
of  septicemia  arc  very  much  aggravated.  Tubercular  meningitis  i-  to  l>e 
expected  as  a  termination  of  cases  of  true  uasal  tuberculosis.  In  the  form 
of  the  disease  characterized  by  tuberculous  tumors,  the  surrounding  tissues 
arc  slow  to  take  on  reactionary  disturbance,  for  the  ulceration  i-  -l<>\\  and 
confined  to  the  little  neoplastic  formations.  It  has  been  observed,  also,  that 
the  general  disturbance  is  much  less  in  these  cases,  and  thai  the  cartilaginous 
structures  escape  destruction  for  a  longer  time.  Perichondritis  and  perios- 
titis, with  necrosis,  may  be  expected,  however,  in  severe  or  neglected  casi  -  ; 
but,  as  a  rule,  excepl  lor  the  destruction  of  the  septal  cartilage,  the  ulceration 
usually  confines  its  ravages  to  the  mucous  membrane. 

The  Pharynx. — Primary  tuberculosis  of  the  pharyngeal  mucous  mem- 
brane is  very  rare,  but  does  occur,  and  may  lie  tolerably  Intent  for  a  time. 
It  is  frequently  more  or  less  mixed  with  syphilitic  disease  or  laryngeal 
phthisis,  and  often  coexists  with  these  affections  or  carcinoma  (Baumgarten, 
M.  Schmidt).  In  my  own  practice  I  have  never  met  with  an  instance  which 
was  not  connected  with  either  a  syphilitic  taint  or  with  laryngeal  or  pulmonary 
phthisis.  Two  notable  examples  which  came  under  my  observation  were 
preceded  in  the  one  case  by  secondary,  and  in  the  other  by  tertiary,  syphilis. 
Kafeman  states  that  there  are  two  forms  of  pharyngeal  tuberculosis,  one  a 
miliary,  and  the  other  a  papular  or  tumor,  form.  (  !ases  of  the  former  class 
are  characterized  by  the  development  in  many  places  of  small  miliary  tuber- 
cles, and  in  the  latter  by  the  formation  of  one  or  two  patches  only — generally 
upon  the  lateral  walls  and  posterior  surface  of  the  velum  palati.  The  naso- 
pharynx does  not  seem  to  participate  very  often  in  the  disease,  but  the  base 
and  tip  of  the  tongue  and  the  oral  cavity  are  more  likely  to  do  so.  The 
ulcers  are  small,  surrounded  by  a  narrow7  red,  raised  rim.  As  the  disease 
advances  they  may  coalesce  and  excavate  more  or  less  beneath  the  edges  of 
the  mucous  membrane,  giving-  the  edges  a  raised,  worm-eaten,  or  irregular 
appearance  later  on.  In  some  cases  considerable  infiltration  take-  place,  so 
that  the  mucous  membrane  in  the  neighborhood  or  all  over  the  pharynx  (if 
it  be  the  miliary  form)  appears  edematous.  The  pharyngeal  wall  suffers, 
and  the  velum  palati  is  also  very  apt  to  participate,  in  which  case  the  uvula 
is  edematous  and  very  tender.  The  shapes  of  the  ulcerations  vary,  but  are 
usually  oval,  more  or  less  elongated,  and  covered  with  muco-pus,  either  -"ft 
or  partially  desiccated.  When  situated  upon  the  posterior  wall,  which  is 
exceptional,  the  surface  presents  a  cleaner  and  rawer  appearance.  Degluti- 
tion is  always  very  painful — the  patient  shrinking  from  swallowing  very  hot, 
very  cold,  or  salty  food.  In  some  instances  the  deglutition  of  the  saliva  i< 
very  painful.  In  advanced  cases  the  cervical  glands  are  more  or  less  swollen 
and  tender,  as  are  also  the  muscles  of  the  neck.     The  patienl    presents  an 

anxious  expression  of  c itenance,  i-  pallid,  and  emaciates  rapidly  alter  the 

disease  lias  progressed  for  some  time,  owing  to  the  difficulty  oi  obtaining 
sufficient  nourishment.  When  the  tongue  i-  involved,  the  part-  especially 
affected  are  the  tip,  sides,  and  base.  Ulcerous  cracks  and  fissures,  more  or 
less  surrounded  by  small  papilla?,  are  characteristic.  The  organ  i-  always 
very  sensitive.  In  these  cases,  even  if  confined  to  the  pharyngeal  cavity, 
thetonsils  are  apt  to  be  involved.  Indeed,  the  tonsils  are  said  b)  Strassman, 
Denochowsky,  Dieulafoy,  and  others  to  be  extremely  liable  to  tuberculous 
disease.  The  first-named  observer  found  the  tonsils  tuberculous  in  13  oul  of 
21  autopsies  made  upon  tuberculous  subjects,  and  Denochowsky,  in  each  ol 
15  autopsies  of  similar  subjects,  found   the  tonsils  tuberculous.     Dieulafoy 


1056  TUBERCULOSIS  OF   THE  A  Hi- PASSAGES. 

injected  parts  of  extirpated  tuberculous  tonsils  into  61  animals,  13  percent. 
of  which  contracted  general  tuberculosis.  Cornil,  on  the  other  hand,  ex- 
amined 70  cases,  and  found  giant  cells  in  I  only  ;  while  Virchow  has  declared 

that  tonsillar  tuberculosis  is  very  rare.  It  is  also  said  that  the  tubercular 
process  in  these  glands  takes  place  primarily  in  the  deeper  tissues — the  lower 
endothelial  lining  «>t'  the  follicles  or  crypts  and  lymph-spaces— and  that  ulcer- 
ation doc-  not  readily  follow.  For  this  reason  the  surface  indications  are 
therefore  wanting  and  the  disease  may  escape  notice.  The  conclusions  of 
sonic  observers  seem  to  indicate  that  these  glands  are  common  seats  of  latent 
tuberculosis.  Nevertheless,  the  theory  that  a  very  favorable  lodgement  for 
tubercle-bacilli  i-  offered  by  the  crypts  of  the  tonsils,  and  also  that  the  sur- 
face-manifestation of  the  disease  may  he  Infrequent  owing  to  deep  infection, 
would  seem  to  offer  to  a  practical  mind  an  inadequate  explanation  of  the 
infrequency  of  the  visible  manifestations  of  tonsillar  tuberculosis.  Again, 
why  should  the  advent  of  tubercle-bacilli  into  the  deeper  structures  of  the 
tonsil  through  the  blood-vessels  and  lymph-channels,  instead  of  from  without 
inward,  he  a  selected  mode  of  infection".'  The  only  explanation  worthy  of 
acceptance  would  he  that  perhaps  an  antitoxic  character  belonging  to  the 
secretions  of  the  tonsil  is  sufficient  to  render  the  surface  immune  to  the 
action  of  tubercle-bacilli — that  is.  supposing  that  the  bacilli  are  the  only 
cause  of  the  tonsillar  disease.  It  will  he  remembered  that  St.  Clair  Thomson 
and  others  have  shown  that  the  nasal  and  buccal  secretions  are  probably 
strongly  bactericidal  ;  and.  if  this  be  a  fact,  therein  may  lie  the  explanation 
of  the  frequent  escape  of  these  glands,  as  well  as  the  upper  air-tract  gener- 
ally,  from    tubercular  disease. 

The  diagnosis  of  nasal  and  pharyngeal  tuberculosis  is  not  always  very 
easy.  Syphilitic  inflammation  of  the  nasal  septum,  lupus,  and  sarcoma  may 
easily  be  mi-taken  for  tuberculosis.  Indeed,  lupus  and  syphilis  are  often 
much  alike  in  their  local  characteristics,  as  well  as  tuberculosis  and  lupus. 
In  syphilis,  besides  the  history  of  the  case,  it  will  be  found  that  the  whole 
nasal  septum  is  very  much  infiltrated,  and  that  the  disease  is  taking  a 
more  rapid  course.  When  ulceration  has  taken  place  in  syphilitic  disease 
there  is  breaking  down  of  larger  areas,  which  may  subsequently  coalesce, 
although  at  first  remaining  quite  distinct.  The  character  of  the  ulcera- 
tion i-  not  particularly  distinctive,  for  we  may  have  in  either  disease  a 
serpiginous,  ragged,  undermined  sort  of  ulceration  with  raised  red  edges. 
In  pure  syphilitic  affection-  of  the  septum,  where  the  disease  is  confined  to 
the  triangular  cartilage,  the  differential  diagnosis  is  quite  difficult  in  the 
absence  of  supporting  clinical  history.  Nevertheless,  a  microscopical  exami- 
nation may  serve  to  determine  the  diagnosis,  although  it  will  not  be  safe  to 
resl  always  upon  the  discovery  of  the  tubercle-bacilli  alone,  for  these  micro- 
organisms may  be  always  presenl  to  a  greater  or  less  extent  in  the  nasal 
secretion,  even  in  cases  which  are  not  really  tuberculous,  as  shown  by  the 
researches  of  Strauss  and  other-,  from  lupus,  tuberculosis  may  be  distin- 
guished  by  the  much  slower  course  of  the  former  affection  and  the  presence 
of  lupous  disease  of  the   skinjusl    external  to  the   nose,  or  somewhere  about 

the  face,  and  the  ab-ence  « » f " : .  1 1  v  greal  ai mi  of  surrounding  infiltration  and 

constitutional  disturbance.  Then,  t<><..  the  presence  of  the  characteristic 
-mall,  pointed,  pinkish  granulations  will  serve  i"  distinguish  lupus.  The 
lupous  ex  ulceration  i-  inclined  to  heal  and  leave  it-  characteristic  scar-tissue, 
while  the  tuberculous  is  not.  The  age  of  the  patient  also  may  serve  to 
gthen  the  differential  diagnosis,  for  lupus  of  the  nose,  a-  a  rule,  attack- 


HITS  OF  THE  NOSE.  1057 

the  young  or  the  very  old  ;  while  tuberculosis  of  the  upper  air-tract  is  very 
rare  under  fourteen  years  of  age  (Demme,  Bollinger). 

From  sarcoma,  tuberculosis  may  be  distinguished  in  the  course  of  the 
disease  by  the  absence  of  a  distinct  tumor,  which  i-  soft  to  the  touch,  of 
red  color,  of  considerable  size,  and  showing  ;i  disposition  to  rapidly  enlarge 
from  its  point  <>t"  attachment  outward.  The  sarcomatous  growth  bleeds 
easily.  Sarcoma  can  only  be  mistaken  for  the  so-called  tubercular  tumors 
which  sometimes  appear  in  the  nose.  But  the  latter  are  usually  small  and 
multiple;  while  sarcoma,  as  a  rule,  is  confined  to  one  or  two  points. 

The  prognosis  of  tuberculous  disease  of  the  nose  or  pharynx  is  cer- 
tainly very  grave,  although  if  the  disease  be  recognized  early  the  prospects 
of  the  patient  are  not  so  bad,  because  in  this  situation,  if  there  be  little  or 
no  general  infection,  there  is  an  opportunity  of  entirely  eradicating  the 
morbid  process. 

The  treatment  for  the  disease  in  either  of  these  situation-  should  be 
chiefly  local  and  surgical.  No  time  should  be  lost  in  removing,  as  far  as 
possible,  the  diseased  masses,  either  with  the  curette  or  the  galvano-cautery, 
wherever  they  may  be  situated  within  reach.  After  this  has  been  done  a 
vigorous  local  treatment,  consisting  of  the  application  of  antiseptics,  such  as 
formaldehyd,  formate  of  sodium,  carbolic  acid,  resorcin,  iodoform,  chlorin 
water,  or  guaiacol,  must  be  adopted.  The  last  agent  i>  reported  by  E. 
Frankel  and  H.  Bergeat  to  be  highly  useful  in  lupus.  It  i>  also  efficient 
in  local  tuberculosis.  The  thorough  removal  of  the  disease,  as  suggested 
above,  will  be  found  in  all  cases  the  most  efficient  method  of  treatment. 
Besides  local  measures,  great  benefit  will  be  obtained  from  the  internal 
administration  of  iodin,  chlorid  of  gold  and  sodium,  arsenic,  and  phosphorus. 
Climatic  changes  are  not  as  markedly  beneficial  as  when  the  larynx  ami 
pulmonary  organs  are  involved,  although  any  regimen  and  hygienic  measure 
which  will  promote  the  health  of  the  individual  will,  of  course,  be  beneficial. 
No  attempt  to  repair  the  edges  of  the  perforation  of  the  septum  after  the 
disease  process  has  become  checked — by  such  methods  as  scarification,  trim- 
ming of  the  edges,  or  cauterization — will  prove  efficient.  It.  will  be  found 
far  better  to  simply  promote  the  covering  of  the  vA^c^  of  the  perforation, 
however  extensive  it  may  be,  by  emollient   applications. 

LUPUS  OF  THE  AIR-PASSAGES. 

lyUpUS  vulgaris,  the  variety  with  which  we  arc  mainly  concerned — as 
is  well-known — is  particularly  a  disease  of  the  external  -kin.  It  appears 
insidiously,  as  a  rule,  and  slowly  extending  in  that  apparatus,  terminates  in 
a  process  of  exulceration.  It  is  also  not  infrequently  met  with  upon  the 
mucous  membrane,  which  in  many  respects  is  histologically  analogous  to  the 
externa]  -kin.  Indeed,  some  observers  believe  that  the  mucous  membranes 
are  more  often  affected  firsl  in  lupus  of  the  face.  One  of  the  most  frequent 
sites  for  the  development  of  lupus  vulgaris  is  at  the  angle  of  the  nose,  the 
mouth,  the  eye,  or  somewhere  in  the  neighborhood  of  an  external  opening  of 
the  body.  While  some  dermatologists  asserl  that  any  portion  of  the  -kin  is 
liable  to  its  attack,  others  assert,  upon  an  apparently  equal  basis  of  facts, 
that  certain  covered  portion-  of  the  skin  are  invulnerable,  h  has  been 
asserted,  a-  a  rule,  that  lupus  vulgaris  always  primaril)  occurs  upon  the 
skin  and  affect-  the  mucous  membrane  afterward.  However  the  rule  may 
1,,.,  there  are  instances  enough  on  record  of  the  primary  invasion  oi  the 
mucous  membrane  to  constitute  at   leas!   marked  exceptions.      It   is  stated 

67 


1058  LUPUS  OF  THE  AIM-PASS  AGES. 

that  there  arc  many  instances  of  lupous  disease  of  the  lining  membrane  of 
the   nasal   chambers,  which  ran  for  a  long  time   without   being  discovered, 

where  no  dermatic  involvement  ever  took  place.  The  point  of  origin  of 
lupus  of  the  nasal  cavity  is  most  frequently  in  the  mucous  membrane  cover- 
ing the  cartilaginous  septum.  From  this  point  it  may  gradually  spread 
intranasally  along  the  septum  <»r  extranasally  to  the  vestibule  of  the  nose 
and  the  skin.  Sometime-  the  pharynx  is  involved  secondarily  from  a  focus 
on   the  nasal   septum. 

Etiology. —  The  principal  etiological  factor  in  lupus  of  the  nose,  as  else- 
where. i<  supposed  to  be  the  tubercle-bacillus.  However,  as  this  question 
will  be  fully  discussed  under  the  caption  of  Lupous  Laryngitis,  it  need  not 
detain    us    here. 

Symptomatology. — The  objective  symptoms  of  lupus  are  usually  very 
mild,  rendered  so  by  its  well-known  tendency  toward  a  chronic  course.  The 
lir-t  symptoms  may  be  unaccountable  sneezing  and  slight  coryza,  although 
the  discharge  is  not  apt  to  be  profuse  except  in  the  first  stages  of  the 
disease.  After  the  histological  changes  incident  to  the  first  stages  of  the 
disease  have  become  developed,  the  breaking  down  or  ulceration  begins  to 
take  place  in  small  spots,  and  then  there  will  be  more  or  less  formation  of 
yellowish  <>r  brownish  crusts  with  slight  ichorous  or  serous  discharge.  The 
appearance  of  the  spot  is  not  so  characteristic  as  when  the  skin  is  affected. 
In  the  nose  the  infiltration  is  quite  insignificant,  and  does  not  present  that 
peculiar  brownish  granular  appearance  until  after  ulceration  has  taken  place. 
When  this  has  happened,  lines  or  valleys  with  bacon-colored  bases  may  be 
seen,  interrupted  and  surrounded  here  and  there  by  little  pinkish-red  granules, 
all  of  which  are  more  or  less  covered  with  scales  or  crusts  somewhat  ad- 
herent. A-  -aid  before,  perforation  soon  takes  place,  and  gradually  enlarges 
a-  the  disease  advances.  The  course  of  the  lupous  ulceration  does  not  differ 
from  that  of  other  ulcerations,  advancing  by  infiltration  and  subsequent 
breaking  down,  but  its  trail  is  covered  by  the  formation  of  characteristic 
scar-tissue,  which  is,  however,  much  more  delicate  and  less  characteristic  here, 
as  in  other  mucous  membrane,  than  upon  the  skin.  I  have  never  seen  a 
case  of  na^al  lupus  in  which  the  adjacent  skin  was  not  involved.  The  de- 
struction of  the  skin  and  consequent  contraction  of  cicatricial  tissue  neces- 
sarily  produce  more  or  less  deformity  of  the  nose.  Lupus  vulgaris  is 
inclined  to  -top  before  the  osseous  tissue,  confining  its  ravages  to  the  softer 
parts.  Exceptionally,  however,  especially  in  syphilitic  cases,  bone  as  well 
as  cartilage  proves  no  hairier  to  it-  advance.  In  such  cases,  the  destruction 
of  the  tissues  being  greater,  the  deformity  is  also  proportionately  greater. 

The  prognosis  is  quite  favorable,  although  the  disease  can  rarely  be 
checked  without  the  production  of  more  or  less  destruction  of  the  nasal 
septum,  with  at  ha-t  permanent  perforation.  A  -ort  of  eczematOUS  eruption 
i-  apt  to  per-i-t  even  after  the  recovery  from  the  lupoid  ulceration,  which 
i-  a  matter  of  considerable  annoyance  to  the  patient  and  very  difficult  to 
overcome. 

I,upus  of  the  pharynx  i-  much  more  rare  than  lupus  of  the  nasal 
passages,  ami  although  appearing  without  any  relationship  whatever  to 
syphilis,   is,   nevertheless,   more   often    found    in    syphilitic    subjects.     It    is 

ed  by  many  author-  that   Inpii-    i-  a  disease  which  i-  found  in  tuberculous 

subjects  or   those  of  tuberculous   tendency;    indeed,  as  will   be  seen   sub- 

sequently,  many  authors  regard  the  two  diseases  a-  identical.     This  question, 

i-    -till    a    practically  unsettled  one,  and    need    not    detain    us   here. 

'fh"    portion    of  the    pharynx    more  often    attacked    i-  the    -oft    palate,  and  of 


LUPUS  OF  THE  PHARYNX.  1059 

this  the  buccal,  more  frequently  than  the  pharyngeal,  surface.  Nexl  in  order 
of  frequency  of  occurrence  may  be  mentioned  the  lateral  wall  of  the 
pharynx,  or  rather  the  faucial  arches,  especially  at  their  junction  with  the 
velum  palati.  In  the  cases  of  lupus  of  the  pharynx  which  have  fallen  under 
my  observation,  the  soft  palate  or  the  faucial  folds  have  been  the  primary 
seal  of  the  disease  in  all  but  one  instance.  The  course  of  the  ulceration  in 
this  situation  is  usually  very  mild,  and  leads  to  no  more  constitutional  dis- 
turbance than  when  situated  upon  mucous  membranes  elsewhere,  excepting 
as  it  interferes  more  or  less  with  proper  deglutition.  In  such  instances  the 
loss  of  body-weight  and  consequent  development  of  general  physical  weak- 
ness is  progressively  marked  during  the  period  of  ulceration.  After  cica- 
trization takes  place,  however,  these  difficulties  disappear  and  the  nutrition 
of  the  patient  soon  assumes  a  normal  condition.  In  a  case  which  has  been 
under  my  treatment  the  ulceration  and  destruction  of  tissue  was  consid- 
erable for  a  time,  and  as  deglutition  grew  extremely  painful,  the  patient, 
in  consequence  of  lack  of  food,  became  very  weak.  This  ease  occurred  in 
a  woman  whose  family  were  free,  as  far  as  could  be  ascertained,  of  any 
tuberculous  tendency,  but  who  had  suffered  two  years  previously  from  a 
severe  attack  of  small-pox — indeed,  the  skin  all  over  the  body  presenting 
the  marks  or  pits  of  the  disease.  We  were  unable  to  trace,  however,  any 
causal  relation  between  the  eruption  of  lupus  and  the  variola ;  neither  could 
there  be  traced  in  this  case  any  syphilitic  taint  after  the  most  thorough 
investigation  into  the  life-history  of  both  the  patient  and  the  patient's 
husband.  I  have  ascertained  of  no  instance  on  record  of  lupus  of  the  naso- 
pharynx. 

The  prognosis  of  lupus  in  these  situations  is  favorable  unless  the  disease 
circumvents  the  tonsil  or  some  other  hidden  place  where  adequate  local 
treatment  cannot  be  pursued. 

Treatment. — The  local  treatment  should  be  a  vigorous  one.  consisting 
of  thorough  excision  or  evulsion  of  the  morbid  tissues.  For  this  purpose 
curettement  and  the  galvano-cautery  offer  the  most  suitable  means.  After 
this  has  been  done,  persistent  local  application  of  resorcin,  iodoform,  .-odium 
formate,  guaiacol,  or  carbolic  acid,  or  escharotics,  such  as  zinc  chlorid, 
chromic  acid,  etc.  The  general  treatment  by  iodin,  iodid  of  potassium,  and 
arsenic  will  prove  very  efficacious,  especially  the  former.  In  the  case  of 
lupus  affecting  the  soft  palate  or  pharynx  so  as  to  interfere  with  proper 
deglutition,  4  per  cent,  solution  of  cocain  should  be  freely  applied  to  the 
diseased  parts  just  before  a  meal  i-  taken,  and  the  meal  should  be  such  as  t<» 
contain  the  most  nutrition--  constituents  of  alimentation.  Out-door  life  and 
proper  hygienic  surroundings  will  add  material  benefits  to  any  course  of 
treatment. 

Notwithstanding  the  fact  that  the  tubercle-bacillus  is  so  often  absenl  in 
many  specimens  of  lupous  tissue,  yet  the  majority  of  writers  persisl  in  ascrib- 
ing the  essential  cause  of  the  disease  to  the  tubercle-bacillus  of  Koch, 
although  the  same  observers  note  the  discovery  of  the  bacillus  ol  Lustgarten 
as  well.  To  account  for  the  diverse  clinical  behavior  of  lupus,  as  compared 
with  so-called  tubercular  affections  of  other  tissues,  Councilman  believes  thai 
the  quality  of  the  bacillus  and  the  resistance  or  definite  reactionary  charac- 
teristics of  the  tissue  invaded  are  quite  sufficient,  holding,  for  instance,  that 
the  histological  peculiarities  of  the  Bkin  will  resisl  the  developraenl  of  the 
tubercle-bacilli  in  it-  tissues,  and  thus  give  rise  to  the  slow  and  heterogeneous 
clinical   phenomena  observed   in   lupus. 


1060  HITS  OF  THE  M H-I'Assm ; /•>'. 

LUPOUS  LARYNGITIS. 

Lupous  laryngitis  is  a  chronic  inflammation  of  the  mucous  membrane, 
characterized  by  the  formation  of  small  nodules  or  tubercles  in  the  deeper 
tissm — the  submucosa.  These  nodules  disappear  either  by  resolution,  ex- 
foliation, or  ulceration,  leaving  a  peculiar  cicatricial  tissue.  There  are 
several  varieties  of  lupus  described  by  dermatologists,  chief  of  which  is 
lupus  vulgaris— the  variety  usually  found  affecting  mucous  membranes. 
Lupus  erythematosus  has  received  its  name  from  Cazenave  on  account  of  its 
healing  with  the  formation  of  scar-tissue  similar  to  lupus  vulgaris.  Many 
modern  dermatologists  and  pathologists,  however,  think  that  it  should  nol  be 
classed  with  lupus  vulgaris,  because  no  tubercle-bacilli  have  been  found  in 
the  tissue-formation  of  its  eruptions.  Inna,  for  instance,  suggests  that  it  be 
called  seborrhea  eongestiva,  and  nol  classed  with  the  tubercular  affections. 
Besmier  of  Paris  and  some  others  argue  that  it  is  a  tuberculous  affection, 
and  should  therefore  retain  its  present  name.  Leloir  also  believes  that  it  is 
tuberculosis,  and  capable  of  reproducing  itself  by  inoculation.  The  disease 
commonly  attack-,  and  is  confined  to,  the  skin  ;  but  when  the  site  is  in  the 
neighborhood  of  any  of  the  orifices— such  as  the  nares,  mouth,  ears,  vagina, 
,„.  rectum — it  is  apt  to  extend  and  involve  the  contiguous  mucous  membrane. 
Exceptionally,  however,  it  affects  the  mucous  membrane  primarily,  in  which 
case  the  nasal  or  buccal  mucous  membrane,  or  that  of  the  soft  palate, 
pharynx,  larynx,  conjunctivae,  rectum,  or  vagina,  may  be  the  part  affected. 
LekuVs  statistics  show  (Morrow)  thai  out  of  a  total  of  .312  cases  of  lupus, 
mucous  membrane-  were  involved  109  times — the  mucous  membrane  second- 
arily— vet  primary  lupus  of  the  nose,  a  more  common  type  than  formerly  sup- 
po-ed,  may  escape  notice.  Neisser  concludes  that  Lupus  of  the  face  i-  gener- 
ally caused  by  extension  from  adjoining  mucous  tract-,  especially  from  that  of 
the  nose.  The  internal  mucous  membranes,  such  as  the  gastric,  intestinal, 
or  bronchial,  are  n<>t  subject  to  invasion,  although  a  case  is  reported  where 
the  process  was  observed  on  the  mucous  membrane  of  the  trachea. 

Primary  lupous  laryngitis  is  quite  rare,  many  laryngologists  of  large 
experience  not  having  seen  a  case,  while  others  have  seen  but  very  few  cases 
each.  Among  these,  Bosworth  mention-  having  seen  but  one.  M.  Mackenzie 
two.  Lefferts  four,  and  Rice  three.  A-  the  invasion  is  insidious  and  very 
chronic,  and  the  sign-  of  the  same  very  obscure,  many  observers  believe  (as 
also  of  the  nasal  mucous  membrane)  that  the  disease  occurs  in  the  larynx 
oftener  than  is  supposed — especially  as  it  generally  attacks  the  young,  who 
do  not  come  under  observation  as  readily  as  older  persons.  Among  these 
observers,  IJ.  De  la  Sota  y  Lastra  and  Rice  make  this  suggestion.  The 
epiglottis  i-  generally   the   part   attacked,  according  to  Chiari  and    Richl. 

Symptoms. — The  constitutional  disturbance  incident  to  this  affection  is 
practically  slight,  mile--  the  disease  is  so  situated  or  so  advanced  a-  to  inter- 
fere with  the  fiinetion-  of  deglutition  or  respiration,  or  mile--  some  compli- 
cation attended  by  unusual  inflammatory  or  septic  processes  in  the  neighbor- 
ing glands  or  tissues  Bupervene.  Such  complication-  are  rare,  however,  until 
the  disease  ha-  run  a  very  long  and  aggravated  course;  for  there  i-  usually 
but  little  tendency  to  general  infection  of  any  Bort,  although  Leloir  and 
other-  say  that  it  may  produce  partial  or  general  infection.  Hoarseness  and 
a  sense  of  dryness  or  thickening  referred  to  the  throat,  with  slight  dysphonia 
or  dyspnea,  are  among  the  early  and,  it  may  be  -aid,  persistenl  symptoms. 
There  is  little  or  no  pain  complained  of  mile--  the  disease  is  advanced  and 
extensive,  or  ulceration  with  an   unusual  amount  of  inflammation   has  taken 


l  upo  us  l  A/n  rm  ?  /  ris.  L061 

place,  when  more  or  less  difficulty  of  swallowing  ma)  occur,  although  not 
even  then  very  much.  When  there  is  much  swelling,  attention  is  required 
in  order  to  prevent  the  ingress  of  particles  of  food  into  the  larynx  during 
the  act  of  deglutition.     The  temperature  rarely  rises  until  the  disease  is  quite 

advanced  and  complicated,  and  then  perhaps  only  to  !»!»  F.  The  local 
appearances  are  usually  less  marked  on  mucous  membranes  than  on  the  skin. 
Michelson  has  shown  that  it  is  almost  impossible  to  trace  accurately  the  limits 
which  separate  the  lupous  tissue  from  the  mucosa,  because  it  is  <>nlv  in  the 
cicatrices  that  we  find  the  characteristic  lupous  nodule  when  the  mucous 
membrane  is  the  .-eat   of  disease. 

The  laryngeal  face  of  the  epiglottis  is  usually  first  affected,  and  presents 
a  slightly  swollen  hyperemic  condition  with  a  tew  papular  projections  like 
granulations,  which  afterward  break  down  into  an  ulcerated  patch  (se<  I 
618).  In  some  cases  the  free  border  of  the  epiglottis  appear-  whitish  or 
gray,  thickened  and  studded  here  and  there  with  dark-red  papillomatous 
patches.  After  a  while  the  laryngeal  vestibule  becomes  altered  in  shape  from 
the  infiltration,  etc.  The  thickened  and  misshapen  mucous  membrane  pre- 
sents irregularly  circular  folds  or  ruga?,  appearing  similar  to  a  slightly  pro- 
lapsed and  puckered  membrane,  and  is  studded  here  and  there  with  grayish 
glistening  fissures  and  dark-red  papules,  which  in  turn  may  he  coalesced  to 
form  a  patch.  These  places  are  not  very  painful  to  the  touch  nor  during 
.-wallowing.  At  a  later  stage  these  spots  become  softened  and  soon  -how- 
evidences  of  slow,  dry  ulceration  bounded  by  ragged  edges  or  a  -lightly  red- 
dened granular  areola.  According  to  Leloir  and  contrary  to  Baumgarten, 
suppuration  of  the  lupous  patch  is  not  an  essential  characteristic,  and 
when  present  is  due  to  the  combined  action  of  the  agents  of  suppuration 
(streptococci)  and  the  bacillus  of  Koch.  If  the  seat  of  the  disease  he  the 
border  of  the  epiglottis,  it  may  appear  as  if  worm-eaten  (Lastra).  Even 
now  the  swelling  and  hyperemia  of  the  surrounding  parts  may  he  quite  insig- 
nificant; for  the  infiltration  seems  undulatory  and  very  chronic,  so  that  the 
general  condition  of  the  patient  may  remain  good  in  every  particular.  The 
progress  of  the  disease  is  so  slow  that  it  may  cover  a  number  of  year-,  and 
then  may  terminate  in  pulmonary  or  meningeal  tuberculosis  or  epithelioma 
(Morrow),  although  not  necessarily,  for  many  observers  have  never  known  a 
case  in  a  tuberculous  subject  (Bosworth).  At  the  same  time,  the  local  process 
during  this  period  is  subject  tout-cat  variations  of  exacerbation  and  quiescence. 
This  is  true  of  lupus  affecting  mucous  membranes  as  well  a-  the  -kin. 

A  retrogression  is  marked  mainly  by  a  gradual  healing  of  the  ulceration, 
with  the  formation  of  a  thin,  bluish-gray,  glistening  cicatrix,  somewhat  more 
moist  and  duller,  however,  than  the  lupous  scar-tissue  of  the  -kin,  and  sur- 
rounded by  zones  of  thickened,  rough,  dark  mucous  membrane.  Then  after 
a  period  of  quiescence  more  or  less  prolonged  (which  in  some  cases  leads  one 
to  the  conclusion  that  a  cure  has  been  effected)  there  i-  a  recrudescence, 
which  at  the  time  may  not  he  accounted  for  by  any  event  in  the  domestic  or 
clinical  history  of  the  patient.  It  will  now  lie  observed  that  two  or  more 
foci  of  papillary  swelling  with  inflammation  are  starting  from  about  the 
periphery  of  the  old  lesion.  These  may  perhaps  go  through  a  more  rapid  or 
aggravated  course  of  softening,  tumefaction,  and  ulceration,  etc.,  ami  may  he 
accompanied  by  more  infiltration  of  the  surrounding  tissue  than  at  the  former 
period.  Indeed,  some  cases  present  a  greater  severity  of  local  action  at  each 
successive  exacerbation,  so  that  the  ulceration  and  inflammation  may  become 
somewhat  alarming,  while  the  ulceration  perhaps  assumes  the  serpiginous 
form  spoken  of  by  some  writers.     This  evenl  is  quite  dangerous  when  affect- 


1062  i.rn  s  of  Tin:  A I n-PASSAGES. 

ing  the  larynx,  and  apt  to  be  extensive  in  its  ravages,  simulating  to  a  certain 
degree  lupus  exulcerans  (lupus  exedens)  of  the  skin.  Besides  this,  the  cor- 
responding  cicatrices  from  such  an  amount  of  destruction  leave  troublesome 
and  sometimes  vicious  deformities,  which  may  endanger  life  through  interfer- 
ence with  the  laryngeal  or  esophageal  openings  (stenosis). 

Etiology. — Lupus  was  formerly  regarded  as  related  to  scrofula,  or 
cancer — if  not  reallv  cancerous — by  the  older  authors,  mainly  on  account  of 
the  observation  of  cases  becoming  cancerous.  It  was  also  considered  a  se- 
quence of  syphilis.  Ricord  held  that  it  was  an  inherited  manifestation  of 
tertiary  syphilis.  Kaposi,  however,  says  positively  that  syphilis  in  a  parent 
has  no  connection  with  lupus  in  the  children;  moreover,  Ilebra  and  Kaposi 
have  found  recent  syphilis  and  lupus  in  the  same  individual.  The  latter 
(syphilitic)  view  is  to  some  extent  prevalent  nowadays.  Again,  it  has  been 
considered  a  scrofulous  disease  ;  but  as  so-called  scrofula  is  generally  consid- 
ered to  be  of  tuberculous  nature,  or  practically  a  form  of  tuberculosis,  this 
view  would  coincide  with  the  opinion  now  prevailing  that  lupus  is  a  local 
chronic  tuberculosis!  Some  authorities  have  believed,  and  do  yet,  that  lupus 
vulgaris,  especially  in  the  skin,  belongs  to  the  scrofuloderms  ;  that  it  is 
essentially  a  scrofulous  disease  !  Kaposi  and  others  combat  this  idea,  and 
say  in  effect  that  scrofula  is  entirely  absent  in  many  cases  of  lupus.  In- 
deed, it  is  now  so  classed  by  the  majority  of  modern  dermatologists  and 
pathologists,  and  may  be  found  in  the  category  with  tuberculosis  ver- 
rucosa cutis,  scrofuloderma  (tuberculosis  of  the  subcutaneous  tissue),  tuber- 
culous cutis,  etc. 

The  tubercular  nature  of  lupus  was  suspected  for  years  before  the  dis- 
covery of  the  tubercle-bacilli  of  Koch,  on  account  of  the  histological  analo- 
gies between  the  several  affections  as  persistently  pointed  out  by  Friedlander 
and  others;  but  the  hematogenetic  origin  of  lupus  was  not  assailed  until  the 
discovery  of  the  tubercle-bacilli  in  lupous  tissue  (lupoma)  by  Demme, 
Koch,  and  afterward  by  others,  when  all  doubt  seemed  to  be  swept  from  the 
minds  of  the  majority,  and  the  tubercle-bacilli  (as  in  other  tubercular  disease) 
became  the  recognized  cause  of  lupus  vulgaris.  Moreover,  these  views  have 
been  strengthened  from  time  to  time  by  experimental  and  other  observations 
apparently  showing  the  inoculability  and  infectiousness  of  lupous  tissue,  for 
.!.  Jadassohn,  Leloir,  and  others  have  cited  instances  of  the  production  of 
lupus  by  inoculation,  and  they  regard  every  case  of  lupus  vulgaris  as  due  to 
inoculation  with  the  tubercle-bacillus,  thus  denying  the  so-called  hematog- 
enous development  of  the  disease  as  promulgated  by  Baumgarten.  Koch, 
Leloir,  and  others  claim  to  have  demonstrated  this  by  the  transmittal  to 
guinea-pigs  and  rabbits  of  tuberculosis  by  inoculation  with  lupous  tissue- 
cultures.  Tin-  Btarting-poinl  i-  probably  the  entrance  into  the  skin  or 
mucous  membrane  of  the  tubercle-bacilli  in  one  of  the  following  ways:  1, 
indirect  inoculation  from  without  ;  2,  indirect  inoculation  by  continuity  from 
deep  tuberculous  foci  ;  :;,  inoculation  by  way  of  lymphatics  or  the  veins  pass- 
ing through  a  tubercular  focus  more  or  less  remote;  I,  infection  of  hematic 
origin ;  ■"»,  infection  by  inheritance. 

Methods  I  and  2  are  probably  the  most  frequent.  However,  there 
are  no  instances,  I  believe,  where  lupus  has  been  a  result  of  contact  (con- 
tagion) of  one    lupous    patient    with    another,    nor    where    the    inoculation    of 

bacilli  into  the  -kin  experimentally  has  produced  lupus.     Kaposi  and  other 

European  dermatologists,  and   Dunring  in  this  <•< try,  are  rather  skeptical 

a-   to   the    identity   of    lupus   with    tuberculous  affections.       Kaposi    says: 
theless,   the    attempted   demonstration   of    the   identity   of  scrofula, 


urors  LAiiYxarris.  L063 

tuberculosis,  and  lupus  1ms  not  yet  proven  such  identity.  Cases  of  'inocu- 
lating tuberculosis'  arc  reported  in  constantly  increasing  numbers,  but  it 
seems  to  be  regarded  as  immaterial  that  years  may  have  elapsed  between  the 
assumed  'inoculation'  and  the  occurrence  of  the  tuberculosis  of  the  skin. 
No  experimental  proof  has  been  offered,  however,  that  characteristic  lupus 
vulgaris  can  be  produced  by  inoculation  of  tubercle-bacilli/'  Drs.  Morison 
and  Symington1  examined  the  tissue  from  twenty  lupous  cases  without  find- 
ing the  tubercle-bacilli,  and  M.  Cornil  examined  the  skin  of  eleven  lupous 
patients,  and  found  only  one  tubercle-bacillus.  Dr.  Henneage  Gibbes  be- 
lieves lupus  a  tubercular  affection,  but  says  that  the  bacilli  are  sometimes 
not  found  in  the  lupous  tissue.  Kaposi  and  others  deny  the  infectiousness  and 
heredity  of  lupus;  but  eases  have  been  recorded  where  a  parent  of  ;i  patient 
suffered  from  lupus,  and  an  instance  where  several  brothers  and  sisters  of 
another  patient  suffered  from  lupus.  Leloir  again  says  that  diversity  in  the 
phenomena  of  the  several  varieties  may  be  accounted  for  by  the  mode  and 
seat  of  the  inoculation  (inoculation  from  within  outward  or  from  without 
inward) ;  the  deposit  of  the  virus  in  parts  more  or  less  vascular  ;  the  greater 
or  lesser  virulence  of  the  virus  inoculated,  and  different  degrees  of  reaction 
of  the  tissues.  All  authorities  agree  that  it  is  a  disease  of  early  life. 
According  to  Leloir  it  begins  generally  in  infancy,  and  may  produce  partial 
or  general  infection  of  the  system.  Concerning  the  exciting  causes  of  lupus, 
especially  as  regards  the  mucous  membrane,  there  seems  to  be  a  paucity  of 
positive  information.  Syphilis  and  eczema  of  the  nose,  and  fistula?  hading 
to  the  site  of  tuberculous  disease,  are  cited  as  having  induced  the  formation 
of  lupus  in  a  few  cases;  but  mechanical  or  chemical  injuries  are  not  spoken 
of  as  probable  causes  of  the  disease  in  mucous  membranes,  unless  we  accept 
the  theory  of  those  who  believe  in  the  direct  or  indirect  inoculation  with 
tubercle-bacilli,  and  who  think  that  a  previous  abrasion  is  necessary  for  the 
introduction  of  the  germ.  Leloir's  classification  of  the  varieties,  all  varieties 
which  he  believes  are  tubercular,  is  as  follows  : 

(a)  True  lupus,  non-exedens  and  exedens. 

(6)  Atypical  varieties  of  lupus:  1,  lupus  vulgaris  calloide;  2,  lupus  vul- 
garis myxomatosus;  3,  lupus  vulgaris  sclerosis  and  demi-sclerosis ;  1.  lupus 
vulgaris  erythematoid. 

(c)  Scrofulo-tuberculosis,  gummata-dermatic  and  hypodermatic. 

(d)  Ulcerative  tuberculosis  :  1,  secondary;  2,  primary. 

(e)  Mixed  tegumentarv  tuberculosis  resulting  from  a  combination  oi  two 
or   more   of  these    varieties. 

A  review  of  the  conflicting  literature  upon  the  etiology  of  lupus  from 
a  clinical    standpoint    might    lead    to   the   following  consideration-: 

(.1)  If  lupus  is  due  to  the  presence  of  the  tubercle-bacilli,  and  therefore 
of  the  same  pathological  nature  as  the  other  so-called  local  tuberculous  diseases, 
how  can  its  peculiar  clinical  course,  which  is  much  at  variance  with  thai  oi 
other  of  the  tubercular  affections,  be  accounted  for?  I-  there  in  the  his- 
tological, biological,  or  chemical  constituents  of  either  the  -Kin  or  raucous  mem- 
branes at  the  orifices  of  the  body  any  special  antidotal  property,  in  the  form 
of  either  serum,  cell,  proteid,  ferment,  secretion,  or  tissue,  which  will  so 
effectually  resist  the  development  or  growth  of  tubercle  bacilli  or  the  exten- 
sion of  their  accompanying  toxins  as  almost  to  nullify  their  hitherto-accepted 
destructive   tendencies? 

(B)  What,  also,  is  th<-  reason  that  the  implantation  of  tubercle-bacilli 
in  the  mucous  membrane  of  the  larynx   in  one  instance  produces  a  biow- 

1  ./mint.  Cut.  and  Qen.-Ur.  Dig.,  vol.  i\.  p.  268. 


ld.il  LUPUS  OF  rin:  MR- PASSAGES. 

going,  practically  non-infectious  local  disease  (lupus);  while  in  another 
instance  the  same  micro-organism  rapidly  develops,  extends,  and  thereby 
sets  up  a  destructive  local  disease  and  a  fatal  general  infection? 

I  confess  that  all  the  explanations  with  which  I  am  familiar  touching 
these  points  are  inadequate  to  explain  these  clinical  anomalies.  'The  histo- 
logical resisting  character  of  the  skin  or  its  temperature  and  movements  is 
urged  by  some  observers  in  explanation  of  the  very  chronic  and  innocuous 
course  of  this  disease.  The  paucity  of  the  tubercle-bacilli  and  their  encap- 
sulation— contributing  to  render  them  latent — is  stated  by  Unna.  Lastra, 
however,  seeks  to  account  for  the  incongruities  observed  by  the  supposition 
that  the  bacilli  or  their  accompanying  toxins  may  be  attenuated,  and  in  sub- 
stantiating this  view  he  reasons  by  analogy,  and  ingeniously  cites  the  effects 
of  attenuated  doses  of  chemical  agents  on  the  system  as  compared  with  larger 
quantities  or  more  concentrated  qualities  of  the  same,  thus  assuming  that  the 
cytogenesis  or  mitosis  of  a  part  depends  upon  the  dosage.  According  to 
lima,  the  smallesl  number  of  tubercle-bacilli  are  able  to  stimulate  produc- 
tive inflammation,  the  formation  of  giant  cells,  and  serofibrinous  exudation  ; 
but  lie  that  as  it  may,  could  we.  under  even  these  conditions  of  attenuation, 
expert  any  such  pathological  process  in  the  mucous  membrane  of  the  larynx, 
a  part  whose  susceptibility  to  tubercle-bacilli  and  tuberculous  toxins  are  con- 
tinually alleged  as  a  matter  of  fact".'  father  we  have  not  yet  fully  learned 
the  morphology  of  the  tubercle-bacillus,  or  we  must  look  upon  the  doctrine  as 
a  fiction  that  it  (tubercle-bacillus)  is  independently  the  cause  of  lupus  of  the 
larynx.  There  i-  no  use  of  taking  up  .--pace  by  theorizing,  but  it  seems  cer- 
tain from  the  clinical  history  ami  pathological  anatomy  of  lupus  vulgaris  of 
the  larynx  that  its  etiology  depend-  essentially  in  some  way  upon  a  perverted 
or  aberrant  (karyokinesis— catogenesis — or  nutations)  process  of  regeneration 
of  the  constructed  or  formed  tissues  of  the  part,  or  that  the  bacillus  of  lupus, 
instead  of  being  identical  with  the  real  tubercle-bacillus  of  ordinary  tubercu- 
losis, is  perhaps  more  closely  allied  to  the  bacillus  of  Fisch,  which  is  found 
in  rhinoscleroma. 

Age. — All  authorities  agree  that  lupus  is  a  disease  of  early  life,  although 
there  are  instances  on  record  of  its  occurrence  at  an  advanced  age. 

Sex. — The  female  sex  seems  to  be  more  susceptible  than  the  male.  Of 
7!)  cases  collated  by  Bosworth,  51  were  females  and  18  males.  Other  statistics 
on  this  point  coincide. 

Heredity. — There  have  been  differences  of  opinion  regarding  the  hered- 
itary transmission  of  lupus,  but  unquestionably  the  instances  of  such  trans- 
mission are  rare. 

Inoculability. —  I  think  the  majority  of  dermatologists  believe  that  the 
disease  is  inoculable,  either  directly  or  indirectly  j  but  as  that  question  has 
been  dealt  with  in  the  discussion  of  the  etiology,  there  is  nothing  to  be  added 
here,  excepting  to  recite  the  oft-quoted  verdict  of  the  territorial  jury — viz., 

"  not    /iron  ft" 

Traumatism  ha-  been  cited  as  a  predisposing  cause  of  the  disease  in  the 
skin,  and,  by  those  who  accept  the  doctrine  of  inoeiilability  of  the  disease,  is 
believed  to  be  an  important  etiological  factor. 

Pathology.  -According  to  Prudden  and  Delafield,  lupus  consists  in  the 
presence  of  '--mall  multiple  nodule- of  new-formed  tissue,  somewhat  resem- 
bling granulation-tissue,  in  the  cutis  mucosa  or  submucosa.  By  the  formation 
of  new  nodule-  and  a  more  diffuse  cellular  infiltration  of  the  tissue  between 
them,  the  lesion  tend*  t--  spread,  and  by  the  confluence  of  the  infiltrated  por- 
tion- a  dense  and  more  or  less  extensive  area  of  nodular  infiltration  may  be 


LUPOUS  LARYNGITIS.  1065 

formed.     There  may  be  an  excessive  production  and  exfoliation  of  epidermis 
over  the  infiltrated  area,  or  an  ulceration  of  the  new  tissue." 

In  the  clinical  group  of  diseases  culled  Lupus  there  are  other  forms  of 
lesion   which  arc  not  caused  by  the  tubercle-bacilli. 

Tuna  lays  great  stress  upon  the  {tart  played  by  the  large  so-called  plasma- 
cells  of  Waldeyer,  and  think-  the  giant  cells  are  of  secondary  formation.  He 
also  points  out  that  the  tubercle- bacilli  are  encapsulated  in  the  giant  cells, 
and  therefore  become  latent.  Jadassohn  thinks  the  plasma-cells  are  not  of 
any  particular  importance  in  lupus,  because  occurring  in  other  inflammatory 
processes. 

Kaposi  says  that  the  pathology  of  the  disease  relating  to  the  -kin  does 
not  differ  essentially  from  that  affecting  the  mucous  membrane. 

In  all  instances  of  tuberculosis  we  find  the  tubercle  the  product  of  the 
tubercle-bacilli — a  nodule  of  so-called  granulation-tissue,  composed  histoL  gi- 
callv  of  small  round  cells,  deeply  stained  by  coloring-agents,  together  with 
larger  cells  possessing  a  clear  nucleus  that  have  been  called  epithelioid  cell-, 
and  large  cellular  elements,  with  peripherally  arranged  nuclei  and  homogene- 
ous center,  the  Langhans  giant  cells.  These  cells  are  enclosed  between  the 
meshes  of  connective  tissue,  and  are  characterized  in  distinction  from  normal 
cells  by  their  instability.  Sooner  or  later  a  modification  begins  in  the  nodule. 
Its  center  becomes  necrotic — i.  e.,  the  cell-protoplasm  i-  coagulated,  the  nuclei 
lose  their  power  of  responding  to  staining-agents,  the  intercellular  substance 
al>o  takes  part  in  the  degeneration,  and  there  results  a  coagulation-necrosis 
in  the  Weigert  sense — a  condition  that  has  been  called  cheesy  degeneration. 

Diagnosis. — Lupus  of  the  larynx  may  simulate  tuberculosis,  syphilis, 
epithelioma,  rhinoscleroma,  or  chronic  glanders.  According  to  Neisser 
(Morrow),  the  chief  diagnostic  points  of  lupus  are  the  beginning  in  childhood 
and  its  verv  chronic  course.  If  the  lupus  laryngis  be  secondary  \<>  the  -ante 
disease  of  the  skin  or  an  extension  from  it  to  fauces  and  larynx,  then  the 
diagnosis  may  be  easily  made  out.  But  when  the  larynx  is  primarily  affected 
the  task  may  be  a  more  difficult  one,  at  least  in  some  of  its  stages. 

The  general  clinical  history,  showing  an  absence  of  constitutional  disturb- 
ances of  any  moment,  will  serve  to  distinguish  it  from  laryngeal  phthisis,  and 
from  syphilis  by  lack  of  the  history  belonging  to  the  latter  disease.  On 
inspection,  the  absence  of  much  inflammation,  the  dry,  negative,  unsuppurat- 
ing  appearance  of  the  ulceration,  Hunted  in  situation  and  not  clearly  defined, 
with  rather  coarse  granulated  edges,  will  usually  serve  to  differentiate  it  from 
the  sharply-cut  suppurating  ulcers  of  syphilis  surrounded  with  highly-colored 
and  tolerably  well-marked  areola,  and"  from  the  -hallow  roundish  lenticular 
ulcers  on  a  pale  and  swollen  mucous  membrane  which  distinguish  from  syph- 
ilis and  tubereulo-is  this  disease.  When  ulceration  i>  active  the  local  appear- 
ances might  lead  to  some  confusion,  but  in  such  cases  the  clinical  history,  a-  well 
as  the  characteristics  of  the  local  formation,  will  remove  perplexity.  Syph- 
ilitic ulceration  of  the  nose  often  resembles  lupus,  and  diagnosis  in  such  i 
mav  have  to  be  suspended  to  await  developments. 

Rhinoscleroma  usually  begins  first  on  the  skin  of  the  nose.  It-  ulcera- 
tion is  flat  and  soon  covered  by  a  -till'  crust.  There  is  usually  no  softening 
nor  ulceration,  nor  very  much  contraction,  and  no  such  melting  away,  80  t" 
speak,  of  the   tissues  as    in    lupus. 

Epithelioma  can  only  be  mistaken  for  lupus  when  it  is  of  local  origin  in 
the  larynx,  which  is  not  often.  When  so  occurring  i1  is  generally  Bituated 
at  first  either  upon  the  epiglottis  or  in  a  laryngeal  ventricle.  It  may  be  Been 
as  a  more  or  less  reddish  growth  of  uneven  although  unbroken  surface  and 


1066  LEPROSY  OF  THE  AIR-PASSAGES. 

to  -land  out  from  the  tissues.  When  breaking  down  it  presents  sinuous 
slough-patches  «>r   pockets  and  granulations,   hut   no  cicatricial   tissue. 

Treatment. — The  treatment  should  be  both  constitutional  and  local. 
Tlif  systemic  treatment  should  be  upon  the  tonic  and  so-called  alterative 
plan.  The  subjects  of  lupus  more  often  than  otherwise  show  the  effects  of 
privation  or  malnutrition.  Therefore,  a  generous  diet,  out-door  life,  and 
suitable  clothing,  together  with  such  tonics  as  salicin,  quinin,  Fowler's  solu- 
tion of  arsenic,  tincture  oi*  the  chlorid  of  iron,  etc.,  should  be  administered. 

Arsenic  in  one  form  or  another  has  been  considered  highly  beneficial  for 
the  last  century.  Indeed,  it  has  been  deemed  by  some  as  almost  a  specific 
lor  lupus.  It  certainly  is  one  of  the  most  useful  remedies  in  vogue.  Iodin 
and  iodid  <>f  iron  are  also  of  great  value,  especially  if  combined  with  the 
syrup  of  the  hypophosphites.  In  my  limited  experience  the  use  of  arsenical 
preparations  and  iodin,  either  hypodermatically  or  by  the  mouth,  has  given 
the  best  general  results.  Iodid  of  arsenic  and  Fowler's  solution  are  the 
favorite  preparations.  Cod-liver  oil  and  malt-preparations  may  also  be 
taken  with  benefit.  When  there  is  a  cachectic  sallow  appearance  with  ten- 
dency to  lymphadenitis,  phosphorus  in  oil  should  be  given  three  times  a  day. 

The  chief  indication  for  local  treatment  is  the  removal  of  the  offending 
tissue.  This  has  always  been  the  desideratum.  The  older  practitioners  sought 
to  accomplish  this  elimination  by  means  of  powerful  caustics,  such  as  caustic 
soda,  caustic  potassa,  arsenious  and  nitric  acids,  chlorid  of  zinc,  etc.  More 
recently  the  dermatologists  have  resorted  to  either  the  knife  or  curette  for 
the  speedy  removal  of  lupous  tissue.  This  surgical  plan  has  also  been 
adopted  in  cases  of  lupus  of  the  mucous  membranes,  but  according  to 
Bosworth  with  the  effect  of  aggravating  the  disease.  Undoubtedly,  when 
so  situated  that  the  diseased  tissues  can  be  wholly  cut  away  at  once,  such  an 
operation    would   be   performed. 

The  use  of  the  ga  I  \  a  no-cautery  ought  in  many  cases  to  supersede  other 
escharotic  treatment,  although  strong  solutions  of  chlorid  of  zinc  or  lactic 
acid  arc  very  satisfactory  in  their  effects.  The  case  which  I  have  cited 
was  treated  locally,  mainly  by  occasional  applications  of  lactic  acid  followed 
by  daily  applications  of  a  spray  of  a  strong  solution  of  resorcin.  Pvok- 
tanin,  topically  applied  as  Bougard's  paste  or  injected  into  the  parts  by  the 
hypodermatic  syringe,  is  reported  as  being  efficient.  I  have  u^-d  a  solution 
of  iodin  in  this  manner,  but  could  not  see  that  the  effects  were  more  striking 

than  when  introduced  elsewhere  under  the  skin.     The  applicati f  balsam 

of  Peru  has  been  reported  as  giving  g I  results.  There  is  danger  of  pro- 
ducing edematous  or  phlegmonous  inflammation  of  the  larynx  by  rough 
treatment  ;  for  that  reason  it  is  obvious  that  the  same  thorough  treatment  as 
applied  to  the  -kin  would  be  inadmissible  for  application  to  the  larynx.  For 
routine  local  treatment  it  will  be  found  that  resorcin  or  iodoform,  or  both, 
in  conjunction  with  the  careful  use  of  the  galvano-cautery,  lactic  or  chromic 
acids,  will  constitute  the  most  efficient  and  safest  treatment  for  this  disease. 

The  use  of  tuberculin  and  tuberculocidin    seems  to  have  been    abandoned. 

LEPROSY   OF  THE  AIR-PASSAGES. 

Leprosy  often  involves  the  mucous  membranes  in  the  course  of  the  gen- 
eral affection,  and  it-  lesions  might  be  confused  with  the  others  here  consid- 
ered :  I. nt  ii  i-  probably  always  secondary  to  the  cutaneous  manifestations  of 
the  disease,  which  should  make  dear  the  diagnosis,  and  i-  too  rare  to  demand 

di9CUS8ion   here. 


SYPHILIS  OF  THE  AIR-PASSAGES. 

By  WILLIAM  C.  GLASGOW,   M.  I)., 

OF   ST.    LOUIS,    MO. 


Next  to  the  skin,  the  respiratory  traet  furnishes  the  mosl  frequent  man- 
ifestations of  syphilis.  Owing  to  the  slight  disturbance  caused  by  the  initial 
and  secondary  lesions,  these  are  often  overlooked;  and  the  Latest  stage,  from 
its  greater  destruction  of  tissue  and  its  marked  disturbances,  has  been  placed 
in  greater  prominence  as  a  factor  in  the  disease.  The  initial  lesion  here  has 
been  considered  by  many  to  be  only  a  possible  contingency  ;  and  they  are 
apt  to  ascribe  the  infection  to  a  hidden  chancre  of  the  genital-.  The  obser- 
vation of  men  of  large  experience  has  proven,  however,  that  syphilis  may  be 
"insontia;"  that  occurrence  of  the  extra-genital  chancre  is  not  rare;  and 
that  its  possibility  must  be  considered  in  all  eases  where  the  initial  lesion  i- 
not  plainly  apparent.  The  secondary  lesions  of  the  upper  air-passages  are 
always  more  or  less  evident.  To  differentiate  them  from  similar  conditions 
due  to  other  causes  is  not  always  easy;  and  in  some  eases  a  positive  diagnosis 
can  be  made  only  through  the  presence  of  the  well-known  lesions  of  tin- 
skin.  Tertiary  lesions  are  usually  marked  and  distinctive,  and  in  only  a 
small  percentage  of  cases  can  there  be  any  doubt.  According  to  anatomical 
classification,  syphilis  of  the  air-passages  may  be  divided  into  diseases  of 
the  nose,  diseases  of  the  pharynx,  diseases  of  the  larynx,  diseases  of  the 
trachea,  and  diseases  of  the  lungs. 

SYPHILIS  OF  THE  NOSE. 

Primary  syphilis  of  the  nose  is  acknowledged  by  all  authorities  to  be 
very  rare.  When  we  consider  the  uncleanly  habits  of  certain  people,  and 
the  frequent  interchange  of  handkerchiefs  and  towels  among  the  members 
of  the  family,  by  which  means  infection  can  be  so  readily  carried,  and  also 
the  frequency  of  abrasions  at  the  entrance  of  the  nostrils,  we  are  surprised 
that  it  does  not  occur  more  frequently.  Buckley,  from  an  analysis  ol  9058 
cases  of  extra-genital  syphilis,  gives  95  cases  occurring  in  the  nasal  cavity. 
In  his  personal  experience  he  has  found  one  case  occurring  in  II".  cases 
of  extra-genital   syphilis.     He  thus  describes   the  symptoms  of   this  case: 

"There  was  great    swelling  of  the   left   nostril,  which   si I   open   and   was 

covered  internally  with  a  dry  crust,  and  on  the  margin  there  was  an  ulcer- 
ated surface  free  from  crust.  The  passage  of  the  nose  was  red  and  uneven 
from  small  nodular  masses."  There  was  no  history  of*  a  preceding  syphilis, 
and  the  lesion  was  suspected  to  be  a  chancre,  rather  than  a  later  manifesta- 
tion of  the  disease.  Under  the  mixed  treatment,  and  calamine  and  zinc 
ointment  applied  to  the  lesion,  there  was  greal  improvement  with  healing  ol 
the  ulcer.  Secondary  syphilis  appeared  later,  confirming  the  diagnosis.  Hie 
infection  in  tin-  case  seems  to  have  come  from  the  use  of  an  infected  towel. 
The  most  frequent   site  of  primary  lesions  in  the  nose  is  the  cartilaginous 

1067 


1068  SYPHILIS  OF  THE  AIR-PASSAGES. 

septum,  and  the  infection  is  usually  carried  by  the  linker-nail.  In  some 
cases  the  surgeon  is  responsible  through  the  use  of  unclean  instruments. 
Several  cases  are  recorded  of  infection  by  the  Eustachian  catheter.  Bosworth 
describes  a  case  of  Moure  :  "  The  ulcer  presented  a  large  granular  mass  which 
hied  easily  upon  touch,  and  which  not  only  produced  notable  stenosis,  but 
also  pressed  upon  the  ala  of  the  nose  to  such  an  extent  as  to  produce  a 
marked  deform  it  v."  In  a  case  of  Watson,  the  base  of  the  chancre  presented 
the  appearance  of  a  hard  cartilaginous  tumor  with  an  ulcerated  surface  which 
bled  easily  upon  touch,  and  projected  so  far  into  the  nostril  as  to  produce  a 
marked  stenosis. 

An  indolent  swelling  of  the  submaxillary  glands  is  constant  at  this  stage, 
and  the  constitutional  disturbances  of  early  syphilis  are  often  \\  itnessed.  Ery- 
thema or  a  subacute  rhinitis  is  the  one  pronounced  symptom  of  the  sec- 
ondary stage.  If  mucous  patches  occur,  they  must  be  exceedingly  rare. 
The  "snuffles"  of  the  new-born  child  is  one  of  the  frequent  symptoms  of 
congenital  syphilis. 

Syphilitic  rhinitis  differs  in  appearance  in  no  way  from  an  ordinary  rhi- 
nitis. The  diagnosis  can  be  made  with  certainty  only  when  the  lesions  of 
the  skin  show  the  recognized  eruptions  of  syphilis.  Its  duration,  however, 
is  longer  than  a  simple  catarrhal  rhinitis;  and  this  chronicity  and  resistance 
to  treatmenl   add  to  its  suspicious  character. 

The  third  stage  of  syphilis  shows  the  most  marked  manifestations  in  the 
Qose,  causing  ulcerations,  superficial  and  deep,  and  gummata.  Gummatous 
deposit  may  occur  in  any  portion  of  the  nose.  The  most  frequent  site  is  the 
septum  and  the  floor  of  th<'  cavity,  it  is  most  commonly  limited  in  extent, 
forming  a  tumor  as  large  as,  or  larger  than,  a  pea.  In  some  cases,  however, 
the  infiltration  is  more  extended.  It  commences  most  frequently  in  the 
submucous  tissues,  extending  both  to  the  surface  and  the  deeper  tissues.  It 
may  continue  for  months  with  an  unbroken  surface;  but  sooner  or  later 
degeneration  occurs,  and  ulcerations,  either  superficial  or  deep,  result.  The 
periosteum  or  perichondrium  becomes  involved,  and  later  there  is  necrosis 
of  the  bony  structures.  The  septum  is  a  frequent  site  of  ulceration,  espec- 
ially the  junction  of  the  cartilaginous  with  the  bony  septum.  Perforation 
of  the  septum  is  a  common  result.  Many  consider  a  perforation  of  the 
septum  to  be  an  evidence  of  syphilis ;  but  experience  shows  that  the  per- 
foration may  l>c  due  to  the  breaking  down  of  a  tubercular  infiltration  or  may 
be  the  resull  of  any  constant  and  repeated  irritation  of  the  septum.  Where 
the  bony  septum  is  involved,  the  existence  of  syphilis  is  unquestionable. 
Next  to  the  septum,  gummata  are  -ecu  most  frequently  in  the  floor  of  the 
nasal  cavity.  The  mucous  membrane  and  the  submucous  tissues,  with  the 
underlying  hone,  are  involved,  and  perforation  of  the  hard  palate  occurs. 
Frequently  gummata  are  found  in  other  portions  of  the  nasal  cavity,  pro- 
ducing necrosis  of  the  bones  and  greal  development  of  fibroid  tissue.  The 
deformity  resulting  from  the  destruction  of  the  bony  frame-work  of  the  nose 
and  the  shrinking  of  the  lihroid  tissue  produce--  the  typical  saddle-nose  which 
i-  characteristic  of  syphilis. 

The  symptom  of  the  early  stage  of  nasal  syphilis  is  a  profuse  secre- 
tion. It  can  hardly  !><•  distinguished  from  thai  of  a  catarrhal  rhinitis,  except 
that  it  is  more  obstinate  and  resists  ordinary  treatment.  When  it  occurs  in 
the  new-born  it  is  probably  syphilitic.  In  the  later  stage  there  is  a  greal 
tendency  to  the  formation  of  crusl  with  a  muco-purulent  secretion;  the 
peculiar  fetor  of  drv  or  syphilitic  caries  j-  unmistakable.  \\  ith  the  forma- 
tion of  the  gummata  there  i-  mure  or  less  obstruction  of  the  nostrils  through 


SYPHILITIC  LESIONS  OF  THE  PHARYNX.  1069 

edematous  swelling.  When  degeneration  lake-  place  beneath  the  mucous 
membrane,  or  when  perichondritis  exists,  there  is  always  more  or  less  pain 
until  the  pus  reaches  the  surface. 

SYPHILITIC  LESIONS  OF  THE  PHARYNX. 

Lesions  of  the  pharynx  occur  in  some  form  in  the  majority  of  cases  "l 
syphilis.  The  chancre  or  primary  infiltration  is  more  common  than  is 
ordinarily  believed,  and  it  is  often  overlooked  owing  to  the  insufficient 
illumination  of  the  pharynx  during  examination.  Excluding  primary  lesions 
of  the  lips  and  tongue,  we  find  the  tonsils  to  be  the  most  frequenl  site,  and. 
next  to  this,  the  soft  palate.  Contrary  to  the  usual  belief,  infection  in  these 
cases  has  taken  place  most  frequently  through  the  use  of  pipes,  eating- 
utensils,  and  public  drinking-cups.  The  use  of  the  lasl  seems  to  be  the 
most  common  source  of  infection.  We  can  well  imagine  that  the  use  of  a 
cup  by  one  having  mucous  patches  on  the  lips  would  carry  the  infective 
material  to  the  next  one  who  used  it.  Unclean  practices  are  responsible  for 
only  a  limited  number  of  cases.  Referring  to  Table  3,  published  by  Buckley, 
we  find  307  cases  of  chancre  of  the  tonsil  among  9058  cases  of  syphilis. 
Schadek,  among  68  cases  of  extra-genital  chancres  found  in  the  fauces, 
locates  34  on  the  tonsil. 

Chancre  of  the  tonsil  presents  the  appearance  of  an  indurated  ulcer  of 
the  organ,  which  may  be  limited  in  extent  or  invoke  a  large  surface  (com- 
pare Fig.  575).  The  ulceration  is  superficial,  but  may  be  small,  with  it-  base 
covered  with  dirty-gray  secretion.  The  indurated  condition  of  the  periphery 
declares  the  diagnosis,  which  will  soon  be  confirmed  by  the  glandular  swell- 
ings and  the  lesions  of  the  skin.  In  some  cases  the  symptoms  of  the  chancre 
are  so  slight  as  to  escape  notice  ;  in  others  they  are  marked.  Pain  may  be 
very  prominent,  either  confined  to  the  pharynx  or  radiating  to  tin  ear.  The 
submaxillary  gland-  become  swollen,  but  their  suppuration  is  rare. 

Erythema  of  the  fauces  is  frequent.  We  find  a  circumscribed  redness  of 
the  mucous  membrane  involving  the  soft  palate,  the  pillars  of  the  fauces,  or 
the  tonsil.  The  color  is  a  coppery-red.  and  it  i-  sharply  limited  t<>  certain 
areas.  Frequently  it  is  confined  to  one  side,  with  a  well-marked  line  of 
demarcation  in  the  median  line  and  in  the  line  between  the  hard  and  soft 
palates.  Occasionally  we  find  patches  of  congestion  on  the  two  sides,  with 
the  median  line  free— the  so-called  "Dutch  garden  symmetry"  (Hutchinson  . 
This  condition  usually  coincides  with  the  early  skin-lesions  of  syphilis,  and 
is  often  overlooked,  a-  it  rarely  give-  any  special  symptoms.  Erythematous 
patches  maybe  present  in  the  naso-pharynx,  giving  rise  to  catarrhal  symp 
torn-.  We  occasionally  see  in  those  who  have  passed  through  the  secondary 
sta^e,  perhaps  years  afterward,  the  occurrence  of  a  subacute  angina,  which 
will  yield  only  to  the  specific  treatment.  In  a  case  of  the  writer,  an  angina 
which  had  been  under  treatment  for  a  longtime  by  several  physicians  yielded 
at  once  to  a  mixed  treatment,  and  the  redness  entirely  disappeared.  With 
the  cessation  of  treatment  owing  to  an  attack  of  grippe,  the  angina  returned, 
and  permanently  disappeared  only  after  a  prolonged  specific  course. 

Mucous  patches  are  of  frequenl  occurrence  in  secondary  syphilis.  Lney 
aie  found  on  the  pillar-  of  the  palate,  the  tonsil,  and  other  parts  of  the  buccal 
cavity.  They  are  usually  circumscribed  in  extent,  presenting  -mall  patches 
of  a  mother-of-pearl  color.  Asa  rule,  they  are  level  with  the  surface  of  the 
mucous  membrane,  and  are  broughl  into  greater  prominence  through  the 
congestion  of  the  surrounding  tissues.     The)  presenl   somewhat  the  appear- 


1H7D  SYPHILIS   OF   Till:  AHi-PASSAdKS. 

ance  of  the  mucous  membrane  after  the  surface  has  been  touched  with 
nitrate  of  silver.  In  a  certain  number  of  cases  we  find  the  patch  thickened 
and  somewhat  raised  above  the  surface,  resembling  in  a  certain  degree  the 
patch,-  of  diphtheria.  They  have  a  tendency  to  remain  unchanged  over  long 
periods,  unless  modified  by  treatment.  Occasionally  we  see  the  infiltrated 
patches  presenting  ulcerations  and  erosions.  These  are  superficial  in  char- 
acter and  have  a  tendency  to  extend  at  the  periphery.  Secondary  lesions 
appear  from  six    month-  to   two   years  after  infection. 

Tertiary  syphilis  of  the  pharynx  is  strictly  the  result  of  a  gummatous 
infiltration  of  the  tissues,  the  mucous  membrane,  the  submucous  tissues,  or 
the  hone-.  Manifold  in  its  pictures,  modern  medicine  ascribes  all  these  con- 
ditions to  degeneration  of  the  gummatous  infiltration.  More  or  less  rapid 
ulceration,  with  great  destruction  of  tissue  and  the  development  of  a  cirrhotic 
contractile  tissue,  is  the  usual  sequel.  Gummatous  tumors  may  be  confined 
tn  limited  area-,  or  the  deposit  may  be  extensive.  Unless  checked  by  treat- 
ment, they  may  break  down  rapidly,  giving  rise  to  ulceration,  which  in  the 
beginning  may  be  small  and  may  occur  at  several  points.  If  unchecked,  it 
is  prone  to  extend,  producing  great  destruction  of  tissue.  The  ulcer  may  be 
round  or  irregular,  and  is  surrounded  by  a  red  areola.  It  has  sharply  defined 
edges,  and  its  base  shows  feeble  granulation-tissue  exuding  secretions  com- 
posed largely  of  pus  and  broken-down  epithelium.  The  posterior  pharyngeal 
wall  is  a  frequent  site  of  the  gummatous  infiltration  and  extensive  ulceration. 
Superficial  ulcers  frequently  occur  in  the  upper  part  of  the  pharynx,  and  are 
hidden  from  view  unless  discovered  through  a  rhinoscopic  examination. 
When  the  ulcers  extend  deeply  into  the  tissues,  they  may  involve  the  perios- 
teum with  a  subsequent  caries  of  the  bone. 

The  posterior  surface  of  the  palate  is  a  common  site  of  a  softening  gumma. 
The  destructive  process  may  be  very  rapid,  and  perforation  of  the  palate  is 
quickly  established  ;  unless  checked,  the  eroding  process  may  continue  until 
more  or  less  of  the  palate  is  destroyed.  The  dependence  of  the  ulceration 
upon  the  gummatous  deposit  is  strikingly  shown  in  some  of  these  perforations 
of  tin'  -oft  palate,  where  we  see  large  areas  destroyed,  with  normal  strings  of 
tissue  remaining  between  the  perforations.  Ulcers  of  the  tonsil  are  not 
usually  a-  large  a-  those  of  the  palate  ;  they  are  more  longitudinal,  and  show 
less  tendency  to  extend.  Several  ulcers  may  be  seen  at  the  same  time  on  the 
ton-,il  with  sound  interme  liate  tissue.  The  deep  perforating  ulcer  has  occa- 
sionally produced  erosion  of  a   blood-vessel    with    hemorrhage.     Gummatous 

tu rs  occur  on  the  posterior  pharyngeal  wall  and  the  hard  palate,  where  tiny 

show  little  tendency  to  -often.  fliev  appear  as  hard,  firm,  rounded  tumors 
covered  with  mucous  membrane.  They  may  be  quite  large  and  present  the 
appearance  of  a  fibroma  or  ,-i  sarcoma.  A  case  of  the  writer  presented  a 
gummatous  tumor  of  tin-  tonsil,  a-  large  as  a  small  hen's  egg,  largely  block- 
ing up  the  fauces.  In  some  of  these  cases  the  diagnosis  is  difficult,  and 
<:in  only  be  affirmed  after  a  microscopical  examination  or  the  te>t  of  treat- 
ment. 

Another  resull  of  gummatous  infiltration  i-  -ecu  in  the  developmenl  <»f 
contraction  and  scar-tissue.  A  greai  and  varied  distortion  of  the  pharynx 
i-  tin'  result,  and  membranous  fold-  are  formed  which  cause  greal  incon- 
venience and  distress.  Adhesion  of  the  sofl  palate  to  the  posterior  phar- 
yngeal wall,  often  complete,  or  with  a  small  opening,  is  not   ommon.     A 

membranous  adhesion  between  the  lower  pharynx  and  the  root  of  the  tongue, 
largely  closing  the  larynx  and  esophagus,  ha-  -everal   time-  been  observed. 

;i  a  case  came  under  mj  observation  a  few  years  ago.     The  opening  was 


SYPHILITIC    LESIONS  OF  THE  LARYNX.  1071 

large  enough  to  allow  free  respiration,  but  greal  difficulty  was  experienced 
in  swallowing.  Adhesions  between  the  soft  palate  and  the  palatine  folds  arc  of 
frequent  occurrence.     They  are  usually  unilateral. 

Symptoms  of  secondary  syphilis  of  the  pharynx  may  differ  but  slightly 
from  those  of  an  ordinary  catarrhal  pharyngitis.  There  may  be  a  sensation 
of  dryness  of  the  membrane,  and  more  or  less  pain  on  swallowing.  The 
secretions  are  usually  increased.  The  glands  of  the  Deck  are  swollen  ;  but 
this  may  also  result  from  other  causes.  The  occurrence  of  the  tertiary  stage 
gives  rise  to  more  prominent  symptoms.  The  pain  of  swallowing  may 
become  so  intense  as  almost  to  preclude  the  taking  of  food.  It  may  radiate 
to  the  ears  and  assume  the  form  of  a  neuralgia.  The  secretions  are  greatly 
increased,  and  become  purulent  and  ropy.  When  the  palate  is  involved 
either  through  infiltration  or  ulceration,  we  find  a  disturbance  of  the  speech, 
and  fluids  are  often  regurgitated  into  the  nasal  cavities. 

SYPHILITIC  LESIONS  OF  THE  LARYNX. 

The  larynx  becomes  involved  in  a  large  number  of  cases  of  syphilis. 
The  disease  may  be  in  the  milder  forms,  and  be  overlooked,  or  in  the  most 
destructive,  which  cannot  escape  notice.  Authorities  are  greatly  at  variance 
as  to  its  frequency,  laryngologists  meeting  a  larger  percentage  of  cases  than 
the  dermatologists.  In  a  large  number  of  cases  laryngeal  syphilis  appears 
secondary  to  syphilis  of  the  pharynx.  It  has,  however,  been  frequently 
observed  independently,  often  occurring  many  years  after  the  initial  lesions. 
It  may  occur  in  varied  forms  from  two  months  to  fifteen  years  after  infec- 
tion. Primary  syphilis  of  the  larynx  is  almost  unknown,  although  it  has 
been  reported.  Secondary  syphilis  has  been  observed  as  early  as  the  second 
month — the  usual  time  is  from  six  months  to  three  years  after  the  infection. 
It  assumes  the  forms  of  an  erythema,  mucous  patches,  and  erosions. 

Erythema  or  syphilitic  catarrh  is  an  early  and  most  constant  lesion.  It 
resembles  so  closely  an  ordinary  catarrhal  laryngitis  that  in  many  cases  it  is 
impossible  to  make  a  differential  diagnosis  unless  it  is  accompanied  by  the 
skin-lesions.  Even  in  such  cases  the  occurrence  of  laryngeal  hyperemia  may 
be  an  accidental  condition  of  ordinary  catarrhal  laryngitis  in  a  syphilitic 
subject.  The  true  nature  of  the  lesion  can  be  determined  only  by  the  result 
of  treatment.  In  certain  typical  cases  the  color  of  the  membrane  is  of  a 
deeper  red  than  that  of  an  ordinary  catarrhal  hyperemia.  It  i^  more  per- 
sistent, and  there  is  usually  a  greater  swelling  of  the  membrane.  In  other 
cases  it  is  found  confined  to  limited  areas.  Mucous  patches  are  not  frequent. 
They  have  been  reported  as  occurring  on  the  under  surface  of  the  epiglottidean 
folds,  the  true  and  the  false  cords.  They  are  similar  in  appearance  to  the 
mucous  patches  of  the  pharynx.  They  seem  to  be  the  origin  of  the  erosions 
which  are  often  seen  in  the  larynx.  Occasionally  they  present  the  appearance 
of  condylomata. 

Symptoms  of  the  second  stage  are  obscure,  and  will  depend  upon  the  ana 
affected.  When  the  vocal  cords  are  concerned,  the  symptoms  resemble  those 
of  a  catarrhal  laryngitis;  the  voice  may  become  rough  and  hoarse.  It'  the 
arytenoid  cartilage-  or  the  interarytenoid  fold  arc  involved,  the  patient  may 
have  an  irritative  or  tickling  cough  and  clearing  of  the  throat.  The  tertiary 
lesions  of  the  larynx  appear  from  the  third  year  of  infection  on  to  an  indefi- 
nite period.  Cases  are  on  record  in  which  the  laryngeal  affection  has  arisen 
twenty  year-  after  the  primary  lesion.  It  assumes  the  form  of  a  gummatous 
infiltration  or  tumor;  and  when  softening  occurs  there  is  ulceration,  and   the 


1072 


SYPHILIS  OF  THE  AM-PASSAUKS. 


gummatous  infiltration  will  present  the  appearance  <>i'  a  thickened,  infiltrated 
area.  This  may  extend  through  the  submucous  tissue,  involving  the  peri- 
chondrium, while  the  mucous  membrane  of  the  affected  area  may  be  normal 
or  reddened.  The  epiglottis  is  the  must  frequent  site  of  the  infiltration  (Fig. 
620), bul  it  is  also  seen  on  the  true  cords,  false  cords,  and  the  ary-epiglottidean 
folds.    The  epiglottis  may  be  changed  into  a  swollen,  deformed  organ,  and  the 


Fig.  620.— Fresh  gummata  on  the  epiglottis  and  Fig.  621.— Tertiary  syphilitic  deposits  in  the 

syphilitic  infiltration  of  the  righl  true  vocal  cord       right  cord  and  ventricular  hand  with  gumma  of 
and  ventricular  hand  (Griiuwald).  the  adjacent  part  of  the  epiglottis  (Griinw  aid  . 


ary-epiglottidean  folds  become  large  and  prominent  :  the  swollen  false  cords 
may  largely  till  the  glottic  opening.  Gummatous  tumors  are  simply  circum- 
scribed area-  of  infiltration  which  develop  into  the  form  of  a  tumor  (  Fig.  621 ). 
They  occur  in  all  parts  of  the  larynx,  and  may  be  single  or  multiple.  The 
tendency  of  the  gummatous  formation  is  to  soften,  and  when  this  occurs  the 
destructive  process  isveryrapid.  It  burrows  deeply  in  the  tissues,  producing 
a  deep,  excavated  ulcer,  with  destruction  of  the  underlying  cartilage.  The 
epiglottis  may  be  partially  eroded  or  completely  destroyed  through  the 
necrotic  process.  The  crico-arytenoid  joint  and  both  the  true  and  false  cords 
may  be  involved  in  the  same  process.  The  collateral  edema  and  swelling  may 
be  so  greal  as  to  occlude  the  glottis.  The  deep  nicer  of  syphilis  has  a  certain 
characteristic  appearance  :  the  <A^-<  are  sharply  defined,  and  the  base  is  cov- 
ered with  gray  secretion.  In  form  it  is  irregular  and  it  is  surrounded  by  in- 
filtrated tissue.  The  superficial  ulceration  is  not  so  characteristic.  It  may 
have  an  extensive  surface,  and  has  a  great  resemblance  to  a  tubercular 
ulceration. 

The  differential  diagnosis  between  a  syphilitic  ulcer  of  the  late  stage  and 

the  tubercular  will  often  be  difficult  and 
at   times  impossible, without  the  consid- 
g^L  eration  of  other  signs  and  symptoms  of 

f""*  l   y\  ^^       the  disease;   this  will   especially   be  the 

case  where  a  mixed  infection  is  present 
(  Fig.  622).  The  syphilitic  ulcer  has  sharp, 
better-defined  edges  ;  it  is  apt  to  be  single, 
and  presents  the  appearance  of  an  exca- 
vated1 area  with  a  reddened,  thickened 
surrounding.  The  tissue  aboul  a  tuber- 
cular nicer  shows  an  anemic  color.  A 
common  sequence  of  the  ulceration  will 
be  found  in  the  developmenl  of  the  contractile  scar-tissue,  which  produces 
great  distortion  of  the  laryngeal  structures  and  which  remains  permanently, 
giving  in  after  years  positive  evidence  of  the  disease.  Adventitious  mem- 
branes may  be  formed   between  the  cords,  largel}    closing  the  glottis. 


i  ubercular  outgrowth  in  the  In- 
irysyphilitii 
.i  and  ulcer  ol  tie  .  piglottl     i  !i  mwald). 


SYPHILITIC  LESIONS  OF  THE  LUNGS.  1073 

SYPHILIS  OF  THE   TRACHEA. 

Syphilis  of  the  trachea  assumes  the  form  of  erythema  in  the  curly,  and 
gummatous  infiltration  in  the  later  stage;  it  is  frequently  consecutive  to 
the  disease  in  the  larynx.  Erythema  of  the  trachea  can  be  discovered  only 
through  the  use  of  the  laryngeal  mirror.  There  arc  no  symptoms,  unless 
there  be  irritating  cough.  The  gummatous  ulcer  can  occasionally  be  seen 
in  the  mirror,  if  it  occurs  on  the  portion  of  the  trachea  which  can  be  illu- 
minated. It  is  more  frequently  entirely  overlooked,  and  is  suspected  only 
when  the  development  of  stenotic  symptoms  shows  the  presence  of  contrac- 
tile scar-tissue.  It  may  be  multiple,  and  invade  large  areas  of  the  trachea, 
and  it  may  be  superficial  or  deep.  The  deep  ulcer  may  break  down  the  car- 
tilage  and  form  a  connection  with  the  adjacent  organs.  Contractile  adhesions 
may  result,  largely  occluding  the  lumen  of  the  trachea.  In  a  case  of  the 
writer  the  upper  portion  of  the  trachea  was  almosl  entirely  closed  by  adhe- 
sions ;  the   patient  survived  fourteen  years  after  a   low   tracheotomy. 

SYPHILITIC  LESIONS  OF  THE  LUNGS. 

That  syphilitic  lesions  of  the  bronchi  and  lungs  occur  has  been  proven 
by  post-mortem  examinations,  but  the  diagnosis  in  most  cases  is  extremely 
difficult,  if  not  impossible,  during  life.  Post-mortem  specimens  have  shown 
the  presence  of  the  gummatous  infiltration,  and  this  has  been  found  broken 
down,  forming  cavities.  Syphilitic  phthisis  can  only  be  suspected  when  it 
occurs  in  a  person  subject  to  syphilis,  and  even  then  a  possibility  of  a  mixed 
infection  must  be  considered.  The  physical  signs  and  symptoms  are  similar 
to  those  occurring  in  many  cases  of  ordinary  phthisis,  and  it  resembles  those 
cases  which  have  been  justly  termed  a  local  tuberculosis  of  the  lungs.  The 
general  symptoms  are  slight,  and  emaciation  is  not  so  marked  as  in  tuber- 
cular phthisis.  The  physical  signs  will  show  a  local  infiltration  confined  to 
single  portion-  of  the  lungs.  We  may  have  the  moist  rales  and  bronchial 
breathing  with  dulness,  if  a  perceptible  area  has  been  infiltrated  :  the  cavity 
signs  will  be  present  where  an  abscess  has  emptied  into  a  bronchus.  The 
iodid-of-potash  test  will  be  the  leading  element  in  the  diagnosis. 

TREATMENT. 

The  treatment  of  syphilis  of  the  respiratory  tract  follows  the  rides  of 
the  treatment  of  general  syphilis,  with  the  addition  of  such  local  treatment 
as  may  be  needed  in  individual  cases.  The  accepted  rule  of  giving  the  mer- 
curials in  the  early  stage  and  the  iodidsin  tin-  later  will  be  generally  followed. 
The  experience  of  the  writer  has  shown,  however,  the  greater  value  of  the 
so-called  "mixed  treatment"  in  almost  all  stage- of  the  disease.  The  fresh 
solution  of"  a  combination  of  corrosive  sublimate,  gr.  j1.,,  and  iodid  ol  potas- 
sium, gr.  x.  has  given  quicker  and  better  results  than  the  use  of  the  same 
drug-  in  pill  form,  as  biniodid  or  protiodid  of  mercury.  In  addition,  when 
it  i-  necessary  to  cheek  ulcerative  action  or  to  promote  the  absorption  of  gum- 
matous infiltration,  the  iodid-  inu-t  be  given  in  larger  and  increasing  doses. 
Occasionally  a  course  of  mercurial  inunction  will  develop  the  power  ol  the 
iodid-  when  the  response  to  treatment  is  not  satisfactory.  In  all  cases  where 
there  has  been  a  development  of  syphilitic  anemia  a  course  ol  tonics  will  be 
indicated  ;  and  we  should  have  decided  benefit  from  the  use  of  iron,  man- 
ganese, strychnia,  and  cod-liver  oil. 

68 


1074  SYPHILIS  OF  THE  AIBrPASSAGES. 

The  local  treatment,  although  secondary,  will  be  essential  in  most  cases 
of  nasal  and  throat  syphilis.  The  thorough  cleansing  of  the  surface  by 
means  of  the  spray  or  syringe,  using  an  antiseptic  and  alkaline  solution,  will 
favor  resolution  and  will  prepare  the  way  tor  the  proper  application  of  such 
local  remedies  as  may  he  indicated.  In  nasal  syphilis  such  local  treatment 
is  all-important.  The  dead  hone  should  he  removed,  it'  this  can  be  done 
without  violence,  and  the  ulceration  touched  with  nitrate  of  silver.  In  the 
pharynx  and  larynx  the  application  of  compound  solution  of  iodic  will  hasten 
I  he  resolution  of  the  gummatous  infiltration  ;  and  acid  nitrate  of  mercury  or 
nitrate  of  silver  will  tend  to  bring  about  the  healing  of  the  ulceration.  In 
ulcers  of  the  larynx  the  insufflation  of  aristol  or  iodoform  with  morphia  will 
be  grateful  and  useful.  The  cicatricial  contractions,  with  the  resulting  stenosis 
in  both  the  pharynx  and  the  larynx,  will  be  troublesome  and  obstinate.  The 
results  of  surgical  treatment  of  these  conditions  have  been  most  nnsatisfac- 
tory — division  of  the  adhesions  and  membranous  formations  by  either  the 
knife  or  the  cautery  being  almost  always  followed  by  a  re-growth  of  the 
divided  structures.  Gradual  dilatation  has  given  the  best  results.  No  sur- 
gical   interference  is  justifiable  until  the  disease  has  become  quiescent. 


NEOPLASMS  OF  THE  UPPER  AIR-PASSAGES. 

By  JONATHAN   WRIGHT,  M.  1)., 

OF    BROOKLYN,   N.  Y. 


As  introductory  to  the  subject,  I  translate  from  the  interesting  and 
valuable  work  of  Prof.  Moritz  Schmidt,  the  initial  page  of  his  chapter  on 
"  New  Growths  of  the  Upper  Air-Passages  :" 

"In  order  to  give  some  idea  of  the  frequency  of  neoplasms  in  the  upper 
air-passages,  I  will  make  a  resume  of  those  observed  by  me  in  the  last  ten 
years.  These  occurred  among  a  total  number  of  32,997  patients,  and  were 
as  follows  : 

In  the  nose  : 

'/.  Mucous  polypi,  757  (462  men  ;  295  women). 

b.  Fibroma,  2  (men). 

c.  Papilloma,  6  (3  men  ;  3  women). 

d.  Lymphoma,  2  (women). 

e.  Lvmpho-sareoma,  2  (women). 
/.    Cyst,  1  (man). 

g.  Sarcoma,  (3  (1  man;  5  women). 
//.  Carcinoma,  5  (3  men;  2  women). 

In  the  naso-pharynx  : 

a.  Fibroma,  13  (7  men;  6  women). 

b.  Cysts,  101  (60  men;  41  women). 
'•.   Angio-sarcoma,  1  (man). 

<\.  Sarcoma,  1  (man). 

In  the  oro-pharvnx  : 

a.  Fibroma.  3  (1  man  ;  2  women). 

b.  Papilloma,  40  (29  men  ;  11  women).     In  reality  the  figures  should  be  higher, 

since  from  the  slight  interest  in  these  growths,  careful  account  of  them 
was  not  kept. 

c.  Cyst,  1  (man). 

d.  Tonsillar  polypi,  5  (3  men;  2  women). 

e.  Sarcoma,  2  (1  man  ;  1  woman). 

/.    Carcinoma,  16  (15  men  ;  1  woman). 

In  the  larynx  : 

a.  Fibroma,  256  (178  men  ;  7X  women). 

b.  Papilloma,  46  (31  men;   15  women). 

c.  Singers'  nodes,  L09  (56  men;  53  women). 

d.  Lipoma,  1  (man). 

e.  Myxoma.  3  (men).    In  recent  years  they  are  not  especially  mentioned.    Weigert 

regards  them  as  edematous  fibrous  polypi.    They  arc  included  under  (a). 

f.  Fibro-myxoma,  1  (man). 

fj.  Tubercular  tumors,  36  (14  men;  22  women). 

//.  Cyst,  8  (-  men  ;  6  women). 

i.    Sarcoma,  3  i  men). 

k.  Carcinoma,  75  (61  men;  14  women). 

In  the  trachea  : 

'/.   Carcinoma,  2  il  man;    I   woman)." 


[076  NEOPLASMS  OF  THE   UPPER  AIR-PASSAGES. 

NASAL   NEOPLASMS. 

Neoplasms  of  the  nose  and  throat,  of  inflammatory  origin,  arc  met  with 
very  frequently.  At  a  glance  it  may  be  seen  in  Schmidt's  tables  how  mark- 
edly the  mucous;  polypi  preponderate  over  all  other  nasal  growths.  The 
same  may  be  observed  in  the  larynx,  under  the  heads  of  fibroma  and  singers' 
node-.  True  tumors,  especially  those  of  benign  origin,  are  excessively  rare. 
Much  confusion  has  arisen  from  the  mistaken  conceptions  of  Iaryngologists 
in  regard  to  the  pathological  character  of  these  growths.  Much  of  this  has 
resulted  from  the  exceedingly  unsatisfactory  theories  of  the  pathogenesis  of 
tumors  in  general.  It  is  doubtless  true  that  there  are  many  neoplasms 
which  to  all  histological  appearances  are  true  tumors,  which  yet  depend  on 
the  over-nutrition  of  inflammatory  processes  for  their  origin.  It  is  not  the 
province  of  the  writer  to  attempt  here  the  task  of  drawing  a  satisfactory 
line  of  division   between   true  tumors  and   the  neoplasms  of  inflammation. 

Edematous  polypi  of  the  nasal  mucous  membrane  belong  to  the  latter 
category.  They  arc  usually  called  myxomata,  which  in  some  degree  they 
resemble,  both  microscopically  and  macroscopically  ;  but  they  are  in  the  vast 
majority  of  the  ease-,  in  the  nose,  the  result  of  a  chronic  inflammation  ;  and 
hence,  serous  infiltration  being  their  most  marked  characteristic,  they  are 
better  called  edematous  polypi.  It  should  be  remembered  that  the  word 
polypus  refers  simply  to  their  pedunculated  form.  Exactly  the  same  histo- 
logical   condition    i-  found   in    the   nasal   mucous  membrane  in  a  sessile  form. 

Histology. — The  epithelium  resembles  that  of  the  surrounding  mucous 
membrane — i.  e.,  columnar  ciliated  cells  in  the  upper  part  of  the  nasal 
chambers  and  non-ciliated  below  ;  ilat  cells  in  the  lower  pharynx  and  larynx. 
This  epithelium  may  undergo  metamorphoses  from  the  attrition  of  surfaces 
or  other  irritation,  such  as  the  flowing  of  pus  from  the  ethmoidal  sinuses,  so 
that  the  cilia  may  be  lost  from  the  columnar  cells  and  the  latter  become  more 
or  less  flattened,  resembling  the  squamous  type.  The  layers  may  become 
thickened  either  uniformly  or  (limitations  may  form,  dipping  into  the  stroma 
at  irregular  intervals.  The  epithelium  may,  on  the  other  hand,  be  entirely 
unchanged. 

Tin  stroma  is  separated  by  the  effused  serum  into  bundles,  leaving  space- 
between.  The  size  of  these  spaces  or  meshes  and  the  quantity  of  the  stroma- 
flbers  differ  greatly — apparently  according  to  the  degree  and  the  age  of  the 
process. 

'/7m  fluid  contains  some  mucin  and  fibrin.  When  coagulated  in  the  hard- 
ening processes  of  histological  technic,  the  fibrin,  unless  broken  up  into  gran- 
ules, may  be  easily  mistaken  for  connective-tissue  fibers.  Round  cells  of 
varying  diameters  are  entangled  in  the  meshes  of  the  stroma  and  in  the  fibrin. 

These  mid  connective  tissue  are  f< 1  most  abundantly  in  the  region  of  the 

blood-vessels  |  Fig.  623)  and  glands,  if  they  exist. 

Glands  arc  usually  scanty.  If  present  at  all,  they  are  usually  found  in 
or  near  the  pedicle,  from  being  barely  visible,  they  are  frequently  dilated 
30  as  to  form  cysts  of  a  size  occupying  almosi  the  whole  of  a  large  pedun- 
culated polypus  (Fig.   624).     They  are  found  al-o  in  the  sessile  forms. 

Blood-vessels    are    also    -canty    and    capillary    in     -izc,    being    found    most 

abundantly  ju-t  under  the  epithelium,  forming  a  delicate  red  tracery  visible 
tot  he  naked  eye. 

Verves  have  been  demonstrated  in  the  stroma. 

The  pedicle,  when  it  exists,  i-  made  up  of  the  firmer  unseparated  stroma 
of  the  mucous  membrane. 


NASAL  POL  VPS. 


1077 


Etiology. — The  so-called  "polypoid  degeneration,"  although  histologi- 
cally the  same,  is  more  conveniently  considered  under  the  head  of  chronic 
rhinitis,  where,  indeed,  both  forms  pathologically   belong. 

Both  forms  are  the  result  of  chronic  inflammation  of  the  nasal  mucosa. 
There  may  or  may  not  have  been  previous  symptoms  of  this  rhinitis,  but 
evidently  the  effusion  of  serum   into  the  tissues  is  caused  by  some  vascular 


Fk;.  623.— Stroma,  round  cells,  and  blood-vessels  of  an  edematous  nasal  polyp. 

change  which  is  a.s  yet  imperfectly  understood.  We  may  conjecture  from 
anatomical  reasons,1  which  it  is  not  necessary  to  detail  here,  thai  there  is 
some  interference  with  the  efferent  blood-current  as  well  as  with  the  walls  of 
the  capillaries  themselves.  Chronic  hypertrophic  rhinitis  rarely  occurs  in 
children  ;  therefore  these  growths  are  more  common   in  adults  than  before 


Fig.  624.    Cysts  in  a  polyp 


twenty.  They  have,  however.  been  reported  at  all  ages,  and  even  congenital 
cases  have  been  observed.  They  are  more  common  in  men  than  in  women. 
Out  of  200  cases,  according  to  Morel!  Mackenzie.-'  123  occurred  in  men. 

1  "  A  Consideration  of  the  Vascular  Mechanism  of  the  Nasal   Mucous  Membrane,"  etc., 
Amrr.  Journ.  M"l.  Sd.t  May.  1895.  "  Diseases  of  th<-  Th         ■    ;   \ 


luTS  NEOPLASMS  OF  Till:   CWEll  A  I R-I'ASSAii i:s. 

Situation. —  A  nasal  edematous  polypus  has  its  origin  in  the  vast  major- 
ity of  cases  from  the  mucous  membrane  covering  the  middle  turbinated  hone 
or  from  that  part  of  the  ethmoid  near  the  hiatus  semilunaris.  Edematous 
polypi  may  be  found.  however,at  any  point  within  the  nasal  chambers.  At 
the  posterior  end  of  the  turbinal  bodies  and  on  the  septum  we  usually  find 
the  sessile  form  combined  with  dilatation  of  Mood-vessels;  rarely,  peduncu- 
lated growths  are  found  in  these  localities.  The  size  of  the  polypi  varies 
greatly — from  that  of  a  pin's  head,  sprinkled  over  the  mucous  membrane 
of  the  middle  turbinated  bone,  to  enormous  dimensions.  1  extracted  one 
from  the  nostril  of  a  man  with  symptoms  extending  over  twenty  years, 
which  presented  externally  and  projected  posteriorly  into  the  pharynx.  It 
had  filled  one  nostril  completely,  and  had  pushed  the  cartilaginous  and  bony 
septum  SO  far  to  the  other  side  as  to  cause  complete  occlusion.  It  was  folded 
mi  itself,  so  that  when  it  lay  straightened  out  on  the  table  it  measured  nearly 
5  inches  in  its  long  diameter,  and  in  some  places  was  more  than  1 .',  inches 
thick.  Its  pedicle  was  comparatively  small.  The  pressure  which  it  had 
exerted  had  resulted  in  the  atrophy  of*  the  internal  structures  of  the  nose  to 
such  an  extent  that  the  enormous  cavity  left  after  extraction  had  smooth 
walls.  I  can  find  no  record  of  any  as  large  as  this;  but  several  have  been 
reported  that  approximated  it  in  proportions.  They  rarely  exist  separately, 
but  when  complete  nasal  obstruction  exists  there  are  usually  multiple  growths. 
Occasionally  they  till  the  ethmoid  cells,  causing  absorption  of  their  bony 
walls,  and  once  or  twice  I  have  seen  distortion  of  the  bridge  of  the  nose. 
The  edematous  process,  by  pressure  or  the  extension  of  the  inflammation, 
frequently  causes  caries  or  disintegration  of  the  ethmoidal  bony  tissues,  and 
tin-  has  been  called  by  Woakes '  "necrosing  ethmoiditis."  On  this  account 
the  masses  removed   frequently  have  spiculse  of  bone  embedded   in   them. 

The   1 has   been   described    by  some  writers  as   newly  formed.     This  is 

probably  a  mistake. 

Symptoms. — These  depend  largely  upon  the  size  and  number  of  the 
polypi  and  the  extent  of  the  edematous  process.  Nasal  obstruction  may  lie 
complete  on  both  sides,  giving  rise  to  great  discomfort,  or  one  or  more  polypi 
may  exisl  in  the  nose  for  years  without  signs.  A  flapping  valve-like  action 
on  respiratory  efforts  may  be  appreciated  by  the  patient  or  even  heard  by 
the  examiner. 

Headaches  arc  very  common,  and  this  is  especially  the  case  when  the 
polypi  have  their  bases  of  attachment  high  up,  or  if  they  invade  the  acces- 
sory sinuses. 

A  watery  discharge  from  tin1  nose  frequently  exists,  causing  excoriation 
of  the  margins  of  the  nostrils  and  redness  of  the  skill  of  the  nose.  This 
may  be  accentuated  to  an  erysipelatous  Hush  over  the  nasal   regions. 

Various  complications — ethmoiditis,  frontal,  maxillary,  or  sphenoidal 
Binus-troubles — may  be  present  ;  the  patient  frequently  suffers  from  catar- 
rhal deafness.     All  symptoms  are  aggravated  by  cold,  damp  weather. 

Examination  -how  -  masses  of  varying  extent  blocking  the  nasal  chambers 
or  hanging  down  from  above.  They  have  the  appearance  of  the  pulp  of  a 
grape,  and  are  frequently  traversed  by  a  delicate  tracery  of  red  capillaries. 
The  color  may  be  pink  or  of  a  dusky-red  hue.  Rarely,  in  large  nasal 
chambers,  the  attachments  may  be  -ecu  along  the  borders  of  the  middle  tur- 
binal. lint  usually  the  masses  themselves  preclude  any  attempt-  at  inspection 
of  the  upper  region  of  the  nose,  and  it  i-  impossible  in  the  majority  of  cases 
even  to  ascertain  with  a   probe  the  exacl   point  of  insertion.     There  maybe 

1  Nasal  Polypus. 


NASAL  NEOPLASMS.  L079 

great  tenderness,  bui  usually  the  fossae  arc  toleranl  of  examination.  With 
a  rhinoscopic  mirror  the  masses  may  be  seen  projecting  into  the  naso-pharynx. 
They  may  be  confined  to  one  side,  but  usually  exist  to  an  unequal  degree  on 
both. 

Treatment. — Modern  rhinology  has  practically  abandoned  all  methods 
of  removal  but  that  by  the  nasal   snare. 

It  is  frequently  desirable,  and  occasionally  possible,  to  remove  the  ante- 
rior end  or  lower  border  of  the  middle  turbinated  bone  in  order  more  surely 
to  reach  their  place  of  origin.  This  has  been  especially  urged  by  Dr.  (  'asscl- 
berry,1  who  has  devised  an  instrument  tor  that  purpose.  Various  other 
instruments  have  been  used,  such  as  rongeur  forceps,  snares,  drills  and 
trephines.  It  is  an  operation  which  the  writer  has  frequently  found  impos- 
sible to  do  satisfactorily.  When  disease  of  the  ethmoid  cells  and  of  the 
middle  turbinated  bone  coexist  with  the  polypi,  as  happens  in  a  large  pro- 
portion of  cases,  it  is  well  to  remove  as  much  of  the  bony  walls  as  can  be 
included  in  the  snare  or  nipped  off  with  rongeurs,  care  being  taken  not  to 
encroach  upon  structures  lying  too  close  to  the  cribriform  plate  of  the  eth- 
moid. When,  however,  extensive  bone-involvement  coexists,  the  treatment 
of  that  becomes  the  chief  aim  and  the  extraction  of  polypi  merely  incidental. 

It  is  said  that  edematous  polypi  tend  to  recur.  When  a  polypus  is 
severed  at  its  base,  it  is  doubtful  if  another  appears  in  the  same  locality. 
When  the  middle  of  the  mass  is  cut  through  by  the  wire,  that  portion  left 
behind  will  sometimes  shrivel  up,  but  usually  it  will  grow  again  to  nearly 
its  former  size.  Apparent  recurrence  comes  from  the  pathological  fact  that 
large  areas  of  mucous  membrane  in  the  middle  meatus  are  edematous  and 
send  forth  new  buds  and  projections  as  fast  as  room  is  made  below  for 
them.  An  attempt  should  therefore  always  be  made  to  curette  this  surface 
or  cauterize  it  thoroughly.  The  cautery,  however,  should  never  be  used 
unless  a  view  can  be  had  of  the  field  of  operation.  Most  frequently  the 
bases  of  these  growths  are  out  of  sight.  The  curette  in  skilful  hands  is  then: 
of  service.  As  may  be  readily  understood,  no  certain  assurance  can  ever  be 
given  after  any  operation  or  series  of  operations,  however  thorough,  that 
further  polypi  may  not  subsequently  develop;  and  the  patient  should  be  cau- 
tioned to  present  himself  after  a  lapse  of  several  months  for  a  careful  inspec- 
tion of  the  nasal  chambers.  Not  infrequently  it  will  then  be  seen  that 
recurrence  has  not  taken  place,  but  that  more  or  less  atrophy  of  the  mucosa 
lias  supervened.  The  question  of  the  degeneration  of  nasal  polypi  into  sarcoma 
has  been  much  discussed.  It  is  impossible  to  deny  that  this  doc-  sometimes 
take  place,  but  many  of  the  cases  so  reported  are  open  to  well-grounded 
suspicion  of  having  been  sarcomatous  from  the  first,  as  many  malignant 
growth-   presenl   an  edematous  appearance. 

Vascular  Neoplasms  of  the  Septum. — These  are  very  frequently 
called  angiomata,  but  they  usually  have  exactly  the  same  structure  as  do 
the  hypertrophies  of  the  posterior  border  of  the  inferior  turbinal  bodies, 
and  are  evidently  dilatation-  of  new  and  old  blood-vessels  in  the  mucous 
membrane  of  this  locality.  Many  cases  reported  as  angiomata  are  appar- 
ently sarcomatous  or  fibromatous  growths,  in  which  vascular  dilatation  i-  a 
marked  feature.  This  is  especially  true  of  growths  occurring  elsewhere  than 
on  the  septum  or  in  the  erectile  tissue  of"  the  turbinal  bodies.  Such  are 
many  of  the  growth-  reported  in  Roe's  tallies,  in  the  Transactions  <</  lh< 
American    Laryngological  Association,   L885. 

In   the   Archiv fur  IJaryngologie,  Bd.  1,  there  is  ;i   symposium  of  reports 

1  Trans.  Amer.  Laryng.  Assn.,   L894. 


L080  NEOPLASMS  OF  THE   UPPER  AIR-PASSAGES. 

of  vascular  tumors  of  the  septum:  13  were  reported,  and  5  cases  may  be 
selected  from  Roe's  tables  as  undoubtedly  benign  vascular  neoplasms  ;  I 
have  sections  of  2  other  growths,  making  altogether  20. 

Some  of  these  doubtless  are  true  angiomata — i.  e.,  made  nj)  of  newly 
Formed  and  dilated  vascular  channels ;  but  it  is  impossible  to  separate  them 
from  the  vascular  growths  which  are  entirely  made  up  of  an  hypertrophy 

of  one  or  more  of  the  elements  of  the  mal  mucous  membrane  combined 

with  marked  vascular  changes.  The  fibrous  elements  may  predominate  or 
the  lymphoid  layer  may  be  greatly  proliferated  ;  but  more  frequently  there 
is  an  unequal  and  irregular  increase  of  all  the  elements  of  the  mucous  mem- 
brane. The  surface-epithelium  is  usually  proliferated,  and  frequently  the 
cells  are  altered  in  shape.  In  other  words,  marked  vascularity  is  a  character- 
istic of  all  septal  neoplasm-. 

Growths  of  similar  structure  in  the  erectile  tissue  of  the  turbinal 
bodies — the  " turbinal  varix "  of  English  writers — will  not  be  considered 
here,  as  they  are  usually  included   under  the  head  of  hypertrophic  rhinitis. 

Symptoms. —  Nasal  obstruction  <>n  the  affected  side  may  have  existed 
for  many  year-.  Hemorrhage  from  the  nostril  frequently  occurs,  and  may 
be  dangerously  abundant.  The  growth  does  not  erode  the  neighboring 
tissues,  although  it  may  completely  fill  the  lumen  of  the  naris.  Some  of  the 
cases  reported  have  been  of  rapid  growth,  and  yet  apparently  benign. 

Examination  shows  a  rounded  growth  with  a  somewhat  irregular  surface 
of  a  bright-red  or  dark-purple  appearance.  It  may  he  abraded  in  place-, 
and  when  probed  bleed  easily.  It  is  more  or  less  movable,  according  to  its 
size  and  the  thickness  of  its  pedicle.  It  is  usually  attached  to  the  anterior 
part  of  the  septum. 

Prognosis. —  If  the  growth  i-  shown  to  have  no  malignant  elements, 
the  prognosis  is  good.  Removal  ir-  comparatively  easy,  and  recurrence  is 
very  exceptional. 

Treatment. — The  galvano-cautery  snare,  armed  with  an  irido-platinum- 
wire  loop,  i-  the  instrument  of  choice.  Jarvis's  original  snare  may  be  used 
and  the  steel-wire  loop  -lowly  tightened,  sometimes  using  several  hours  in 
the  process.  A  rapid  cutting-operation  is  pretty  sure  to  he  followed  by 
severe  hemorrhage,  and  this  may  occur  after  any  operation  with  the  wire,  how- 
ever -low.  For  slighl  oozing  the  galvano-cautery  is  sometimes  efficacious. 
Firm  packing  with  -trio-  of  iodoform  or  borated  gauze  should  he  employed 
in  obstinate  cases,  and  pressure  exerted  against  the  ala  from  the  outside,  since 
tlii'  site  of  the  growth  i^  usually  far  enough  forward  lor  this  simple  pro- 
cedure to  avail. 

Fibroma. — While  it  occasionally  occurs  in  and  about  the  naso-pharynx, 
fibroma  springing  from  tin'  nasal  structures  is  exceedingly  rare. 

One  reported  by  Dr.  Charles  H.  Knight1  I  had  the  privilege  of  examin- 
ing microscopically  (Fig.  625).  It  was  a  smooth  movable  growth,  attached 
to  the  posterior  end  of  the  middle  turbinal  body,  ami  was  darker  in  color 
than  the  average  edematous  polyp.  Microscopically  it  was  -ecu  to  he  covered 
by  columnar  epithelium,  and  was  made  up  exclusively  of  homogeneous  bun- 
dles of  curling  elastic  fibers.  It-  removal  l>\  the  cold  snare  was  easily  per- 
formed :ind  produced  no  hemorrhage.     There  was  no  recurrence.     A  number 

of  cases  have  been  collected   fr literature  by  Bosworth,2  Casselberry  and 

other-:  hut  :i  perusal  of  the  reports  leaves  one  in  considerable  doubl  a-  to 
the  accuracy  of  the  histological  diagnosis  or  of  their  intranasal  origin.  Even 
the  case  referred  to  here  as  of  undoubted  histological  character  and  spring- 

1  Manhattan  Hospital  /.'  !  in  vorth :    />>  \    ■  and  Throat. 


NASAL   NEOPLASMS. 


1081 


Fig.  625.— C.  II.  Knight's  case  of  nasal  fibroma. 


ing  from  an  intranasal  structure,  might  be  more  conveniently  considered  under 
the  heading  of  naso-pharyngeal  growths.1 

Fibroma  Papillare  or  Papilloma. — 'Feu  or  a  dozen  undoubted  cases, 
and  probably  a  few  more,  have  been  reported,  but  some  confusion  exists  as  to 
their  identity  ;  the  same  name  having  been  given  by  Hopman2  and  many  of 
the  Germans  to  the  papillary  hypertrophies  of  the  nasal  mucous  membrane, 
which  occur  so  frequently  in  the  regions  of  erectile  cavernous  tissue.  True 
papilloma  is  made  up  of  epithelial  cells 
supported  by  a  delicate  framework  of 
new  connective  tissue,  rising  on  the  sur- 
face as  papillae  and  dipping  into  the  un- 
derlying stroma  as  (limitations.  They 
grow  principally  by  the  proliferation 
of  epithelial  structure.  They  occur  in 
the  nose,  either  as  soft  pedunculated 
masses  or  as  hard  warts  on  the  ante- 
rior portions  of  the  septum.  The  soft 
growths  also  occur  on  the  floor  of  the 
nose  and  on  the  anterior  portions  of 
the  external  wall.  So  constantly  is 
this  the  rule  in  those  cases  which  have 
been  examined  and  properly  classified, 
that  any  papillary  growth  seen  to  be 
springing  from  other  localities  or  re- 
ported without  microscopical  proof  as 
having  been  found  elsewhere  in  the  nose,  may  be  regarded  as  probably  not 
a  papillary  fibroma.  Exactly  such  a  growth  as  figured  in  Zuckerkandl's 
"Anatomy  of  the  Nasal  Fossse" — springing  from  the  middle  of  the  under 
surface  of  the  inferior  turbinal — I  once  examined  and  found  to  be  a  papil- 
lary hypertrophy.' 

True  papillomata  of  the  septum  have  been  observed  at  all  ages.  I  have 
examined  one  for  Dr.  Arrowsmith  of  Brooklyn  coming  from  the  nasal  fossa 
of  a  child  of  five,  and  Santi  has  reported  one  in  a  man  of  eighty-four.  Sex 
seems  to  have  no  influence. 

They  are  usually  of  slow  growth  and  painless,  but  sometimes  bleed 
easily.  They  cause  nasal  obstruction  and  have  a  valve-like  action  on  the 
respired  air,  as  in  the  case  of  the  ordinary  polyp.  They  have  a  vascular 
fungous  look  and  are  freely  movable.  Hemorrhage  on  removal  may  be 
abundant,   but   i-  easily  controlled.      They  do  not   tend   to   recur. 

1  Bosworth,  by  saying  that  all  nasopharyngeal  fibromata  spring  from  the  basilar  process 
of  the  occipital  in-  tl>t-  body  of  the  sphenoid  bone,  excludes  all  of  1 1 1< >^<  whose  origin  is  in  the 
immediate  vicinity,  just  within  the  choanse.  These  lie  evidently  includes  amongthe  nasal 
growths,  since  he  refers  to  -11  eases  in  literature,  most  of  which  seem  to  have  had  all  the  char- 
acteristics of  the  naso-pharyngeaJ  growth  and  some  probably  sprang  in  reality  from  behind  the 
choanse,  forming  secondary  attachments  within  the  nose.  Mackenzie,  mi  the  other  hand,  gives 
a  mi. re  liberal  interpretation  to  the  term  naso-pharyngeal  fibroma,  ami  includes  those  which 
spring  from  tin-  immediate  vicinity  cf  the  naso-pharynx  and  present  the  same  or  nearly  the 
same  clinical  features.  Thus  it  comes  that  he  is  a  hie  to  report  hut  one  case  of  In-  own  ol  nasal 
fibroma  and  to  refer  to  very  few  in  literature.  The  case  of  i  >r.  Knight  sprang  from  the 
posterior  end  ot  the  middle  turbinal  body  and  projected  into  the  naso-pharynx.  So  that 
nearly  all  true  fibromata  have  their  origin  on  or  in  the  immediate  vicinity  of  the  roof  of  the 
naso-pharynx;  and  absolutely  none  occur  in  the  anterior  part  of  the  nasal  fossa?.  'I  his  is 
exactly  what  we  should  expect,  when  we  remember  that  the  fibrous  sheet  at  the  roof  of  the 
pharynx  spreads  out  laterally  upon  the  pterygoid  plates,  and  anteriorh  for  some  little  dis- 
tance  along  the  roof  of  the  nose,  and  on  the  vomer  ami  posterior  surfaces  of  the  upper  turbin 
ated  I, -me-.  \irehou       i  ckiv,  93,  L883,  p.  213. 

3  .V.    )'.  Med.  Journal,  <  ><t.  13,  ls'.'l  (Dr.  Richard's  case  . 


lOS'J 


NEOPLASMS  OF  THE   UPPER   A  Hi- PASSAGES. 


The  following  references  will  be  found  to  include  nearly  all  the  reports 
of  true  papillomata  uj>  to  August,  1896,  though  some  of  these  are  of  doubt- 
ful character  : 

Michel  :  Krankheiten  der  Nasenhohle  (Translated  by  Shurly,  p.  72). 
Zuckerkaudl  :   Anatomic  der  Nasenhohle,  L8S2,  p.  70. 
\  .  -  iguer:  Annates  des  Maladies  de  VOreille,  Nov.  L885,  p.  335. 
ButliD  :  St.  Bartholomew's  Hospital  Reports',  L885,  p.  150. 
Verneuil :   Bull,  et  Men.  <l,-  hi  Socie'ti  de  <  'hirurgiede  Paris,  No.  12,  1886,  p.  658. 
Solis-Cohen :   Revue  de  Laryngologie,  1889,  p.  151. 
Cozzolino :   Revista  Clinica  et  Terapeutica,  No.  '1,  Feb.,  1887,  p.  75. 
Mulhall:    Trans.  Artier.  Laryng.  Assn.,  1890. 
Santi:    The  Lancet,  Dec.  8,  L894. 
Wright  :    Traits.  Amer.  Laryng.  Assn.,  1895. 
Mackenzie  (G.  Hunter) :  Lancet,  Aug.  15,  1896. 

Treatment. — Removal  by  the  snare  can  usually  be  accomplished  with- 
out much  hemorrhage.  As  the  growth-  are  situated  in  the  anterior  part  of 
the  nose,  bleeding,  if  it  occurs,   may  be  easily  controlled. 

Bony  cysts  of  the  nose  are  of  moderately  rare  occurrence.  They  are 
found  in  the  anterior  end  of  the  middle  turbinated  bone,  and  may  contain 
only  air  or  a  yellow  viscid   fluid  or  pus. 

Pathology. — The  middle  turbinated  bone  is  considerably  enlarged  ante- 
riorly, and  is  covered  by  bypertrophied  and  usually  edematous  mucous  mem- 
brane.     Edematous  polypi  are  frequent  complications. 

Microscopical  examination  of  the  bony  wall  must  be  made  after  de- 
calcification. Sections  are  then  cut,  and  it  will  be  seen  that  the  cyst-cavity, 
which  may  be  as  large  as  a  cherry,  is  lined  by  a  scanty  stroma  without 
glands  or   many  blood-vessels  and  by  columnar   ciliated  epithelium.     The 


'■     ■-.'.. 


<re. 


i 


3 


C.e 


l 

'    bone ;  B7,  Howship's  lacunae  with  new  connective  tissue  and  bl l 

■  •   ciliated  epithelial  lining  of  cyst  ca^  Ity  ;  Se,  surface  epithelium  ;  g,  glands. 

bony  tissue  itself  is  seen  to  be  in  a  condition  of  hyperplastic  and  rare- 
fying inflammation,  with  the  formation  of  new  bone-tissue  and  the  absorp- 
tion of  old  and  new  bone.  This  is  carried  on  by  means  of  osteoblasts  and 
oclasts  and  the  formation  of  I  [owship  lacunae.  There  are  lakes,  or  rather 
gulfs  and  bays,  of  im'u  connective  tissue,  which  nourish  the  peculiar  cuboidal 
cells  which   line  their   shore,  and   which   have  the  power  of  secreting  and 


NASAL  NEOPLASMS. 


1083 


absorbing  bone-salts 


Figs.  626,  t>-7,  from  a  section  of  a  specimen  sent  me 
by  Dr.  Butts  of  New  York  City,  show  this  process,  which  is  essentially  the 
same  as  the  physiological  process  of  bone-growth. 

Occurrence. — The  condition  is  almost  wholly  confined   to  women  after 
puberty  and  before  old  age.      We  see  here,  as  well  as  in  atrophic  rhinitis  and 


H.t!~ 


t,.:i     • 


Fig.  627.— Section  of  bony  wall  of  cyst,  showing  a  Howship  lacuna  with  its  marginal  osteoclasts  (Oc) 
below,  and  the  osteoblasts  (Ob)  on  the  convexity  of  the  bony  lamella. 

naso-pharyngeal  fibroma,  the  marked  influence  of  sex  on  morbid  processes 
in  the  nose.  I  am  not  aware  that  these  cysts  have  been  reported  as  existing 
in  any  other  locality  in  the  nose  than  at  the  anterior  end  of  the  middle  tur- 
binated bone. 

Symptoms. — Pain  with  frequent  exacerbations  is  the  prominent  symp- 
tom in  these  cases.  Nasal  obstruction  also  exists,  but  may  not  be  complete  : 
at  times  it  is  the  only  symptom  present.  As  the  patient  nearly  always  has 
edematous  polypi  in  the  same  nostril,  the  symptoms  depend  somewhal  on 
that  condition.     These  symptoms  have  usually  extended  over  many  years. 

Examination  after  removal  of  projecting  polypi  shows  a  rounded  resist- 
ing mass  at  the  anterior  end  of  the  middle  turbinated  hone,  a  part  oi  which 
it  forms,  pressing  firmly  against  the  septum  and  sometimes  causing  a  marked 
deviation  of  it.  The  feeling  imparted  to  a  probe  conclusively  shows  that  the 
mass  is  made  up  of  bone. 

Etiolog-y. —  From  what  has  preceded,  the  inference  is  pretty  clear  that  we 
have  here  a  pathological  condition  which  is  the  resull  of  chronic  inflamma- 
tion. This,  beginning  in  the  mucosa,  results  in  the  formation  of  edematous 
polypi,  as  explained  under  that  heading.  The  inflammatory  process  is  in 
time  transmitted  to  the  underlying  periosteum  and  hone,  and  we  have  then 
the  condition  of  hypernutrition  which  causes  the  growth  of  the  bony  struc- 
ture. This  we  should  expect  to  result  in  the  porous  formation  observed  in 
other  hyperplastic  bone-processes,  and  this  we  frequently  see  in  dried  speci- 
mens of  the  middle  turbinated.  Since  there  is  mucous  membrane  lining  the 
walls  of  these  cysts  provided  with  columnar  ciliated  epithelium,  we  must 
presume  that  communication  has  existed  at    some  time  with  the  external   sur- 


L084  NEOPLASMS  OF  THE   UPPER  AIR-PASSAGES. 

face.  The  demonstratioo  of  the  proliferative  bone-formation  in  the  walls 
of  these  cysts  shows  pretty  clearly  the  method  of  developmenl  into  large 
spaces  of  whal  were  originally  small  cavities.  Their  communication  with  the 
ethmoidal  labyrinth  may  have  closed  before  the  end  of  embryonic  develop- 
ment, or  it  may  have  existed  prior  to  inflammatory  changes  and  have  Ween 
closed  l>v  them,  or  the  communication  may  still  exist.  Dr.  T.  Passmore 
Berens  of  New  York  was  kind  enough  to  show  me  a  dry  specimen  of  cystic 
enlargement  of  the  anterior  end  of  the  middle  turbinated  bone,  in  which  the 
communication  was  wide  and  direct. 

Treatment. -Tin  steel-wire  snare  may  he  used  to  remove  these  bony 
outgrowths.  It'  they  are  too  resistant  <>r  too  firmly  wedged  against  the  sep- 
tum to  allow  the  use  of  this  instrument,  a  perforation  may  be  made  into  the 
cavity  with  a  dental  burr  or  trephine  and  the  bony  walls  then  removed  piece- 
meal with  rongeur  forceps.  Hemorrhage  may  he  considerable,  and  there 
may  be  considerable  inflammatory  reaction.  When,  as  frequently  happens, 
there  are  carious  hone  and  edematous  polypi,  curetting  must  also  he  employed. 

Literature  of  Bony  Cysts  of  the  Nose. 

Zuckerkandl  :    Norm,  and  Path.  Anatomir  ih-r  Xaxrnhiihle,  181>.°>,  vol.  i.  p.  G3. 

Stieda:  "Inaug.  Dissertation,"  Rostock,  1895. 

Glasmacher :  Berlin,  kiln.  Woch.,  No.  36. 

Beyer:  Tnternat.  Oentralb.  f.  Laryngologie,  etc.,  vol.  ii.,  No.  5,  p.  237. 

Schaffer:   Erfahrungen  in  der  Rhin.  und  Laryng.,  Wiesbaden,  1885. 

McBride:  "Diseases  of  Throat,  Nose,  and  Ear,"  original  report,   Edinburgh   Med. 

Jour,,..   Dee..   L888,    p.  304. 

Schmiegelow:   Revue  de  Laryngologie,  etc.,  No.  in,  1890. 
B.  Frankel:   Berl.  klin.  Woch.,  No.  22,  p.  498,  L890. 
P.  I  [egeman  :   Ibid. 

Chas.  II.  Knight:  Tram.  Amer.  Laryng.  Ass,,.,  1891;  i\r.  Y.  Med.  Journ.,  Mar.  19, 
1  392. 

Stieda:  Archiv  f.  Laryn.  und  Rhin..  Bd.  3,  No.  3,  L895. 

Wagnier:   Rev.  de  Laryngol.,  etc.,  No.  22,  L895. 

Castafieda:   Archivos  Latinos  de  Rinologia,  Sept.  and  Oct.,  1895. 

Macdonald:   Lancet,  June  20,  1891. 

Zwillinger:    Wiener  klin.  Woch.,  No.  19,  1891. 

Wright:  N.   V.  Medical  Journal,  June  27,  1896. 

Cysts  of  the  nasal  mucous  membrane,  sometimes  called  cyst- 
omata,  are  occasionally  reported.  They  are  always,  I  believe,  of  glandular 
origin,  resulting  from  the  excessive  dilatation  of  glands  in  edematous  polypi 
or  tissue. 

Osteoma  and  chondroma  have  both  been  reported  as  new  growths  in 
the  nose.  They  are  of  exceeding  rarity,  and  are  not  to  be  confounded  with 
the  very  common  exostoses  and  ecchondroses  of  the  septum. 

A-  has  heeii  intimated,  true  tumor- — i.  e.,  circumscribed  neoplasms  not 
due  to  inflammation  are  rare  in  the  nose,  and  in  my  experience  such  benign 
tumor-  are  much  more  rare  than  malignant  growths.  It  is  exceedingly  diffi- 
cult, however,  to  gain  any  idea  of  tin-  from  rhinological  literature,  a-  all 
sorts  of  inflammatory  phenomena  are  classified  as  tumors.  The  writer  does 
ii'.t  speak  of  true  myxoma  of  the  nose,  because  oul  of  many  hundred  sec- 
tions of  50  or  60  specimens  of  mucous  polypi  examined  microscopically,  and 
many  more  nasal  neoplasms  seen  and  operated  on  clinically,  he  has  never 
observed  a  nasal  growth  thai  was  plainly  a  true  myxoma.  There  is  hardly 
a  case  reported  in  literature,  in  which  the  diagnosis  is  not  open  to  grave  criti- 
cism from  the  data  given  or  from  insufficiency  of  data.  Nevertheless,  it  is 
probable  thai  such  true  tumor-  do  occasionally  groM  in  the  nose. 


NASAL  NEOPLASMS.  1085 

MALIGNANT  TUMOES  OF  THE   NOSE. 

Adenoma  is  said  to  be  a  benign  growth  ;  but  it  is  so  frequently  com- 
bined with  carcinomatous  or  sarcomatous  elements,  and  it  i-  said,  even  when 
pure,  to  degenerate  so  frequently  into  malignancy,  that  its  occurrence  in  any 
structure  is  to  be  looked  upon  with  suspicion  as  to  its  benign  character.  Pure 
adenoma  (Fig.  628)  in  the  uose  is  almost  unknown,  although  hypertrophy  of 


'•V7,\.'     '•    \      "?_  y 


m 


, 


Fig.  628.— Adenoma  of  the  nose. 

the  glandular  structures  of  the  mucosa  is  occasionally  seen  carried  to  such  an 
extent  that  the  question  of  its  inflammatory  origin  may  well  be  raised.  A 
typical  adenoma  is  made  up  of  epithelial  cells  so  arranged  as  to  form  convo- 
lutions and  tubules  more  or  less  resembling  gland-structure.  Cndeed,  it 
usually  springs  from  the  glandular  cells  of  various  organs.  There  is  very 
scanty  connective  tissue,  round  cells,  and  blood-vessels.  I  have  in  my  pos- 
session sections  of  a  nasal  tumor,  in  portions  of  which,  at  least,  pure  adeno- 
matous structure  may  be  observed.  The  case  was  under  the  care  of  Dr. 
Thomas  J.  Harris,  at  the  Manhattan  Eye  and  Ear  Hospital,  and  to  him  I  am 
indebted  for  the  following  history  : 

"  The  patient,  Mr.  C,  is  seventy-five  years  old,  and  lias  been  under  my  care  some 
eighteen  months.  When  lie  first  came  to  the  hospital  in  November.  1893,  he  wa-  a 
most  pitiful  object.  There  was  total  occlusion  of  the  nares,  with  muco-pus  constantly 
dripping  from  them.  They  were  filled  with  masses  of  tumors  presenting  all  the  appear- 
ances of  the  common  gelatinous  polypi.  By  snare  and  curette  in  a  number  of  opera- 
tions I  removed  everything,  making  a  diagnosis  (from  repeated  recurrences)  of  myxo- 
sarcoma. For  nearly  a  year,  with  occasional  gentle  curetting,  the  nares  remained  clear. 
Sis  appetite  returned  and  he  pronounced  himself  (aired.  In  November,  lW-t,  exoph- 
thalmos (left  eye)  a  pp(  a  red  wit  li  constant  pain.  I  then  supposed  that  the  ethmoid 
sinuses  had  been  invaded,  hut  on  account  of  his  age  determined  to  attempt  no  operation. 
The  nose  still  remained  comparatively  i'rrv.  Some  two  week-  ago  the  mass  which  I  sent 
you  suddenly  appeared.  This  I  removed  with  the  cold  snare,  and  considerable  hemor- 
rhage followed.  The  macroscopical  appearances  of  the  tissue  had  long  since  changed, 
and  it  now  -how-  much  necrosis.  Its  malignancy  has  certainly  very  much  increased  in 
tin- eighteen  months  in  which  I  have  observed  the  case." 

This  patient,  Dr.  Harris  informed  me,  lived  until  the  following  summer 
(1895).  The  greater  part  <d"  the  sections  of  the  mass  were  taken  up  with 
convolutions  and  involutions  of  glandular  epithelium.  The  layersoi  epithe- 
lium were  never  more  than  two  or  three  deep,  and  were  supported  by  a  frame- 
work of  new  connective  tissue. 

In  the  portion  of  the  growth  sent  me,  from  which  the  section  shown  in 
Fig. 628  was  made,  I  am  unable  to  find  any  plainly  sarcomatous  tissue;  '"it 
there  are  extensive  area-  of  round  and  spindle-cells  which,  although  they 


L086  NEOPLASMS  OF  THE   UPPER  A  //.'- PASSAGES. 

more  closely  resemble  the  granulation-tissue  of  inflammation,  may  be  of  a 
sarcomatous  nature.  Moreover  the  clinical  history  plainly  shows  that  the 
growth,  at  least  in  its  later  stages,  was  of  a  malignant  character.  By  a  coin- 
cidence, such  as  so  strangely  and  so  often  occurs  in  clinical  work,  a  similar 
instance  of  an  adenoma — this  time,  however,  plainly  showing  sarcomatous 
ti.-sm — came  under  Dr.  Harris's  observation  shortly  after  the  first  case. 

Dr.  Bosworth  says  that  he  has  been  aide  to  rind  in  literature  the  reports 
of  only  a  very  few  cases,  and  even  in  these  there  is  a  reasonable  doubt  as  to 
the  unmixed  character  of  the  growth.  Not  only  does  it  have  on  the  one 
hand  a  puzzling  resemblance  and  a  close  relation  to  glandular  hypertrophy, 
but,  on  the  other  hand,  it  is  frequently  combined  with  epitheliomatous 
appearances — the  so-called   tubular  or   adeno-carcinoma. 

Papillary  Epithelioma  ( gotten krebs). — Closely  allied  to  adenoma, 
if  not  identical  with  it,  is  a  rare  nasal  growth  which  Billroth,1  who  reported 
2  cases,  called  " Zottenkrebs."  Michel,-  Hopman,3  Zarniko,1  and  Kiesel- 
bach5  have  each   reported  a  case. 

The  last  named  called  it  a  papillary  epithelioma.  It  is  a  benign  growth, 
as  a  rule,  and  resembles  a  papilloma.     In  Fig.  029  will  be  seen  the  drawing 


um 


A 


>■.- 


W     04  '^i^'^s 

l'i'..  tVJK.— I'apillary  epithelioma  of  the  nose. 

of  a  slide  sent  me  by  Dr.  Ilinkel  of  Buffalo.  It  came  from  a  tumor  which 
occurred  on  the  middle  turbinal  of  a  woman.  It  will  be  seen  that  it  is 
made  up  of  convolutions  and  involutions  of  columnar  epithelium  supported 
by  a  framework  of  fibrous  tissue  infiltrated  with  round  cells.  It  forms  a 
villous  surface  like  a  papilloma,  but  differs  from  it  in  that  the  layers  of 
epithelial  cells  are  not  thickened  and  do  not  dip  into  the  stroma.  There 
is  no  infiltration  of  tissues  nor  concentric  epithelial  nest-formation  in  the 
tissues,  a-  in  cancer.  In  one  of  Billroth'-  cases  it  had  existed  for  eleven 
year-,  and  in  Kieselbach'a  case  he  had  removed  successive  portions  of  the 
growth  for  a  period  of  six  years.  In  the  cases  of  Zarniko,  Kieselbach,  and 
Ilinkel''  it  ha-  been  reported  a-  occurring  on  the  middle  turbinal.  In 
Zarniko'-  case  it   was  combined  with  edematous  growths. 

From  the  history  of  Verneuil's  case,  which    I   have   placed  among  the 

1  /'.'../•</.  u  Bait  der  Schle&mpolyp.  Di*   Krcmkheiten  der  Nanenhofde,  etc. 

Irehiv,  Bd  93,  j>.  234.  '  VirchoVa  Archiv,  Bd.  128,  \>.  132. 

0  Vircbow's  Archiv,  Bd.  L32,  p.  371.  '  Hinkel,  Trans,  Amer.  Laryng.  Assn.,  1898. 


NASAL  NEOPLASMS. 


1087 


papillomata  because  it  was  so  reported,  we  may  conjecture  that  it  was  pos- 
sibly also  of  this   nature.     Otherwise   it   is  a   unique   case  of  papilloma. 

Sarcoma,  in  my  experience,  is  the  most  common  tumor  of  the  nasal 
fossa?,  if  we  exclude  those  benign  neoplasms  which  are  the  result  of  the 
various  forms  of  chronic  inflammation  or  directly  connected  with  them. 
This,  however,  I  am  aware,  does  not  coincide  with  the  statements  of  those 
who  have  had  larger  experience  and  perhaps  wider  fields  of  observation. 
The  discrepancy,  as  intimated  above,  is  evidently,  however,  one  of  patho- 
logical  nomenclature. 

This  i>  not  the  place  for  an  extended  description  of  the  histology  of 
sarcoma,  which  in  the  nose  presents  no  characteristics  to  distinguish  it  from 
sarcoma  elsewhere  in  the  body.  Dr.  Bosworth  ]  has  given  abstracts  of  the 
histories  of  41   patients  with  sarcoma  of  the  nose. 

Newman,  in  his  excellent  monograph  on  "Malignant  Disease  of  the  Nose 
and  Throat,"  gives  the  history  of  3  cases  of  sarcoma  and  '2  of  carcinoma  of 
the  nose,  as  well  as  a  complete  bibliography  of  the  subject.  His  table  of 
ages  at  which  sarcoma  occurs  is  given  as  follows: 

Below  10  years 6  per  cent. 

10  to  20 19 

20  "  30 8 

30  "  40 9 

40  "  50 39 

50  "  60 8        " 

60  "  70 9        " 

Above  70 2 

I  have  in  my  collection  microscopical  sections  of  two  specimens  sent  me 
by  Dr.  Thomas  J.  Harris  of  New  York — one  of  adeno-sarcoma,  the  other 
of  angio-sarcoma  (Fig.  631),  also  a  specimen  of  endothelial  sarcoma  (Fig. 


Fig.  630.— Endothelial  sarcoma  of  the  septum. 


Fig.  631.— Angio-sarcoma  of  the  septum. 


630),  from  Dr.  F.  W.  Hopkins  of  Springfield,  Mass.,  and  one  of  alveolar 
sarcoma,  from  Dr.  W.  P.  Brandegee  of  New  York.  Gouguenheim  and 
Hilary,2  Dansac,3  and  Katzenstein  '  have  reported  5  others.  This  makes  53 
cases  in  all,  from  which  certain  facts  are  apparent. 

It  is  difficult  to  ascertain  what  form  of  Barcoiua  h;i~  been  most  fre- 
quently observed  in  the  nose,  as  the  nomenclature  in  the  reports  varies  eo. 
All  forms  seem  to  have  been  noted,  the  round-celled  variety  perhaps  more 
frequently. 

As  to  age,  15  of  them  were  between  forty  and  fifty,  11  were  over  fifty, 


1   Disease*  of  lh>-  Aw;  ami  Throat. 
1  Bid.,  1893. 


■■    I  „„.//.,•  ,/.     1/  de  FOreilk,  1893. 

♦  Ibid.,  1891. 


1088  NEOPLASMS  OF  THE   UPPER  AIR-PASSAGES. 

and  17  were  under  forty  years  of  age.  <  >f  those  in  whom  sox  was  mentioned, 
29  were  women,  24  were  men.  The  right  side  of  the  nose  was  affected  15 
times  and  the   left   side  !»  time-. 

Etiology. — This  is  entirely  unknown.  Too  many  people  have  chronic 
rhinitis  to  permit  as  to  state  thai  nasal  catarrh  is  a  predisposing  factor. 
Injury  is  too  infrequent  an  incident  in  the  clinical  history  to  allow  us  to  look 
on  it  as  an  exciting  cause.  It  occur-  mosl  frequently  in  middle  life,  when, 
as  a  rule,  over-nutrition  of  cell-life  has  ceased  and  before  degeneration- 
changes  have  set  in. 

It  may  be  well  again  to  say  that  convincing  evidence  of  sarcomatous 
degeneration  in  benign  tumors  or  in  inflammatory  neoplasms  of  the  nose  is 
lacking.  None  of  the  cases  of  such  asserted  raalignanl  transformation  are 
frc.  from  the  reproach  of  insufficient  observation  or  incomplete  examination. 
Surface  appearances  and  the  early  clinical  history  are  not  criteria  of  histo- 
logical structure.  The  possibility  of  such  transformation,  however,  cannot 
be  denied. 

Symptoms. — Unremittent  and  increasing  unilateral  nasal  obstruction, 
accompanied  often  by  repeated  epistaxis,  is  the  initial  sign  of  malignant 
oasal  disease.  The  patient  soon  complains  of  pain,  referred  to  the  brow  or 
temple.  At  first  a  watery,  then  a  sanious  muco-purulent,  discharge  comes 
from  one  or  both  uostrils.  Photophobia  and  epiphora  on  the  affected  side 
are  usually  present,  and  there  may  be  affection  of  the  vision  from  pressure  on 
the  optic  nerve.  The  general  health  is  at  first  but  slightly  affected.  As  the 
tumor  grow-,  pain  and  loss  of  appetite,  sleepless  nights,  frequent  epistaxis, 
the  nauseous  odor  and  the  mental  distress  cause  rapid  loss  of  strength  and 
flesh,  making  an  unmistakable  picture  of  human  misery.  Exophthalmos,  the 
widening  of  the  bridge  of  the  nose  (the  so-called  "  frog- face  "),  edema  and 
discoloration  of  the  face  are  the  external   evidences  of  the  disease. 

Examination  at  an  early  stage  may  reveal  implantation  of  the  growth 
at  any  point  in  the  nasal  chambers.  It  may  be  a  smooth,  somewhat  resilient 
growth  ;  but  it  is  usually,  especially  in  the  later  stages,  a  friable  fungous 
mass,  bleeding  easily  when  touched.  Portion-  of  it  are  apt  to  be  edematous, 
and  it  may  have  every  appearance  of  the  ordinary  nasal  polyp,  but  the  coloi 
is  apt  t«»  be  darker.  It  is  evidently  more  vascular,  and  it  may  not  be  at  the 
usual  site  of  origin  of  the  ordinary  polypus.  The  growth  soon  reaches  such 
a  size  thai  it  is  impossible  to  make  out  its  origin.  The  nasal  cavity  is  filled, 
and  it  encroaches  upon  and  fills  the  naso-pharynx.  It  may  grow  into  the 
antrum.  It  soon  projects  from  the  nostril  anteriorly.  It  may  grow  upward, 
absorbing  the  cribriform  plate  and  causing  death  ;  or  it  may  grow  downward, 
pushing  down  the  sofl  palate  or  eroding  the  bony  nasal  floor.  Cervical 
glands  al   the  angle  of  the  jaw  are  usually  not  involved  until  a  late  stage  of 

the     di-ea-e.     wllell     the     diagnosis     is     tolerably    ele:ll\ 

Diagnosis. — The  patienl  usually  does  not  presenl  himself  until  it  i<  per- 
fectly evident  that  we  have  a  malignant  growth  to  deal  with,  but  some  cases 
have  been  reported  a-  seen  in  their  earliesl  stages,  [ts  vascularity  or  its  lack 
of  transparency,  it-  unusual  implantation,  its  proueness  to  considerable  hem- 
orrhage, or  it-  appearing  a-  a  single  growth,  may  arouse  suspicion  that  it  is 
not  .in  ordinary  edematous  polypus.  It-  prompl  extirpation  and  microscop- 
ical examination  should  follow.  11"  the  microscope  should  reveal  theappear- 
ances  of  a  round-celled  sarcoma,  the  clinical  observer  musl  not  unreservedly 

l>t  the  diagnosis,  however  -killed  a  microscopisl  may  have  made  it.  The 
vigorous  administration  of  the  todid  of  potash  combined  with  mercury  may 
disprove  the  mosl  positive  assertion  of  the  pathologist  and  the  mosl  careful 


TUMORS  OF  THE  SINUSES.  1089 

diagnosis  of  the  clinician.  The  other  forms  of  sarcoma,  however,  do  not  so 
much  resemble  the  granulation-tissue  of  syphilis  or  tuberculosis.  From  the 
vascular  growths  of  the  septum,  the  so-called  bleeding  polypi  or  angiomata, 
sarcoma  is  to  be  distinguished  by  its  more  rapid  growth  and  by  its  greater 
friability  and  tendency  to  bleed  on  slight  provocation.  A  sarcoma  of  the 
septum  in  its  early  stages  may,  however,  closely  resemble  these  vascular 
growths  both   in  structure  and  general  appearance. 

Prognosis  depends  largely  on  the  character  of  the  elements,  the  situa- 
tion, involvement  of  parts,  rapidity  of  growth,  and  the  promptness  with 
which  the  character  of  the  trouble  is  recognized  and  the  proper  treatment 
instituted.  Mingled  with  fibrous,  vascular,  or  glandular  hyperplasia,  prompt 
and  thorough  eradication  may  result  in  cure,  or  at  least  in  indefinitely  putting 
off  recurrence.  Frequent  recurrences  do  not  necessarily  make  the  ease  hope- 
less. It  should  be  carefully  watched  and  new  growths  promptlyand  thoroughly 
removed.  When  situated  in  the  upper  part  of  the  nose  it  may  easily  have 
involved  intricate  and  vital  structures,  rendering  complete  removal  impos- 
sible. Wherever  it  may  lie  attached,  no  operation  should  he  attempted  that 
does  not  hold  out  a  chance  of  complete  removal.  Any  incomplete  operative 
measures  will  only  accelerate  the  growth  and  render  the  patient's  doom  more 
certain. 

Treatment.' — When  the  growth  is  circumscribed  or  has  a  pedicle,  re- 
moval by  the  hot  or  cold  snare  and  subsequent  curetting  of  its  base  may  be 
efficient.  Application  of  caustics,  cauterization,  or  electrolysis  should  be 
avoided.  An  external  operation  may  hold  out  prospects  of  thorough  re- 
moval which  internal  operations  do  not :  if  so,  this  heroic  treatment  should 
be  promptly  adopted. 

Carcinoma  of  the  nose  is  of  rare  occurrence.  Many  of  the  eases 
referred  to  by  Bosworth  are  apparently  not  substantiated  by  a  microscopical 
diagnosis.  Seifert  and  Kahn  picture  one  in  their  histological  atlas,  and  Dr. 
Beaman  Douglas  has  lately  reported  one  in  the  X  V.  Medical  Record, 
Aug.  8, 1896.  The  symptoms  do  not  differ  materially  from  those  of  sarcoma, 
from  which  it  must  be  diagnosticated  by  means  of  the  microscope. 

The  prognosis  is  entirely  bad.  Operation  does  not  lengthen  life  nor,  as 
a  rule,  alleviate  suffering. 

TUMORS  OF  THE   SINUSES. 

Benign  neoplasms  of  the  maxillary  sinus  are  :  Bony  cysts,  which 
occur  in  connection  with  the  roots  of  the  teeth.  Edematous  polypi,2  which 
occur  occasionally  as  the  result  of  purulent  inflammation,  but  are  also  fre- 
quently found  at  autopsy,  having  given  no  sign  during  life. 

Cysts  of  the  mucous  membrane  are  also  seen  very  frequently  post- 
mortem. Rarely  they  till  the  whole  antrum,  as  in  a  case  reported  by  Dr. 
Chas.  II.  Knight.3 

The  suggestion  was  made  many  years  ago  and  adopted  by  \  irchow  '  that 
the  cases  of  the  so-called  hydrops  of  the  antrum  of  Highmore  were  probably 
of  this  nature.     The  cysts  are,  as  in  the  nose,  of  glandular  origin. 

1  Coley's  method  of  treatment  by  erysipelatous  streptococcus-serum  is  credited  with  some 
success  in  otherwise  hopeless  Belected  cases,  especially  of  spindle-celled  sarcoma,  wherever 
situated. 

2  Zuckerkandl,  Normale  and  Pathologische  Anatomie;  Heyman,  Virchow's  Arckiv,  I'd.  cxliii., 
Heft  1  ;   Frankel,  Arcliir  fiir  L<\njmj<>\<>[\\t\  \V\.  iii.,  IU-1't  :'. ;   I  >iiiochowski,  ll>"l. 

3  Trans.  Amer.  Laryng.  Asm.,  1895.  '  Dit  Qt         •     '  .  Bd.  i..  p.  244 

69 


L090  NE0PLA8M8  OF  THE   UPPER  AIR-PASSAGES. 

Osteoma,  apart  from  the  very  common  exostoses,  is  occasionally  noted 
post-mortem. 

1  >e  Roaldes  has  reported  a  remarkable  case  of  compound  follicular  odon- 
toma of  the  antrum.1 

Malignant  Neoplasms  of  the  Antrum. — Sarcoma  lias  frequently 
been  reported  as  primary  in  the  antrum,  and  Schmidt  makes  the  statement 
thai  carcinoma  is  nol  an  infrequent  occurrence.  While  1  have  seen  several 
cases  of  sarcoma  which  presumably  began  in  the  antrum,  I  have  never  seen 
:i  carcinoma,  and  I  am  familiar  with  only  one  report  in  general  literature/ 
This  rase  is  s,,  wdl  authenticated  and  the  history  so  well  reported  by  Dr. 
Reinhard,3  that  an  abstract  of  some  of  the  points  may  be  useful  to  the 
rhinologist  as  illustrating  the  course  of  malignant  disease  in  this  locality. 
The  patient  was  a  man  of  sixty-live.  For  five  years  he  had  suffered  from 
left-sided  nasal  obstruction,  and  for  one  year  from  unilateral  nasal  suppu- 
ration and  radiating  pain  in  the  left  side  of  the  face,  with  loss  of  flesh 
and  strength.  The  anterior  molar  tooth  of  the  upper  jaw  having  become 
carious,  the  patient  had  it  removed,  and  this  was  followed  by  the  discharge 
of  foul-smelling  pus  through  the  alveolus  into  the  month.  The  left  side 
of  the  face  became  somewhat  swollen,  and  the  alveolar  opening  into  the 
antrum  became  larger.  On  using  a  probe  it  was  evident  that  it  did  not 
move  freely  in  the  antrum,  but  was  engaged  in  some  soft  substance.  Fluid 
syringed  in  the  opening  came  out  of  the  hiatus  semilunaris  much  more  quickly 
than  in  simple  empyema  of  the  antrum.  There  were  no  glandular  enlarge- 
ments and  no  eye-symptoms ;  the  patient  receiving  no  benefit  from  constant 
irrigation  of  the  antrum,  a  snare  was  introduced  through  the  alveolar  open- 
ing and  some  of  the  tissue  removed.  A  polyp  was  also  removed  from  that 
side.  Microscopical  examination  showed  the  antral  growth  to  be  carcinoma- 
tons,  and  that  the  nasal  polyp  was  a  hypertrophy  of  the  nasal   mucosa.     On 

a( mt  of  the  severe  pain, excision  of  the  jaw  and  extirpation  of  the  growth, 

which  was  more  extensive  than  expected,  was  performed,  with  at  least  tempo- 
rary relief  from  all  symptoms.  The  patient  was  discharged  live  months  later 
with  no  recurrence.  A  similar  case  has  been  reported  by  Dr.  Wendell 
Phillips.4  I  have  had  the  privilege  of  seeing  the  patient  ami  examining  the 
specimen. 

This  illustrates  how  a  malignant  growth  may  set  up  an  empyema  of  the 
antrum,  which  may  be  taken  for  the  sole  and  primary  trouble.  It  also  shows 
that  the  excision  of  the  jaw  may  he  indicated  and  successfully  performed  for 
temporary  relief  of  the  symptoms,  which  in  this  case  and  in  all  such  cases 
are  unendurable  if  the  operation,  however  severe  and  dangerous,  holds  out 
any  hope  of  relief.  heath  on  the  operating-table  may  perhaps  he  considered 
the  mosl  successful  outcome  for  the  patient. 

The  neoplasms  of  the  ethmoidal  sinuses  may  be  considered  as 
having  been  treated  of  under  the  head  of  nasal  neoplasms.  Nearly  all  the 
edematous  polypi  spring  from  the  mucosa  of  this  region,  and  they  may  .infil- 
trate the  ethmoidal  cells  to  such  an  extent  as  to  simulate  malignant  growths 
by  causing  external  deformity.  The  malignant  growth-  of  the  ethmoid  are 
inoperable,  and   prove  rapidly  fatal   by  extension  to  the  cerebral  cavity. 

Neoplasms  of  the  Frontal  Sinuses.— Osteomata  sometimes  occur 

/  ■         i         - 1 1 1 
-'  Vemeuil  ;il-"  reported  a  case  <>i  epithelioma  of  the  left  maxillary  Binus  in  the  />'»//.  de  In 
i  '.,        ..  ,i    i \  ■     .  1886,  p 
I  in   I  :ill  Von   Primaren   Epithelial  Carcinom  der  Oberkieferhohle,"  Arehiv  f.  Laryn- 

.  Bd  ii  .  i'.  230. 

'    /  /.  i  \gy    .1  nl\ 


TUMORS  OF  THE  NASO-PHARYNX.  1091 

in  the  frontal  sinuses,  and  usually  give  rise  to  uo  symptoms.  Schmidt1  says 
that  occurring  in  the  uose  they  usually  start  from  the  mucosa  of  the  frontal 
sinus,  and  the  same  is  true  of  many  orbital  exostoses.  (  !ysts  of  the  mucous 
membrane  arc  tare,  but  even  dermoid  cysts  have  been  noted  in  the  frontal 
sinuses  and  in  the  anterior  part-  of  the  nose. 

Edematous  polypi  and  especially  edematous  swelling  of  the  mucous 
membrane  are  found  in  connection  with  empyema  of  the  sinus,  and  occasion- 
ally without  pus-formation,  as  a  complication  of  a  similar  condition  in  the 
nasal  mucosa. 

Sphenoid  Sinus. — Similar  pathological  condition-  as  to  neoplasm-  are 
reported  by  Zuckerkandl  as  having  been  found  in  the  sphenoidal  sinus,  bul 
the  diseases  of  these  cavities  have  n<>t  a-  yet  been  sufficiently  studied  to  make 
a  consideration  of  their  neoplasms  profitable  here. 

TUMORS   OF  THE  NASOPHARYNX. 

Naso -pharyngeal    Fibroma. — Naso-pharyngeal   fibroma  is  a  tumor 

which,  in  many  respects,  presents  peculiar  characteristics.  It  is  histologi- 
cally a  benign  growth,  but  owing  to  its  situation  give-  rise  to  symptoms 
which,  if  unrelieved,  are  almost  certain  to  result  in  death  ;  and  it  demand- 
operative  treatment  which  the  most  skilled  rhinologist  and  the  most  daring 
surgeon  are  sometimes  unable  to  afford  with  success. 

It  occurs  almost  exclusively  in  males  between  ten  and  twenty-five  years 
of  age.  So  marked  is  this  influence  of  age,  that  not  a  few  cases  are  recorded 
of  spontaneous  recession  of  the  growth  after  this  period,  affording  in  this 
respect  a  marked  resemblance  to  another  naso-pharyngeal  growth — viz., 
lymphoid   hypertrophy  or  adenoid  vegetations. 

It  is  fortunately  tolerably  rare, and  it  falls  to  the  lot  of  very  few  rhinolo- 
gists  to  have  seen  more  than  two  or  three  instances.  Situated  at  the  base  of  the 
brain  and  at  the  junction  of  the  air-  and  food-paths,  almost  at  the  center  of 
the  skull,  endowed  with  the  faculty  of  unlimited  growth,  pressing  upon  and 
absorbing  even  bony  structure,  its  early  recognition  and  its  prompt  and  vig- 
orous treatment  are  of  vital  importance  to  the  patient  and  of  great  difficulty 
to  the  surgeon. 

It  springs  from  the  dense  fibrous  tissue  and  periosteum  which  cover 
the  under  surface  of  the  basilar  process  of  the  occipital  bone  and  the  body 
of  the  sphenoid.  This  fibrous  tissue  extends  to  some  extent  laterally  down 
to  the  pterygoid  plate  of  the  sphenoid  and  perpendicular  plate  of  the  palate- 
bone,  as  well  as  on  to  the  posterior  ends  of  the  upper  turbinated  bones  and 
the  vomer.  From  these  situations,  also,  fibroma  occasionally  take-  its  origin. 
From  whatever  source  it  springs,  it  may  contract  adhesions  with  contiguous 
structures  by  inflammatory  processes. 

Histology. —  It-  structure  is  dense,  being  made  up  almosl  entirely  <>t 
white  fibrous  tissue,  between  the  fibers  of  which  may  be  seen  in  place.-  areas 
of  round   and   spindle-cells,    which    remind   one   of  sarcoma. 

Etiology. —  Its  more  or  less  sharp  limitation  to  the  age  of  adolescence 
and  the  male  sex  would  seem  to  point  to  some  connection  with  the  cranial 
development,  which  i-  so  marked  during  this  period  ;  but  it  i-  not  an  un- 
known affection  in  the  female  or  before  or  after  the  period  of  ten  to  twenty- 
five,  which  include-   the  great    majority  of  cases.2 

1  Dit   Krankheiten  der  Oberen  Luftwege,  1894,  p.  506. 
See  the  chapters  devoted  t<>  it  in  the  works  of  Morel]  Mackenzie,  Bosworth,  and  Greville 
Macdonald,  and  Lincoln's  classical  papers,  Trans.  Atner.  Laryn.  Assn.,  1879  and  L882;  A.   ) 

.1/.-/.  ./,,,„..  May  -Jf.,  1894,  p.  653. 


1092  NEOPLASMS  OF  THE  UPPER  AIR-PASSAGES. 

Symptoms. — The  initial  symptoms  arc  apt  to  be  those  of  post-nasal 
catarrh,  accompanied  by  repeated  and  at  times  gravl  epistaxis.  The  evi- 
dences of  post-nasal  obstruction  soon  supervene — the  dead  voice  and  thick 
speech  and  difficulty  in  respiration.  Deafness,  more  or  less  marked,  is  pres- 
ent.    A  peculiar  condition  of  soi lence  has  been  noted  in  many  case.-,  the 

patient  being  often  overtaken  by  sudden  and  irresistible  drowsiness.  Pos- 
sibly this  may  be  akin  in  it-  etiology  to  the  aprosexia  from  which  some 
adenoid  cases  suffer.  Later,  pain  and  a  muco-purulent  discharge  may  be 
present.  Pressure  on  the  neighboring  parts  results  in  external  deformity — 
the  separation  of  the  maxillary  bones  and  the  exophthalmos — producing  the 
hideous  aspect  known  a-  "  I'm-  lace."     Growth  downward  forms  a  hindrance 

t«.  deglutition  ;  whil< asionally,  though  rarely,  upward  growth  through  the 

foramen  lacerura  medium  or  by  absorption  of  the  hone  may  cause  cerebral 
symptoms  and  death.  According  to  Greville  Macdonald,1  vomiting  is  some- 
times a  distressing  symptom. 

Examination  with  the  post-nasal  mirror  shows  a  smooth  rounded  mass 
of  a  color  varying  from  pink  to  dark  purple.  Varicose  blood-vessels  may 
he  -en  on  the  surface.  It  may  project  into  the  nasal  fossae  and  he  -ecu  by 
anterior  inspection.  It  may  grow  through  the  spheno-maxillary  fissure  and 
be  felt  under  the  zygoma.  When  of  moderate  size  its  base  of  implantation 
may  he  seen  ;  hut  usually  it  \\\\<  the  post-nasal  -pace,  and  so  frequently  has 
contracted  adhesions  to  neighboring  part-  that  it-  origin  cannot  he  distinctly 
made  out.  It  usually  ha-  a  broad  base,  hut  it  sometimes  has  a  small  one, 
being  pedunculated  and  freely  movable.  This  may  he  appreciated  by  a 
probe  through  the  nasal  fossae  or  by  the  finger  behind  the  palate.  To  the 
fineer  it  has  a  firm  elastic  feeling.  Considerable  care  and  gentleness  must 
he  exercised  in  these  maneuvers,  as  alarming  hemorrhage  is  apt  to  occur. 

Diagnosis. — The  chief  difficulty  in  diagnosis  is  to  distinguish  it  from 
sarcoma.  The  age  and  sex  of  the  patient,  the  place  of  origin,  and  to  some 
extenl  the  linn  consistence  of  the  tumor,  may  serve  to  establish  its  nature; 
hut  frequently  the  microscope  must  serve  a-  the  final  arbiter. 

Prognosis. — Naso-pharyngeal  fibroma  is  a  grave  disease  at  best,  but  it 
i-  rendered  -till  moresowhen  it  has  progressed  so  far  as  to  render  an  external 
or  preliminary  operation  necessary.  Left  to  itself,  it  usually  results  in  a 
suffering  death ;  although  some  cases  are  related  where  spontaneous  cure  has 
taken  place.  When  occurring  near  the  end  of  the  period  of  liability,  they 
have  been  observed  to  retrocede  and  even  to  slough  away.  This,  however, 
should  never  he  expected  or  waited  for  if  operative  procedure-  hold  out  any 
hope  of  successful  removal.  The  favorable  cases  arc  those  which  present 
themselves  with  a  pedunculated  growth,  and  in  whom  the  whole  naso- 
pharynx i-   not  filled  with  it  ;  and  if  I    may  he  allowed  to  make  the  remark, 

their  chances  are  < siderably  better  if  at  this  stage  they  fall  into  the  hands 

of  a  -killed  rhinologist  rather  than  into  those  of  a  general  practitioner  who 
does  not  at  once  recognize  the  character  ami  gravity  of  the  case,  or  of  a 
general  surgeon  who  i-  disposed  to  recommend  at  once  an  external  oper- 
ation. 

Treatment. — Several  method-  of  procedure  may  he  adopted.  When  the 
whole  or  a  part  of  the  growth  can  he  included  in  the  loop,  the  irido-platinum 
wire. .fa  galvano-cautery  snare  should  be  used.  Sometimes  the  difficulties 
of  the  technic  are  so  greal  that  it  may  he  necessary  to  abandon  this  and 
make  the  attempt  with  the  Bteel  wire  ..fa  cold  snare,  occupying  several 
hour-  m  completing  the  removal.     Subsequent   cauterization  of  the  -tump 

1  Dim  ''•   Throat  and  A 


TUMORS  OF  THE  NASO-PHABYNX.  1093 

of  the  growth  i>  usually  recommended,  but  its  utility  is  open  to  -nine  doubt. 
Unfortunately  there  are  a  number  of  cases  where  tin-  operation  with  the 
snare  is  impossible.  The  shape  and  broad  attachment  of  the  tumor  is  such 
at  times  that  a  wire  cannot  be  made  to  encircle  the  growth.  Electrolysis 
should  then  be  tried,  more  with  the  hope  of  diminishing  the  size  of  the  mass 
or  altering  it-  shape  to  such  an  extent  thai  the  snare-operation  is  practicable. 
It  i-  sometimes  only  possible  to  remove  it  piecemeal.  Hemorrhage  does  ool 
occur  with  the  hot  snare,  and  is  not  uncontrollable  with  the  cold  wire. 
Tamponing  the  post-nasal  -pace  may  be  necessary,  and  firm  pressure  may  be 
made  with  curved  instruments  against  the  .-tump. 

Recurrence  is  frequent,  and  a  number  of  operations  may  be  necessary. 
If  the  growth  can  be  kept  in  check  until  the  period  of  immunity  is  readied, 
the  recurrence  may  be  finally  prevented,  and  even  retrocession  in  the  growth 
may  be  expected.  The  other  methods  of  treatment  are  injection  of  various 
substances  into  the  growth.  Lactic  acid  has  been  recently  used  by  Ingals1 
with  great  success.  The  galvano-cautery  electrode  may  also  be  used  to 
advantage  at  time.-,  but  usually  as  an  adjuvant  to  more  thorough  methods 
of  removal.  Finally,  as  a  last  resort,  the  patient  may  be  submitted  to  the 
risk  of  an  external  operation.  An  operation  for  a  naso-pharyngeal  growth 
which  cannot  be  removed  by  intranasal  maneuvers  is  necessarily  one  of  the 
gravest  and  most  dangerous  which  the  general  surgeon  can  undertake  ;  and 
statistics  of  the  results  both  in  intranasal  operations  and  in  the  preliminary 
external  operations  seem  to  warrant  the  preference  of  the  best  authorities 
for  the  former,  while  the  latter  procedure  should  be  resorted  to  only  when 
all  other  methods  have  been  demonstrated  to  be  absolutely  of  no  avail. 

FTbro-milCOUS  polypi  are  described  by  various  writers  as  partaking 
partly  of  the  character  of  the  pure  fibroma  and  partly  of  that  of  the  edema- 
tous polypus  within  the  nose.  These  growths  are  evidently  fibromata  of 
sluggish  growth  which  have  become  edematous.  Such  growths  usually  have 
their  origin  partly,  at  least,  within  the  nose.  They  do  not  bleed,  nor  do  they 
tend  by  their  pressure  to  invade  other  regions  and  absorb  adjacent  structures. 
They  are  usually  pedunculated,  and  their  removal  is  not  attended  with  any 
great  difficulties.  They  seem  to  be  regarded  as  of  rare  occurrence  ;  but  it  is 
probable  that  their  comparatively  trivial  character  has  led  to  less  frequent 
reports  than  of  the  more  formidable  fibromata.  They  are  said  by  Bosworth 
to  occur  more  frequently  in  female-. 

The  symptoms  are  those  of  post-nasal  obstruction  and  irritation. 

Examination  shows  that  the  growth  is  paler  in  color  and  has  a  softer 
consistency  and  a  smaller  pedicle  than  the  true  fibroma.      It  is  more  movable. 

Treatment  i-  correspondingly  easier,  it  being  usually  possible  to  remove 
it  with  the  cold  snare  introduced  through  tin-  oose  or  to  twisl  it  from  its 
attachment  with  forceps  or  fingers  from  the  mouth.  It  -how-  little  or  no 
tendency  to  recurrence. 

Bnchondroma.  —  Bosworth  reports  from  literature  only  2  cases  of 
enchondroma  of  the  naso-pharynx.  Nasal  obstruction,  with  headache-  and 
some  external  deformity  from   pressure,  were  noted. 

Hairy  Pharyngeal  Polypi. —  Reports  of  ten  of  these  curious  growths 
have  been  collected  by  Conitzer,2  who  contributed  to  the  number  a  case  of 
hi-  own.  They  contained  not  only  hair- and  their  follicles,  but  also  the  other 
normal  constituent  part-  of  the  -kin.  Most  of  them  also  contained  cartilage. 
They  were  pedunculated  tumors,  attached  usually  i"  the  posterior  surface  of 

the   soft    palate   and  more  frequently  to  the  left  of  the  median    line,  but  some 
1  .V  V.  Med.  Journ.,  Sept.  19,  1896.  /'    I  Woch.,  No.  51,  1892. 


1004 


NEOPLASMS  OF   /'///■:  UPPER  A  IB- PASSAGES. 


in  the  vault  and  posterior  wall  of  the  pharynx.  They  were  presumably  all 
congenital.  A  similar  growth  was  reported  by  Wagner,1  in  1884,  who  called 
it  a  dermoid  oyst.      It  Is  not  included  in  Conitzer's  table. 

Under  the  head  of  Teratomata,  a  number  of  similar  eases  are  referred  to 
by  Lennox  Browne,  in  Burnett's  System  of  Diseases  <>/  the  Ear,  Nose,  >t>t<l 
Throat,  vol.  ii.  j>.  726  ;  and  he  speaks  of  them  as  occurring  also  in  the 
middle  and   lower  pharynx. 

Sarcoma  of  the  Naso-pharynx. — Sarcoma  is  an  occasional  occurrence 
in  the  naso-pharynx.  Bosworth,2  in  1892,  had  collected  from  literature  is 
cases,  and  addetl  the  complete  history  of  a  remarkable  case  of  his  own. 
Fourteen  of  these  cases  were  in  males  and  •">  in  females.  Their  ages  ran 
as  follows  : 

L  to  10 2 

10  to  20 5 

20  to  :;o 3 


30to40 2 

40  to  50 7 


Wr  sec  here,  as  in  sarcoma  of  the  nose,  that  from  forty  to  fifty  is  the 
decade  of  life  furnishing  the  largest   number  of  cases. 

It  is  hardly  necessary  to  repeat  here  the  history  of  the  symptoms  of  naso- 
pharyngeal fibroma,  which  those  of  sarcoma  so  closely  resemble ;  but  it  is 
more  profitable  to  point  out  some  differential  points.  In  the  first  place,  we 
do  not  expect  fibroma  after  twenty-five  years  of  age,  but  younger  than  this 
the  growth  in  question  may  he  either  sarcoma  or  fibroma.  The  symptoms 
have  usually  run  a  more  rapid  course  in  sarcoma,  and  on  examination  it  will 
he  seen  there  has  been  a  correspondingly  rapid  growth  in  the  tumor.  Epis- 
taxis,  while  as  frequent,  is  not  apt  to  he  as  copious  as  in  fibroma.  Ulceration 
of  the  surface  appear-  earlier.  In  Bosworth's  case  and  in  one  other  there 
was  a  general  diffusion  of  the  growth  over  the  pharynx.  Under  the  micro- 
scope  the  appearances  are  usually  characteristic  enough;  but  even   here  the 

diagnosis  of  sarc a,  especially  when  of  the  round-celled  variety,  is  in  some 

cases  extremely  difficult.     Many  cases  of  undoubted  fibroma  present  in  places 
histological  appearances  almost  identical  with  round-celled  sarcoma. 

The  prognosis  is  almost  uniformly  had,  although  Bosworth's  ease  recov 
ered   after   piecemeal    removal    with    the   snare,  and  Warren's   eases  were   all 
well    or   nearly  so   after   external    operation.      This   is   so   unusual  as  to  raise 
some    doubt    a-    to    the    diagnosis,   although   well    certified   to    in    Bosworth's 

ca-e. 

Treatment. —  Fortunately  the  treatment  doe-  nol  hinge  on  a  differential 
diagnosis  between  fibroma  and  sarcoma.  Prompt  and  thorough  removal  by 
intranasal  procedure,  if  possible,  i<  indicated  in  both  cases.  In  Bosworth's 
case  this  was  done  piecemeal  with  the  cold  snare,  and  although  the  mucous 
membrane  was  extensively  infiltrated,  complete  success  was  attained  and  the 
growth  had  not  recurred  after  -even  years.  While  encapsulated  or  circum- 
scribed  sarcomata   may  hi'  thoroughly  removed   l>v  means  of  the  snare,  it   is 

difficult   to  ( ceive  how  a  new  growth,  with  malignant   potentialities  widely 

infiltrating  the  tissues,  can  he  so  thoroughly  removed  by  means  of  a  snare, 

/'  i  a  ■  •■/'  iln  Throat  "ml  \  - 
1  Since  then  cases  have  been  reported  by  Thomas,  Bennett,  Delie,  Lange,  Mclntyre,  Cohen, 
Paige,  Robertson,  [wanicki,  Logan  and  Scheineman,  mid  .-i  case  i-  reported  by  the  I'.  S.  Surgeon- 
General's  Office,  references  to  .-ill  of  which  will  be  found  in  tin-  Uentralblatt  fur  Laryngologie, 
from  1--.  i-  1895  inclusive.  In  addition  t<>  these,  cases  have  been  reported  l>\  Zematski 
{SajovJ  8  Annual,  1  395,  vol.  iv.,  I»  19),  Delavan  (Journal  of  Laryngology,  1894,  p.  360),  and 
Wan  -  urgical  Pathology  ").     I  know  of  2  other  cases,  which  havr-  noi  :i~  vet  U'cn 

reported 


NEOPLASMS  OF  THE  FAUCES,    TONSILS,    ETC.  L095 

which  necessarily  only  removes  surface-protuberances,  as  to  destroy  its  power 
of  growth  ;  yel  the  microscopical  diagnosis  in  the  case  is  indisputable,  so  far 
as  the  skill  of  the  examiners  is  concerned. 

The  treatment  by  external  excision  is  so  frequently  fatal  and  ineffectual 
that  the  question  of  its  advisability  is  in  many  cases  doubtful. 

Carcinoma. — Carcinoma  of  the  naso-pharynx  is  of  much  rarer  occur- 
rence. Bosworth  having  had  one  ease  himself,  lias  collected  from  literature 
the  records1  of  5  others.  In  only  one  of  the  latter,  however,  doe-  there 
seem  to  have  been  a  microscopical  examination.  1  have  a  microscopical  sec- 
tion of  another  case  which  was  reported  by  the  late  Dr.  Sidney  Allan  Fox2 
of  Brooklyn.     An  abstract  of  the  history  of  this  case  may  he  of  value  here. 

The  patient  was  a  man  forty  years  old.  Family  history  was  good  and 
the  patient  had  always  enjoyed  good  health.  A  year  previous  to  his  coming 
under  observation  he  was  much  exposed  to  wet  and  cold  weather.  This  was 
followed  by  sharp  pain  in  the  ear,  partial  deafness,  and  a  feeling  as  if  his 
own  voice  was  very  loud.  His  general  strength  began  to  fail  somewhat,  and 
his  nervous  system  to  deteriorate.  Six  months  later  he  began  to  he  troubled 
very  much  with  headache,  especially  in  the  daytime.  He  was  also  troubled 
with  the  earache  above  mentioned,  with  deafness  and  with  obstruction  of  the 
posterior  nares.  When  he  came  under  observation  his  appetite  was  poor  ;  he 
was  unable  to  sleep  at  night  because  of  an  inability  to  breathe  through  the 
nose  and  the  constant  annoyance  of  mucus  dropping  in  the  throat.  His 
hearing  was  defective  and  he  was  diploic.  The  odor  from  the  naso-pharynx 
was  fetid  in  character.  Anterior  rhinoscopy  showed  nothing,  but  posteriorly 
the  naso-pharynx  was  seen  to  be  tilled  by  a  cauliflower-like  growth.  The 
lateral  walls  of  the  pharynx,  as  well  as  its  posterior  wall,  were  matted  with 
the  growth,  as  were  also  the  choanse  and  the  spaces  about  the  Eustachian 
orifices.  There  was  no  evidence  of  external  or  internal  </l<tn<Uil<tr  involvement. 
Microscopical  examination  showed  it  to  be  an  epithelioma. 

A  preliminary  operation  (Annandale)  was  done  by  Dr.  Fowler,  and  as 
much  as  possible  of  the  growth  removed.  It  rapidly  grew  again,  and  the 
patient  died  two  months  later.  Autopsy  showed  that  the  growth  had  perfo- 
rated the  base  of  the  skull,  involved  the  brain,  and  had  extended  into  the 
left  orbit,  possibly  also  the  right. 

As  was  slid  in  speaking  of  the  treatment  of  nasal  sarcoma,  the  best  hope 
that  can  be  held  out  to  the  patient  in  advising  such  a  surgical  operation  is 
that  he  may  not  survive  it.  Life  can  doubtless  be  prolonged  more  by  cleans- 
ing and  cautious  removal  of  obstructing  protrusions  of  the  growth  with  the 
cold  snare  than  by  any  radical  operations. 

BENIGN  NEOPLASMS   OF  THE  FAUCES,   TONSILS,   AND  OROPHARYNX. 

By  the  oro-pharynx  we  mean  that  portion  of  the  anatomical  pharynx 
which,  we  may  say  roughly,  can  be  seen  by  direct  vision  in  its  whole  extent — 
i.  e.,  from  the  level  of  the  hard  palate  to  the  level  of  the  arytenoid  summits. 
Below  this  point  the  region  belongs  to  the  digestive,  and  not  to  the  respiratory, 
system. 

Papilloma  of  the  soft  palate,  and  especially  of  the  uvula,  is  the  most 
common  of  all  true  tumors  of  the  nose  and  throat.      They  vary  from  the  size 

1  Fereri,  Archwi  di  Otologia,  1893,   p.   40,   has   reported  a  case,  and   McBride  another, 

Z>we«.se.s  "/'  tin-  Throat,  NoeCf  and  Ear,  p.  322. 

2  N.Y.  M<'<lir«l  Journ.,  March  8,  L890.  The  editor  lias  specimens,  from  a  case  of  IN.litzer, 
involving  tlic  Eustachian  tube. 


L096  NEOPLASMS  OF  THE   UPPER  AIR-PASSAGES. 

of  a  pin's  head  to  that  of  a  cherry,  though  the  majority  of  them  are  not 
larger  than  a  pea.  They  arc  more  frequently  found  on  the  anterior  than  on 
the  posterior  surface.  They  are  attached  frequently  to  the  free  edge  of  the 
palate  and  faucial  pillars.  They  arc  of  the  same  structure  as  true  papil- 
loma, or  fibroma  papillare,  elsevi  here.  The  normal  epithelium  lining  the  oro- 
pharynx, made  up  of  pa vement-cells,  is  exposed  to  attrition  by  the  passage  of 
food  and  the  rubbing  of  opposing  mucous  surfaces.  Probably  it  is  to  this, 
rather  than  to  the  change  in  the  type  of  epithelium  which  takes  place  behind 
and  above  the  soft  palate,  that  we  are  to  ascribe  the  frequency  of  these 
growths.  Jurazs1  -peak-  of  having  seen  II  cases  in  his  clinic-,  of  which 
In  weir  between  twenty  and  thirty,  and  all  between  nineteen  and  forty-four 
years  of  age.      Eleven  of  them  were  men. 

Symptoms. — They  usually  give  rise  to  no  symptoms,  but  are  frequently 
seen  in  examining  the  pharynx,  either  as  sessile  warts  on  the  mucous  mem- 
brane or  as  pedunculated  growths  hanging  from  the  tip  of  the  uvula  or  the 
edge  of  the  palate.  Sometimes  they  cause  tickling  and  coughing;  bul  this 
seems  to  depend,  quite  as  much  on  the  idiosyncrasy  of  the  patient  and  the 
hyperesthesia  of  the  mucous  membrane  as  upon  the  size  and  shape  of  the 
growth. 

The  diagnosis  is  easily  made  from  the  gross  appearances,  and   because  it 

i-  by  far  the  most   < imon  of  all  growths  in  this  locality  ;  but  occasionally 

the  best  of  observers  is  deceived.  A  notable  instance  of  this  was  in  a  case 
reported  by  \h\  Lefferts,2  in  I889,as  a  typical  papilloma  in  a  girl  of  sixteen. 
lie  made  no  microscopical  examination.5  The  growth  recurred  after  removal, 
and  was  again  removed  by  Dr.  Simpson4and  reported  by  him,  after  micro- 
scopical examination, as  an  instance  in  which  a  benign  neoplasm  had  degener- 
ated into  a  sarcoma.  It  seems  very  evident  that  the  growth  was  malignant 
from  the  first.  Lennox  Browne  relates"'  a  similar  mistake  as  occurring  in  the 
practice  of  Morell  Mackenzie:  so  that,  however  great  the  probability,  the 
microscope  must  < Lplete  the  evidence. 

Prognosis. — They  are  benign  growths  and,  as  a  rule,  of  no   significance. 

Treatment. —  When  large  enough  to  cause  symptoms  or  give  the  patient 
any  alarm,  they  may  be  cut  oil'  with  a  pair  of  uvula-scissors. 

Fibroma. — Bosworth  refers  to  7  cases  in  the  tonsils  and  7  in  the  oro- 
pharynx. Lefferts6  ha-  reported  a  case.  They  are  benign  growths  and 
easily   removed. 

Angioma. —  Phillips  has  reported  a  case,7  Bosworth  refers  to  2  others, 
and  Flatau  to  another.8 

I/ipomata  have  Keen  reported  by  Farlow9and  Schmidt. 

Adenoma. — Natier  report-  a  case.10  He  refers  to  2  cases  by  Hutch- 
inson." 

Cysts  of  the  Mucous  Membrane.— I  have  observed  one  case  in  a 
middle-aged  woman  who  complained  that  something  had  Keen  growing  in 
her  throat  for  the  la-t  eighteen  month-.  A  -mall  round  tumor,  a  little  larger 
than  a  pea,  was  seen  growing  at  the  base  of  the  right  posterior  faucial  pillar. 
It  was  -month  and  sessile.     It   gave  no  evident fit-   presence  until  the 

/■     Krankheiten         0  Luflwege,  1891.  2  Trans.  Amer.  Laryng.  .!»■».,  1889. 

1  I'his  case  i~  quoted  by  Bosworth,  and  accepted  :>~  a  papilloma,  in  hi-  book  pnl.lisiH.il  just 
Dr.  Lefferts's  report  and  befori    Dr,  Simpson's.  '  Trans   Amer.  Laryng.  Assn.,  1893. 

'  Burnt         s  /'     a        -   ■      I         \      .  ,iu,l  Throat,  vol.  ii.  p.  724. 

V    >     Medical  Record,  March  L2,  1887,  p.  I".'.".. 
Rachen  »»»/  Kehllcopf  Krankheiten,  p.  331  '  /'  Imer.  Laryng.  .1    n.,  1895. 

\fen  weUed*   Laryngologie,  So.  II,  1887,  p.  618.  "  Lancet,  Maj  22,  1886,  p.  973. 


NEOPLASMS  OF  THE  FAUCES,    TONSILS,    ETC. 


1097 


patient,  who  had  a  family  history  of  cancer,  noticed  it.  Fig.  632  shows  a 
section  of  the  walls,  which  are  fibrous  and  lined  on  both  sides  with  squamous 
epithelium  similar  to  that  of  the  surrounding  mucous  membrane.  There 
were  do  glands  and   no  lymphoid  tissue.      Its  fluid  contents  escaped  in  the 


Pig.  632.— Oropharyngeal  cyst :  P,  point  from  which  high-power  drawing  is  taken. 


removal.  It  was  probably  an  inclusion-cyst,  having  its  origin  in  some  acute 
inflammatory  condition  of  the  mucosa. 

It  will  be  noted  in  Schmidt's  table  thai  he  mentions  one  cysi  of  the  oro- 
pharynx, hut  L;ives  no  further  details. 

'['here  i-  a  growth  connected  with  the  tonsils  which  is  occasionally  seen 
in  the  throat — usually  bul  wrongly  called  ;i  supernumerary  tonsil.  Eta  for- 
mation -(•••in-  to  he  broughl  uhont  by  a  fibrous  growth  shutting  oil'  a  portion 
of  th<-  lymphoid  tissue  of  ;i  hypertrophied  tonsil.  The  fibrous  tissue  is 
gradually  lengthened  into  ;i  pedicle.  Such  a  growth  I  have  examined  micro- 
scopically for  Dr.  W.  ]•'.  Dudley  of  Brooklyn.  These  growths,  as  well, 
indeed,  as  many  other-  of  the  oro-pharynx,  may  by  the  length  of  their 
pedicle  cause  alarming  dyspnea  or  interfere  markedly   with  deglutition. 


[098  NEOPLASMS  OF  THE  UPPER  AIR-PASSAGES. 

MALIGNANT    TUMORS    OF    THE    FAUCES. 

There  seems  to  be  a  certain  practical  line  of  division  between  malignant 
disease  of  the  contiguous  structures  of  the  soft  palate,  tonsils,  and  oro-pharynx, 
due,  doubtless,  to  difference  in  anatomical  structure,  physiological  function 
;md  pathogenic  influences.  This  makes  it  seem  desirable  to  consider  them 
separately. 

( )n  looking  over  Schmidt's  tables  we  see  that  more  carcinomata  were 
observed  in  the  oro-pharynx  and  larynx  than  all  other  growths  combined, 
it'  we  rule  out  papillomata  and  the  inflammatory  growths,  the  so-called  laryn- 
geal fibromata  and  tubercular  tumors.  It  will  also  be  seen  that  it  is  very 
much  more  frequent  in  men  than  in  women — at  a  ratio  of  15  to  1  for  the 
pharynx.  This  same  influence  of  sex  is  discernible  in  the  reports  of  30 
cases  of  carcinoma  of  the  fauces  collected  by  Bosworth.  Only  one  was  in 
a  woman.  Bosworth  comments  on  this  as  a  curious  coincidence.  The  chances 
are  very  great,  however,  that  there  i-  hidden  behind  the  fact  an  etiological 
significance  of  which  we  can  at  presenl  form  no  surmise.  The  cases  that  I 
have  observed  and  know  of  personally  have  all  Ween  in  men.  \\  e  can  hardly 
suppose  that  the  greater  exposure  of  men  in  their  occupation  to  irritative 
causes   would   entirely   account    for  this. 

Sarcoma  of  the  Soft  Palate. — A  few  cases  have  been  reported.  Bos- 
worth, in  1892,  collecting  20.  It  is  much  more  frequent  in  males  ( 1.')  to  \ ),  and 
occurs  as  often   in   patient-  over  forty  years  of  age  as  in  younger  ones. 

All  forms  have  been  noted,  with  no  especial  preponderance  of  any  one. 

Symptoms. —  It  is  usually  of  slow  growth  and  does  not  tend  to  ulcerate' 
quickly.  It  frequently  gives  rise  to  no  symptoms  until  it  has  existed  some 
time.  Interference  with  deglutition  and  the  thick  sound  of  the  voice  may 
be  the  first  symptoms  complained  of.  Pain,  however,  may  be  prominent 
from  the  first,  and  this  is  especially  so  it'  ulceration  has  occurred,  in  which 
case  excessive  salivation  and  foulness  of  the  breath  add  to  the  discomfort  of 
the  patient.  The  general  health  deteriorates.  As  a  rule,  glandular  involve- 
ment in  the  neck  doc-  nut  occur  until  the  growth  has  invaded  other  struc- 
ture-. Hemorrhage  is  not  reported  as  an  incident  in  the  course  of  the 
disease. 

The  tumor  i-  usually  circumscribed — a  round,  smooth  growth  covered  by 
mucous  membrane  ami  enclosed  in  a  capsule,  or  it  may  be  more  diffuse  and 
nodulated.  It  may  spring  from  any  part  of  the  soft  palate  and  spread  over 
it-  whole  extent,  but  does  not  -how  a  marked  tendency  at  first  to  invade 
contiguous  structures. 

flic  duration  of  the  disease  varies  from  six  months  to  several  years. 
Sometimes  it   ha-  apparently  existed   for  years  in  a  quiescent   condition. 

Diagnosis. — The  same  caution  should  be  observed  iii  excluding  a  syph- 
ilitic growth  by  the  administration  of  large  doses  of  the  iodid  of  potash. 
This  should  be  especially  borne  in  mind  when  the  microscope  reveals  round- 
celled  structure. 

It  i-  easily  distinguished  from  tuberculosis,  which  almost  never  occurs 
without  manifestations  elsewhere.  From  fibroma  it  cannot  be  surely  distin- 
guished without  a  histological  examination.  The  rarity  of  fibroma  in  this 
situation,  and  the  slowness  of  it-  growth,  it-  firmness  of  consistence,  and  the 
lack  of  pain  in  the  history  will  tend  to  exclude  it. 

'fhe  prognosis  i-  always  grave ;  but  not  a  few  cases  have  been  reported 
in  which  many  year-  had  elapsed  without  any  recurrence  after  thorough 
operation,     Much  will  depend  on  the  rapidity  of  growth  and   involvement 


MALIGNANT  TUMORS  OF  THE  FAUCES.  1099 

of  neighboring  structure,-.  Those  cases  arc  particularly  favorable  which  are 
seen   early. 

Treatment. —  [ncision  of  the  mucous  membrane  may  enable  the  operator 
io  shell  out  an  encapsulated  growth  ;  but  usually  the  field  of  operation 
should  include  healthy  tissue,  and  suspicious  areas  should  be  thoroughly 
burned  out  with  the  thermo-cautery.  No  radical  operation  should  be  under- 
taken unless  with  hope  of  the  complete  extirpati f  the  growth.     Without 

such  hope,  removals  of  projecting  and  obstructing  portions  with  the  snare 
(from  time  to  time)  may  be  advisable.  The  use  of  a  cleansing  mouth-wash, 
such  as  the  ordinary  Dobell  solution  or  the  peroxid  of  hydrogen,  will  tend 
to  relieve  the  fetor.  Weak  solutions  of  cocain  or  a  10  per  cent,  spray  of 
antipyrin  help  to  assuage  the  pain  when  violent.  The  liberal  use  of  opiates 
is   indicated   in   these   hopeless  cases. 

Carcinoma  of  the  soft  palate,  although  somewhat  more  frequenl 
than  sarcoma,  is  still  a  very  rare  growth.  Bosworth  has  collected  the  reports 
of  30  cases  up  to  1889.  In  looking  over  Semon's  Centralblatt  fur  Laryn- 
gologie  for  the  years  since  then,  I  can  find  a  reference  to  only  one  case.1  We 
see  at  once  what  a  marked  contrast  this  forms  to  the  frequency  of  epithelioma 
of  the  tongue  ;  while  the  benign  epithelial  growth — papilloma — is  so  frequently 
seen  on  the  soft  palate  and  so  rarely  on  the  tongue. 

Among  Bosworth's  cases  is  one  of  twenty-five  and  another  of  twenty- 
seven  years  of  age  ;  but  forty  to  fifty  shows  a  slightly  larger  number  (5) 
than  any  other  decade. 

Of  the  31  eases,  including  Katzenstein's,  all  but  one  were  in  men,  afford- 
ing a  more  striking  example  even  than  sarcoma  of  the  greater  frequency  of 
malignant  growths  of  the  throat  in  men.  Owing  to  insufficient  microscopical 
reports,  it  is  impossible  to  ascertain  what  form  of  carcinoma  is  most  frequent. 

It  occurs  as  a  rapidly  growing  infiltrating  neoplasm  with  a  fungous  or 
irregular  surface.     Ulceration   occurs  early  in   its  course. 

Symptoms. —  Pain  radiating  in  various  directions  is  usually  the  promi- 
nent symptom,  but  is  not  always  present  at  first.  Stiffness  of  the  palate  is 
complained  of  in  some  eases.  Notwithstanding  these  symptoms,  the  growth 
has  usually  advanced  so  rapidly  that,  when  it  comes  under  observation, 
considerable  infiltration  of  the  soft  palate  and  ulceration  have  already 
taken  plaee.  The  ulceration  is  characteristic  as  of  cancer  elsewhere.  The 
underlying  infiltration  raises  the  floor  of  the  ulcer,  while  the  surrounding 
fibroid  border  is  not  sharp-cut,  but  rounded.  The  floor  of  the  ulceration  may 
be  covered  with  whitish  secretion  or  may  be  fairly  clean  and  pink-looking; 
but  it  is  always  irregular  and  nodular.  Hemorrhage  frequently  occurs  and 
the  general  health  rapidly  deteriorates.  Foul-smelling  secretions  from  the 
ulcer  and  lancinating  pains  destroy  the  appetite  and  render  the  patient's  life 
miserable.  Glandular  enlargement  is  sometimes  absent  even  in  late  stages 
of  the  disease,  and  is  usually  not  present  until  the  disease  h;is  spread  to  con- 
tiguous structures.  This,  however,  it  rapidly  does,  involving  the  base  of  the 
tongue,  the  lateral  pharyngeal  wall,  and  the  hard  palate;  but,  as  Bosworth 
remarks,  they  usually  die   even    before   this   takes    place. 

The  prognosis  is  entirely  hopeless. 

The  diagnosis  from  sarcoma  has  been  sufficiently  indicated  by  the  pre- 
vious remarks.  The  microscope  must,  of  course,  be  the  final  arbiter  between 
the  two.  A.S  between  cancer  and  syphilis,  the  micro-cope  i-  a  perfectly  sat- 
isfactory means  of  diagnosis  and  should  always  be  promptly  employed.  ( !arci- 
noma  rarely  resembles  papilloma  in  this  situation.    The  infiltration  is  marked. 

1  Katzenstein,  Berl  /din.  Woch.t  No.  !>.  L892. 


linn  NEOPLASMS  OF  THE   UPPER  MR-PASSAGES. 

Treatment. — Occasionally  a  radical  operation  may  be  advisable;  but 
usually  this  holds  out  to  the  "patient  no  hope  even  of  diminishing  suffering. 
Cleansing  and  disinfecting  washes  and  opium  include  the  palliative  indica- 
tions. 

Sarcoma  of  the  Tonsils. — Gray,1  in  reporting  a  case,  gives  a  list  of  L8 
other  report-  of  sarcoma  found  in  literature.  I  have  been  able  to  find  trust- 
w  »rthy  accounts  of  13  other  cases2  since*  then.  Others  have  been  reported  ; 
but  either  the  reports  are  not  accessible  to  me  or  satisfactory  data  are  not 
given.  Indeed,  Bosworth  in  his  hook  has  collected  45  cases,  and  others  have 
been  reported  since  then.  ( >f  the  32  cases  which  1  have  studied,  the  follow- 
ing facts  are  apparent.  As  lympho-sarcoma  and  round-celled  sarcoma  are 
synonyms  in  the  report-,  we  find  that  all  the  cases  but  5  come  under  that  one 
head,  showing  pretty  conclusively  that  the  growths,  as  a  rule,  spring  from 
the  lymphoid, and  not  from  the  fibrous,  elements  of  the  tonsil,  even  at  an  age 
when   the  lymphoid  activity  has  sunk  into  insignificance. 


From  50  to  60  i 

here 

were  9  cases. 

"      til)  to  70 

it 

■•     8    " 

<  >ver  70 

u 

"     4     " 

From  10  to  20 

" 

"      3     " 

"      30  to  40 

(t 

u         .,       « 

•'     20  to  30 

a 

was    1  case. 

••     40  to  50 

" 

••      1     " 

Younger  than  Id 

.. 

..      |     .. 

From  this  analysis  we  see  that  more  than  half  the  cases  occurred  in  per- 
sons over  fifty  years  of  age.  With  the  exception  of  one  case  of  six  years,  the 
:;  youngest  cases  were  seventeen  years  old.  Therefore  we  see  that  this 
lymphoid  growth  almost  always  occurs  in  the  pharynx  at  an  age  when  benign 
lymphoid  hypertrophies  (enlarged  tonsils)  are  unknown  to  begin.  Sex  seems 
to  have  no  influence  ( 13  to  17)  ;  and  there  seems  to  he  no  marked  preponder- 
ance on   either  side  of  the   throat. 

Symptoms. — The  onset  of  the  symptoms  frequently  resembles  an  attack 
of  tonsillitis,  [nstead  of  entirely  subsiding,  some  swelling  and  tenderness 
are  left  behind.  This  may  remain  stationary  for  a  few  weeks;  hut  gradually 
Hi,,  size  of  the  tonsil  increases,  the  surrounding  tissue  of  the  pillars  of  the 
fauces  and  the  -oft  palate  and  uvula  become  reddened  and  edematous.  The 
pain  increases,  as  a  rule,  although  in  some  cases  it  is  never  a  prominent 
symptom.  Ulceration  occur-  much  earlier  than  is  usual  in  sarcoma.  Gland- 
ular involvement  is  also  more  frequent  and  comes  on  earlier.  Hemorrhage 
i-  an  occasional  symptom.  The  general  health  becomes  seriously  affected 
after  a  fw  months;  the  sense  of  taste  and  smell  are  soon  lost  ;  foul  dis- 
charge and  odor  are  present.  The  growth  may  extend  backward  and  down- 
ward, interfering  with  deglutition  ami  respiration. 

Prognosis. — The  disease  usuall}  goes  to  a  fatal  termination  within  a  year, 
and  sometimes  in  a  few  months.  Round-celled  sarcoma  in  any  situation  has 
a  most  unfavorable  prognosis,  but  in  the  tonsil  it  isespecially  rapid  and  fatal. 
One  of  Newman's  cases   lived   five  year-  after  the  operation  ami  died  oi  a 

1    Inter.  Journ.  of  Medical  Science,  February,  1889,  p.  154. 

MacCoy,  Phila.  Med.  News,  Feb.  •_',  1889;  Mygind,  Journ.  of  Laryng.,  Aug.  1890,  p.  301  ; 

\     |      i/       i:         ,  May  25,  1889;  Wolfenden,  Journ.  of  Laryng.,  Oct.,  1889;  Schon- 

born,  Centralblati        I       nq.,  vol.  v. ;   Lediard,  Journ.  oj    Laryng.,  1890,  p.  17 ;  Homans,  Journ. 

[891,   p.   428;' Cohen,    Phila.    Med.  News,  Jan.   '11.   1894;  Wagner,    .V.     V.   Med. 

b.  3,    1894;   Watson,   V.   )'.    l/../.  ./..,/,„..    Nov.    in,  1894,  p.   584;  Newman,    Malig' 

I      at  •<»'/    A'...     2   ;    Mikulicz,    Atlaa  der   KrankheUen   der  Mund   mul 

i. 


MALIGNANT  TUMORS  OF  Til!-:  lACCI.s.  llul 

recurrence  in  the  other  tonsil  :  this  was  a  spindle-celled  sarcoma.  W'cin- 
lechner's  case  (quoted  by  Bosworth),  another  spindle-celled  sarcoma,  was 
injected  with  iodoform  and  ether  and  the  common  carotid  artery  was  tied 
after  the  case  had  been  pronounced  hopeless  by  Billroth  :  the  case  entirely 
recovered.  Another  case,  which  was  called  a  lympho-adenoma,  lived  two 
and  a  half  year-  after  operation,  and  -till  another  lived  -even  years.  In 
reading  the  literature  it  seems  that  the  chance  of  a  favorable  prognosis  is 
proportionate  to  the  chance  of  mistake  in  diagnosis;  and  the  suspicion  arises 
that  the  microscope  or  our  understanding  of  the  pathology  of  sarcoma  is  a1 
fault. 

Diagnosis. —  What  has  been  said  of  tertiary  syphilis,  in  connection  with 
the  diagnosis  of  sarcoma  elsewhere,  applies  with  equal  force  to  tonsillar 
growths.  The  growths  are  so  rare  that  differential  diagnosis  between  sar- 
coma and  carcinoma  can  only  he  settled  by  the  microscope,  because  no  one's 
experience  is  wide  enough  to  trust  to  the  "'clinical  sense"  which  i-  of  value 
in  -o  many  cases.  Iodid  of  potash  and  the  microscope  should  he  our  chief 
aid-. 

Treatment. — Owing  to  the  hope,  though  a  forlorn  one.  which  has  been 
realized  in  a  few  cases,  thorough  extirpation  should  he  undertaken  where  it 
i-  a  possibility.  The  necessity  of  an  external  incision  for  the  removal  of 
diseased  glands,  as  well  as  for  the  complete  removal  of  the  growth,  i-  fre- 
quently evident.  Otherwise,  palliative  measures  are  to  he  adopted  a-  men- 
tioned  above. 

Carcinoma  of  the  tonsils  is  of  more  frequent  occurrence  than  sar- 
coma.     About  100  cases  may  be  found  in  literature.1 

It  has  been  reported  in  a  case  as  young  as  seventeen  (Bryant)  and  a-  old 
as  eighty-two.  Sarcoma,  however,  has  not  only  been  reported  at  a  younger 
age  (six),  but  also  in  a  woman  of  eighty-nine.  The  average  age  of  carcinoma, 
according  to  Bosworth,  is  fifty-two  and  one-half  years.  It  occur-  much  more 
frequently  in  males. 

Calculating  from  the  figures  given  by  Bosworth.  it  occurs  in  the  tonsils 
about  once  in  2000  cases  of  carcinoma  of  all  parts. 

Symptoms. — A  careful  study  fails  to  note  any  essential  difference  be- 
tween the  subjective  symptoms  of  sarcoma  and  those  of  carcinoma  of  the 
tonsils.  The  duration  also  seems  to  he  about  the  sink — from  a  few  months 
to  a  year  and  a  half. 

Diagnosis. — The  appearance  of  the  growth  seems  to  vary  a  little  from 
that  of  sarcoma.  There  i-  more  apt  to  he  ulceration  with  carcinoma.  A 
fleshy  pinkish  mass,  fungoid  and  rough,  projects  into  the  pharynx,  sprouting 
from  the  swollen  tonsils  and  the  infiltrated  mucous  membrane  around  it.  A 
sarcoma,  on  the  other  hand,  usually  -how-  a  smooth  projecting  surface,and  is 
less  completely  covered  with  ulceration  or  fungoid  excrescences.  However, 
a-  -aid  before,  tin'  microscope  must  he  the  final  arbiter,  for  nothing  i-  so 
deceiving  as  the  external   configuration  of  tumor.-. 

The  prognosis  is.  of  course,  as  had  a-  possible,  although  in  one  of  X,  u- 
man'-  cases  operated  upon  by  him,  there  was  no  recurrence  at  tin  end  of  two 
years,  and  in  another  case  no  recurrence  at  the  end  of  five  months. 

Treatment. —  It  is  hardly  necessary  to  -peak  of  treatment.  The  only 
treat  incut  for  cancer  is  the  knife  and  at  once,  if  there  is  any  possibility  of 
complete  eradication  of  all  the  tissue.  Palliative  treatment  has  been  men- 
tioned above  for  sarcoma. 

1  Bosworth  refer-  to  aboul  85  cases.  Newman  has  reported  8  other  cases  since  Bosworth, 
and  Beveral  others  are  referred  to  in  literature  since  the  publication  of  Newman's  work. 


1102  A'/;o/'/..i,v.i/\  OF  THE   UPPER  AIR-PASSAGES. 

Sarcoma  of  the  Oro-pharynx. — Few  authenticated  case-  have  been 
reported.  Dr.  F.  I.  Knight1  reported  a  rase  in  1679,  and  reviewed  the 
reports  which  had  been  made,  of  pharyngeal  growths,  up  to  that  time;  but 
many  of  them  were  apparently  not  really  sarcoma.  Bosworth,in  L892,men- 
tioned  14  or  15  cases.  By  referring  to  Semon's  Centralblatt  fur  Laryngologie, 
I  find  the  following  cases  reported  since  L886  : 

Felix:  Mbnatsch.  f.  ohm,.,  1894,  p.  255. 

2  cases,  spindle-celled;  pedunculated;  removal  .successful. 
Montaz:  Mtdtcine  Mod.,  Sept..  1894. 

■•  Lymphadenoma  :  "  eleven  years  old  :  death  from  suffocation. 
Delmas  and  Cannieu:  Journ.  de  Mid.  de  Bordeaux,  No.  L4,  April  7,  1895. 
Boppe:   Die  Maligne  Geschwulste  der  Pharynx.  Dissert.,  Berlin,  1892. 
Katzenstein :   Berl.   Laryng.  Soc,  May  20,  1892;    in   Centralblatt  fur  Laryngologie, 
No.  9,  1892.     Short  notice,  2  cases  in  report. 

Cheatham:   Amer.  Practitioner  and  News,  Dec.  7,  1889. 
Norton  :  M"L  Press  <m<l  Cirru/nr.  May  22,  1889. 
Fefici:   II  Morgagni,  March,  1888  (mentioned  by  Bosworth). 
Black:   Glasgow  Med.  Journ.,  Feb.,  1886. 

This  makes  a  record  of  25  or  30  cases  altogether,  and  the  list  is  tolerably 
complete. 

We  have  seen  how  malignant  a  growth  is  sarcoma  of  the  tonsils.  When 
it  occur-  iu  the  oro-pharynx  this  is  far  from  being  the  case.  Jn  this  Locality 
the  growth  is  very  frequently  pedunculated  or  has  a  small  base  of  attach- 
ment. It  grows  more  or  less  slowly  and  does  not  have  a  tendency  to  glandu- 
lar involvement.  It  is  more  frequently  of  the  spindle-celled  variety,  which 
is  usually  less  virulent.  They  are  reported  as  springing  from  the  posterior 
pharyngeal   wall   or  low  down  on   the  sides  of  tiie   pharynx. 

Their  usual  occurrence  is  after  middle  life,  although  we  again  see  here  an 
instance  in  a  child  of  eleven  years.      It  is  here  also  more  frequent  in  men. 

Symptoms. — It  usually  gives  rise  to  no  symptoms  until  deglutition  or 
respiration  is  interfered  with,  which  occurs  at  an  early  date,  however,  owing 
to  it-  situation  and  the  common  presence  of  a  pedicle.  It  may  cause  cough 
by  encroaching  in  its  growth  upon  the  arytenoid  summits  or  folds.  Dyspnea 
from  this  cause  has  Keen  reported  as  severe  and  dangerous;  and,  in  the  case 
of  the  child  reported  by  IVIontaz,  death  occurred  from  the  impaction  of  a 
portion  of  the  growth  in  the  larynx.  As  to  duration,  it  seems  from  the  his- 
tories that  the  disease  may  extend  over  several  years,  although  it  is  some- 
times rapidly   fatal. 

Prognosis. — Of  course,  the  usual  termination  is  in  death;  hut  if  the 
tumor  is  such  in  shape  and  situation  as  to  allow  of  complete  removal,  there 
i-  a  fair  chance  of  no  recurrence  ;  and  if  it  recurs,  a  second  operation  may  be 
more  successful. 

Treatment. — When  pedunculated  and  not  too  large,  the  growth  may  be 
removed  with  the  galvano-cautery  snare.  When,  however,  it  has  a  broad 
base  of  attachment,  or  when  it  is  SO  large  as  to  make  such  a  manipulation  of 
doubtful  success,  a  lateral,  or  better  :i  subhyoid,  pharyngotomy  may  be  done. 
One  "i"  two  cases  were  operated  on  through  the  mouth  after  preliminary 
t  racheotomy. 

Carcinoma  of  the  Oro-pharynx. — Below  the  tip-  of  the  arytenoid 
cartilages  —  i.  <..  in  the  laryngo-pharynx — carcinoma,  often  of  scirrhous 
nature,  is  a  very  frequent  occurrence.  Above  this  point,  however,  it  is  one 
of  the  rarest  of  growths  I  Fig.  633). 

Boswort  1 1  refers  to  about  30  cases,  although  some  of  these  had  their  origin 

1  Trans.  Amer.  Laryng.  Assn.,  1879 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


I  1  ( i: 


have  been  able  to  find  very 
< me  case  was  reported 


evidently  in  the  laryngeal  part  of  the  pharynx 
feu  reports  since  then. 

The  variety  is  usually  epitheliomatous  or  scirrhous 
as  young  as  twenty;  l>ut  pharyngeal  carcinoma  is 
no  exception  to  the  rule  which  obtains  elsewhere 
as  to  age.  The  larger  number  of  cases  seem  to 
have  been  in  females,  a  contrast  to  what  we  have 
hitherto  noted  in  neoplasms  of  the  upper  air- 
passages. 

Symptoms. — Gradually  increasing  discom- 
fort and  pain  in  swallowing  first  attract  the 
patient's  attention.  Extension  of  the  growth  to 
the  larynx  and  esophagus  causes  dyspnea  and 
increases  the  difficulty  of  deglutition.  Involve- 
ment of  the  cervical  glands  occurs  early,  and 
deterioration  of  the  general  health  rapidly  en- 
sues. There  may  or  may  not  be  any  bleeding. 
The  duration  of  the  disease  is  from  six  to  eight- 
een months. 

Prognosis  is  of  course  bad,  but  some  pro- 
longation of  life  by  early  surgical  interference 
may  be  expected  in  favorable  cases. 

Treatment,  if  radical,  of  course  belongs  to 
the  general  surgeon.     Tracheotomy,  feeding  per 
rectum,  and  opium  are  the  palliative  measures  that  are  indicated  in  sonic  of 
the  cases. 


Fig.  633.— The  author's  case  i  t 
epithelioma  of  the  oro-pharynx  in 
a  man  of  sixty,  springing  from  base 
of  post-faucial  pillar.  Began  aboul 
five  months  before  drawing  was 
made. 


BENIGN    NEOPLASMS    OF    THE    LARYNX. 

It  is  said  by  Moure,1  quoting  from  Schwartz's  tables  of  FauvePs  case-, 
that  these  growths  occur  in  about  1  per  cent,  of  the  cases  of  laryngeal 
disease.  Of  late  years  chronic  laryngeal  disease,  except  the  specific  lesions 
of  tuberculosis,  syphilis,  and  cancer,  seems  almost  to  have  disappeared  from 
our  nose-  and  throat-clinics  in  America.  There  is  hardly  any  way  of  ex- 
plaining this  except  by  suggesting  that  the  prompt  and  thorough  treatment 
of  nasal  diseases,  which  all  patients  receive  in  this  country,  has  produced 
this  marked  diminution  of  laryngeal  disease. 

It  is  my  impression,  however,  that  the  proportion  of  benign  growths  to 
other  affections  of  the  larynx  is  rather  more  than  1  per  cent,  in  New  York 
City.  Nevertheless,  such  are  exceedingly  rare,  and  very  few  of  us  see  more 
than  a  very  few  cases  each  year  in  the  public  clinics.  (  me  has  only  to  look 
:it  the  works  of  Tiirck,  Stork,  Fauvel,  and  Mackenzie  to  realize  that  the 
early  laryngologists  saw  a  much  larger  number  than  occurs  in  the  practice  of 
any  laryngologist  to-day. 

This  may  be  graphically  seen  on  referring  to  Semon's  statistical  tables2 
of  his  investigations,  where  Fauvel  and  Stork  each  say  they  had  -ecu  <!<io 
cases  of  benign  laryngeal  growth-,  and  other-  with  " prerhinological " 
experience   note   very    large   numbers. 

They  are  more  comn in  men  than  in  women.    According  to  Mackenzie, 

out  of  287  cases  of  benign  laryngeal  growths  in  \\\>  own  practice  and  in  thai 
of  other-,  lit?  were  males  and  90  were  females.  They  are  most  common  in 
middle   life,  although   some  form- — as  papilloma  —  are  more   frequent  in  chil- 

1  I ',-  gona  bui  lea  Maladies  du  Larynx,  p.  394.        '  Centralblatt  fur  I  March,  L889. 


lint  NEOPLASMS  OF  THE   UPPER  AIR-PASSAGES. 

clivn.  They  are  more  common  in  those  who  make  professional  use  of  their 
voices.  In  children  an  attack  of  the  measles  lias  been  frequently  noted  as  the 
time  at  which  the  symptoms  of  papilloma  began.  Syphilis  and  tuberculosis 
produce  their  own  neoplastic  phenomena  in  the  larynx,  but  have  no  appre- 
ciable influence  in  producing  independent   tumors. 

Looking  at  Schmidt's  tables,  we  again  note  the  great  preponderance  of 
certain  laryngeal  growths.  ETibroina,  papilloma,  singers'  nodes,  and  tubercular 
tumor-  solar  outnumber  the  other  benign  growths — lipoma,  myxoma,  and 
cysts— that  the  contrast  is  striking;  while  adenoma,  chondroma,  angioma, 
neuroma,  with  others  which  Gerhardl  mentions,1  have  not  been  seen  in  his 
experience.  This  clinical  fact  alone,  which  is  the  common  experience  of  all 
laryngologists,  is  strongly  suggestive  of  the  conclusion  that,  if  they  are  not 
all  of  them  results  of  chronic  inflammation,  the  latter  is  a  prominent  factor 
in    their  etiology. 

"Singers'  nodes"  are  acknowledged  by  all  to  be  the  direct  products 
of  chronic  inflammation.  The  name  refers  to  their  external  appearance  and 
tin!  etiological  factor  in  their  occurrence.  Their  histological  structure,  while 
always  giving  evidence  of  inflammation,  is  not  always  the  same.  Occasion- 
ally the  principal  hyperplasia  is  in  the  epithelium,  whose  flat  layers  are 
thickened  and  supported  by  subjacent  structure.  More  frequently  there  is 
marked  increase  in  the  lymphoid  elements,  raising  up  the  epithelium  into 
surface-protuberances;  while  in  other  cases  the  stroma  is  increased  in  volume, 
and  frequently  its  fibers  are  separated  by  effused  serum.  Usually,  however, 
there  is  a  combination  of  these  pathological  changes  with  an  increase  of  the 
vascularity  of  the  parts.  They  are  seen  only  upon  the  true  cords,  nearly 
always  in  their  anterior  thirds,  either  upon  their  superior  surfaces  or  at  their 
edges.  They  are  sometimes  bilateral  at  the  edges,  but  of  unequal  size,  hav- 
ing the  appearance  that  one  had  been  formed  first  and  then  affected  by  attri- 
tion the  n\>^i.'  of  tin1  opposite  cord.  Occasionally  it  will  he  observed  that  the 
protuberance  on  one  curd  has  made  a  little  concavity  at  the  vih^o  of  the 
opposite  cord  (see  page  1105). 

Etiology. — They  occur  chiefly  among  professional  people  who  overuse 
their  voices.  This  especially  is  the  case  in  amateur  singers.  It  is  occasion- 
ally observed   in    news-hoys  and    in   choir-boys.2 

Symptoms. — A  young  woman  who  has  been  singing  a  few  months,  or  a 
vocalist  from  the  music-halls  who  has  been  overstraining  her  voice,  comes 
with  the  complaint  of  inability  i<>  produce  certain  notes  or  that  a  very  little 
practice  tire-  her  larynx.  Later  in  the  course  of  the  trouble  there  is  com- 
plaint of  occasional  hoarseness  and  fatigue  of  the  voice  in  ordinary  conver- 
sation.     The    patient    may  he  otherwise   in    perfect    health. 

Examination  reveals  one  or  both  cords  congested  and  rough  at  the  a]^' 

or   fchrougl t    the   whole   extent.       It    may  he   swollen    and    ecchvinosed,  and 

look-  :i-  it'  it  had  been  bruised  between  two  hard  surfaces.  A  sessile  growth 
from  the  size  of  a  pin's  head  to  that  of  ;i  -plit  pea  mav  he  -ecu  on  the 
anterior  part  of  one  or  both  cords,  or  there  may  he  a  number  of  these  little 
protuberances  scattered  over  their  surfaces. 

Prognosis,  of  course,  relate-  entirely  to  the  restoration  of  the  voice,  and 
this  depend-  largely  on  whether  the  voice  has  broken  down  under  use  or 
abuse.  It  is  doubtless  true  that  in  many  of  these  cases  the  trouble  at  the 
bottom  i-   really   a   natural    structural    weakness  of  the   vocal   organs.     In 

Kehlkopfgeschwtilste,"   Nothnagel's  SpeeielU,  Path,  mnl  Therapie. 
Moore,  "Laryngite  Nodulaire  dea  Enfante,"   Eemu    Hebd.  '/<■  Laryngologrie.  Nos.  6,7,8, 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


1105 


others  overuse  of  the  voice  has  produced  the  trouble.  The  former  cannot 
be  corrected,  and  these  patients  cannot  sing  except  in  extreme  moderation  ; 
but  the  ordinary  voice  may  be  entirely  restored.  Others,  by  proper  care 
and  treatment,   may  regain   the  singing-voice. 

Treatment. —  First,  rest  as  absolute  as  possible  must  be  insisted  on  for 
the  larynx.  The  patient  should  not  be  allowed  to  talk  more  than  necessity 
requires.  The  air-passages  in  the  pharynx  and  nose  must  of  course  he  put 
in  order.  Applications  <>f  nitrate  of  silver  or  sulphate  of  zinc  (10  gr.-Jj) 
should  he  made  daily  or  three  times  a  week.  Usually  after  several  weeks 
this  will  result  in  the  subsidence  of  the  neoplasm.  II'  it  is  of  large  size  and 
should  persist,  attempts  at  removal  may  he  made.  It  is  occasionally  of  such 
a  size  and  shape  that  it  may  he  seized  with  forceps  or  shaved  off  with  the 
laryngeal  guillotine  or  snare.  The  laryngeal  bistoury,  either  protected  or 
unprotected,  cannot  he  too  strongly  condemned.  The  most  disastrous  wounds 
have  been  inflicted  by  it  even  in  skilled  hands.1  The  galvano-cautery  elec- 
trode  is   usually  to  he   preferred  for  operative  procedures  on  these  growths. 

laryngeal  Polypi. — By  this  term  we  understand  benign  growth-  of 
the  larynx,  whatever  their  histological  structure,  which  have  more  or  less 
circumscribed  bases  of  attachment.  Their  symptomatology  and  treatment 
are  so  nearly  identical  that  these  will  lie  spoken  of  as  a  whole,  following  a 
brief  account  of  the  pathogenesis,  histology,  gross  appearances,  and  occur- 
rence of  each. 

Edematous  Polypi  of  the  larynx— the  so-called  Fibromata.— 
As  in  the  nose,  where  edematous  hypertrophies  of  the  mucous  membrane  are 


PlG.  634.— Angioma  of  larynx  (from  Krieg*s  Atlas). 


Fig.  635.— Edematous  fibroma  of  vocal  cord. 


often  called  myxomata,  so  in  the  larynx  we  find  practically  the  same  struct- 
ure in  growths,  which  until  very  recently  have  been  almost  universally  called 
fibromata  or  fihro-myxomata. 

In  the  nose  these  serum-soaked  neoplasms  are  covered  by  a  translucent 
columnar  epithelium,  and  are  scantily  supplied  with  blood-vessels.  In  the 
larynx,  on  the  other  hand,  they  are  covered  by  an  opaque  stratified  pavement- 
epithelium.  They  are  more  exposed  to  bruising  by  the  muscular  movements 
of  the  vocal  cords  and  the  forcible  air-currents  in  coughing  and  loud  -peek- 
ing, which  produce  extravasations  of  blood  into  the  meshes  of  the  separated 
stroma-fibers.  These  two  circumstances  give  them  cither  a  solid  white  look 
or  a  dark-red  appearance. 

Mv  own  histological  examinations  as  well  as  clinical  experience  lead  me 
to  believe  that  Chiari2  is  correct  in  stating  that  they  are  local  hypertrophies 

1  See  Schrotter'e  Vorlesungen  iiber  di<  Krankheiten  der  Kehlkopfes,  1892,  p.  295. 

2  Archiv  fur  Laryngologie,  Bd.  ii.,  Heft  i. 
70 


L106  NEOPLASMS  OF  THE   UPPER  AIR-PASSAGES. 

of  the  vocal  cords.  Their  structure  closely  resembles  thai  of  edematous 
nasal  polypi.  As  has  been  stated,  the  surface-epithelHiin  and  the  extrava- 
sated  blood  constitute  the  chief  differences.  There  are  also  more  blood- 
vessels, which  are  usually  much  dilated,  making  vascular  channels  across  the 
loose  stroma.  Hyaline  bodies  are  also  frequently  met  with,  and  supposed  to 
he  due  to  the  degeneration   of  the  stroma-fibers  (Fig.  635). 

Etiology. —  In  studying  their  structure  we  see  al  once  that  they  are  the 
resull  of  chronic  inflammation,  and  therefore  have  the  same  cause  as  do  the 
singers'  nodes  already  referred  to.  A-  a  matter  of  fact,  their  structure  is 
identical  with  many  of  the  latter  growths,  which  may  therefore  he  looked 
upon  as  early  stages  of  laryngeal  polypus.  They  are  more  common  in  men, 
and  are   seldom   .-ecu    in   children. 

Physical  Appearances. —  They  are  smooth,  rounded  bodies,  which  may 
he  sessile  or  may  have  a  Ion--  pedicle.  They  may  he  red  and  congested  or 
look  pale  ami  opaque.  They  usually  have  their  attachment  to  the  anterior 
part  of  the  true  cords,  hut  may  aho  spring  from  the  ventricles  or  false  cords, 
the  subglottic  space  (see  Fig.  563),  or  from  the  anterior  commissure.  They 
may  he  very  small,  in  which  case  they  are  usually  sessile  (singers'  nodes);  or 
they  may  he  so  large  as  almost  to  fill  the  larynx,  leaving  surprisingly  little 
room  for  respiration.  When  large  they  are  commonly  pedunculated,  pear- 
shaped  growths.     They  are  usually  single,  hut  may  have  several  lobules. 

Papilloma  is  of  such  frequeni  occurrence  in  the  larynx  and  is  so  closely 
allied  to  various  manifestations  of  inflammation,  such  as  pachydermia  and 
the  surface-phenomena  of  certain  tubercular  ami  syphilitic  lesions,  that  we 
musl  presume  that  the  local  irritation  of  inflammation  is  an  important  ele- 
ment in  its  pathogenesis.  Generically  it  has  been  classified  by  pathologists 
among  the  fibromata  and  called  a  papillary  fibroma  ;  hut  its  chief  character- 
istic i-  epithelial  proliferation,  and  to  be  consistent  with  pathological  laws  it 
would  seem  that  its  name  should  rather  be  "benign  epithelioma."  Accord- 
ing to  Schmidt's  tahles,  he  met  it  in  about  1<>  per  cent,  of  his  cases  of  laryn- 
geal neoplasms.  Schrotter1  place-  its  proportions  at  IS  per  cent.,  while 
Moure-'  agrees  with  Bruns,  Fauvel,  Massei,  Krishaber,  and  Elsberg  in  saying 
that  it  occurs  in  about  50  percent.,  and  Mackenzie  puts  the  figure  as  high  as 
67  per  cent.  Schnitzler 3 says  it  i-  the  mosl  frequeni  of  all  laryngeal  growths, 
especially  in  children  ;  while  in  adult-  papilloma  becomes  less  frequent  and 
fibroma  more  common.  This  discrepancy  probably  depends  on  how  many 
of  the  inflammatory  nodule-,  already  spoken  of,  are  placed  in  the  category 
of  tumor-.  It-  mosl  frequeni  site  of  attachment  is  the  vocal  cords  in  their 
anterior  third  and  at  the  anterior  commissure,  hut  it  may  occur  everywhere 
in  the  larynx.  A  growth  may  have  a  long  pedicle  which  allows  its  attach- 
ment beneath  the  cords,  and  yet  the  ma—  may  presenl  above  them. 

In  children  it  presents  certain  feature-  in  diagnosis  and  treatment  not 
observed  at  other  period-  of  life  nor  in  other  growths.  Congenital  cases 
have  been  reported  in  which  the  child  was  aphonic  from  birth.  In  very  young 
children   laryngoscopical   examination    i-  usually  unsatisfactory  and   always 

moie  mi-  less  incomplete.       When    the    growths   are   situated  in  the  upper   part 

of  the  larynx  fchey  can  sometimes  he  felt  by  the  examining-finger.  Hoarse- 
ness in  a  child,  -lowly  increasing  to  aphonia  and  dyspnea,  render  the  diagnosis 
eedingly  probable.  Tracheotomy  may  then  he  indicated,  in  the  course  of 
which  the  diagnosis  will  he  established.  The  growths  are  usually  sessile  and 
frequently   disseminated.      While    Hooper*   ha-   succeeded    in   operating  on 

lit   Kranlcheiten  di     Keldkop/es.  Leeon         h     Maladies  dm  Larynx. 

l//.i   der  Laryngologie.  '  International  Clinics,  <  October,  1891. 


BENIGN  NEOPLASMS  OF  THE  LARYNX. 


1107 


children  after  tracheotomy,  and  even  without  it.  by  endo-laryngeal  methods 
under  ether,  this  is  usually  uot  practicable  nor  satisfactory.  Tracheotomy 
should  be  performed,  when  indicated,  for  the  dyspnea,  and  the  tube  lefl  in  for 
several  months  before  thyrotomy  is  done,  which  may  result  in  permanent 
loss   of  voice  or  serious   impairment    of  it. 

A  large  number  of  cases  have  been  reported  of  spontaneous  cure  after 
tracheotomy,  presumably  due  to  the  rest  afforded  the  larynx.  Thyrotomy 
may  be  done  and  the  larynx  thoroughly  curetted  and  cauterized,  bul  recur- 
rence even  then  is  common.  Intubation  has  been  tried  in  hope  that  the 
pressure  of  the  tube  would  cause  absorption  of  the  growths,  but  not  with 
satisfactory  results. 

Physical  Appearances. — They  may  he  single  of  multiple,  with  a  long 
pedicle  or  broad-based.  They  may  dot  the  surface-  of  the  cords  as  little 
buds  or  fill  the  whole  cavity  of  the  larynx  with  a  fungus-looking  mass, 
which  may  be  pale  or  of  a  dark-red  color.  Their  size,  however,  is  not 
usually  larger  than  a  pea. 

Differential  Diagnosis. — There  are  certain  conditions  in  the  larynx  which 

may  give  rise  to  a  mistaken  diagnosis  of  papilloma.     The  one  which  possi 

most  interest  is  epithelioma.  As  has  been  said,  papilloma  is  itself  a  dis- 
tinctly epithelial  growth.  Every  laryngologist  knows  that  occasionally  a 
beginning  cancer  will  present  exactly  the  same  appearance  in  the  larynx  as  a 
papilloma.  Indeed,  there  may  be  no  carcinomatous  elements  in  the  surface- 
proliferations,  and  thus  a  microscopical  examination  of  portions  removed  by 
endo-laryngeal  procedure  may  be  misleading.  A  papillary  tumor  occurring 
in  the  larynx  under  twenty-five  is  in  all  probability  a  benign  growth.  <  Occur- 
ring in  a  patient  over  fifty,  who  has  had  no  previous  laryngeal  trouble,  how- 
ever benign  in  its  appearance,  it  is  always  to  be  looked  upon  with  suspicion. 

If  it   is   pedunculated,  and  after   existing   several    nth-   the  surrounding 

mucous  membrane  presents  no  appearance  of  infiltration  nor  zone  of  inflam- 
mation, it  is  presumably  benign.  Any  limitation  of  movement  in  the  excur- 
sion of  the  vocal  cord-  i-  a  suspicious  circumstance,  which  if  marked  is 
almost  pathognomonic  of  malignant  disease.  Re- 
currence after  thorough  removal  in  case  of  malig- 
nancy is  apt  to  be  accompanied  by  infiltration, 
while  when  benign  this  is  not  noted  ;  but  recur- 
rence it-elf  in  a  patient  past  middle  life  is  not  a 
favorable  omen,  although  in  children  it  is  the  rule 
in  benign  growths.  Unless  the  piece  removed 
for  examination  include-  some  of  the  tissue  from 
which  the  growth  springs, a  negative  microscopical 
examination    is  not  conclusive.       On    the    other 


6. — Cyst  "f  larynx  (from  Mackenzie). 


:  larynx  (fi 


hand,  even  a  surface-clipping  may  -how  the  character  of  the  growth  ;  but 
frequently  a  concentric  arrangement  of  epithelial  cells  leaves  the  examiner 
in  doubt  a- to  their  significance.     Under  such  circumstances  time  must   lie 


1    108 


NEOPLASMS  OF  THE   UPPER  AIR-PASSAGES. 


allowed  to  watch  the  progress  of  the  case,  but  it  should  be  examined  at  fre- 
quent intervals  by  a  competent  diagnostician. 

Tuberculosis  of  the  larynx  presents  occasionally  an  appearance  which 
to  the  novice  closely  resembles  a  papillomatous  growth  (see  Figs.  <>12,  616, 
617,  622).  Papillary  masses  at  the  posterior  commissure,  or,  less  frequently, 
more  anteriorly,  may  so  project  into  the  larynx  as  to  bide  underlying  infil- 
tration or  ulceration.  Examination  of  the  chest  or  sputum  may  even  be 
negative  or  the  former  doubtful.  The  position  of  the  growth  at  the  posterior 
commissure,  its  sessile  character,  the  paleness  of  the  larynx,  the  prominence 
of  cough  as  a  symptom,  and  the  general  history  of  the  case,  will  usually  allow 
the  experienced  laryngologisl  to  make  a  diagnosis  without  the  aid  of  pulmo- 
nary signs.  .Microscopical  examination  will  frequently  show  tubercle-bacilli ; 
but  these  may  also  be  absent,  and  only  the  epithelial  proliferation  is  to  be 

noted. 

Cysts1  (Fig.  636),  angioma2  (Fig.  634),  myxoma,-1  lipoma4  (Fig.  637), 
chondroma,5  adenoma,'''  lymphoma7  (Fig.  638),  and  colloid  growths  are  all 
occasionally  met  with  in  the  larynx,  while  amyloid  degeneration8  has  been 
noted   in   various  tumors. 


I 


w& 


Fig.  638. — Papillary  lymphoma  of  larynx. 


Symptoms  of  Benign  Laryngeal  Growths.— In  a  general  way  it 
may  be  said  thai  supraglottic  tumors  first  produce  cough,  neoplasms  of  the 
vocal  cords  firs!  give  rise  to  hoarseness,  and  infraglottic  growths  to  dyspnea  ; 
lait   it  will  be   readily  understood   that   no  absolute  rule  can  be  laid  down. 


1  Garel,  CentralbLf.  Laryng.,  iv.,  1  17;  Lyon  Mid.,  April  12,  L885;  Richard  Ubrich,  Disser- 
tation, VVurzburg,  L887;  Ledderhose,  Deutsch.  Zeit.  /.  Ckirurg.,  xxix.,  4,  1889;  Ref.  CentralbLf. 
Laryng.,  vi  .  255;  Chiari,  Oentralbl.  (.  Laryng.,  viii.,  308;  Thost,  Deutsch.  med.  Woch.,  1891,  No. 
20,  p.  686;   [ngals,  N.  )'■  Med.  Journ.,  Sept.  1,  1894,  p.  260. 

Wblfenden,  Journ.  "/'  Laryng.,  L888,  p.  291  ;  Glasgow,  Trans.  Amer.  Laryng.  Assn.,  1888, 
p.  146;   Loomifl,  N.  Y.  Med.  Record,   Vpril  5,  L896. 

1  have  sections  of  two  specimens  in  my  possession.  The  reports  of  myxoma  are  so  con- 
fused with  those  of  edematous  growths  thai  it  is  difficult  t<>  distinguish  the  true  from  the  false. 
Bosworth  refers  to  12  or  15  i 

'  Farlow,  A  )  Med  Jon  ii.,  p.  610,  Nov.  16,  1895;  Schrotter,  Vorlesungen  tiber  die 
Kranfcheiten  des  Kehlkopfes,  p.  '-'71. 

'Virchow,   Die  Krankhaften  GeschwiiUte,  L,  p.    Ill;   Bond,    British  M<<li<;il  Journ.,  May  6, 

Gerhardt,  Kehlkopf geschwiilste ;   \'otlm:iLrcrs  Spi .-.  Path,  und  Therapie. 
'  It  is  doubtful  whether  these  occur  in  the  larynx,  though  Cornil  and  Ranvier  (Histologic 
Pathologique,  ii.)  *-p>;il<  of  n  diffuse  condition  there  which  they  call  adenoma. 

7  The  "nl\  reports,  without  general  lymphomatosis,  are  Wolfenden  and  Martin's  Studies  in 
Path.   AnaL,   rase  "J,  26;    Jonathan   Wright's  "Subglottic    Neoplasms,"  Journ.   Amer.  Med. 
26   1891. 
Martuscelli,  Archivi  Italianid*  Laryngologie,  I  asc.  ■"■.  1896;  Gerhardt,  loc  <it. 


MALIGNANT  TUMORS  OF  THE  LARYNX.  1109 

Glottic  spasms,  aphonia,  and  apnea  are  the  graver  forms  of  the  same  clinical 
character.  Pedunculated  growths,  by  changing  their  position  in  relation  to 
the  glottis,  frequently  cause  intermittency  or  exacerbation  of  these  symptoms. 

Benign  tumors  being  usually  of  slow  growth,  the  advent  of  dyspnea  is 
not  noted  by  the  patient,  except  in  the  case  of  pedunculated  growths,  when 
it  is  intermittent  or  spasmodic,  until  very  surprising  encroachmenl  has  been 
made  on  the  air-way.  They  so  gradually  become  accustomed  to  interference 
with  respiration  that  it  is  not  noticed  until  some  sharp  attack  of  inflamma- 
tion ^till  further  blocks  the  larynx  and  perhaps  produces  dangerous  choking. 
The  laryngoscope,  of  course,  establishes  a  diagnosis  which,  until  it  is  used, 
is  mere  surmise. 

Treatment. — The  treatment  of  benign  laryngeal  neoplasms  consists  in 
their  removal  from  the  larynx  or  their  destruction  in  situ.  The  method  and 
means  employed  will  depend  almost  entirely  upon  the  size,  shape,  and  situa- 
tion of  the  growth.  Small  sessile  growths  can  West  he  destroyed  by  the 
ualvano-cautery.  The  various  forms  of  laryngeal  forceps,  snares,  and  guil- 
lotines are  the  endo-laryngeal  instrument-,  among  which  .-election  must  he 
made  for  the  pedunculated  or  circumscribed  growths.  Thi-  -election  will 
be  largely  a  matter  of  the  individual  preference  of  the  operator.  Urgent 
dyspnea  may  necessitate  immediate  tracheotomy.  In  many  eases  the  tumor 
may  be  so  large  that  it  is  advisable  to  have  tracheotomy-instruments  at  hand 
for  immediate  use,  should  the  emergency  of  the  moment  require  it  during  an 
endo-laryngeal  attempt.  Rarely,  in  subglottic  or  in  broad-based  hard  growths, 
such  as  chondromata,  a  thyrotomy  is  necessary. 


MALIGNANT  TUMORS  OF  THE  LARYNX. 

Carcinoma  of  the  Larynx. — It  is  not  intended  here  to  treat  of  those 
cases  of  cancer  which,  originating  elsewhere,  have  spread  by  continuity  or 
metastasis  to  the  larynx.  Such  are  the  malignant  growths  of  the  laryngo- 
pharynx  and  esophagus,  and  of  the  cervical  glands. 

In  1889  Semon1  collected  the  statistics  of  laryngeal  cancer  in  such 
numbers  that  from  the  fact-  given  we  are  able  to  gather  a  better  and  more 
definite  knowledge  of  malignant  growths  in  the  larynx  than  in  any  other 
part  of  the  air-passages.  This  was  due  to  the  interest  aroused  in  the  tragic 
fate  of  the  Emperor  Frederick  of  Germany,  and  to  the  unfortunate  quarrels 
of  his   medical   attendants. 

Semon's  tables  show  the  reports  of  107  observers,  whose  collective  experi- 
ence comprised  10,717  cases  of  benign  growths  and  1550  malignant  tumors, 
a  proportion  of  about  7  to  1.  Since,  a-  we  -hall  see  later,  considerably  less 
than  !<>(>  report-  of  laryngeal  sarcoma  could  be  collected  in  1894  from  litera- 
ture, we  may  disregard  these  growths  in  estimating  the  relative  frequency  of 
carcinoma  of  the   larynx. 

A-  will  be  -ecu  from  his  list.  Schmidt  had  himself  seen  7">  cases.  From 
Semon's  tables  we  find  that  Stork  had  seen  loo  in  Vienna,  Oertel  1<">  in 
Munich,  Massei  •"!!•  in  Naples,  Fauvel  150  in  Pari-,  Simon  56  in  London, 
Cohen  loo  in  Philadelphia.  These  are  figures  given  in  some  cases  as  esti- 
mated, and  the  Dumber  i-  proportionately  larger  owing  to  the  numerous  cases 
seen  in  consultation. 

Gerhard  t  says  carcinoma  of  the  larynx  is  three  times  more  common  in  men 
than  in  women.     According  to  Schmidt's  experience  it  is  nearly  lour  time-  a- 

1  Centralblatt  fur  Laryngologie. 


1110  NEOPLASMS  OF  THE  UPPER  AIR-PASSAGES. 

frequent.  Jurasz's  own  experience  was  15  men,  1  woman.  He  quotes  Bara- 
toux's  collected  statistics  as  showing  88  per  cent,   in  men. 

Jurasz's  cases  showed  it  most  frequent  in  the  decade  from  50  to  60. 
Gerhardt,  quoting   Kran-.  gives  the  following  table  as  to  age. 

20  to  30 i 

30  to  40 18 

10  to  50 49 

50  to  60 7<i 

60  to  70 30 

70  to  80 10 

1ST 

Schrotter  says  he  has  seen  it  in  a  child  of  three  and  a  half  and  in  a  girl 
of  ti'ii  and  a  half  years.  It  has  been  noted  that  it  occurs  more  frequently 
in  well-to-do  people,  and  especially  in  those  who  use  their  voices  constantly. 
Heredity  seems   to   have  a   marked   influence  in  some  eases. 

The  site  of  growth  in  Jurasz's  cases  was  as  follows: 

Whole  larynx 1 

Right  Bide  of  larynx 2 

Epiglottis  of  Larynx     3 

True  cords,  1  right,  1  left,  2  both 4 

True  cords  and  ventricular  bands 3 

Arytenoids  and  interarytenoid  space      2 

15 

In  Mackenzie's  53  cases,  however,  28  sprang  from  the  ventricular  hands. 

Bosworth,  quoting  from  Gurlt,  says  that  out  of  11,131  cases  of  carci- 
noma  it  occurred  in  the  larynx  in  <>•'!  cases,  as  against  47  in  the  air-passages 
above  it. 

Epithelioma  i-  the  form  usually  observed,  but  encephaloid,  adeno-carci- 
ooma,  and  scirrhus  have  all  beeo  reported  in  the  larynx.  The  medullary  can- 
cer i-  more  frequently  extrinsic  and  the  scirrhus  is  very  rare.  Oul  of  68  cases 
collected  by  v.  Ziemssen,  57  were  epithelioma.  '.»  encephaloid.  and  2  villous 
tumor- :  out  of  Mackenzie's  53  cases,  2  were  scirrhus.  The  usual  duration 
i-  aboul  three  years,  bul  some  cases  of  adeno-carci noma1  have  lately  been 
reported  which  lasted  five  or  six   years. 

Symptoms. — Hoarseness  is  the  first  symptom,  which  usually  come-  on 
gradually  and  lasts  for  several  months  before  any  other  symptom  supervenes. 
'I'lir  majority  of  the  patients  are  in  good  general  health.  The  hoarseness,  after 

;i  longer  or  shorter  time,  i-  ace panied  by  dyspnea  and  cough  :   the  former 

rapidly  increases  until  tracheotomy  is  urgently  indicated.  Later  in  the  disease 
glandular  enlargements  may  be  fell  in  the  neck  ;  but  they  are  usually  not 
present  at  first,  although  Frankel  reports  cases  in  which  the  glandular  in- 
volvement was  the  mosl  marked  feature  of  the  case  from  the  first.  Dys- 
phagia  sooner  or  later  occurs,  and   pain,  worse  at    night,  robs  the  patient  of 

sleep.     These   symptoms   are   more   marked  and  con sarlier  when   the 

ulcerated   growth    is  on    the   posterior   wall    or   the  epiglottis  and    aryteno 
epiglottic  fold-  ;   lint  are    late  when    the  tumor  i-  on  the  vocal  cord-  or    in  the 
laryngeal   ventricles. 

The  general  health  deteriorates,  the  appetite  fails,  and  there  i-  loss  of  flesh 
and  strength. 

Ulceration   gives  ;i    peculiar   and,    Frankel   says,  characteristic    odor  to 
the  I. ie;ith.  which  i-   identical  with  that  from  a   pharyngeal   carcinoma.     In 
1  »w8ki,    I  /  ■  yngokffie,  Bd.  i.,  heft  1  ;   Krieg,  Tbid.,  l;,l.  i.,  hefl  2. 


MALIGNANT  TUMORS  OF  THE  LARYNX.  1111 

a  recent  case  of  carcinoma  of  the  pharynx,  before    I    realized  the  source  of 
the  odor,  the  firs!  impression  I    had  of  it  was  that  the  patienl  had  been  using 

a  gargle  of  the  solution  of  the  ehlorid  of  iron   on  ;i  fetid   surface. 

Finally  the  growth  becomes  apparent  to  external  palpation,  perforating 
the  laryngeal  cartilages,  which  crackle  under  the  finger  on  pressure.  It  may 
even  perforate  the  skin  and  appear  as  a  fungous  mass  externally.  The  last 
phases  of  the  disease  present  a  most  pitiable  aspecl  of  human  suffering. 
Tracheotomy  has  long  since  become  necessary.  Granulations  block  the  tube 
and,  growing  below  it,  slowly  suffocate  the  patient.  ( lontinual  cough,  ii nihility 
to  swallow,  lancinating  pains,  and  the  foul  odor  make  a  picture  which  every 
laryngologist  should  have  in  mind  in  considering  the  treatmenl  of  the  disease 
in  its  early  stages.  Pieces  of  necrosed  cartilage  are  coughed  out,  or  portions 
of  the  tumor  may  fall  into  the  trachea  and  bronchi.  Perforation  of  the 
esophagus  frequently  supervenes  and  food  may  penetrate  the  bronchial  tubes. 
Hemorrhage  i>  sometimes  abundant,  although  Mood  is  usually  only  mixed 
with  the  copious  discharges  from  the  throat.  Perforation  of  the  carotid  may, 
however,  end  the  case.  Death  may  come  thus,  or  from  exhaustion,  or  from 
supervening  pneumonia  due  to  penetration  of  pieces  of  the  growth  or  food 
and  blood  into  the  lungs — the  so-called  "Schluck  Pneumonic"  Suffocation 
is,  therefore,  not  the  only  termination  of  the  disease,  although  it  is  a  fre- 
quent one. 

Diagnosis. — The  laryngoscopical  appearances  of  laryngeal  cancer  must  he 
considered  in  connection  with  its  differential  diagnosis,  so  far  a-  it-  initial 
stages  are  concerned.  Its  differentiation  from  papilloma  has  already  been 
alluded  to.  In  its  incipient  stages  epithelioma  frequently  resembles  the 
benign  growth.  At  other  times  a  flat,  indolent  ulcer  on  the  vocal  cord  may 
be  seen  at  the  first  laryngoscopical  examination.  When  the  c(\^{'>  are  infil- 
trated and  round  we  may  suspect  carcinoma,  hut  sometimes  this  is  not  the 
appearance.  The  edges  may  be  more  or  less  flat  and  sharp-cut.  Anti- 
syphilitic  treatment  in  decisive  doses  of  mercury  and  the  iodid  of  potash 
must  be  given  while  a  microscopical  examination  i:-  being  made.  Tuberculosis 
must  be  thought  of.  and  an  examination  of  the  lung-  for  physical  sign.-,  and 
of  the  sputum  for  bacilli,  must  be  made. 

When  the  growth  occur-  in  the  ventricles  of  the  larynx,  the  problem  is 
a  much  harder  one  to  solve.  We  find  a  smooth  swelling  presenting  above 
the  cords.  Being  covered  by  mucous  membrane  it  i-  impossible  to  remove  a 
piece  fbr  examination.  There  i>  a  limitation  or  entire  abolition  of  movement 
of  that  side  of  the  larynx.  There  is  nothing  to  be  done  bin  to  try  to  ex- 
clude a  syphilitic  gumma  bv  the  vigorous  administration  of  the  iodid  of 
potash.  Once  I  saw  such  a  growth  which  was  evidently  tubercular.  We 
must  remember  that  cancer  may  coexist  either  with  a  syphilitic  history  or 
pulmonary  phthisis.  We  mu-t  also  remember  that  the  administration  of  the 
iodid  of  potash  may  cause  a  sensible,  although  temporary,  diminution  in  the 
size  of  a  cancerous  swelling.  As  Frankel  says,  it  seems  a-  though  the  dis- 
ease was  -imply  catching  it-  breath  for  a  fresh  -tart.  The  surface  linalb  is 
involved  and  the  diagnosis  become-  evident. 

The  appearance  of  the  growth,  which  in  the  early  stages  varies  so,  in  the 
later  stages  i-  more  uniform  and  characteristic.  The  ulcer  of  cancer  then 
differs  in  no  way  from  it-  appearance  elsewhere.  A  fungous  mass  covered 
by  grayish  or  whitish  secretion  fills  the  larynx  more  or  less  completely.  The 
growth  eat-  into  the  cartilages,  causing  the  swelling  characteristic  of  peri- 
chondritis. It  has  nearly  always,  even  in  the  initial  stages,  burrowed  more 
deeply  into  the  underlying  tissues  than  appear-  on   the  surface,      ft  grows 


1112  NEOPLASMS  OF  THE   UPPER  AIR-PASSAGES. 

upward  over  the  t » » j »  of  the  larynx,  infiltrating  the  surrounding  tissues  and 
producing  then  marked  glandular  involvement. 

Semon  bas  pretty  conclusively  settled  by  his  statistics  the  question  of  the 
degeneration  of  a  benign  into  a  malignant  growth  of  the  larynx.  The  ex- 
ceeding rarity  and  doubtfulness  of  this  occurrence  was  one  of  the  assertions 
of  pathologists  which  clinician-  had  been  loath  to  accept.  In  only 45  out  of 
the  10,747  cases  reported  did  this  seem  possible;  while  as  following  upon 
endo-laryngeal  operation-  it  was  only  reported  33  times.  Many  of  these  re- 
ports render  the  opinions  expressed  extremely  doubtful  ;  so  that  excluding 
all  but  the  certain  cases,  Semon's  proportion  isl  to  1645  of  malignant  degen- 
eration after  endo-laryngeal  operation.  And  after  all.  we  may  say  that  the 
proof  is  uecessarily  a  jmsl  hoe,  ergo  'propter  hoc  argument.  We  must  allow 
the  possibility  of  a  benign  tumor  becoming  malignant,  although  the  strongest 
microscopical  proof  musl  be  required  to  admit  of  its  probability  in  any  case. 

The  prognosis  of  laryngeal  carcinoma  i-.  of  course,  very  had;  but  the 
statistics  hereafter  quoted,  it  should  be  remembered,  include  many  cases  in 
which  the  growth  was  not  confined  to  the  "  fox  of  the  larynx." 

The  same  rule  here  holds  good,  as  to  the  difference  in  the  prognosis  of 
those  cases  operated  on  early  and  those  operated  on  late,  as  elsewhere  in  the 
body  :  although  the  cartilaginous  walls  shutting  off  the  growth  from  sur- 
rounding tissues  would  seem  theoretically  to  give  the  incipient  cases  an  espe- 
cially good  prognosis.     Without  operation  all  cases  die  miserably. 

Treatment. — Of  late  year-  the  conviction  has  grown  among  laryngolo- 

-  that  every  primary  intrinsic  carcinoma  of  the  larynx  in  its  early  stages 
i-  a  case  for  extra-laryngeal  rather  than  endo-laryngeal  operation.  The 
diagnosis  once  made,  the  laryngologist  should  see  noli  me  tangere  written  in 
the  larynx  of  every  case.  No  operator,  however  skilled,  can  ever  be  sure  that 
he  has  removed  the  infiltrating  cancer-cells.  There  is  every  reason  to  believe 
that  cancer  i-  a  local  disease,  which,  if  disturbed  by  any  operative  procedures 
short  of  extirpation,  is  apl  to  spread  rapidly  beyond  the  reach  of  the  knife. 
Frankel  and  Moure  both  state  their  belief  that  the  removal  of  pieces  for 
histological  examination  doe-  no  harm,  but  that  the  wound  usually  heals  over. 
Tin-  majority  of  observers,  however,  do  not  agree  to  this.  Doubtless,  in- 
effectual  tampering  with  an  already  malignant  though  quiescent  growth  has, 
by  it-  results, given  rise  to  the  opinion  formerly  held  by  some,  that  such  pro- 
cedures were  the  exciting  cause  of  a  malignant  degeneration. 

No  rules  for  operation  can  lie  laid  down  that  will  apply  to  every  case. 
In  :i  general  way  it  may  lie  -aid  that  all  cases  which  arc  confined  to  the  in- 
terior of  the  larynx  and  in  which  there  i-  no  glandular  involvement  arc 
cases  for  operation  by  laryngectomy  or  some  of  its  modifications.  Excision, 
according  to  Power- and  White,1  has  been  performed  upwards  of  300  times. 
From   them  I  quote  the  following  table,  which  gives  at  a  glance  a  general 

report  of  the  results  attained  : 

1.  T"i  \  i.    1a.  [SION   "i     i  m;   I.  \i:y\x. 

ported  prior  to  January,  1892 180 

Died  .-I-  result  of  operation 7'J 

I '  ■ 'I  in  lir-t  year,  5  from  recurrence       8 

Recurred  in  first  year,  either  dead  or  living  when  reported ">1 

irred  after   I  year    13  months  •_'.  2  years  'J,  "J  years  1  month,  2  years  7 

ii ili-.  3  years  I  month                        .    . .    .  8 

R<  ported  in  tir-i  year,  free 16 

ond  year,  free II 

Reported  in  third  year,  free .'{ 

Reported  after  3  years,  free                                ][ 

1  Mediea  I  irch  28,  l- 


MALIGNANT  TUMORS  OF  THE  LARYNX.  1113 

•2.  Partial  Excision  cm    che  Larynx. 

<  lases  reported  prim-  to  January,  L892 77 

Died  as  result  of  operation  (8  weeks) 26 

Died  in  tir>t  three  years    3  from  recurrence 5 

Recurrence  in  tir<t  year,  either  dead  or  living  when  reported 17 

Recurrence  after  1  year  i  13  months,  1 » »  months,  17  months] 3 

Reported  in  first  year,  free 13 

Reported  in  second  year,  tree 4 

Reported  in  third  year,  free '1 

Reported  alter  •">  years,  free 7 

After  what  has  been  said  of  the  course  of  laryngeal  cancer  left  to  itself, 
it  will  be  admitted  that  the  many  cases  who  died  as  a  result  of  operation  are 
not  to  lir  looked  upon  as  necessarily  an  argument  against  the  procedure;  nor 
arc  the  cases  of  complete  recovery  to  be  looked  upon  as  unqualified  successes. 
The  loss  of  a  larynx  is  a  terrible  mutilation  of  the  human  organism,  and  the 
after-life  of  the  patient,  with  or  without  an  artificial  vocal  apparatus,  i-  not 
an  enjoyable  existence.  Gussenbauer  and  Wolf  have  invented  mechanisms 
which  permit  these  patients  to  produce  articulate  speech  :  but  many  cases 
have  been  reported  in  whom  some  fold  of  tissue  has  been  formed  by  nature 
to  serve  as  a  vibrating  membrane  in  the  production  of  sound  and  its  modifi- 
cation by  the  lips  and  tongue  into  speech. 

Cohen's  well-known  case  of  adeno-carcinoma,  in  which  the  larynx  and 
upper  part  of  the  trachea  being  removed,  the  remaining  tracheal  orifice  was 
stitched  to  the  -kin  above  the  episternal  notch,  is  still  alive  (November,  1896) 
— nearly  five  years  after  operation — and  he  speaks  hoarsely,  but  distinctly, 
by  means  of  swallowed  air  which  he  holds  in  a  kind  of  a  pouch  in  his 
pharynx  and  expels  past  some  vibrating  fold  of  mucous  membrane  in  the 
neighborhood  of  the  pillars  of  the  fauces.  He  breathe-  without  cannula 
through  the  cervical  opening. 

Excision  of  the  larynx  is  an  operation  which,  in  fairness  to  the  patient. 
should  only  be  performed  by  a  surgeon  skilled  in  all  the  technic  of  modern 
surgical  methods  and  equipped  by  previous  surgical  experience  with  the 
ability  and  presence  of  mind  to  meet  grave  and  often  unexpected  problems 
which  may  arise  during  its  performance.  Cohen  and  especially  Semon x  are 
the  Iaryngologists  who  have  had  the  most  gratifying  results  in  these  opera- 
tions; but.  a- a  rule,  it  is  not  a  task  to  be  undertaken  by  even  the  experienced 
laryngologist. 

In  many  cases  the  tumor  has  spread,  either  by  direct  growth  or  by  metas- 
tasis, beyond  the  larynx.  The  inclusion  of  these  in  the  table-  given  is  what 
make-  the  percentages  of  recurrence  ami  death  so  high.  In  each  case,  n-  it 
i-  met,  a  decision  a-  to  a  radical  operation  or  a  palliative  treatment  is  to  be 
decided  on  its  merits  ami  according  to  the  wishes  of  the  patient,  when  the 
conditions  are  explained  to  him.  Tracheotomy  for  the  passage  of  air  i- 
always  indicated,  and  even  gastrotomy  for  the  introduction  of  food  may  lie  a 
mean-  of  prolonging  a  miserable  existence. 

Sarcoma  of  the  Larynx. — Bergeat  -  ha-  presented  the  most  i iplete 

and  exhaustive  review  of  t hi'  report-  of  sarcoma  of  the  larynx  yet  published. 

Hi-  li-t   i-  ;i-  follows  : 

Laryngeal  sarcoma,  primary 85  Tracheal  and  bronchial  Barcoma,  primary  .    7 

Laryngeal  sarcoma,  secondary,  by  continuity    1"  Tracheal  and  bronchial  Barcoma,  secondary 

Laryngeal  Barcoma,  secondary,  by  metas  in  man .    .     i> 

tasis        -  Tracheal  and  bronchial  sarcoma,  secondary 

Doubtful 17  in  animal     dog)        1 

111  17 

1  Semen  Lancet,  Dec.  15,  1894,  •'  eq.  .  in  a  series  of  private  cases,  has  attained  tin-  best 
results  hitherto  published.  '  Monateckrift  fur  OhrenheUkwide,  1895,  V-.  -  and  12. 


1114  NEOPLASMS  OF  THE   UPPER  AIR-PASSAGES. 

Reports  of  the  following  cases  (not   included  in   Bergeat's  tables)  are  at 

hand  : 

Chappell,1  female,  aged  32,  symptoms  1  years.  Sarcoma  (perithelioma) 
of  epiglottis,  very  large,  pedunculated,  removed  with  hot  snare;  weight  360 
grains;  size  1'.    ■  3|  inches  in  circumference. 

Thompson,2  male,  aged  35,  blacksmith,  symptoms  <>  months,  right  side  of 
larynx,  laryngectomy. 

Mackenzie  says  that  he  had  seen  only  5  cases  of  sarcoma  of  the  larynx. 
A-  lie  had  seen  53  cases  of  carcinoma,  we  have  the  ratio  in  his  experience  of 
about  1  t<>  1<>.  Schmidt's  proportion,  it  will  he  seen,  is  3  to  75  or  1  to  25; 
while  Bergeat  quotes  Gurlt  as  giving  the  general  relative  occurrence  through- 
out the  body  as  1  to  13.  Bosworth,  quoting  Gurlt,  says  that  out  of  848 
sarcmnata,   the    larynx    was   the   seat   of  disease    in    only    1    case. 

In  Bergeat's  tables,  out  of  (i<>  cases  of  primary  sarcoma,  48  were  of  the 
male  sex  and  IS  femah — in  general,  lie  says,  sarcoma  occurs  in  men  10  per 
cent,  more  frequently.  It  occurred  in  men  almost  twice  as  frequently  (15) 
from  50  to  60  as  in  any  other  decade ;  the  next  in  frequency  (8)  being  from 
40  to  50.  The  youngest  was  7  years  old;  the  oldest  SI.  In  women  it 
occurred  from  21  to  53  inclusive,  there  being  5  each  from  30  to  40  and  from 
40  to  50.  and  only  2  from  50  to  60.  Curiously  enough  he  notes  its  more 
frequent   occurrence   in    people   who  came  often    in   contact   with    horses. 

In  variety  they  were  spindle-celled,  22;  round-celled,  12;  alveolar,  5  or 
6;  mixed,  1;  giant-celled,  2  or  3 ;  fibro-myxomatous,  1. 

It  had  its  origin  most  frequently  on  the  vocal  cords,  but  also  occurred  in 
almost  every  other  locality.  On  the  vocal  cords  and  epiglottis  the  spindle- 
celled  sarcoma  was  almost  the  exclusive  form  found.  Xo  instance  is  recorded 
in  which  the  growth  originated  in  the  larynx  and  spread  to  the  pharynx  ; 
the  secondary  invasion  was  always  the  other  way.  Erosion  and  perforation 
of  cartilage  were  rarely  observed.  In  spite  of  the  numerous  observers  who 
have  drawn  attention  to  the  lateness  of  glandular  involvement  in  laryngeal 
carcinoma,  Bergeal  noted  it  in  15  per  cent,  of  the  cases  of  laryngeal  sarcoma. 
This  was  especially  marked  with  the  round-celled  and  alveolar  sarcomata. 
The  course  of  these  form-  is  frequently  very  rapid  ;  but  the  duration  of 
sarcoma  of  the  larynx  seems  to  vary  greatly,  the  symptoms  sometimes  dating 
hack  only  a  few  weeks  and  sometimes  running  back  for  several  years;  some 
of  the  eases  having  lived  ;is  long  as  7,  8,  and  10  years.  Pain  and  dyspnea 
are  not  SO  prominent  as  in  carcinoma,  and  ulceration  is  also  not  SO  usually 
observed.  The  general  health  is  frequently  not  seriously  affected ;  but  there 
is  the  greatesl  variation  in  the  severity  of  the  symptoms. 

Diagnosis  from  carcinoma  is  usually  impossible  without  a  microscopical 
examination.  The  same  caution  niu-t  be  observed  here  as  elsewhere  in 
distinguishing  small  round-celled  sarcomata  from  syphilitic  and  other  granu- 
lomata.  In  summing  up  all  the  cases,  as  Bergeat  has  done,  it  is  seen  that 
the  average  course  and  clinical  picture  differ  materially  from  those  of  car- 
cinoma, and  vet  in  any  given  case  the  differentia]  diagnosis  upon  these  alone 
is  not  satisfactory.  Bergeat  lays  some  stress  on  a  striking  yellow  color 
which  i-  sometimes  observed  in  sarcoma,  but  never  in  carcinoma,  on  the 
slower  growth,  the  later  and  more  infrequent  ulceration.  Sarcoma  is  some- 
times pedunculated.      There    are    rarely  any  sharp-pointed  projections,  but 

they    are    Usually  round    and    broad. 

Prognosis. —  In  a  general  way  the  prognosis  after  all  methods  of  opera- 
ting is  better  than   in  carcinoma,  one  ease  of  total  extirpation  being  well  and 

1  Laryngeal  Neoplasms,  case  -•  '  Tfu  Medical  News,  Oct.  26,  1895. 


NEOPLASMS  OF  THE   TRACHEA.  I  1  1  5 

able  to  work  after  fifteen  years  ;  and  in  one  case  the  duration  was  twenty-one 
years,  during  which  many endo-laryngeal  operations  were  performed.  In  the 
larynx,  as  elsewhere,  there  are  many  cases  in  which  the  diagnosis  i>  a  matter 
of  considerable  doubt,  even   with   microscopical  examination. 

Treatment. —  The  same  indication-  obtain  as  in  carcinoma. 

NEOPLASMS    OF    THE    TRACHEA. 

Avellis'  gives  a  regime  of  the  literature  of  benign  tracheal  growths.  He 
refers  to  17  reports,  making  with  his  own  about  _!<»  undoubted  cases.  A  few 
have  been  reported  since  l<S!>:i.- 

Many  eases  are  reported  of  granulation-papillomata  and  polypi  around 
tracheotomy-wounds,  and  a  few  eases  are  recorded  of  the  projection  of  pieces 
of  thyroid  hypertrophies  into  the  trachea.  There  are  also  some  reports  in 
which  it  seems  evident  that  the  growths  really  sprang  wholly  or  principally 
from  the  subglottic  portion  of  the  larynx.  The  benign  growths  were  usually 
papillomata  or  fibromata.  An  adenoma  and  a  chondroma  have  also  been 
noted;  but  we  may  be  permitted  to  doubt  the  nature  of  these,  since  the 
former  is  so  rare  anywhere  in  the  air-track  and  of  such  a  doubtful  nature 
when  reported,  and  chondroma  is  apt  to  be  confounded  with  ecchondrosis. 
Ecchondroses  pure   or  partially  ossified  have  often    been   noted  'postmortem. 

Carcinoma  of  the  trachea  is  so  rare  that  when  Cornil  and  Ranvier  pub- 
lished their  work  in  1**4  they  denied  ''  absolutely  that  it  ever  occurred  there 
primarily.  Nevertheless,  several  had  been  reported.  Ten  year.-  later  Pogre- 
binski 4  Mas  able  to  give  abstracts  of  13  reports  of  carcinoma  of  the  trachea. 
3  of  which  he  looked  upon  as  doubtful,  while  1  was  known  to  have  started 
in  the  esophagus.  To  this  number  he  adds  a  case  of  his  own.  an  epithelioma 
primary  in  the  trachea.  Many  of  these  eases  were  of  the  encephaloid 
variety.  There  are  a  number  of  other  cases  reported  in  which  the  trachea 
was  secondarily  involved  from  growths  in  the  esophagus  and  in  the  thyroid 
gland.  Not  included  in  this  list  is  a  doubtful  case  of  Schmidt's  and  a  genuine 
case  described  by  Oestreich.5  Another  case  is  referred  to  in  the  Centralbl.  fur 
LaryngoL,  viii.  p.  396.  We  have  seen  that  in  Bergeat's  tables  but  7  cases 
of  primary  tracheal  sarcoma  are  on  record,  thus  refuting  the  statement  of 
Koch,6  that  sarcoma   is  the  more  frequent  malignant   neoplasm. 

The  chief  symptom  is  dyspnea,  and  when  dyspnea  occurs  from  a  tracheal 
growth,  that  growth  always  dangerously  occlude-  the  air-way.  In  the  upper 
part  of  the  trachea  always,  and  in  the  lower  pari  usually,  the  laryngoscope 
will  reveal  the  nature  of  the  trouble.  The  physical  characteristics  of  the 
growth-  differ  in  no  way  from  similar  neoplasms  in  the  larynx.  A  low 
tracheotomy  may  gain  time  for  a  more  extensive  opening  of  the  air-tube  and 
extirpation  of  a  benign  growth.  Many  case-  of  death  from  it  arc  on  record  : 
but  endo-tracheal  operations  are  usually  impracticable.  Malignant  growths 
are  almosl  uniformly  unrelieved  mid  fatal  ;  although  in  Schmidt'-  case  of 
epithelioma,  diagnosticated  microscopically  by  Weigert,  the  patienl  was  alive 
two  years  after  operation.  Dyspnea  without  other  s}  mptoms  usually  appears 
so  late  that  in  malignant  cases  the  patient-  presenl  themselves  only  when 
their  condition  i-  hopeless.  Indeed,  many  of  the  reports  are  from  tin  post- 
mortem table. 

1  M<maiseh.f.  OhrenheiUc,etc,  1892,  No.  7.  p.  195. 

'  CentralbLf.  Laryngolooie,  1  892,  viii.  pp.  [04-492;   1894,  \.  p.  100;   1895,  \i  p.  184. 

Vol.  ii.  p.  65.  *  Rented   Laryngolooie,  1894,  No    12,  p    111. 

I>  at  rh.  „u<l.  Woe/,.,  lsy.-,,  p.  34.  f'  Am*.  dea  Maladies  a\  I'O  rille,  etc.,  1890,  ; 


INJURIES  AND   DEFORMITIES  OF  THE   NOSE  AND 

THROAT. 


By  .JOHN  O.  ROE,  M.  I)., 

OF    ROCHESTER,    N'.  V. 


[njuries  of  the  nose  may  be  considered  under  the  following  heads:  (1) 
contusions,   wounds,  and   burns;   (2)   fractures  of  the  hones  and  cartilages; 

and  (3)  dislocations  of  the  hones  and  cartilages. 

CONTUSIONS,  WOUNDS,  AND  BURNS  OF  THE  NOSE. 

Contusions. — Owing  to  the  prominent  and  unprotected  position  of  the 
aose,  it  is  subject  to  frequent  injuries.  The  most  frequent  of  such  injuries 
are  contusions  caused  by  falls  or  by  blows  inflicted  upon  the  nose  with  the 
li-t  or  any  hard  substance,  'lucre  i>,  according  to  the  amount  of  the  imping- 
ing force,  more  or  less  hemorrhage  from  the  nose,  and  ecchymosis  at  the  point 
of  injury.  When  the  injury  is  confined  to  the  upper  part  of  the  nose,  it  is 
followed  by  more  extravasation  of  blood  into  the  loose  cellular  tissues  at  the 
base  of  the  uose  and  around  the  eves,  and  also  by  much  more  swelling  of  the 
sofl  parts,  than  when  the  injury  is  confined  to  the  end  or  lower  part  of  the 
nose,  owing  to  the  firmness  of  the  tissues  in  the  latter  region. 

Treatment. — When  the  injury  is  comparatively  slight  it,  as  a  rule,  gives 
rise  only  to  moderate  epistaxis,  from  the  rupture  of  the  capillaries  of  the 
pituitary  membrane  (usually  at  the  juncture  of  the  bony  with  the  cartilag- 
inous porti f  the  septum),  which  generally  stops  spontaneously.     Severe 

lesions,  and  sometimes  even  slighl  injuries,  will  be  followed  by  profuse  and 
persistent  hemorrhage,  owing  to  the  great  vascularity  of  the  pituitary  mem- 
brane, or  to  a  hemorrhagic  tendency,  requiring  the  application  of  pressure, 
or  cold  externally,  or  tamponing  of  the  nose.  The  simplest  manner  in  which 
pressure  can  l>"  applied  is  by  grasping  the  nose  firmly  between  the  thumb 
and  forefinger  aa  close  to  the  face  as  possible.  In  this  manner  hemorrhage 
from  the  anterior  portion  of  the  nose  can  be  immediately  arrested;  and  at 
the  same  time  by  holding  the  head  forward,  so  as  to  allow-  the  blood  to  grav- 
itate into  the  dependent  (tort  ion  of  the  nose,  a  clol  is  formed,  which  will  favor 
the  arrest  of  hemorrhage  in  the  deeper  parts. 

In  Bevere  injuries  there  may  be  an  effusion  of  blood  between  the  laminae 

of  the  sepl ,  causing  what   is  termed  a  bloody  tumor,  which  if  allowed  to 

remain  until  decomposition  take-  place,  will  result  in  abscess  of  the  septum 
.  639).  This  should  be  incised  through  the  nostril  and  thoroughly  evac- 
uated, and  the  cavity  irrigated  with  bichlorid  solution,  1  :  5000.  Gentle  press- 
ure should  then  be  applied  to  each  side  of  the  septum  l>v  means  of  a  clamp 
having  the  arm-  covered  with  gauze  or  aseptic  cotton,  so  as  to  obliterate  the 
cavity  and   maintain  coaptation  until  healed. 

Wounds. — Wounds  of  the  nose  may  be  divided  into  incised,  lacerated, 
no; 


CONTUSIONS,    WOUNDS,   AND   BUBNS  OF  THE  NOSE.     1117 


i 


and  punctured  wounds,  according  as  they  arc  produced  by  cutting,  blunt  or 

bruising,  or  pointed  instruments.     They  may  affect  the  sofl   parts  alone;  the 

soft   part-  and   bones  and  cartilaginous  framework  ;  or  the  sofl   parts,  hard 

parts,  and  pituitary  membrane.     They   may  also   be  so 

extensive  as  to  involve  the  nasal   fossae,  the  <>rl>it.  and 

the  accessory  sinuses  of  the  uose,  and  even  the  cranial 

cavity. 

{a)  Incised  wounds  may  vary  from  a  slight  cut  of 
the  skin  to  the  complete  severance  of  the  organ.  They 
may  be  vertical,  transverse,  or  oblique. 

Simple  incised  wounds  of  the -kin  arc  of  importance 
only  so  far  as  they  cause  disfigurement.  In  case  of  ver- 
tical wound-  the  edges  of  the  skin  come  together  very 
readily  and  can  be  easil)  held  in  position  by  adhesive 
plaster  or  styptic  collodion  :  whereas  in  transverse  wounds 
there  is  more  retraction  of  the  parts,  which  necessitates 
the  uniting  of  the  edges  of  the  skin  with  fine  sutures. 
Special  care  must  be  exercised  when  the  inferior  por- 
tion and  wings  of  the  nose  are   involved,  because  the 

elasticity  of  the  cartilages  of  the  ala?  tend-  to  separate     the  nasal" s'eptumTshow- 
the  parts,  while  the   functional   importance   is  great.  siaes.SW' 

Transverse  incised  wounds,  involving  the  deeper 
structure  of  the  nose,  may  allow  the  end  of  the  uose  to  drop  down  on  the 
upper  lip,  held  only  by  the  septum  and  tissues  at  the  base  of  the  uose.  In 
some  instances  a  transverse  incised  wound  may  he  so  extensive  as  to  pass 
through  the  nose,  involving  the  deeper  structure  and  the  maxillary  hones. 
Larrev  report-  a  case  in  which  with  "  un  coup  de  sabre"  the  inferior  half 
of  the  nose,  the  corresponding  two  sides  of  cheek  and  upper  lip.  and  the 
two  maxillary  bones  were  divided  clear  to  the  palate.  The  parts  were  care- 
fully sutured  in  place,  with  complete  recovery  in  forty-five  days. 

In  other  cases  the  nose  may  hang  by  a  slender  pedicle  or  be  completely 
severed.  A  number  of  cases  are  recorded  in  which  the  union  took  place 
when  the  nose  was  set  on  again  after  it  hail  been  severed  for  several  hours. 
In  Cagarlinge's1  well-know  n  case  it  was  detached  five  and  one-half  hour-. 
and  in  Garenot's  case  the  severed  end,  which  had  been  bitten  off,  was 
recovered  from  the  .-ewer  into  which  it  had  been  thrown.  It  was  cleansed 
with  warm  water,  reapplied,  and  on  the  fourth  day  was  quite  firmly  united. 
In  all  cases,  even  if  a  number  of  hours  have  elapsed  since  the  accident  took 
place,  attempt-  should  be  made  at  the  restoration  of  the  part  by  carefully 
cleansing  the  detached  parts  with  warm  sterilized  normal  -alt  solution,  and 
scarifving  or  scraping  the   raw  surface  to  encourage  its  attachment. 

Galin  and  Hoffacker  claim  an  advantage  in  waiting  a  short  time  before 
restoration  of  the  severed  end  by  reason  of  there  being  a  complete  arrest  oi 
hemorrhage,  'flic  surfaces  can  be  thoroughly  cleansed,  ami  the  danger  ol 
formation  of  blood-clot-  between  the  surfaces  will  thereby  be  avoided.  In 
attaehing  the  severed  portion  the  soft  parts,  including  the  cartilaginous  por- 
tion, should  be  carefully  Btitched  together,  and  the  interior  of  the  nose  should 
be  tamponed  with  antiseptic  gauze  to  protect  the  part-  from  the  inside  ami 
to  maintain  the  nostrils  in  their  normal  form.  The  union,  a-  a  rule,  takes 
plaee  slowly;  tin-  end  may  remain  cold  and  pale  for  twelve  hours  or  even 
two  or  three  day-,  and  therefore  we  niu-t  not  be  in  haste  to  regard  the  op.  p- 
ation  a-  a  failure. 

1  Traitedes  Operations  d*  Chirurgie,  17-_'l.  Chap,  iii-.  Art.  2,0b 


Ills      INJURIES  AND   DEFORMITIES  OF  THE  NOSE,   ETC. 

(/,)  Lacerated  wounds  are  usually  produced  by  blunt  instruments,  falls 
<>u  angular  or  rough  surfaces,  projectiles,  etc.  Wounds  from  Muut  instru- 
ments are  usually  attended  with  a  fracture  or  dislocation  of  the  nasal  hones. 

In  ease  of  projectiles,  when'  a  bullet  comes  from  a  lateral  direction,  it 
usually  passes  through  the  nose,  involving  both  walls;  hut  in  case  of  spenl 
bullets  they  may  penetrate  only  one  wall  of  the  nose  and  lodge  in  the  meatus, 
the  orbit,  in  an  accessory  sinus,  or  they  may  penetrate  the  brain.  In  some 
cases  the  wad  of  a  gun  may  be  forced  into  the  wound  with  the  bullet  and 
remain  there  as  a  foreign  substance.  In  one  case  reported  by  Legouest,  the 
wad  <>f  ;i  -nil  was  found  astride  of  the  septum.  The  skin  cicatrized  after  its 
introduction  and  the  accident  was  forgotten.  There  was  a  continuous  fetid 
discharge  from  the  nose,  and  after  four  years  the  wad  was  discovered  during 
a  rhinoscopic  examination  and  removed.  The  treatment  of  lacerated  wounds 
of  the  nose  requires  especial  care  to  render  the  parts  aseptic  and  to  coaptate 
tin'  -kin  and  maintain  the  normal  contour  of  the  nose,  as  far  as  possible. 

(c)  Punctured  wounds  are  produced  by  sharp-pointed  instruments.  In 
some  cases  the  instrument  or  foreign  body  may  enter  through  the  nasal  fossae 
and  penetrate  the  cranial  cavity  through  the  cribriform  plate  of  the  ethmoid 
bone,  without  external  manifestation  of  the  injury.  Punctured  wounds  of 
the  base  of  the  nose  are  frequently  followed  by  emphysema  of  the  soft  parts, 
owing  to  the  looseness  of  the  connective  tissue  in  this  region.  This  takes 
place  most  frequently  when  the  penetrating  wound  of  the  nose  communicates 
with  the  nasal  cavity,  and  the  emphysema  is  caused  by  the  air  being  forced 
through  this  opening  under  the  skin  when  the  patient  blows  his  nose,  or 
during  forcible  expiration  through  the  nose.  It  accordingly  appears  quickly, 
giving  the  sensation  of  a  sharp,  hot  streak  as  the  air  is  forced  under  the  skin. 
It  may  be  limited  to  the  superior  part  of  the  nose,  when;  the  cellular  tissue 
is  quite  loose,  or  it  may  extend  to  the  eyelids,  and  sometimes  to  the  neigh- 
boring portion  of  the  face.  Slender  instruments,  or  such  foreign  bodies  as 
knives,  pencils,  ami  the  like,  may  penetrate  the  walls  of  the  nose  and  break 
off,   remaining  in   the   wound. 

Treatment. — Simple  punctured  wounds  of  the  external  nose,  as  a  rule, 
require  only  ordinary  antiseptic  care.  In  complicated  cases,  however,  in 
which  the  end  of  the  instrument  has  broken  off  and  remains  as  a  foreign 
body,  it  must  be  extracted  either  through  the  wound,  from  the  interior  of  the 
nose,  or  removed  through  an  artificial  opening,  and  the  wound  afterwards 
treated  :i-  an  incised  wound.  Each  case,  however,  must  be  treated  according 
to  the  peculiarity  of  the  conditions  found.  The  emphysema  of  the  face 
which  sometimes  accompanies  punctured  wounds  of  the  nose  usually  sub- 
gides  in  a  short  time,  although  the  disappearance  can  be  hastened  by  poul- 
tices and  compression. 

Burns  and  Scalds.  —  Burns  and  scalds  of  the  nose  do  not  differ  in  their 
nature  and  treatmeni  from  burns  and  scalds  of  other  portion- of  the  body. 
They  are  of  special  significance  only  so  far  as  the  resulting  cicatrices  cause 
distortion  of  the  organ  and  contraction  of  the  nasal  passages.  It  i-  there- 
fore during  the  healing   pr ■--  of  the  burn  or  scald  that   we  should  give 

particular  attention   to  prevent   any  such  complication. 

The  contraction  of  the  burn  can  be  overcome  in  :i  great  measure  by  re- 
sorting to  skin-grafting  before  the  wound  is  healed,  thereby  replacing  the 
3kin  that  has  been  destroyed  and  preventing  the  formation  of  cicatricial 
tissue,  by  which  the  edges  of  ;i  wound  are  forcibly  drawn  together.  Special 
care  should  be  taken  in  this  particular  when  the  nasal  orifices  are  involved. 
Ivor,  or  vulcanite  plugs  or  tubes  should  be  inserted  into  the  nostrils  to  keep 


FRACTURES  OF  BONES  AND   CARTILAGES  OF  NOSE.     11 11) 

the  nasal  openings  widely  dilated,  until  all  tendency  to  contraction  of  the 
tissues  lias  passed.  When,  however,  this  contraction  of  the  tissues  lias  taken 
place  and  the  nasal  orifices  have  become  greatly  narrowed,  the  treatment  to 
he  adopted    is  described  under  the  head  of  Stenosis  of  the  Nasal   Passages. 


FRACTURES  OF  THE  BONES  AND  CARTILAGES  OF  THE  NOSE. 

Fractures  and  dislocations  of  the  nose  may  vary, according  to  the  severity 
of  the  injury,  from  simple  displacement  of  some  one  of  the  hones  of  the 
nose,  without  wounding  the  skin,  to  compound  comminuted  fracture  of  the 
hones,  attended  with  more  or  less  destruction  and  escape  of  the  bony  frag- 
ments, resulting  in  marked  distortions  and  permanent  disfigurement  of  the 
nose. 

Fractures  Of  the  bones  Of  the  nose  are  comparatively  rare  when 
we  consider  the  prominent  and  exposed  position  of  the  aose  and  the  fre- 
quency with  which  bodily  injuries  occur.  I  nis  is  accounted  for  somewhat 
by  the  yielding  condition  of  the  cartilaginous  portion  of  the  nose,  which 
more  or  less  resists  fracture,  and  the  arched  form  of  the  osseous  portion  or 
bridge  of  the  nose,  which  enables  it  to  withstand  a  considerable  amount  of 
external  force.  The  nose  is  also  in  many  cases  protected  by  the  prominence 
of  the  frontal  hone. 

Fracture  of  the  nose  is  more  frequent  in  men  than  in  women,  and  also 
more  frequent  in  adults,  owing  to  the  cartilaginous  and  more  yielding  char- 
acter of  the  parts  in  the  young. 

Fractures  of  the  nose  always  result  from  force  applied  externally,  oftenest 
in  the  form  of  blows  or  falls  directly  on  the  nose.  They  are  usually  attended 
with  lesions  of  the  integument,  and  are  frequently  associated  with  fractures 
of  the  nasal  process  of  the  superior  maxilla,  together  with  dislocation  or 
fracture  of  the  nasal  septum.  In  severe  injuries  the  osseous  portion  of  the 
nasal  septum,  together  with  the  nasal  hones,  has  been  driven  backward  into 
the  brain. 

Such  injuries  are  usually  attended  with  severe  hemorrhage  and  escape  of 
cerebral  matter,  with  all  the  symptoms  of  fracture  at  the  base  of  the  cranium, 
and  are  generally  fatal. 

Fractures  of  the  hones  of  the  nose  are 
almost  always  bilateral,  unilateral  fractures 
being  rare.  In  some  cases,  when  the  force  is 
applied  entirely  to  one  side,  fracture  of  the 
hone  on  this  side  may  he  attended  with  dislo- 
cation of  the  hone  on  the  opposite  side,  to- 
gether with  lateral  dislocation  of  the  nasal 
septum,  as  represented  in   Fig.  (>40. 

Fractures  of  the  nose  may  be  divided  into 
simple,  comminuted, and  compound.  In  simple 
fractures  of  the  aose  the  line  of  the  fracture 
may  be  vertical,  oblique,  or  transverse,  accord- 
ing to  the  direction  of  the  blow.  In  vertical 
fractures  one  fragment  may  slide  under  the 
edge  of  the  other,  the  latter  prof ruding  sulli- 
ciently  to  form  a  ridge  readily  fell  by  the 
finger.  In  oblique  or  transverse  fractures 
the  lower  fragmenl  is  depressed  ;  the  upper 
fragment  remain-  unbroken  and,  accordingly,  maintain 


I',..     640     Fracture   of   the    right 
,,i  displacement   of  the 
left,  « nil    lateral   dislocation   of  the 
ptum. 


its  normal  position. 


1120     INJURIES  AND   DEFORMITIES  OF  THE  NOSE,    ETC. 

In  a  comminuted  fracture  the  fragments  arc  more  or  less  numerous,  and  in 
case  it  is  compound  they  may  escape  through  the  wound  and  thereby  he 
destroyed  and  lost.  Simple  fractures  may  exisl  without  any  resulting  dis- 
figurement ;  whereas  comminuted  or  compound  fractures  may  be  followed  by 
narrowing  and  obstruction  of  one  or  h<>th  nasal  passages,  and  of  one  or  both 
lachrymal  ducts,  causing  lachrymal  tumors  and  styllicidium. 

The  lachrymal  bones  may  be  fractured  by  a  slight  or  very  moderate  blow, 
accompanied  by  discoloration  of  the  eyelid--,  and  sometimes  emphysema  of 
the  cellular  tissue  of  the  orhit   may  take   place,  on  blowing  the  nose,  by  the 
-    ipe  of  air  from  the  nostrils  through  the  fractured  edges  of  the  bone. 

Diagnosis. — The  diagnosis  of  fractures  of  the  nose  in  some  cases  is  ex- 
tremely simple,  whereas  in  other  cases  it  is  attended  with  great  difficulty. 
Simple  fracture- of  the  nose  may  exist  without  displacement  of  t he  fragments, 
the  latter  being  held  in  place  by  the  periosteum,  the  soft  parts,  and  the 
mucous  membrane.  The  line  of  the  fracture  can  often  be  felt  under  the 
finger  as  a  slight  fissure.  In  other  cases  it  is  manifested  only  by  pain  in  the 
seat  of  the  injury.  When  there  is  displacement  of  the  fragments  the  pro- 
truding edges  of  the  fracture  form  a  ridge,  which  is  not  only  readily  per- 
ceptible to  the  finger,  but  can  be  -ecu  on  inspection.  In  order  to  determine 
the  extent  of  the  fracture  and  the  condition  of  the  part,  the  examination 
should  follow  the  injury  as  speedily  as  possible,  for  the  swelling  of  the  soft 
part-  so  quickly  supervenes  as  to  make  the  diagnosis  very  difficult. 

Vertical  fracture-  can  be  detected  by  the  careful  movement  of  the  lateral 
fragments  against  the  edges  of  the  unbroken  portion.  In  oblique  or  trans- 
verse fractun-.  since  the  lower  fragment  becomes  depressed,  the  edge  of  the 
unbroken  portion  is  prominent.  ( )ften,  in  making  a  rhinoscopic  examination, 
the  depressed  portion  of  the  hone  can  be  seen  projecting  into  the  interior  of 
the  nose.  In  comminuted  fracture-  the  crepitation  of  the  fragments  is  gen- 
erally readily  detected,  but  great  care  should  be  exercised  when  making  the 
examination  not  to  increase  the  displacement.  In  compound  fractures  the 
condition  of  the  bony  part-  can  be  easily  discovered  by  exploration  with  a 
probe  through  the  wound.  When  the  contused  parts  have  become  greatly 
swollen  before  the  patient  come-  under  observation,  it  is  then  usually  neces- 
sary to  wait  until  the  inflammation  and  swelling  have  been  reduced,  hefore 
the  exact   condition  of  the  part  can  he  made  out. 

Two  of  the  mo-t  prominent  symptoms  of  fracture  of  the  nose  are  epis- 
taxi-  and  emphysema  of  the  tissues  of  the  nose.  Emphysema  of  the  nose 
is  indicative  of  rupture  of  the  mucous  membrane,  through  which  opening 
air  i-  forced  into  the  tissues.  It  usually  comes  on  rapidly  when  the  patient 
blows  hi-  nose,  a-  in  the  case  of  punctured  wounds.  It  is  generally  limited 
to  tin'  region  at  the  base  of  the  nose  ;  although  it  may  extend  to  the  periocu- 
lar cellular  tissue  (sometimes  completely  closing  the  eyes)  and  throughout 
the  face.  In  exceptional  cases  it  may  involve  the  tissues  of  the  neck. 
It  i-  detected  by  crepitation,  much  as  given  by  the  edges  of  the  broken 
hone.  Epistaxis,  which  i-  almost  always  present,  varies  according  to  the 
extent  of  the  injury,  ami  max-  he  very  slight  or  very  profuse,  although  it  i- 
never  sufficient  to  endanger  the  life  of  the  patient.  It  usually  ceases  spon- 
taneously, although  in  severe  cases  tamponing  the  nose  may  he  necessary  to 
prevent  weakening  the  patient  from  loss  of  blood.  In  these  cases  the  pres 
enee  of  hemorrhagic  exudate-,  which  may  accumulate  between  the  hard  and 
-oft  parts,  should  he  recognized  and  evacuated  to  prevent  purulent  forma- 
tion- or  -eptic  infection  and  the  breaking-down  of  the  lacerated  tissues. 

In   nil   cases  "I    fracture  of  the   nose  the  gravity  of  the  case  depends 


FRACTURES  OF  BONES  AND   CARTILAGES  OF  NOSE.     llJl 


entirely  upon  the  brain-complication.  The  secondary  complications  which 
may  follow  these  injuries  are  deformities  of  the  nose,  injury  to  the  lachrymal 
apparatus,  impairment  of  the  sense  of  smell  (either  from  occlusion  of  the 
nasal  passages  or  injury  to  the  olfactory  oerve),  and  lack  of  resonance  in  the 
voice,  owing  to  the  contraction  of  the  nasal  passages. 

Treatment. —  In  all  cases  of  fracture  of  the  nose  the  replacement  of  the 
fragments  should  be  effected  a-  speedily  as  possible,  before  swelling  of  the 
parts  has  supervened  to  prevent  it  ;  for  when  the  swelling  i-  extensive  it  i- 
frequently  necessary  to  wait  until  it  subsides  before  the  fragments  can  be 
replaced.  This  can  usually  he  delayed  for  three  or  four  days  with  perfect 
safety,  although  if  the  case  is  seen  early,  much  of  the  swelling  can  he 
prevented   by  attention   to  antiseptic  and  antiphlogistic   measures. 

In  case  the  fracture  i-  a  compound  one.  we  should  attend  carefully  to  the 
wound  of  the  skin  (as  in  case  of  lacerated  wounds  of  the  nose)  in  order  to 
prevent,  as  far  as  possible,  disfigurement  from  resulting  scars.  Laceration 
of  the  mucous  membrane  should  also  receive  attention  and  he  rendered, 
as  far  as  possible,  aseptic. 

In  simple  fractures  the  reduction  is  best  accomplished  with  a  smooth 
sound,  placed  in  the  interior  of  the  nostril  to  raise  the  depressed  fragments, 
and  their  coaptation  is  facilitated  Avith  the  fingers  on  the  outside  of  the  nos<  . 
When  no  sound  is  at  hand  and  the  nasal  passages  are  sufficiently  large  to 
admit  the  little  finger,  it  can  be  very  advantageously  substituted.  In  some 
cases  the  fragments  are  best  and  most  easily  adjusted  by  mean-  of  a  pair  of 
smooth-blade  forceps,  one  Made  placed  in  the  nostril  and  the  other  outside, 
according  to  the  plan  of  Weber,  care  being  exercised  not  to  use  too  much 
pressure;  and  to  avoid  lacerating  the  tissue  the  blades  can  be  covered  with 
rubber  or  adhesive  plaster,  for  this  purpose  Molliere  uses  forceps  with 
ivory  blades.  When  the  septum  has  at  the  sime 
time  become  fractured  or  dislocated,  it  also  should 
be  put  in  place. 

When  the  fragment-  have  been  replaced,  they 
must  be  held  with  some  form  of  retentive  appa- 


Metallic 
Fonn 


Adhesi 
Plaster 


Fig.  641.— The  author's  metallic  form. 


Fig,  642-  Metallic  form  and  adhesive 
plaster  a-  app] 


ratu8.  If  the  -kill  i-  unbroken,  a  piece  of  rubber  adhesive  plaster,  cut  oi  the 
shape  to  completely  cover  the  nose,  has  been  found  by  the  author  to  be  one 
of  the  most  Important  aids  in  rendering  tin'  exterior  contour  smooth  and 
symmetrical.     This  i-  to  be  covered  with  a  metallic  form  (Fig.  641),  made 


1111!'      INJURIES  AND   DEFORMITIES  OF  THE  .Vox/:.    ETC. 


of  a  sheet  of  aluminum  cut  the  requisite  size  and  shape,  so  that  when  bent 
the  internal  contour  is  the  same  as  the  normal  nose,  and  of  sufficient  size  to 
rest  lightly  over  the  nasal  border  of  the  superior  maxilla.  Before  this  form 
i-  applied  to  the  nose,  I  usually  cover  and  line  it  with  adhesive  plaster,  which 
materially  assists  in  holding  it  in  place.  It  is  then  adjusted  to  the  nose  and 
securely  held  in  place  with  adhesive  straps,  as  shown  in  Fig.  6  l'_. 

Various  other  methods  have  Keen  devised  for  maintaining  the  fractured 
nasal  bones  in  place.  Thus  Malgaigtie  has  used  moulds  of'  lead,  which 
have  the  disadvantage  of  being  heavy.  Hamilton  uses  gutta-percha,  but  it  is 
not  readily  adjusted  to  the  desired  shape  of  the  nose.  Weber  employ-  strips 
of  gutta-percha,  maintained  in  place  by  plaster.  Dumreicher  employs  succes- 
sive collodion  bandages,  applied  to  the  nose.  Walsham  usesa  mask  of  leather, 
moulded  to  the  face  with  braces  controlled  by  screws,  to  maintain  the  bones 
in  place.  Adams  has  devised  a  nasal  truss  attached  to  a  headband,  which 
is  buckled  firmly  around  the  head,  with  a  padded  arm  controlled  by  screws 
resting  against  each  side  of  the  nose  to  hold  it  in  position,  as  shown  in  Fig. 
643.  None  of  these  methods,  however,  has  given  me 
the  satisfactory  results  obtained  by  the  simple  method 
which  I  have  described. 

Numerous  internal  supports  have  also  been  em- 
ployed for  holding  these  hones  in  position  after  the 
deformity  has  been  corrected.  Hamilton  packs  the 
nose  with  pledgets  of  lint,  to  each  of  which  is  attached 
a  thread  for  ready  extraction.  Packard  employs  plugs 
of  hard  rubber,  placed  inside  the  nostril.  These  methods 
have  t  heir  advantages  since  no  one  ping  large  enough  to 
maintain  the  hone-  in  place  can  he  introduced  through 
the  nasal  aperture-.  For  the  purpose  of  maintaining 
the  vault  of  the  nose,  Mason,  of  Brooklyn,  has  de- 
vised a  method  of  transfixing  the  nose  with  nickel  or 
gold  needle-  through  the  base,  on  a  line  with  the  maxillary  junction.  He 
then  passes  under  the  needles  and  over  the  nose  a  bandage  of  rubber.  This 
i-  efficient  to  prevent  spreading  at  the  base  of  the  nose,  and  at  the  same 
time  to  hold  the  nose  snugly  together  and  prevent  depression  of  the  vault. 
Tin-  i-  considered  an  exceedingly  ingenious  arrangement,  and  may  be  of 
service  in  some  cases.  After  the  part-  have  become  solidified,  at  the  end  of 
seven  or  eight  days,  the  needles  are  removed.  Many  discourage  the  employ- 
ment of  internal  supports,  because  of  the  irritation  which  they  cause.  This 
objection  is  ill-founded,  for  the  reason  that  the  irritation  is  invariably  due  to 
the  excessive  amount  of  pressure  employed.  Very  slight  pressure  only  is 
required  to  maintain  the  part-  in  position,  because  they  are  naturally  immov- 
able ami  there  i-  no  muscular  ten-ion  to  cause  their 
displacement,  nor  any  other  force  when  the  nose  is 
thoroughly  protected  by  a  uniform  external  support. 
The  fragments  can  most  easily  be  maintained  in  place 
by  means  of  an  elastic  spring  placed  in  the  nostril, 
the  tension  of  which  i-  regulated  l>v  means  of  a  screw 
on  the  outside,  as  shown  in  Fig.  644. 

Before  the  spring  i<  inserted   the  interior  of  the 
DOStril  i-  carefully  irrigated  with  an   antiseptic  solu- 
tion and  dusted  with  iodoform  or  some  other  strong  antiseptic  powder. 

\lter  the  bones   have  been  put  into  place  a  portion  of  iodoform-gauze  is 
made  into.-,   roll  th.it   will    jn-t    lit    the  upper   porti f  the   na-al  cavity,  and 


l  [g.  643.     Adams's  na-al 
truss. 


I  I        I  he    author's    intra 
na-al  -print;. 


FRACTURES  OF  BONES  AND   CARTILAGES  OF  NOSE.     1123 

forced  up  into  the  vault  sufficiently  to  hold  the  fragments  in  place  in  perfect 
coaptation  with  the  external  metallic  mould  thai  i-  placed  on  the  outside  of 
the  nose.  I  In  many  cases,  however,  it  i>  better  to  insert  the  internal  support 
before  the  metallic  form  is  applied.)  Under  this  gauze  is  placed  the  upper 
arm  of  the  spring,  the  lower  arm  resting  on  the  floor  of  the  nose.  The  spring 
should  be  made  of  the  proper  size  and  shape  to  lit  the  interior  of  the  nose  ; 
while  the  tension  exerted  is  regulated  by  a  screw  at  the  lower  end  of  the 
spring.  The  pressure  in  these  cases  should  be  jusl  sufficienl  to  support  the 
part  without  causing  pain.  The  lower  arm  of  the  spring  i-  covered  with 
rubber  tubing,  to  prevent  irritation  of  the  soft  part-.  J5y  this  method  the 
lower  respiratory  passage  remain-  unobstructed,  so  thai  nasal  respiration  is 
not  materially  interfered  with.  The  interior  of  the  nose  also  can  be  kept 
clean  by  frequent  cleansing  with  an  antiseptic  wash,  until  the  fragments  are 
united  and  the  nose  is  self-supporting. 

In  those  cases  in  which  the  fractured  bones  are  allowed  to  go  unreplaced 
until  firm  union  lias  taken  place,  re-fracture  of  the  hones  becomes  necessary 
in  order  to  restore  them  to  their  normal  position.  This  operation  will  be 
described  under  deformities  of  the  nose. 

Fracture  of  the  Cartilages  of  the  Nose. — The  lower  portion  of 
the  nose  is  composed  of  two  lower  lateral  shield-cartilages,  united  in  the 
center.  These  shield-cartilages  are  connected  with  the  nasal  hones  above  by 
two  upper  lateral  cartilages,  which  maintain  the  contour  of  the  central  por- 
tion of  the  dorsum  of  the  nose,  as  shoAvn  in  Fig.  G45.     In  cases  of  moderate 


lU^v    \    V NasaJ  bone. 

jl) i__\__  Nasal  process  of  the 

Jjj  Y      \    superior  maxillary  bone. 

J  I     _  _  \ U  ppe  r  I  aTe  ral  cartilage. 

Sesamoid JJJS,        ___\  .Lower  lateral  cartilage 

cartilages      Lr^^-^       \ 


Fig.  645.— Profile  view  of  the  bony  and  cartilaginous  constituents  <>f  the  nose. 

injuries  to  the  nose  these  cartilages  are  rarely  fractured  ;  but  when  the  injury 
is  severe,  particularly  if  inflicted  by  a  more  or  less  sharp  body  like  the  sharp 
edge  of  a  hoard,  fracture  of  the  cartilages  sometime-  takes  place.  This  is 
especially  true  of  the  upper  lateral  cartilages,  which  maintain  the  contour  ot 
the  dorsum  of  the  nose.  Fracture  of  the  shield-cartilage  i-  readily  detected 
by  the  resulting  deformity  and  by  the  crepitation  which  can  he  elicited  by 
careful  manipulation;  hut  fracture  of  the  upper  lateral  cartilages  is  frequently 
so  obscured  by  the  attending  swelling  and  inflammation  thai  it  i-  undetected, 
and  only  manifested  by  the  resulting  depression  and  deformity  ot*  the  nose 
that  follow  after  the  inflammatory  symptoms  have  subsided. 

Treatment. —  In  many  cases  of  fracture  of  the  shield-cartilages  the  frag- 
ments are  bed  held  in  place  by  means  of  the  spring  above  described.  "  hen 
the  fracture  is  in  such  a  position  that  this  cannot  lie  readily  maintained  in 
place,  a  strip  of  vulcanite  or  celluloid  can  he  moulded  with  heat  and  made  t.. 
fit   the   nostril  SO  as  to  maintain    it    in  its  normal  position  until  the   fragments 


Ill' 1      INJURIES  AND   DEFORMITIES  OF  THE  XOSF,    ETC. 


are  united.  Perforated  cork-splints  arc  also  especially  serviceable  on  account 
.it'  their  lightness  and  the  readiness  with  which  they  can  be  fitted  to  the  con- 
tour of  the  nostril.  When  these  are  not  at  hand  the  nostrils  can  be  packed 
with  antiseptic  gauze,  so  as  to  maintain  them  in  their  proper  form.  It  is 
advisable,  however,  to  insert  through  the  center  an  open  tube  for  respiration 
Figs.  573,  57  1 1. 
Fractures  of  the  Nasal  Septum. — The  nasal  septum  being  com- 
posed of  three  pieces,  as  shown  in  Fig.  (>4(>,  and  as  each  one  of  these  pieces 
may  be  fractured  independently,  we  therefore  can  divide  fractures  of  the 

septum  into  three  groups:  as  the  frac- 
ture of  the  triangular  cartilage,  of  the 
vomer,  and  of  the  perpendicular  plate 
of  the  ethmoid. 

The  portion  most  frequently  frac- 
tured is  that  of  the  triangular  cartilage  ; 
it  is  always  the  result  of  traumatism. 
Fracture  of   the  cartilage  alone    may 


Fig.  646.— Bones  ami  cartilage  of  nasal  septum. 


Fig.  647.— Dislocation  of  the  triangular  cartilage. 


take  place  as  an  independent  lesion  or  it  may  he  associated  with  dislocation 
of  the  cartilage  at  its  attachment  with  the  vomer,  as  shown  in  Fig.  647. 
fractures  of  the  cartilage  are  also  frequently  associated  with  hematoma, 
which  is  bilateral  ;  the  bloody  tumor  filling  both  nostrils,  communicating 
through  the  fissure  in  the  septum.  Separation  of  the  cartilage  may  take  place 
from  displacement  of  the  fragments,  although  they  will  more  frequently  be 
found  overriding  each  other.  The  diagnosis  of  this  accident  is  important, 
as  the  integrity  of  the  Dose  depends  on  its  recognition  ami  proper  treatment. 
When  there  is  no  displacement  it  can  be  recognized  only  by  the  attendant 
pain,  the  greater  mobility  of  the  structures  associated  with  swelling  of  the 
-oft  parts,  and  the  fissure  can  be  found  by  exploration  with  a  probe.  The 
crepitus  can  be  found  by  careful  manipulation  of  the  parts.  Displacement  of 
the  fragments  is  manifested  by  depression  of  the  end  of  the  nose,  which  is 
distorted  to  one  side,  producing  a  double  deformity.  Sometimes  the  end  of 
the  nose  is  flattened  on  the  face.  When  the  fracture  is  compound  it  is 
accompanied  by  more  or  less  epistaxis,  and  sometimes  by  subcutaneous 
emphysema. 

Fracture  of  the  vomer  alone  i»  a  rare  accident,  and  from  its  situation  and 
position  displacement  of  the  fragments  does  not  readily  take  place;  the  line 
of  the  fracture  can,  however,  be  detected  by  a  careful  exploration   with  a 

blunt-pointed    probe,  and  on    inspecting    the    nostril   with  the  aid  of  a  strong 

light   it  can  sometimes  be  recognized  bv  a  hemorrhage-point. 

Fracture  of  the  perpendicular  plate  of  the  ethmoid  is  usually  accom- 
panied bv  comminuted   fractures  of  the  bones  of  the  nose,  although  sub- 


DISLOCATIONS  OF  BONES  AND  CARTILAGES  OF  NOSE,   1125 

stances  penetrating  the  nasal  cavity  have  been  known  to  fracture  this  bone 
alone.  The  cribriform  plate  may  also  be  fractured  and  the  foreign  body  at 
the  same  time  enter  the  cranial  cavity,  the  latter  being  always  a  very  serious 
accident.  When  the  fracture  of  the  perpendicular  plate  exists  alone  it  i- 
usually   at   a   point   on  a   level   with  the  vomer. 

Treatment. — When  there  is  displacement  of  the  parts,  they  should  be 
firs!  put  in  place  by  mean-  of  a  pair  of  forceps  with  flat  parallel  blades,  one 
blade  being  inserted  into  each  nostril,  and  by  gentle  pressure  the  hone-  can 
then  lie  restored  to  their  normal  position,  aided  by  gentle  manipulations. 
When  there  is  displacement  of  the  fragments  to  one  side  it  is  frequently 
necessary  to  insert  an  internal  support  only  on  that  side;  and  when  there  i- 
laceration  of  the  mucous  membrane  also  on  that  side  of  the  septum,  the  besi 
form  of  support  is  made  by  winding  sublimate  cotton  around  a  metallic  plate 
from  H  to  '2  inches  in  length  and  of  sufficient  size  to  be  inserted  in  the 
nostril,  the  nostril  being  first,  however,  irrigated  with  bichlorid  solution, 
1  :  5000,  and  dusted  with  iodoform.  Other  forms  of  support  are  frequently 
used  for  this  purpose,  as  tubes  made  of  hard  rubber,  of  -oft  rubber,  of  cork. 
or  of  metal,  each  of  which  is  excellent  in  cases  to  which  it  is  adapted  ;  bu1 
in  cases  where  it  is  necessary  to  maintain  the  support  only  on  one  side, 
leaving  the  other  nostril  free  for  respiration,  the  cotton  plug,  having  a  metal- 
lic core  to  stiffen  it  for  insertion,  is  preferable  to  all  others.  In  cases  in 
which  it  is  necessary  to  maintain  support  on  both  sides  a  cotton  plug  can 
frequently  be  inserted  in  one  nostril  and  a  tube  in  the  other. 

DISLOCATIONS  OF  THE  BONES  AND  CARTILAGES  OF  THE  NOSE. 

Dislocation   of  the   nasal   bones  is  an  accident  of  comparatively 

infrequent  occurrence,  and  always  occurs  as  the  result  of  blows  against  the 
nose,  usually  from  a  lateral  direction.  According  to  Marchant,  dislocation 
of  the  nasal  bones  was  recognized  by  Heister  in  1770  and  by  Bell  in  1796  ; 
but  the  first  published  example  was  by  Bourguet  in  1851,  and  later  by 
Longuet  in  1881.  In  Bourguet's  case,  a  man,  twenty-two  years  of  age,  was 
thrown  against  a  sidewalk,  striking  on  the  left  side  of  the  nose.  The  upper 
third  of  the  nose  was  deviated  to  the  right,  the  lower  end  remaining  normal. 
The  elevation,  which  was  a  dislocation  of  the  nasal  bones,  was  reduced  by 
introducing  the  ring-finger  of  the  right  hand  into  the  nostril  and  exerting 
pressure  on  the  outside,  when  the  bone  slipped  into  place  and  the  dislocation 
did  not  recur.      No  deformity  of  the  nose   resulted. 

A  similar  case  recently  came  under  my  observation.  A  young  lady, 
twenty-two  years  of  age,  was  thrown  from  her  carriage,  striking  on  the  righl 
side  of  her  face,  injuring  the  nose  quite  severely.  There  was  considerable 
swelling  of  the  nose,  but  no  crepitation  and  no  fracture  of  the  bones  of  the 
nose  could  be  detected.  The  patient  was  very  ill  for  a  short  time  a-  a  result 
of  the  accident,  and  it  was  feared  that  concussion  of  the  brain  had  taken 
place.  On  her  recovery,  both  nasal  bone-  were  found  dislocated  to  the 
left  and  the  nose  was  quite  crooked;  the  right  na-al  bone  h;i-  depressed, 
while  the  left  na-al  bone  was  thrown  outward  and  upward,  overriding  the 
right,  as  shown  in  Fig.  640,  forming  a  hump  on  tin!  side.  A- the  accident 
occurred  four  years  before  I  -aw  her  the  deformity  was  permanent,  bul  was 
corrected  by  me  according  to  t  he  methods  that  will  be  described  in  the  -ec- 
tion   relating  to  deformities  of  the  nose. 

In  another  case,  a  little  girl  about  live  years  old,  while  coasting,  wa- 
fchrown  from  her  sled,  striking  her  nose  againsl   the  edge  of  an  iron  railing. 


1126      INJURIES   AND   DEFORMITIES  OF  Till:  NOSE,  ETC. 


which  drove  the  central  portion  of  the  nasal  hone-  backward,  dislocating 
them  outward  and  leaving  the  nose  in  a  flattened  condition.  Before  sur- 
gical aid  was  secured  the  swelling  of  the  nose  so  masked  the  injury  thai 
it  was  allowed  to  go  uncared  for.  This  resulted  iii  a  permanent  flatten- 
ing of  the  central    portion   of  the  nose  and   a   bulging  outward   of  the   nasil 

holle-. 

Dislocation  of  the  bones  of  the  nose  can  readily  he  detected, first,  by  the 
deformity  of  the  nose,  and  secondly,  by  the  elevation  of  the  dislocated  edges, 
which  can  he  felt  as  a  ridge  under  the  finger.  The  amount  of  dislocation 
varies  usually  with  the  amount  of  force  exerted  against  the  nose.  There 
may  he  simple  dislocation  of  one  of  the  nasal  hones,  or  all  the  various  hones 
of  the  nose  may  he  more  or  less  dislocated  to  one  side.  In  these  cases  the 
dislocation  to  one  side  is  usually  associated  with  fracture  of  the  other,  as 
shown  in  Fig.  640,  against  which  the  impinging  force  came.  In  some 
instances  the  cribriform  plate  of  the  ethmoid  is  fractured,  and  may  he 
driven  upward  into  the  base  of  the  brain. 

Treatment. — The  reduction  of  dislocations  of  the  nasal  hone  is  most  easily 

ac uplished  by  placing  a   smooth  sound  in  the  interior  of  the  nose,  and  by 

gentle  manipulation  with  the  finger  on  the  outside  the  hone  can  ordinarily  he 
slipped  into  place.  In  some  cases,  especially  if  the  nostril  is  large,  the  little 
finger  can  he  passed  into  the  nasal  chamber  and  the  depressed  hones  elevated, 
as  in  case  of  fracture  of  the  uose.  Tn  this  manner,  with  the  thumb  or  finger 
on  the  outside  of  the  nose,  the  dislocation  can  he  reduced  with  great  precision, 
as  we  are  enabled  by  the  sense  of  touch  to  detect  the  exact  position  of  the 
hones.  Usually  there  is  no  tendency  for  the  dislocation  to  recur,  owing  to 
the  lack  of  muscular  tension  on  the  part;  hut  it  is  far  better  to  apply  a 
retentive  apparatus  to  guard  against  such  a  possibility.  This  is  best  done 
by  covering  the  whole  of  the  nose  with  a  piece  of  adhesive  plaster,  cut  to  lit, 
and  by  placing  on  the  outside  an  aluminum  form  of  the  proper  size  and 
shape  for  the   requirements  of  the  nose,  according   to  the   plan   described  for 

the  retenti f  fractured  nasal  hones.     This  is  to  he  worn  a  short  time,  until 

the  inflammation  and  swelling  have  subsided  and  the  bones  are  firmly  fixed 
in  position. 

Dislocations  of  the  cartilages  of  the  nose  may  he  divided  into 

dislocation  of  the  external  cartilages  of  the  nose  and  dis- 
location of  the  internal  or  triangular  cartilage  forming  the 
anterior   portion  of  the  septum. 

(a)  Dislocation  of  tin  <.rl<rn<il  cartilages  of  the  nose 
usually  takes  place  from  blows  inflicted  on  the  dorsum 
of  the  nose.  Owing  to  their  elasticity  and  firm  attach- 
ment the  shield-cartilages  are  rarely  dislocated,  hut  the 
upper  lateral  cartilages  filling  the  dorsum  of  the  nose  arc 
more  Bubjeci  to  injuries  and  more  frequently  dislocated, 
r-.  ( )w  ing  to  the  9mallness  of  these  cartilages  and  the  swelling 

which  masks  the  injury  the  dislocation  frequently  passes 

unnoticed  until  it  i-  recognized  by  the  depression  of  the 
dorsum  of  the  nose,  after  recovery  from  the  injury,  as 
shown  in   Fig.  648.      This   accident  can  he  recognized   and 

properly  treated  only  directly  after  it-  occurrence  and  be- 
fore swelling  of  the  soft   parts  takes  place,  when  the  de- 
pression   and    the  luck    of  -upport  of  the  dorsum    of  the  nose  can    he   readily 

detected.     The  cartilage  can  then  he  forced  into  place  and  held  there  by  gauze 

pack.. |    into   the  interior  of  the    opse   at    this   point,  supported    by  the  spring 


^ 


I'm.'.!-      I' 
in  tin-  dorsum  "i  the 
inn  dislocation 
of  ili''    nppei 
cart  it 


FOREIGN   BODIES  IX  AIR-PASSAGES  AND   ESOPHAGI'S.    \\Ti 

described  on  page  1122,  Fig.  644,  together  with  adhesive  plaster  applied  to 
the  exterior  of  the  nose. 

{!>)  Dislocation  of  the  triangular  cartilagi  of  the  septum  is  of  frequenl 
occurrence.  It  takes  place  most  often  in  children  as  the  result  of  a  fall 
upon  the  nose.  In  older  persons  it  may  result  from  a  fall,  Mows  upon 
the  nose,  or  various  accidents.  The  dislocation  mosl  frequently  found 
is  that  at  the  juncture  of  the  triangular  cartilage  with  the  perpendicular 
plate  of  the  ethmoid.  It  consists  in  the  sliding  backward  of  the  cartilage  to 
the  side  (A'  the  hone,  giving  the  septum  the  appearance  of  being  deflected  to 
that  side,  as  shown  in  Fig.  647.  Since  the  posterior  portion  of  the  carti- 
lage is  thrown  to  one  side,  the  anterior  portion  is  naturally  turned  in  the 
opposite  direction,  so  that  both  nostrils  are  obstructed.  There  is  often  also 
dislocation  of  the  lower  border  of  the  cartilage  at  its  junction  with  the  vomer, 
and  also  of  the  vomer  at  its  juncture  with  the  superior  maxilla,  projecting 
into  the  meatus  on  the  side  on  which  the  dislocation  takes  place.  This  con- 
dition is  readily  detected  by  anterior  rhinoscopic  examination,  and  should  be 
differentiated  from  ecchondrosis  and  other  pathological  conditions  which 
frequently  obstruct  the  nostrils.  It  is  also  readily  seen  that  the  convexity 
on  one  side  is  proportionate  to  the  concavity  on  the  opposite  side.  The 
perpendicular  plate  of  the  ethmoid  is  very  often  deflected  to  one  side, 
together  with  the  triangular  cartilage;  but  its  dislocation  alone  can  only 
result  from  great  external  violence  or  from  foreign  bodies  penetrating  the 
nasal  chamber. 

Treatment. — This  dislocation,  if  recent,  can  easily  be  put  into  place  with 
the  fingers,  one  finger  being  inserted  in  each  nostril  and  the  parts  held  there 
by  a  tampon  placed  in  the  nostril  into  which  the  dislocation  took  place.  In 
other  cases  the  dislocation  may  be  reduced  by  the  use  of  a  smooth-bladed 
dressing-forceps,  or  the  blades  of  an  ordinary  forceps  covered  with  adhesive 
plaster  to  prevent  wounding  the  soft  parts.  When  the  dislocation  has  be- 
come firmly  fixed  it  can  only  be  reduced  by  loosening  the  cartilage  along  its 
lower  and  posterior  border.  The  parts  are  then  forcibly  put  into  position, 
and  held  there  by  a  retentive  apparatus.  The  success  of  the  operation  de- 
pends entirely  upon  the  thoroughness  with  which  the  cartilage  is  loosened 
from  its  attachments,  thereby  preventing  the  tendency  to  return  to  its  former 
position.  In  some  cases  it  may  be  expedient  to  dissect  out  any  redundant 
cartilage  through  a  small  incision  made  in  the  overlying  tissue,  reuniting 
the  edges  with  fine  sutures. 

FOREIGN  BODIES  IN  THE  AIR-PASSAGES  AND  ESOPHAGUS. 

Foreign  Bodies  in  the  Nose.— Foreign  bodies  found  in  the  nose  may 
be  either  animate  or  inanimate.  They  may  be  introduced  from  without  or 
formed  within  the  nose,  as  in  the  case  of  calcareous  concretions  termed 
rhinoliths. 

Animate  foreign  bodies,  such  as  leeches,  flies,  worms,  etc.,  sometimes  find 
their  way  into  the  nasal  cavity  ;  and  other  living  creatures,  such  as  maggots, 
mav  develop  from  the  ova  of  flies  deposited  there  ;  this  more  frequently  occurs 
in  tropical  countries. 

Inanimate  foreign  bodies  may  enter  through  the  anterior  nares,  through 
the  posterior  nares,  or  through  the  walls  of  the  nose. 

Those  that  enter  the  anterior  nares  are  chiefly  such  substances  as  beads, 

peas,  stones,  buttons,  fruit-stones,  pieces  of  w 1,  coin-,  and,  in  fact,  near!} 

every  substance  that  it  i<  possible  to  crowd  into  the  nostrils  may  sometime 


1128      INJURIES  AND   DEFORMITIES  OF  THE  NOSE,   ETC. 

be  found  there.  They  arc  however,  usually  introduce^  intentionally  by  mis- 
chievous  children.  Lunatics,  <»r  hysterical  women. 

Substances  that  enter  through  the  posterior  nares  are  generally  such  as 
teeth,  rings,  fruit-stones,  pieces  of  bone,  etc.,  which  have  previously  been 
swallowed  and  afterward  expelled  from  the  stomach  and  thrown  forcibly  into 
the  nares  during  emesis.  Substances,  such  as  piece-  of  cotton  and  portions  of 
sponges  left  after  plugging  the  posterior  nares,  are  sometimes  found  there 
;i« -t  i 1 1 u  as  foreign  bodies. 

Foreign  bodies  that  enter  through  the  wall  of  the  nose  are  usually  spent 
bullets,  fragments  of  stone  from  blasting,  or  of  iron  from  the  bursting  of  guns. 
Splinters  of  wood  forced  through  the  walls  of  the  nose  have  been  extracted 
from  the  nasal  cavity. 

Symptoms. — There  is  usually  a  more  or  less  profuse  sero-mucous  dis- 
charge tVom  the  nose,  or  if  ulceration  has  taken  place  the  discharge  becomes 
muco-purulent  and  bloody,  and  is  more  or  less  fetid.  There  is  also  more  or 
less  obstruction,  according  to  the  size  of  the  body,  and  a  swollen  condition  of 
the  mucous  membrane,  sometimes  attended  by  frequent  attacks  of  sneezing 
and  neuralgic  pains  of  the  face.  In  the  case  of  peas,  beans,  etc.,  much  press- 
ure may  he  caused  by  the  swelling  of  the  body,  and  sometimes  germination 
take-   place. 

Living  bodies,  such  as  maggots,  termed  in  India  "  peenash,"  cause  intense 
pain  in  the  nose  and  frontal  region,  of  a  throbbing  character,  attended  by  a 
sensation  of  formication.  There  is  swelling  and  edema  of  the  face,  eyelids, 
and  palate,  and  epistaxis  is  usually  present.  Abscesses  may  form  in  the  nose 
and  destruction  of  hone  may  take  place,  leading  to  meningitis. 

The  diagnosis  of  foreign  bodies  in  the  nose  is  usually  not  difficult.  If 
there  is  no  history  of  the  accident,  which  at  best  is  unreliable,  the  occurrence 
of  a  unilateral  fetid  discharge  from  the  nose  should  lead  us  to  suspect  the 
presence  of  a  foreign  body,  especially  in  children.  In  adults  it  musl  be  dif- 
ferentiated from  syphilis  and  from  disease  of  an  accessory  sinus,  from  which 
the  discharge  is  almost  always  unilateral,  and  from  sarcoma  or  carcinoma. 
If  it  is  large  and  located  in  the  anterior  portion  of  the  nose,  a  foreign  body 
may  lie  suspected  by  a  bulging  of  the  ala. 

The  question  can  ordinarily  be  very  easily  decided  with  the  probe.  In 
children  a  few  whiffs  of  chloroform  are  advisable  to  quiet  their  fear-;  but  in 
adult-  the  n-e  of  coeain  is  all  that  is  necessary,  both  for  diagnosis  and 
extraction. 

The  treatment  of  foreign  bodies  in  the  nose  consists  simply  in  their 
removal,  although,  a-  Mackenzie  observes,  there  i-  no  occasion  for  undue 
haste.  Before  this  is  attempted,  therefore,  their  nature,  situation,  size,  and 
fixedness  should  be  determined. 

Animate  foreign  bodies,  such  a-  insects  and  maggots,  are  best  removed 
with  chloroform.  In  fact,  chloroform  i-  the  only  effectual  remedy.  It  should 
be  diluted  one-half  with  water,  on  accounl  of  the  pain  caused  in  using  it  full 
strength.  It  is  then  agitated  and  injected  at  once  before  the  water  and  chlo- 
roform separate.  This  was  discovered  by  Dauzat,  an  apothecary's  assistant 
in  Mexico,  in  the  year  1805.  The  vapor  al ■  will  sometimes  cause  a  dis- 
charge of  the  maggots.  If  necessary  to  use  it  full  strength,  the  dilution  being 
ineffectual,  general  anesthesia  should  previously  be  produced  with  the  vapor, 
;,_  suggested  by  Mackenzie,  to  prevent  the  intense  suffering. 

Inanimate  foreign   bodies  when  bine-  Bomewhal  loosely  in  the  cavity  are 

lily  extracted  with  a  pair  of  mouse-toothed  forceps;  but  when  more  or 
less    embedded    in  the    tissues    they  should    be   carefully  raised    from  their  bed 


FOREIGN  BODIES  IN   THE  AIR-PASSAGES.  1129 

by  a  suitably  curved  probe.  Sometimes  the  use  of  sternutatories,  a  forcible 
blowing  of  the  nose,  or  the  use  of  Politzer's  bag  in  the  opposite  nostril  will 
cause  the  foreign  body  to  be  expelled.  In  some  cases  the  method  of  Sajous 
will  succeed  where  others  have  tailed,  which  is  by  drawing  a  cotton  or  wool 
tampon  through  the  nasal  passage  from  behind. 

When  a  foreign  body  is  impacted  in  the  nose  it  may  be  necessary  to 
break  it  up  by  means  of  strong  forceps,  or  by  sawing  it  in  two,  or  by 
drilling  it. 

\\  hen  a  foreign  body  i-  Lodged  in  the  posterior  nares  it  can  generally 
he  forced  down  into  the  pharynx  with  a  sound  introduced  through  the  nose, 
care  luiii-  taken  that  it  is  not  inhaled  into  the  larynx  or  trachea,  or  .-wal- 
lowed. 

Rhinoliths,  or  Nasal  Calculi. — These  consist  in  the  deposition  of 
the  salts  of  the  secretions  of  the  nasal  passages  forming  more  or  less  -olid 
bodies,  usually  having  for  their  nucleus  some  foreign  substance  which  has 
been  introduced  from  without.  Occasionally  they  form  around  some  inspis- 
sated secretion,  favored  by  a  gouty  diathesis.  They  enlarge  slowly  by  accre- 
tion of  the  earthy  .-alts  to  the  surface,  being  composed  mainly  of  phosphate 
of  lime  and  magnesia,  or  chlorid  of  sodium,  carbonate  of  lime,  magnesium 
and  sodium.  They  may  attain  considerable  proportions,  completely  tilling 
the  naris,  sometimes  distending  it  like  a  foreign  growth.  From  one  patient 
I  removed  a  rhinolith  weighing  40  grains,  having  for  its  nucleus  a  -mall 
pledget  of  cotton.  They  are  usually  single,  though  in  some  cases  there  may 
be  two  or  more.  They  are  almost  invariably  unilateral.  Their  slowness  of 
growth  and  the  absence  of  history  of  the  introduction  of  a  foreign  substance 
may  cause  them  to  remain  undetected  for  a  considerable  period,  the  discharge, 
as  in  the  case  I  have  mentioned  above,  being  regarded  simply  a-  catarrhal. 
The  condition  with  which  they  might  most  easily  be  confounded  i-  necrosis 
of  the  bones  of  the  oose  as  a  result  of  syphilis. 

Their  attending  symptoms,  diagnosis,  and  treatment  are  practically  the 
same  as  that  of  an  inorganic  foreign  body  in  the  nose,  with  which  they  are  to 
be  classed. 

Foreign  Bodies  in  the  Larynx  and  Trachea. — Foreign  bodies 
entering  the  air-passages  may  be  either  fluid  or  solid.  Fluid  foreign  bodies 
comprise  articles  of  Liquid  food  and  drink,  pus  from  a  ruptured  tonsillar, 
retropharyngeal,  or  aryteno-epiglottic  abscess,  blood  entering  during  surgical 
operation-  or  after  an  injury,  and  chyme  or  other  vomited  matter. 

Solid  foreign  bodies  comprise  almost  every  conceivable  substance  that 
•  •an  possibly  enter  or  pass  through  the  Larynx,  and  include  both  animate  and 
inanimate  bodies. 

Among  the  most  curious  and  interesting  cases  of  animate  bodies  may  be 
mentioned  fish,  held  in  the  teeth  during  extraction  of  the  hook,  leeches  enter- 
ing while  drinking  water  from  pools  or  brook-,  lumbricoids  transferred  from 
other  parts  of  the  body.  Hie-  inhaled  while  riding  through  them,  and  the 
epiglottis  of  a  young  woman  which  became  impacted  in  the  larynx  while 
eating.  The  inanimate  bodies  that  most  frequently  enter  the  air-pass 
are    fruit— ton.-,    pebble-,    grains    of   corn,    beans,   coin-,   button-,  and    the 

like. 

The  i le  nf  entrance  of  foreign  bodies  may  be  either  through  the  mouth, 

through  the  neck  or  chest- walls  by  fistulous  openings,  or  from  other  portions 
of  the  body. 

The  entrance  of  substances  into  the  air-passages  through  the  mouth  gen- 
erally occur-  during  mastication  and  deglutition,  while  the  person  is  Laughing 


1130     INJURIES   AND   DEFORMITIES  OF  THE  NOSE,    ETC. 


QOtive    in   the    larynx 

(Johnston  i. 


or  talking,  or  during  sleep.  .Many  case-  of  sudden  death  arc  reported  where 
large  pieces  of  meal  or  other  substances  have  entered  the  larynx  while  eating, 
and  caused   immediate  death   from   strangulation.     Substances  held   in   the 

mouth  are  sometimes  suddenly  drawn  into 
the  larynx  while  laughing  or  during  a  fright, 
or  during  any  condition  which  causes  a  Hid- 
den inspiration.     Such  substances  as  blow- 
gun  darts,  whistles,  and  the  like  are  some- 
times drawn  into  the  larynx  while  the  pers<  >n 
is  amusing  himself  with  these  substances. 
In   some  instances  the  substance   becomes 
lodged  in  the  pharynx  during  sleep.     This 
occiii'-    most    often    in    children    who   go   to 
sleep  with  toy-,  coin-,  buttons,  etc.,  in  their 
mouths.     One  of  the  most  interesting  cases  of*  this  kind  is  reported  by  John- 
ston, where  a   toy  locomotive  was  inhaled   into  the   larynx  of  a   child  during 
sleep,  requiring  thyrotoray  for  it-  extraction  (  Pig.  649). 

In  adults  one  of  the  most  frequent  substances  to  enter  the  larynx  is  a 
tooth-plate  which  has  not  been  removed  before  retiring.  Schwetter  reports 
a  case  where  the  patient  was  not  aware  of  the  accident  until  he  missed  his 
teeth  in  the  morning.  Corks  held  between  the  teeth  during  the  administra- 
tion of  anesthetics,  and  sponges  used  about  the  mouth  during  operations,  have 
been  drawn  into  the  larynx. 

Substances  entering  through  the  neck  or  chest-walls  are  most  frequently 
Hying  fragments  from  explosions,  bullet-,  and  other  projectiles;  and  portions 

of  ill-constructed  tracheotomy-tubes,  not 
properly  eared  for  and  allowed  to  cor- 
rode, may  become  detached  and  fall 
into  the  trachea. 

Substances  lodged  in  the  esophagus 
may  ulcerate  through  into  the  trachea 
or  pass  into  it  through  fistulous  open- 
ings. Bronchial  glands  have  also  ulcer- 
ated through  into  the  trachea  and  acted 
as  foreign  bodies. 

The  location  and  position  of  a 
foreign  body  depends  much  upon  its 
size  and  shape.  Sharp,  penetrating  ob- 
jects are  frequently  found  sticking  in 
the  supraglottic  portion  of  the  larynx. 
Large  alimentary  substances  or  angular 
bodies  are  usually  (bund  in  the  larynx. 
Hat  bodies,  such  as  coins  and  buttons, 
are  usually  found  in  the  ventricles  of 
the  larynx  ;  while  small,  round,  and 
heavy  bodies  commonly  descend  into 
the  trachea.  Small  bodies  that  enter 
the  bronchi  usually  enter  the  right  one, 
since  the  bronchial  septum  is  on  the 
left  side  of  the  median  line,  as  Srst 
pointed  out  by  Goodell  of  Dublin,  as  Bhown  in  Fig.  650.  Of  98  cases  col- 
lected by  the  writer,  58  were  found  to  be  in  the  right  bronchus  and  36  in  the 
left     Of  156  cases,  Bourdillel   found  thai  the  foreign  body  was  arrested  in 


Bi   •  shial    leptum     tra  hea  and 

bronchial  tubes  laid  open  in  front:  1, trachea; 

I  bronchial  tube;  ::,  left  bronchial  tube; 

cbial  Beptum,  Bomewhat    magnified  t" 

render  it  more  consplcm 


/  v ,  R  EIGN  B  ODIES  IN  THE  A I  /.'-  PA  ss.  I  { ;  ES.  1131 

the  larynx  35,  in  the  trachea  80,  in  the  right  bronchus  28,  and  in  the  left 
bronchus   L5  times. 

Substances  lodged  in  the  trachea  change  their  position  more  often  than 
those  in  the  larynx.  Sometime.-  they  play  up  and  dow  u,  as  in  the  ease  reported 
by  Glasgow,  where  a  toy  balloon,  which  had  entered  the  trachea,  moved  up 
and  down  with  each  inspiration.  Physical  changes  also  take  place  in  the 
foreign  body.  Mineral  substances  usually  become  more  or  less  corroded. 
Corks,  beans,  grains  of  corn,  and  other  dry  substances  absorb  moisture  and 
swell  sometimes  to  double  their  original  size,  and  in  some  instances  seeds  have 
been  known  to  germinate  in  the  air-passages. 

The  symptoms  of  foreign  bodies  in  the  larynx  vary  from  complete  and 
instantaneous  suffocation,  as  in  the  case  of  an  impaction  of  a  mass  of  meat, 
to  an  almost  complete  absence  of  manifestations,  as  in  the  case  of  small  or 
smooth,  non-irritating  substances. 

The  usual  symptoms  attending  the  lodgement  of  foreign  bodies  in  the 
larynx  are  those  of  sudden  choking,  cough,  and  efforts  at  dislodging  the  sub- 
stances. When  the  breathing  is  materially  interfered  with  the  patient  often 
becomes  excited  and  alarmed,  and  makes  frantic  efforts  to  obtain  air.  He 
grasps  his  throat,  his  eyes  protrude,  and  his  face  becomes  livid  from  the  lack 
of  oxygenation  of  the  air. 

Frequently  these  symptoms  are  occasioned  only  by  the  spasm  <>f  the 
larynx  excited  by  the  presence  of  the  foreign  body,  and  soon  subside.  In 
cases,  however,  due  to  mechanical  obstruction,  these  symptoms  continue  until 
death  ensues. 

Small,  sharp  bodies,  such  as  fish-bones,  pins,  needles,  and  the  like,  which 
usually  penetrate  the  upper  portion  of  the  larynx,  excite  more  or  less  cough 
and  cause  much  discomfort  on  swallowing. 

Substances  lodged  in  the  larynx,  but  lying  in  such  a  position  as  not  to 
obstruct  respiration,  are  attended  with  more  or  less  hoarseness  and  coughing, 
as  in  the  case  of  coins,  and  in  some  instances  tooth-plates.  These  cause 
active  symptoms  only  after  congestion  or  inflammation  has  taken  place. 

Smooth,  round  bodies  cause  little  irritation;  while  sharp  or  angular  bodies 
cause  inflammatory  symptoms. 

Foreign  bodies  finding  their  wav  into  the  trachea  are  usually  manifested 
by  a  cough,  dyspnea,  and  efforts  at  expulsion.  If  the  dyspnea  is  continuous, 
it  indicate-  that  the  foreign  body  has  become  impacted  in  the  trachea  or  a 
bronchus;  if  intermittent,  that  it  is  movable  in  the  trachea  :  if  there  is  col- 
lapse  of  one  lung,  that  it  occupies  one  of  the  bronchi  ;  or  if  there  is  inter- 
lobular emphysema  of  the  lung,  that  there  is  laceration  of  some  portion  of 
the  air-passages.  Pain  is  almost  always  present,  and  may  clearly  indicate 
the  location  of  the  foreign   body. 

Sometimes  the  presence  of  the  foreign  body  is  manifested  by  frequent 
hemorrhages,  emaciation,  and  all  of  the  symptoms  of  phthisis,  which  cease 
on  the  expulsion  or  removal  of  the  foreign  body. 

When  a  foreign  body  has  been  retained  tor  a  length  of  time,  there  is 
usually  more  or  less  fetor  of  the  breath  from  decomposition  <>1  the  foreign 
body  or  of  the  retained  secrel ions.  Frequently  disease  of  the  bronchi  or 
pulmonary  structure  intervenes,  and  sometime-  pericardial,  mediastinal,  or 
hepatic  alt-cesses  have  resulted  from  ulceration  and  the  extension  of  the 
inflammation   to   the  surrounding  structures. 

The  diagnosis  of  the  case  is  greatly  facilitated  by  the  history  of  the 

accident.  When  there  is  no  history,  as  in  a  case  where  the  foreign  body  h:i< 
entered  during  a  period  of   unconsciousness,  as   in  an  epileptic  seizure  or 


1132      INJURIES  AND   DEFORMITIES  OF  THE  NOSE,    ETC. 

>.  reliance  must  be  placed  upon  the  physical  examination.  A  laryngo- 
scopy examination  can  be  usually  made.  In  the  case  of  a  "  Punch-and- 
Judy  "  whistle  lodged  in  the  lower  part  of  the  trachea  of  a  boy  eight  years 
old,  it  was  readily  discovered  by  the  author  by  the  aid  of  the  laryngoscopic 
mirror.  When  a  laryngoscopic  examination  cannot  be  made  the  larynx  can 
be  explored  with  the  finger ;  and  when  in  the  trachea,  auscultation  will  fre- 
quently  reveal  the  presence  and  location  of  the  body — if  a  whistle,  by  a 
whistling  sound,  and  if  movable,  by  a  "flapping  noise'"  or  Zwinger's  "chat- 
tering bruit.**  When  the  air  is  excluded  from  one  lung  by  reason  of  an 
obstruction  of  a  bronchus,  it'  it  is  in  the  righl  bronchus  the  lower  lobe  will 
be  affected  ;  while  it'  in  the  left  bronchus  the  entrance  of  air  to  the  whole 
lung    will    be    obstructed. 

When  the  nature  and  location  of  the  foreign  body  cannot  readily  be  de- 
termined the  X-rays  should  be  employed,  for  they  may  not  only  locate  the 
substance,  but  also  materially  assist  in  its  extraction  by  showing  its  form 
and    position. 

Dyspnea  caused  by  a  foreign  body  lodged  in  a  bronchus  is  sometimes 
mistaken  for  a  foreign  body  in  the  trachea;  and  in  a  case  where  death  was 
almost  instantaneous  from  the  blocking  of  the  larynx,  the  death  might  be 
attributed  to  epilepsy   or  apoplexy. 

The  prognosis  of  foreign  bodies  in  the  trachea  is  always  more  or  less 
serious.  When  death  does  not  take  place  from  suffocation  serious  inflamma- 
tory disturbance  may  arise,  or  there  may  be  a  sudden  change  of  position  of 
the  foreign  body,  either  in  the  larynx  or  trachea,  which  at  any  time  may 
cause  a  fatal  result.  Small,  smooth,  non-irritating  bodies  rarely  produce 
serious  results,  and  are  almost  always  expelled  spontaneously  ;  whereas  sharp, 
angular  or  pointed  bodies,  even  though  suffocation  be  not  imminent,  should 
be  removed  as  soon  as  possible. 

The  general  consensus  of  opinion  of  surgeons  is  that  no  foreign  bodies 
should  be  allowed  to  remain  any  length  of  time  in  the  air-passages  without 
the  operation  of  bronchotomy.  On  the  other  hand,  Weiss,  from  a  collection 
of  1000  cases,  mostly  those  reported  to  him  privately,  concludes  that  when 
the  trachea  and  bronchus  contain  a  foreign  body,  the  patient  will  be  more 
liable  to  recover  if  trusted  to  spontaneous  expulsion.  The  statistics  on  this 
point  are  not  of  special  value,  for  many  patients  die  from  suffocation  who 
would  have  been  saved  by  an  operation,  and  many  die  after  the  operation 
when  the  foreign  body  might  have  been  expelled  spontaneously  with  re- 
covery. 

Substances  entering  the  air-passages  are  usually  expelled  through  the 
opening  by  which  they  entered,  although  in  many  instances,  like  bullets, 
heads  of  -rain,  etc.,  they  have  entered  through  the  chesl  or  the  esophagus 
and  have  been  expelled  through  the  trachea.  In  other  instances  substances 
like  heads  of  grain  have  entered  through  the  larynx  and  trachea  and  were 
expelled  through  abscesses  of  the  chest-wall. 

Treatment. — The  firs!  and  mosl  important  indication  is  the  removal  of 
the    foreign   body;   but    the    method   of  removal  will    depend    largely  upon    its 

nature  and   location. 

Expulsion  through  the  natural  passages  is  facilitated  by  the  use  of  a  little 
chloroform  to  allay  the  excitability  of  the  patient  and  the  irritability  of  the 
parts  occasioned  by  the  presence  of  the  foreign  body.  A.mong  the  natural 
aid-  are  the  various  expulsive  efforts,  guch  a-  sneezing,  coughing,  vomiting; 
and  by  inversion,  aided  by  percussion  and  circussion  of  the  chest.  The  use 
of  the  sternutatories  and  emetics,  tickling  the  nose  with  a  feather  to  promote 


FOREIGN  BODIES  f.X  THE  AIR-PASSAGES. 


1133 


sneezing,  and  of  the  throat  to  produce  vomiting,  have  been  employed  from 
the  earliest  times.  But  little  reliance,  however,  can  be  placed  upon  these 
methods. 

In  the  case  of  movable  bodies,  such  as  coins,  bullets,  and  similar  weighty 
substances,  inversion  of  the  body  will  sometimes  cause  tin1  immediate  expulsion 
of  the  substance.  The  danger  with  which  some  regard  tln>  method  from  the 
impaction  of  the  substance  in  the  larynx  is  largely  imaginary,  for  no  case  is 
reported  where  death  has  resulted.  Of  several  methods  of  inversion  the  best 
is  that  described  by  Padley  of  Swansea:  The  patient  i>  directed  to  sit  on  the 
elevated  end  of  a  bench,  with  his  knees  flexed  over  the  end.  He  then  lies 
backward  on  the  inclined  plane  thus  formed,  ami  the  coin  drops  into  the 
mouth.  Danger  of  spasm  or  impaction  in  the  larvnx  is  avoided  by  the  ability 
of  the  patient  to  at  once  assume  the  upright  position.  The  patient  should 
inspire  deeply  and  avoid  speaking.  A  blow  or  slap  on  the  chest  will  some- 
times aid  in  the  expulsion  of  a  coin. 

In  the  case  of  animate  bodies  lodged  in  the  larynx,  such  as  leeches  and 
the  like,  they  are  best  dislodged  by  swallowing  turpentine  or  chlorid  of 
sodium. 

In  some  cases  the  introduction  of  an  O'Dwyer  tube  is  temporarily  neces- 
sary to  prevent  suffocation  from  impaction  or  spasm  of  the  larynx. 

Extraction  through  the  Natural  Passages. — This  should  be  done  with  the 
guidance  of  the  laryngeal  mirror;  when  this  is  not  possible  the  instrument 


Fig.  6ol.— Mackenzie's  tube-forceps. 


can  be  guided  with  the  index  finger,  as  in  the  introduction  of  the  O'Dwyer 
tube  (see  page  1030).  When  the  foreign  body  occupies  the  supraglottic  portion 
of  the  larynx,  disco's  lever  blade-forceps  or  Mackenzie's  angular  forceps  are 


Pig  652.— A  coin  in  the  laryngeal  ventricle 
(Grazzi). 


Pio.  <",;>::.    'Hi.-  same  coin  in  tin-  grasp  of  the 
Instrumi  at  (Gro 


the  mosl  serviceable;  but  when  in  the  subglottic  portion  of  the  larynx  or  in 
the  trachea,  Seile^s  or  Mackenzie's  (Fig.  651)  tube-forceps  are  the  best.  Mac- 
kenzie's tube-forceps  with  the  blade  having  a  lateral  grasp  are  especially  Ber- 


1134      TNJ    /.'//>  AND   DEFORMITIES  OF  THE  NOSE,    ETC. 

viceable  for  the  removal  of  coins  impacted  in  the  larynx.  Fig.  (>">-!  represents 
the  well-known  case  in  which  Grazzi  removed  from  the  larynx  a  two  centesimi 
piece  in  this  manner.  Some  rough  or  angular  bodies  lie  between  the  vocal 
cords.  It  is  not  advisable  to  remove  them  through  the  larynx  if  there  is 
danger  of  lacerating  the  larynx  sufficiently  to  impair  the  voice  permanently. 
Sometimes  the  removal  can  be  accomplished  only  after  the  swelling  has  sub- 
sided  under  appropriate  treatment. 

When  the  foreign  body  is  so  located  or  impacted  that  it  cannot  be  expelled 
or  extracted  through  the  natural  passages,  artificial  openings  must  be  resorted 
to.  The  various  operations  that  are  frequently  called  for  are  governed  by  the 
location  of  the  foreign  body  ;  it'  in  the  larynx,  thyrotomy  or  crico-thyroid 
laryngotomy,  or  if  in  the  lower  part  of  the  larynx,  laryngo-tracheotomy  <>r 
tracheotomy  ;  if  in  the  trachea  or  bronchi,  low  tracheotomy. 

When  the  trachea  is  opened  the  foreign  body  may  be  expelled  either 
through  the  larynx  or  the  tracheal  opening-,  or  it  may  he  thrown  up  into  the 
upper  part  of  the  trachea  so  as  to  he  readily  grasped  with  a  pair  of  forceps. 
If  the  substance  is  in  the  larynx,  it  can  now  he  more  readily  extracted,  or  it 
may  he  forced  out  of  the  larynx  from  below  with  a  sound  ;  or  a  piece  of  silk 
may  he  passed  down  from  the  mouth  and  a  piece  of  sponge  drawn  up 
through  the  larynx   from  below. 

Expulsion  from  the  trachea  is  aided  by  turning  on  the  face,  inversion, 
succussion,  and   blowing  into  the  trachea,  or  tickling  it  with  a  feather  to 

excite    COUgh. 

The  tracheal  wound  should  he  held  widely  open  with  suitable  retractors 
such  as  Laborde's  (  Fig.  65  t),  <  rolding-Bird's  (Fig.  655),  or  Minor's  retractor. 


E  ]■..  'i  4.     Laborde's  flilator. 


Fig.  655. — Golding-Bird's  double  retractor. 


If  the  foreign  body  is  not   immediately  expelled.  Wythe's  plan  of  stitch- 
ing the  edge-  of  the  tracheal  wound  to  the  integument  is  an  excellent  scheme 


i  i<,  i.  6     EUx  -  tracheal  forceps,  with  flexible  spiral  tube. 

(lord  ready  exit  lor  the  foreign  body  :i(  any  time.  No  tracheal  cannula, 
of  course,  should  he  introduced.  When  the  body  is  not  expelled  at  once, 
it  should  be  extracted  by  suitable  instruments.     Roe's  tracheal  forceps  (Fig, 


FOREIGN  BODIES  IX  THE  PHARYNX  AND   ESOPHAGUS.    1135 

65G),  the  stem  being  made  of  copper,  so  that  it  can  be  1  >cn t  into  any  required 
position  for  reaching  into  a  bronchus,  is  especially  suitable.  Gross's  and 
('.'lien's  tracheal  forceps  arc  also  serviceable  instruments.  Sometimes  the 
position  »f  the  body  can  be  ascertained  by  reflecting  light,  or  tracheoscopy, 
and  removed  or  dislodged  with  a  hook  made  of  a  silver  probe  l>\  bending  up 

the  end,  and  extracting  with  the  aid  of  the  finger. 

Attempts  at  extraction  should  not  he  sufficiently  prolonged  to  cause  irri- 
tation of  the  part  or  exhaustion  of  the  patient.  We  should  rather  wait  for 
loosening  and  expulsion  to  take  place.  When  this  loosening  does  not  take 
place  and  removal  of  the  body  must  he  effected,  the  operation  of  bronchotomy 
through  the  chest-walls,  as  suggested  by  Quenu  and  Figueira,  or  the  plan  of 
reaching  tin1  bronchi  through  an  opening  in  the  chest-wall  from  behind,  by 
incising  the  third  to  sixth  dorsal  vertebrae,  as  proposed  by  Nesiloff,  is  to  he 
considered. 

Foreign  Bodies  in  the  Pharynx  and  Esophagus. —  Foreign  sub- 
stances of  almost  every  variety  have  been  found  in  the  pharynx  and  esoph- 


|.„..  r,57.— Tooth-i-lat.-  lodged  in  a  diverticulum  in  the  esophagus  for  nearly  twp  years.    The  patient 
insisted  that  the  plate  was  in  her  esophagus,  bul  exploration  railed  to  detect  it  during  life  (Sliver). 

agUS.  They  may  enter  through  the  month  or  through  the  neck,  as  in  the 
case  of  gunshol  wounds,  <>r  the  substance  may  he  thrown  tip  from  the  stomach 
and  impacted  in  the  esophagus. 

Foreign  bodies  in  the  esophagus  are  usually  arrested  in  the  middle  third 
where  it  i-  crossed  by  the  left  bronchus,  <>r  at  the  cardiac  extremity,  winch  i- 
the  narrowest  portion  of  the  tube. 

Many  pathological  conditions  favor  the  lodgement  of  foreign  bodies  in 


1136     INJURIES  AND   DEFORMITIES  OF  THE  NOSE,   ETC 

the  pharynx  and  esophagus,  such  as  inflammatory  affections,  diseased  condi- 
tions of  the  tongue,  tonsils,  pharynx,  larynx,  and  esophagus,  which  interfere 
with  deglutition  and  induce  the  sudden  bolting  of  food  in  large  quantities. 

Substances  carelessly  placed  in  the  mouth  frequently  become  lodged  in 
the  throat,  and  during  sleep  tooth-plates  and  other  substances  often  drop  into 
the  throat  and  become  impacted  in  the  esophagus;  in  some  instances  this 
take-  place  without  the  knowledge  of  the  patient. 

The  symptoms  attending  the  lodgement  of  foreign  bodies  in  the  pharynx 
and  esophagus  are  usually  dyspnea,  laryngeal  spasm,  dysphagia,  and  pain  in 
the  region  of  the  impaction. 

Sometimes  the  dyspnea  from  the  pressure  of  the  foreign  substance  <>n  the 
trachea  is  so  great  that  it  simulate-  the  lodgement  of  a  foreign  body  in  the 
trachea  or  larynx.  In  nervous  and  excitable  people  the  lodgement  of  such 
bodies  in  the  throat  or  esophagus  is  sometime-  purely  imaginary,  although 
all  the  symptoms  of  their  presence  are  produced.  In  other  instances  foreign 
bodies  have  remained  in  the  esophagus  for  years,  entirely  unsuspected,  the 
disturbance  caused  by  them  being  attributed  to  other  causes.  A  pouch  or 
diverticulum  on  one  side  of  the  esophagus  will  sometimes  form  for  their 
lodgement,  leaving  the  passage  free,  and  sometimes  they  become  encysted. 
Fig.  f)-~>7  represents  a  tooth-plate  lodged  in  a  diverticulum  in  the  esophagus 
for  nearly  two  years.  It-  presence  was  suspected,  but  it  could  not  be  detected 
during  life. 

Sharp  and  -lender  substances,  such  as  pins,  needles,  head-  of  grain,  may 
p:i--  through  the  walls  of  the  esophagus,  migrate  to  other  parts,  and  emerge 
through  an  abscess.  Foreign  bodies,  however,  that  remain  for  any  length  of 
time  frequently  produce  the  death  of  the  patient  or  alarming  conditions,  such 
as  edema  of  the  larynx,  abscesses,  ulceration  and  stricture  of  the  esophagus, 
perforati >r  rupture  of  the  walls  of  the  esophagus,  penetration  of  the  peri- 
cardium, the  heart,  the  pleural  cavity,  larynx,  and  trachea,  or  caries  of  the 
vertebras. 

Diagnosis. — Foreign  bodies  lodged  in  the  pharynx  and  upper  part  of  the 
esophagus  may  be  detected  by  inspection  of  the  neck,  if  the  substance  is 
sufficiently  large  to  give  it  a  bulging  appearance,  by  laryngoscopy  examina- 
tion, by  palpation  with  the  finger,  and  by  exploration  with  sounds  or  by  the 
X-rays. 

In  the  lower  part  of  the  esophagus  the  foreign  body  can  be  detected  with 
the  sound  and  by  auscultation  of  the  esophagus  over  the  back  during  degluti- 
tion, where  a  peculiar  gurgling  sound  is  heard  at  the  location  of  the  foreign 
body. 

The  esophagus  can  also  be  inspected  by  means  of  Mackenzie's  esophag- 
oscope,  or  it  can  be  electrically  illuminated  by  .Mikulicz'-  esophagoscope. 
Duplay's  resonator  is  especially  serviceable  for  the  detection  of  metallic 
substances.  The  sound,  having  a  metallic  tube,  is  attached  to  the  hollow 
metallic  cylinder,  from  which  the  sound  is  conducted  to  the  ear.  The  striking 
of  the  metallic  end  of  the  bougie  against  the  metallic  substance  is  so  magni- 
fied that    the  slightesl    touch  can  be  detected. 

Treatment. — Foreign  bodies  are  removed  from  the  pharynx  and  esoph- 
agus, first,  through  expulsion   by  natural  means,  as  coughing,  vomiting,  and 

artificial  digestion  ;  second,  by  extraction  by  mean-  of  forceps,  1 ks,  rings, 

and  dilating  probangsj  third,  by  propulsion  with  the  sponge-probang  or  by 
crushing  the  substance  so  thai  it  will  pass  forward;  fourth,  by  incision — by 
pharyngotomy  or  esophagotomy. 

rhe  employment  of  emetic-  i-  not  only  ill-advised  bul  sometimes  danger- 


FOREIGN  BODIES  IX  THE  PHARYNX  AND   ESOPHAGUS.     1137 
ous,  owing  to  the  Liability  of  rupturing  the  esophagus  or  of  lacerating    it 


Fig.  658.— Fauvel's  forceps,  lateral  grasp. 


Fig.  659.— Fauvel"s  forceps,  antero-posterior  grasp. 


during  expulsion  in  case  of  sharp  angular  bodies.     When  small  bodies  are 
impacted  it  has  been  proposed  that  milk  be  ingested,  and  as  soon  as  it   has 


Fig.  660.— Bond's  forceps  (modified  by  author),  with  blades  bevelled  Inward  to  avoid  grasping  m*. 
membrane,  <m<l  to  permit  Blender  bodies  readily  to  turn  lengthwise. 

had  time  to  form  a  linn  curd  he  ejected  by  the  action  of  a  prompl  emetic,  bo 

72 


1138      TNJUBIES  AND   DEFORMITIES  OF  THE  NOSE,    ETC. 

that  it  may  sweep  away  the  intruder.  <  )n  the  other  hand,  soft,  bulky  food, 
like  oatmeal,  may  be  swallowed  in  the  endeavor  to  sweep  on  the  foreign 
substance,  and  such  loud  should  always  be  freely  given  alter  tooth-plates  and 
such  bodies  have  entered  the  stomach. 

For  the  removal  of  substances  from  the  pharynx  and   upper  pari  of  the 
esophagus    Fauvel's  forceps  (Fig.  658)  and    Bond's  forceps  (Fig.  <><;<>),  as 


i  [..    661  — Moe'fi    gum  elastic 
ibe  so     ifl  thai 
■I  follow  (hi-  curves  "f  the 
bronchi  "r  esophe 


Fig  i  ■  exible  spiral-lever 

exl  ractor  :  <<,  lexer  opened  after  hav- 
ing been  passed  beyond  the  foreign 
boay  :  /.,  closed  during  introducl  Ion 
■  tin-  foreign  body  i>  grasped. 


Fig.  ■  ■  bristle 

probang,  closed  t^  imss  the 
foreign  body,  and  opened 
s< i  iis  gently  t"  Bweep  ii 
upward  in  Its  u  Ithdrawal. 


modified  by  the  author,  having  a  very  narrow  biting  surface,  are  especially 
serviceable  instruments.  Moe'e  flexible-stem  forceps  (Fig.  661)  are  especially 
adapted  for  removing  substances  from  the  lower  part  of  the  esophagus. 

Roe's  flexible  spiral-lever  extractor  (Fig.  662)  and  Graefe's  ring  coin- 


INJURIES  AND  DEFORMITIES  OF  LO  11/7/  AIR-PASSAGES.      1  L39 

catcher  arc  most  useful  tor  removing  coins,  metallic  disks,  and  similar  sub- 
stances. 

Gross's  bristle  umbrella  probang  (Fig.  663),  inserted  beyond  the  foreign 
body  while  closed  and  then  expanded  before  withdrawal,  is  an  excellent 
instrument  for  genera]  use,  and  is  adapted  for  the  extraction  of  a  variety  of 
small   substances,  such   as   fish-bones,  pins,  and   the   like. 

A  great  many  different  devices  are  often  required  for  the  removal  of 
differenl  substances,  as  Baud  and  Leroy  devised  passing  drilled  lead-balls 
over  the  string  to  dislodge  fish-hooks  and  to  protect  the  esophagus  from  the 
sharp  ends  during  extraction. 

In  numerous  instances  similar  ingenious  devices  have  been  resorted  to  for 
the  extraction  of  different  substances.  In  every  case,  however,  great  care 
should  be  taken  not  to  irritate  or  lacerate  or  bruise  the  esophagus  with  the 
bite  of  the  forceps  or  by  the  employment  of  too  much  force  in  extraction,  lest 
serious  inflammation  be  excited. 

When  a  foreign  body  has  become  so  firmly  impacted  in  the  pharynx  or 
the  upper  part  of  the  esophagus  that  it  cannot  lie  extracted  per  was  naturcdes, 
the  operation  of  pharyngotomy  or  esophagotomy  should  be  resorted  to  with- 
out delay.  The  rule  laid  down  by  Fisher  is  a  safe  one  to  follow — viz.,  in 
every  case  in  which  the  foreign  body  cannot  be  removed  within  twenty-four 
hours  after  it  has  been  impacted  in  the  esophagus,  external  operations  should 
be  performed  to  obviate  the  danger  of  fatal  internal  complication. 

Injuries  and  deformities  of  the  pharynx  and  lower  air-passages  are  not 
of  frequent  occurrence  in  forms  that  need  special  consideration  here.  Wounds, 
whether  of  cut-throat  or  other  character,  rather  fall  in  the  province  of  the 
general  surgeon,  except  as  inflicted  by  foreign  bodies  or  laryngological  sur- 
gery, when  they  concern  the  laryngologist  largely  as  causes  of  severe  and 
dangerous  inflammation  or  edema.  The  latter  condition  sometimes  ends 
fatally  in  the  cachectic  after  the  most  trivial  injuries,  as  in  v.  Ziemssen's  case 
of  a  consumptive  dying  almost  instantly  after  a  prick  of  his  ventricular  band 
by  a  bit  of  inhaled  tobacco-leaf.  Scalds  or  other  burns  of  the  throat,  most 
commonly  from  the  swallowing  of  caustic  substances,  may  also  require  a 
prompt  opening  of  the  air-passages  in  order  to  prevent  suffocation,  and  pro- 
longed antiphlogistic  treatment  to  allay  the  inflammation  excited,  with  ulti- 
mate operation  to  relieve  the  resulting  stenosis. 

Fracture  of  the  larynx,  generally  of  the  exposed  rostrum  of  the  thyroid, 
as  in  eases  reported  by  the  author,'  is  occasionally  seen,  with  nol  infrequently 
I'atal  result  ;  while  a  cornu  of  the  thyroid  has  at  times  been  fractured  by  a 
blow  or  throttling  pressure  and  dislocated  inward,  to  be  conspicuous  in  the 
supraglottic  larynx-cavity. 

Stenosis  of  the  larynx  from  pachydermia,  trauma,  or  syphilitic  cicatriza- 
tion  may  demand  dilatation  with  the  laryngeal  catheter  or  such  instruments 
as  the  author's  forceps  (see  page  1209). 

1  Ann.  of  Laryngol.,  April,  1881. 


NEUROSES  OF  THE  UPPER  AIR-PASSAGES. 

r,v   JONATHAN    WRIGHT,  M.  I)., 


OF    BROOKLYN,    N.   V. 


SENSORY  NEUROSES  OF  THE  NOSE. 

Disturbs  nces  of  (  Olfaction. 

Anosmia. — Absolute  loss  of  smell  from  any  cause  is  of  rare  occurrence. 
Greal  variation  exists,  both  in  normal  and  abnormal  conditions  of  the  nasal 
mucous  membrane,  in  the  intensity  of  olfactory  impressions.  Depending, 
as  we  must,  almost  exclusively  upon  the  statements  of  the  patients,  their 
neurotic  vagaries  musl  always  he  taken  into  account  in  considering  the 
etiology.  Zwaardemaker  and  Schmidt  '  have  divided  the  cases  into  the 
respiratory  and  the  essential.  By  the  respiratory  we  are  to  understand  any 
condition  which  prevents  the  access  of  odor-laden  air  to  the  mucous  mem- 
brane of  the  olfactory  region.  Such  are,  especially,  nasal  polypi,  dryness 
of  the  mucous  membrane  and  the  formation  of  crusts  upon  it.  Essential 
anosmia  is  due  to  actual  lesions  of  the  olfactory  tract.  There  may  he  a 
chronic  atrophic  rhinitis  or  an  acute  inflammation  of  the  olfactory  mucous 
membrane,  as  in  the  case  reported  by  Vergniaud.2  The  filaments  given  off 
from  the  olfactory  hull>  may  he  torn  through  by  the  jar  of  blows  or  falls  on 
the  occiput,  as  reported  in  several  cases  by  Ogle,  on  whose  paper,3  in  1870, 
mosl  of  the  literature  is  founded.  There  may  he  an  actual  olfactory  neuritis, 
as  in  a  case  mentioned  by  Althaus.1  Darwin,  in  his  famous  Origin  of. 
Species,  drew  attention  to  the  fact  that  white  sheep  and  pigs  are  poisoned 
by  certain  plants,  while  dark-colored  ones  are  not.  Ogle  enlarges  upon  this 
fact,  and  1 1 note-  the  case  related  by  Hutchinson s  of  the  negro  who.  on  chang- 
ing color  by  losing  his  dark  pigment  and  becoming  an  albino,  also  lost  his 
sense  of  smell.  Ogle  -hows  that  it  is  highly  probable  that  these  phenomena 
depend  upon  the  absence  or  loss  of  pigmenl  in  the  olfactory  mucous  mem- 
brane, lie  -i.ite-  that  the  dark-skinned  animals  are  enabled  by  their  keen 
sense  of  smell  to  avoid  the  noxious  plants;  while  the  white  animals,  with 
pale  Schneiderian  membranes  and  feeble  sense  of  smell,  eal  and  are  poisoned 
by  them  (see  page  839).  It  is  h  fad  easily  observed  that  dogs,  whose  sense 
of  smell  is  acute,  have  a  deeply  pigmented  nasal  mucosa.  Syphilis  of  any 
part  of  the  olfactory  trad  is  Baid  by  Dana1''  to  be  the  mosl  frequent  cause 
of  essential  anosmia.  The  last-named  author  also  mentions  several  cases 
due  to  lesions  of  the  olfactory  bulbs  and  the  cortical  centers  in  the  gyrus 
hippocampi  and   uncinatus.     Cases  are  referred  to  by  Mackenzie7  in   which 

1  Die  Krankheiten  det  Oberen  Luftwege.        ■  Eemu  <!•  Laryngologie,  etc.,  No,  17,  Sept.  1.  L894 
1  Wedico-Chirurg.  Tram  .,  L870,  liii.  p.  263.  *  Lancet,  May  M  and  21,  L881, 

\mer.  ./•.;<,;/.  <./'  tfo  .1/"/.  Sciena  .  L852,  voL  rxiii.  p,  I  W< 
6  N.   7.  Med.  Journ.,  Sept.  7,  18£  7  Diseases  of  the  Throat  and  Nose,  1884. 

ii  in 


SENSORY  NEUROSES  OF  THE  NOSE.  1141 

there  was  congenital  absence  of  the  olfactory  nerves  and  bulbs.  Locomotor 
ataxia  and  cortical  cerebral  tumors  and  abscesses  have  been  shown  to  be  the 
causes  of  anosmia  in  some  cases.  In  cases  of  paralysis  it  has  generally  been 
noted  thai  the  anosmia  is  unilateral  and  on  the  side  of  the  lesion,  there  being 
no  decussation  of  the  olfactory  tracts.  We  find  various  cases  of  anosmia 
reported  as  depending  upon  tobacco-poisoning  |  Parker),  malaria  (Raynaud  — 
when  the  anosmia  was  intermittent  and  cured  by  quinin  —  lead-poisoning 
(Grant),  irritant  substances,  such  as  ether  and  snuff  (Strieker),  and  astringent 
solution,  such  as  alum  (Wendt).  Exceedingly  foul  smells  (Althaus)  or  the 
prolonged  smelling  of  any  perfume,  as  in  the  case  of  the  flour-tester  mentioned 
by  Wagner,  may  blunt  the  sense  of  smell,  or  the  appreciation  only  of  the 
accustomed  odor.  Anosmia  may  arise  from  reflex  causes,  such  as  elongation 
of  the  uvula  (Lennox-Browne,  Mackenzie),  removal  of  the  ovaries  (Gotts- 
chalk),  cauterization  of  the  inferior  turbinal  bodies  (Luc).  Some  doubtful 
cases  are  on  record,  ascribed  to  gout  and  rheumatism  (Durrant.  Mackenzie). 
In  old  age  there  may  he  a  senile  abatement  of  the  acuteness  or  an  entire  loss 
of  smell. 

Notwithstanding  this  lone-  array  of  causes,  there  is  -till  another  and 
perhaps  a  larger  set  of  cases  in  which  the  most  painstaking  search  fails  to 
account  for  the  anosmia.  There  are  also  many  patients,  who  say  they  can 
smell  nothing,  in  whom  evidently  the  olfactory  sense  is  unaffected  or  only 
slightly  impaired. 

Anosmia  is  frequently  accompanied  by  loss  of  taste,  but  not  always. 
Macdonald  supposes  that  the  posterior  part  of  the  olfactory  tract  is  the  region 
which  governs  the  sense  of  taste.  The  essential  qualities  of  taste,  such  as 
bitter  and  sweet,  may  be  retained  in  anosmia,  but  the  more  delicate  aroma 
of  food  is  not  appreciated.  This  is  supposed  to  ascend  through  the  naso- 
pharynx to  the  olfactory  region  above  the  middle  turbinated  bone.  Zwaar- 
demaker  has  found  that  cocain  powder  mixed  with  starch  and  blown  into 
the  olfactory  region  will  produce  temporary  anosmia.  The  latter  author,  in 
1888,  devised  an  instrument  for  measuring  the  olfactive  powers  of  the  nose, 
and  called  it  an  olfactometer  (see  Fig.  554).  More  recently  '  he  has  published 
a  description  of  an  improved,  but  more  ('(implicated,  apparatus  for  the  pur- 
pose. He  recommends  the  use  of  valerianic  acid  in  a  solution  1  :100,000, 
and  various  other  unusual  substances,  among  which  he  prefers  vanillin  1  :  1000. 
For  ordinary  purposes  the  various  essential  oils,  ether,  vinegar,  wood-alco- 
hol, etc.,  in    bottle-,  may  be  used  to  ascertain   the  olfactive  i lition   of  the 

patient. 

The  prognosis  depends  to  a  large  extent  upon  the  lesion,  yet  Mackenzie 
make-  the  statement  that  alter  anosmia  ha-  existed  for  two  years  we  should 
holdout  to  the  patient  little  hope  of  the  restoration  of  the  sense  of  smell. 
The  principal  exception-  to  thi-  rule  are  found  in  the  respiratory  cases  of 
anosmia.  Thus  d'Aguanno  restored  the  -en-'  of  smell  in  a  case  of  anosmia 
from  nasal  polypi  which  had  existed  forty  year-;  and  White,2  in  two  cases, 
one  after  twenty  years  and  one  after  ten  years,  accomplished  a  cure.  Occa- 
sionally the  essentia]  cases  will  recover;  but,  as  a  rule,  it  will  be  Found  that 
no  treatment  i-  efficacious,  even  the  removal  of  the  primary  cause,  because 
structural    change    ha-   taken    place    in    the   olfactory  tract    itself. 

Treatment. —  Removal  of  the  cause  in  the  respiratory  cases,  the  adminis- 
tration of  quinin  and  strychnin  in  the  neurotic,  the  discovery  and  correction 
of  the  cause  in  the  reflex  cases,  are  the  indication-  for  treatment.     Some 

1  Archivf.  Laryngologie,  Bd.  iii..  Heft  ii-.  L895 

'  Burnett's  SysU  «<  ';/;  the  I  I        '  '        '■  *ol.  ii.  p  94. 


1142  NEUROSES  OF   I'll  I.    UPPER  AIR-PASSAGES. 

cases  have  recovered  after  the  application  of  galvanism  ;  and  Mackenzie 
claim-  to  have  given  relief  in  two  cases  by  the  insufflation  of 

K.  Strychnin,  gr.  £$-&  > 

Starch,  gr.  ij         — M. 

Hyperosmia  seems  common  enough  among  highly  neurotic  women  and 
men.  but  their  complaints  of  certain  odors'  would  seem  to  be  due  more  to  their 
mental  attitude  and  lack  of  self-control  than  to  a  really  hyperesthetic  state 
of  the  olfactory  tract.  It  i-  occasionally  noted  in  women  at  the  time  of 
menstruation.  It  differs  from  parosmia  in  being  an  exaggerated  appreciation 
of  one  or  more  odors  rather  than  a  perversion  of  them. 

Schmidt  refers  to  some  cases  of  morbid  hyperosmia;  while  Schech1 
speaks  of  a  boy  (James  Mitchell)  who,  in  the  absence  of  his  other  senses, 
was  able  to  recognize  objects  or  individuals  by  their  odor,  due  same  is  also 
related  of  Laura   Bridgman. 

Parosmia,  or  the  perversion  of  smell,  is  said  to  be  always  either  of 
cerebral  or  hysterical  origin.  It  is,  however,  not  uncommonly  a  more  or  less 
marked  symptom  of  a  bad  coryza.  This  was  especially  noted  during  the  late 
epidemic  of  the  grippe.  The  odor  of  putrid  flesh,  fish,  eggs,  the  smell  of 
cooking  meat,  urine,  petroleum,  musk,  burning  hair,  tar,  pitch,  phosphorus, 
garlic,  or  other  indescribable  and  disgusting  odors,  are  complained  of.  It  is 
rather  singular  that  in  none  of  these  cases  has  there  been  noted  the  occur- 
red  f  agreeable  olfactory  sensations.     Mackenzie  refers  to  cases  in  which 

the  symptom  was  due  to  carcinoma  of  the  frontal  lobe  of  the  brain,  a  glioma, 
gummata,  or  a  fungous  tumor  of  the  cribriform  plate.  Althaus2  relates  a 
case  in  which  parosmia  was  the  beginning  symptom  of  locomotor  ataxia. 
There  arc  many  instances  of  it  found  among  the  insane,  and  it  is  occasionally 
reported  in  tin-  aura  of  epilepsy.  It  is  especially  frequent  in  neurasthenia  ; 
and  in  women  during  pregnancy  and  at  the  menopause.  A  curious  report  by 
Sbreny  states  that,  in  a  patient  of  his,  cocainization  of  the  nasal  mucous 
membrane  repeatedly  produced   the  sensation  of  a   foul   smell. 

Prognosis. —  In  cases  of  cerebral  origin  the  prognosis  is  bad,  unless 
arising  from  a  syphilitic  lesion,  where  treatment  may  be  of  avail.  In  the 
insane  and  hysterical  it  depends  on  the  general  prognosis  in  the  case.  When 
dependent  on  local  causes,  as  coryza,  the  prognosis  is  good. 

Treatment  depend-  on  the  etiology.      Parosmia  is  a  symptom. 

The  sense  of  smell  has  a  more  or  less  direct  connection  with  the  emotional 
lifeofman.  [ts  connection  with  sexual  excitement  isacommon  phenomenon 
in  animal-.  In  the  human  race  young  women  make  use  of  artificial  scents 
not  only  for  their  own  gratification,  but  also  to  enhance  their  attractions  for 
the  other  sex.  Man  being  by  nature  the  aggressive  parte,  i-  less  addicted  to 
their  use. 

Goethe  tells  of  Schiller  keeping  rotting  apples  in  his  writing  desk,  be- 
cause in  their  atmosphere  hi-  poetic  conception-  flowed  more  freely  from  his 
pen.  In  some  individuals  certain  odor-,  or  even  the  thought  of  them,  pro- 
duce headache,  dizziness,  faintness,  or  give  rise  to  certain  conditions.  <  )n 
th<-  other  hand,  psychical  in  Hue  nee-  ma)  give  rise  to  the  subjective  perception 

of  odor-. 

■•  And  I  swear,  as  I  thoughl  of  her  there,  in  that  hour, 
And  et'  how,  after  all,  old  things  are  best, 
Thai  I  smell  the  smell  of  thai  jasmine  flower 
Which  -lie  used  to  w  ear  i  n  her  breast. 

1  K  M    idhohle,  i  tc.,  f.  279.  -  hoe.  ciL 


REFLEX   XEUliOSES  <>l     THE  .VOX/;.  1143 

It  smell  bo  faint,  and  it  -unit  bo  sweet, 

It  made  me  creep,  and  it  made  me  cold  ; 
Like  the  scenl  that  steals  from  the  crumbling  sheet, 

When  a  mummy  is  half  unrolled." 

Disturbances  of  Sensation. 

Anesthesia;  Hyperesthesia;  Paresthesia. — It  is  to  be  remem- 
bered that  a  small  part  of  the  anterior  portion  of  the  nasal  chambers  receives 
its  sensory  nerve-supply  from  the  nasal  branch  of  the  ophthalmic  division  of 
the  fifth  or  trigeminus  nerve,  and  that  the  rest  of  the  nose  is  supplied  by 
the  superior  maxillary  division,  and  the  tongue  and  mouth  by  the  inferior, 
with  it-  gustatory  branch  ;  and  that  these  three  divisions  unite  at  the  Gasser- 
ian  ganglion  within  the  cranial  cavity.  It  is  probable  that  in  many  cases  of 
cerebral  hemorrhage,  especially  those  in  which  there  i-  facial  anesthesia,  the 
nasal  mucous  membrane,  it'  examined,  would  be  found  anesthetic.  The  case 
mentioned  by  Althaus  is  the  only  one  on  record,  so  far  ;i>  I  know,  where 
there  was  a  peripheral  paralysis  of  the  fifth  nerve.  There  were  trophic 
changes  in  the  mucous  membrane  of  the  eye,  nose,  and  mouth  ;  but  the 
senses  of  smell  and  taste  remained  intact. 

Hyperesthesia  and  hyperalgesia  are  so  intimately  connected  with  local 
lesions  and  reflex  neuroses  that  they  will  be  considered  elsewhere. 

Paresthesia  of  the  nose  may  be  the  occasional  symptoms  of  cerebral  and 
nerve  lesions  ;  but  hysteria  here  plays  the  most  important  part  in  the  etiology. 
While  it  is  not  my  plan  to  dwell  long  upon  hysteria,  I  cannot  refrain  from 
giving  the  following  account  of  a  remarkable  case  which  many  American 
laryngologists  will  doubtless  remember,  as  she  has  consulted  a  very  large 
number  of  them. 

The  patient  was  a  nervous  woman  of  fifty,  with  a  good  family  history.  Fifteen 
years  before  she  had  received  a  blow  with  a  parasol  on  the  bridge  of  the  nose:  seven 
years  a«r>  she  began  to  complain  of  nasal  obstruction.  Six  year-  ago  the  menopause 
began.  She  has  the  appearance  of  a  healthy  woman,  but  she  says  that  she  suffers 
agony  from  frontal  headache,  pain  within  the  nose,  and  nasal  obstruction,  Several 
year-  ago  a  surgeon  removed  a  iarge  piece  from  the  nasal  septum.  From  time  to  time 
since  then  several  doctors,  at  her  entreaty,  have  removed  piece-.  (  hie  rhinologist 
opened  the  frontal  sinus  ami  found  it  healthy.  All  these  operations  had  given  her  only 
transient  relief.  She  had  other  neurotic  symptoms,  upon  which,  however,  she  did  not 
dwell.  While  giving  me  her  history  she  drew  from  her  pockel  a  bent-wire  probe  wound 
with  cotton,  and  passing  it  dexterously  into  her  nose,  said  she  could  feel  that  there  was 
still  something  there,  which  -he  begged  me  to  cut  out.  <  In  inspection  I  found  that  the 
whole  septum  from  the  columna  to  the  naso-pharynx  hail  Keen  removed,  with  the  except 
tion  of  a  small  ridge  or  blade  of  tissue  along  the  floor  of  the  nose.  The  middle  turbi- 
nals  met  in  the  middle  line,  so  that  if  there  was  any  septum  above  them  it  could  no1  he 
perceived.  She  assured  me  that  this  had  been  removed  piecemeal  by  differenl  doctors, 
and  placing  her  probe  upon  the  remaining  stump,  and  moving  it  back  and  forth,  she 
told  me  that  if  1  did  not  take  away  that  -lie  would  go  t"  some  one  \\  ho  would.  I  refused, 
and  advised  her  to  seek  an  alienist.     She  left  my  office  in  anger. 

Tin-  may  be  -aid  to  be  a  case  of  "obsession  "  rather  than  <d'  h\  steria. 

REFLEX  NEUROSES   OF   THE  NOSE. 

I  d<>  not  propose  i<>  enter  into  a  discussion  of  the  nature  of  a  reflex  neu- 
rosis further  than  to  say  that  we  commonly  understand  b)  ii  a  process  which 
consists  of  a  nervous  impulse  starting  al  the  peripheral  termination  oi  a  sen- 
sitive nerve,  carried  through  it  to  a  sympathetic  center,  and  from  there  car- 
ried back  to  it-  source  or  to  a  distanl  point,  where  it  manifests  itself  in  an 
excessive  or  disordered  vaso-motor,  sensory,  or  muscular  activity.    To  account 


1144  NEUROSES  OF  THE   UPPER  AIR-PASSAGES. 

for  this  disordered  activity,  we  may  suppose  that  the  terminal  nerve-filaments 
are  diseased  or  subjecl  to  undue  irritation  by  disease  of  their  environment  ; 
or  thai  there  i-  disease  of  the  nerve-trunks  or  their  ganglia  :  or  that  there  is 
neral  excitability  of  the  nervous  organization  of  the  individual.  Pathol- 
has  as  yel  shed  no  new  light  on  these  possible  sources  of  the  trouble; 
and  the  clinical  phenomena  are  so  illusive  that  they  have  furnished  only  a 
multitude  of  bewildering  hypotheses  and  theories.  Since  the  rise  of  special- 
ism in  medicine,  the  devotee  of  each  shrine  has  laid  at  the  feel  of  hi>  deity 
— the  nose,  the  uterus,  the  stomach,  the  male  urethra.  or  other  isolated  organs 
— as  large  a  number  of  reflex  neuroses  as  possible.  It  has  therefore  repeat- 
edly happened  that  the  same  nervous  phenomenon  appears  in  many  classifica- 
tions; and  the  result  has  been  bewildering  and,  to  the  candid  observer,  some- 
what ridiculous. 

Hay-fever,  of  late  years,  has  Ween  most  frequently  considered  as  belong- 
ing etiologically  to  the  nose.  Cases  of  epilepsy,  melancholia,  insomnia,  neu- 
rasthenia, migraine,  persistent  hiccough,  aprosexia,  sneezing,  and  many  other 
puzzling  affections  have  appeared  to  some  of  the  reporters  to  originate  in 

the  nose,  chiefly  because  they  have  observed  some  cas incident  with  nasal 

disease  and  abolished  by  treatment  of  it.  But  the  same  galaxy  of  phenom- 
ena has  also  been  ascribed  with  equal  right  to  other  organs.  Therefore  logic 
teaches  us  that  we  are  familiar  only  with  the  everchanging  factor,  and  not 
with  the  central  <>r  constant  one  which  we  presume  must  exist. 

Hay-Fever.  -John  X.  Mackenzie,1  in  a  historical  study  of  the  nasal 
reflexes,  has  shown  that  hay-fever  and  other  nasal  neuroses  had  been  observed 
clinically  from  the  earliest  ages,  hut  not  classified  in  accordance  with  present 
knowledge  and  theories.  At  the  beginning  of  this  century,  Ileberden  and 
< 'nihil  had  evidently  observed  the  affection;  hut  Bostock,2  in  1819,  was  the 
first  to  describe  it  intelligently.  Phoebus,  Weyman,  Beard,  Blackley,  Ged- 
dings,  and  others  have  made  valuable  contributions  to  the  subject  since  then; 
hut  they  devoted  themselves  to  it-  clinical  manifestations  and  its  etiolog- 
ical depend, nee  on  extraneous  influences  rather  than  upon  local  nasal  dis- 
ease. Daly,  in  1 SS 1 ,  was  the  first  to  draw  attention  to  the  fact  that  a  very 
large  number  of  these  patients  had  well-marked  intranasal  lesions.  In  this 
he  was  supported  in  this  country  by  Roe,3  Harrison  Allen,1  Sajous,5  and 
abroad  by  Hack,  Hertzog,  and  others.  These  gentlemen  were  disposed  to 
look  upon  the  general  neurotic  element  as  a  minor  factor  or  as  a  result  of  the 
local  lesion.  John  X.  Mackenzie,6  in  a  remarkable  series  of  articles,  while 
giving  local  lesions  their  due  consideration,  ha-  shown  that  the  fundamental 
<-au--  lie-  hack  of  these  in  the  abnormal  excitability  of  the  sympathetic  ner- 
vous  system.     Bishop7   ha-   lately  advanced   the  theory,   with  considerable 

force  of  arg ait,  that    hay-fever  is  due  to  the  hyperacidity  of  the  blood 

from  the  excess  of  uric  acid  ;  bu1  it  i-  t sarly  yet  to  judge  of  the  value  of 

this  suggestion. 

Hay-fever  is  a  term  usually  limited  to  manifestations  of  disturbance  in 
the  upper  air-passages,  which  begin  in  May  or  dune,  ami  are  then  sometimes 
called  "  Rose-cold"  or  "June  -old;  "or  it  may  begin  shortly  after  the  1st 
of  A.ugus1  and  last  until  the  advent  of  frost.  The  latter  form  is  the  one 
more  commonly  known  as  hay-fever,  hay-asthma,  rag-weed  fever,  autumnal 
catarrh,  etc. 

1       /  :  L887  Medico-Chirurg    /'  •     .  L819,  p.  L61;   1828,  p.   137. 

1  V.   )'    1/  M  i.   12,19,1883;   W  ay  3,  10,  1884;    Irana.  Am.  Laryng.  At i.,  1884 

'•/       S       Jan  ,1884.  Trans.  A  m.  I  ■       ■     l     «.,  1884. 

ipril,1884.  7  The  Medical  New,  Feb.  24,  L894. 


REFLEX  XE (' ROSES  OF   Til E  NOSE.  1145 

Symptoms. — Its  chief  characteristics  arc  those  of  a  severe  coryza  in  the 
early  stages,  which,  instead  of  terminating  in  the  third  or  resolving  stage 
after  ten  days  or  two  weeks,  is  indefinitely  prolonged  :  or  it  may  suddenly 
cease  on  an  abrupt  fall  of  temperature  or  the  removal  of  the  patienl  to 
another  locality,  [tchingofthe  eyes  and  nose,  alternating  nasal  obstruction, 
furious  and  long-continued  tits  of  sneezing,  lachrymation,  photophobia,  con- 
gestion of  the  conjunctivae,  frontal  headache,  more  or  less  complete  loss  of 
taste  and  smell,  an  annoying  cough,  prostration  and  slighl  fever  make  these 
patients  exceedingly  uncomfortable,  and  for  a  considerable  period  render 
them  unlit  for  any  continuous  occupation.  Damp  weather,  east  wind,  dust, 
and  the  proximity  of  blooming  vegetation  increase  the  intensity  of  the  symp- 
toms. All  degrees  of  severity  are  observed,  from  a  very  slight  "cold  in  the 
head"  to  an  illness  which,  for  a  part  of  the  time,  at  least,  may  confine  them 
to  bed.  The  first  of  the  periodical  attacks  is  slight,  and  the  severity  increases 
with  the  recurring  ones.  The  patients  suffer  much  more  in  the  morning 
hours  than  in  the  afternoon. 

Etiology. —  In  this  country  the  bloom  of  the  rag-weed — ambrosia  artemi- 
sisefolia — is  more  often  regarded  by  patients  as  the  exciting  cause  of  their 
attacks  than  any  other  plant ;  but  the  bloom  of  the  cereals,  dust,  bright  sun- 
shine, and  many  other  influences  are  used  to  explain  the  onset  of  the  disease. 
The  June  cold  or  rose-cold,  which  presents  the  same  clinical  picture,  but  is 
certainly  less  frequent  in  this  country  than  the  autumnal  form,  has  been  sup- 
posed to  be  due  to  the  pollen  of  the  early  flowers.  It  ir-  probable  that  all 
floating-  particles  of  matter  in  the  respired  air  have  their  effect  upon  the  nasal 
mucous  membranes  of  susceptible  individuals.  It  occurs  more  frequently  in 
the  so-called  temperate  climates,  being  unusual  in  very  warm  or  very  cold 
regions.  It  is  a  very  much  more  frequent  occurrence  in  America  and  Ki in- 
land than  in  other  countries.  Geddings,  combining  his  cases  with  those  "f 
Weyman,  says  that  it  i-  more  common  in  men  than  in  women,  in  the  propor- 
tion of  3  to  2.  He  gives  the  following  table  as  to  the  age  when  the  patients 
were  first  attacked  : 

Under  10 -1  cases. 

10-20 23      " 

20-30 38      " 

30-40 19      " 

40-50 16      " 

After  50 3      " 

In  many  cases  heredity  seems  to  play  an  important  part,  many  members 
of  the  same  family  suffering  from  it.  This  i-  especially  so  in  certain  families 
of  a  neurotic  type  or  distinguished  by  intellectual  superiority. 

The  attack  frequently  comes  on  with  great  regularity  as  to  the  time  of 
year.  Sometimes  the  patient  confidently  expect-  it  not  only  upon  a  certain 
day,  but  even  at  a  certain  time  of  day,  although  occasionally  the  attacks 
occur  at  any  time  of  the  year.  Bosworth  quotes  Beard's  statistics  and  his 
own,  from  which  it  appears  that  out  of  278  cases  beginning  from  May  1  to 
September  30,  186  cases  began  between  August  1<>  and  31  inclusive,  while 
the  other  cases  were  pretty  evenly  divided  a-  to  the  date  of  beginning.  The 
attack-  in  nunc  of  the  cases  run  a  shorter  course,  but  the  majority  suffer 
until  frost,  and  some  seem  never  to  be  entirely  free  from  the  trouble.  In 
Geddings's  table-  there  is  :i  marked  preponderance  among  brainworkers — 
physicians,  manufacturer-,  merchants,  clergymen,  and  lawyers  making  up 
much  more  than  half  of  the  cases.  It  occurs  much  more  frequently  among 
neurotic  people,  although  Roe  denies  this.     A  good  many  of  Geddings'a  i 


1146  NEUROSES   OF  THE  UPPER  AIR-PASSAGES. 

are  called  "  bilious."  Most  writers  agree  thai  the  exciting  extraneous  cause 
seems  most  frequently  to  be  the  pollen  of  plants,  since  much  the  larger 
number  of  cases  suffer  only  when  the  flowering  plants  shed  their  pollen,  < >r 
in  August  and  September,  when  the  later  grasses  are  in  bloom.  The  experi- 
ments of  Blackley  and  others  point  to  the  same  conclusion  ;  but  it  is  also 
certain  that  other  irritant-  in  the  respired  air  may  act  in  the  same  way,  since 
many  of  the  cases  suffer  at  irregular  intervals  throughout  the  year. 

Notwithstanding  many  differences  of  opinion  a-  to  the  relative  importance 
of  the  factors  in  the  etiology,  those  who  have  given  the  disease  the  most 
careful  study  agree  that   we  must  usually  take  into  account: 

1.  1 1\ -pei-excitability  of  the  sympathetic  nervous  system,  which  may  or 
may  not  manifest  itself  by  what  we  term  a  neurotic  temperament. 

2.  Some  local  change  in  the  nasal  mucous  membrane  or  its  underlying 
cartilaginous  and  bony  framework.  This  is  mosl  frequently  found  to  con- 
sisl  of  a  real  hyperplasia  or  a  vascular  dilatation  of  the  erectile  tissue  or  of 
an  edematous  (so-called  polypoid)  condition  of  the  stroma,  especially  in  the 
region  of  the  middle  turbinal.  Combined  with  this,  as  pointed  out  by 
J.  \.  Mackenzie,  we  are  able  to  find  more  or  less  localized  areas  of  hyper- 
esthesia in  the  posterior  part  of  the  nose.  Spurs  and  deviations  are  more 
rarely  a  prominent   local   feature. 

■'!.  Some  atmospheric  condition  (pollen,  dust)  which  obtains  principally 
either  in  the  spring  or  the  autumn. 

Now,  as  a  matter  of  fact,  we  not  infrequently  find  eases  in  whom  the 
neurosis  of  hay-fever  is  the  only  evidence  of  a  neurotic  temperament  (Roe). 
We  also  often  meet  with  cases  that  have  no  appreciable  nasal  lesion  when 
not  suffering  from  hay-fever  (Mackenzie).  Finally,  as  said  above,  many 
cases  have  the  same  manifestations  at  other  seasons  of  the  year  or  in  localities 
where  there  i-  pr< ssi 1 1 1 la  1  ily  neither  dust  nor  pollen.  The  writer  cannot  escape 
the  conviction  that,  in  very  many  instances,  but  of  course  not  in  all,  the  local 
disease  is  the  result,  rather  than  the  cause,  of  the  neurosis.  Excessive  and 
long-continued  vaso-motor  disturbances  lead  to  the  demonstrable  permanent 
.damage  of  the  fibro-muscular  walls  of  the  vessels  and  of  the  stroma  of 
the  erectile  tissue  of  the  nose.  Low-grade  inflammatory  fibrous  tissue  takes 
tlii-  place  of  the  elastic  fibers  of  the  normal  stroma.  It  also  encroaches 
upon,  displaces,  causes  absorption  of.  and  hinders  the  functional  action  of  the 
smooth  muscular  tissue  in  the  stroma  and  the  wall-  of  blood-vessels.  Not 
only  does  it  do  this,  but,  a-  a  consequence,  the  serous  fluid  thrown  out  from 
tin-  vessels  is  finally,  after  repeated  attacks,  not  absorbed,  but  remain-  a-  a 
permanent  edematous  infiltration  of  the  stroma;  and  the  cavernous  space- 
remain  permanently  dilated,  owing  to  paresis  of  their  walls,  even  after  the 
vaso-motor  storm  has  for  the  time  passed  away.  This  I  have  lately  been 
able  to  observe  in  ;i  young  man  who.  after  having  had  hay-fever  for  ten  years 
to  some  extent,  began  to  suffer  more  severely  ;  and  after  the  hay-fever  season 
had  passed  tin-  year,  hi-  nose  remained  more  or  less  occluded.  The  mucous 
membrane  of  the  whole  nose  was  pale  and  edematous,  in  addition  to  the 
engorgement  of  the  cavernous  tissue,  and  reacted  sluggishly  to  cocain.  By 
mean-  of  the  -nare.  pieces  were  removed  both  from  the  inferior  turbinal  and 
from  tin-  region  of  the  middle  turbinal.  Small  polyp-buds,  some  as  large 
a-  a  pea,  3ome  a-  -mall  a-  a  pin'-  head,  were  seen  in  proce--  of  budding  or 
protruding  from  the  surface.  Microscopically  there  was  ;i  difference  in  the 
specimens  of  tissue  from  the  two  regions.  There  were  a  large  number  of 
glands  in  the  tissue  from  the  inferior  turbinal-.  which,  except  for  their  dis- 
tention  with   serum,  did   not    look   materially  altered  from   the  normal;  but 


REFLEX  NEUROSES  OF  THE  NOSE. 


1147 


the  stroma-fibers  were  evidently  changing  in  character,  and  the  smooth 
muscle-fibers,  easily  made  out  in  the  erectile  regions  when  normal,  were  few 
and  hard  to  find.  In  the  middle  turbinal  region  the  structure  was  thai 
usually  found  in  the  ordinary  edematous  polypus,1  except  thai  possibly  the 
glands  were  not  so  much  degenerated  as  usual.  This  and  many  other  his- 
tological examination-  simply  tend  to  confirm  the  impression  J  have  long 
received  from  eases  clinically  observed. 

Prognosis. — Notwithstanding  this,  it  i-  undeniably  true  thai  treatment 
directed  to  the  local  lesion,  when  it  exists,  results  always  in  marked  ameliora- 
tion of  the  symptoms,  and  sometimes  in  a  permanent  cure.  The  cases  with 
extensive  nasal  disease  are  the  most  favorable  ones,  for  often  when  operated 
on  they  have  apparently  reached  a  stage  when  the  neurosis  is  on  a  decline. 
Relieved  of  the  peripheral  irritation,  perhaps  originally  brought  aboul  by 
the  neurosis,  nature  so  far  overcomes  the  other  etiological  factors  that 
the  symptoms  do  not  return  at  their  next  period,  it"  the  system  becomes 
still  further  strengthened  they  may  never  recur;  1  nit  after  a  few  years  many 
of  these  eases  relapse.  Another  curious  fact  about  these  cases  i-  that  a  >hock 
to  the  nervous  system,  unconnected  in  any  way  with  the  treatment,  may  give 
temporary  or  lasting  relief;  as  in  the  case  mentioned  by  Dr.  F.  I.  Knight, 
where  a  man,  long  a  sufferer,  broke  his  leg  and  the  attack-  ceased.  lie  had 
also  seen  a  case  relieved  by  the  mind  cure.  The  case  of  Dr.  .1.  X.  Mackenzie 
has  become  famous,  where  an  artificial  rose  produced  a  "rose-cold"  in  a 
sufferer  from  the  affection,  who,  when  disabused,  was  subsequently  able  to 
inhale  the  perfume  of  a  real  one. 

Treatment. — From  what  has  preceded,  the  indications  for  treatment 
seem  prettv  clear,  although  sometimes  difficult  to  follow  out.  A  careful 
inspection  of  the  air-passages  must  be  made,  if  possible,  when  the  trouble  is 
quiescent.  All  polypi,  hypertrophies,  spurs,  and  deviations  in  the  nose  musl 
receive  appropriate  treatment,  and  all  sensitive  spots  should  be  destroyed  by 
the  galvano-cautery.  This  should  be  done  only  by  an  experienced  operator, 
and  not  by  the  tyro  in  rhinology,  or  innocent  structure  may  lie  destroyed 
and  annoying  cicatrices  and  adhesions  be  left  behind. 

As  for  drugs,  tonics  of  strychnin,  quinin,  and  iron  are  indicated,  and 
may  be  administered  for  weeks  or  month-  before  the  usual  onsel  of  the 
symptoms.     Dr.  Mackenzie's  prescription  is  a   pill — 


K.  Zinci  phosphid., 
Quin.  sulph., 
Ext.  nucis  vom., 

Donovan's  solution, 


gr-  ,Y, ; 

gr.  ij  ; 

gr.  j,  before  meals,  and 

gtt.  iij-v,  after  meal-. 


These  patients  must  lead  an  out-door  life,  a-  free  from  mental  .-train  as 
possible.  Should  all  of  these  measures  be  found  inefficacious,  as  often 
happens,  there  is  oothing  left  for  the  patient  but  to  seek  refuge  in  stoic 
philosophy,  or  in  distant  localities,  where  experience  teaches  him  that  he  is 
free  from 'his  trouble.  This  may  be  in  the  White  Mountain-  of  New  Hamp- 
shire. "Of  the  various  places'  mentioned  within  this  territory,  Bethlehem 
and  Jefferson,  Whitefield,  White  Mountain  House,  Fabian's  Twin-Mountain 
Hoii-e.  Crawford  House,  Glen,  Grorham,  and  Mount  Washington  ma\  be 
regarded  as  entirely  exempt"  (Geddings). 

Frequently  immediate  and  entire  relief  i-  here  experienced,  and  there  is 

1  Wright,  -V  V.  M"l-  ■/"<"».,  Nov.  J,  L893.     See  p.  L076  in  thia  work. 


1148  NEUROSES  OF  THE   UPPER  AIR-PASSAGES. 

always  great  amelioration  of  the  oeurotic  phenomena.  The  lake  region  of 
Maine  Lake  Chautauqua  in  Western  New  York,  Put-in-Bay  on  Lake  Erie, 
Little  Traverse  Bay  in  Northern  Michigan,  Cresson  in  Pennsylvania,  many 
parts  of  Canada,  of  California,  and  of  Colorado  arc  free  from  the  disease, 
and  give  relict'  in  many  cases  of  hay-fever.  Indeed,  the  seashore,  the 
mountains — any  change  of  locality — will  relieve  some  patients ;  while  nearly 
all  arc  free  from  ii  during  an  ocean  voyage. 

Spasmodic  Asthma. — Very  shortly  after  the  influence  of  the  local 
nasal  lesion  was  recognized  and  exaggerated  in  the  etiology  of  hay-fever, 
interest  was  revived  in  a  like  causation  of  spasmodic  asthma.  To  Yoltolini 
i-  generally  accredited  the  distinction  of  having  in  L871  first  drawn  attention 
to  the  dependence  of  some  cases  of  asthma  upon  nasal  lesions,  having  cured 
a  case  by  removing  a  polypus  from  the  nose.  This  attracted  a  greal  deal  of 
attention,  and  many  paper-  were  contributed  to  medical  literature  in  con- 
firmation of  his  observations;  but  the  importance  of  nasal  and  pharyngeal 
disease  a-  an  etiological  factor  reached  its  climax  in  1886,  when  Bosworth 
stated  that  in  all  the  cases  of  asthma  which  he  had  seen  there  existed  an 
intranasal  lesion.  In  his  hook  published  in  1889  he  repeated  the  statement. 
Out  of  16  cases  of  asthma,  28  were  rwnA  and  12  improved  by  intranasal 
treatment,  while  only  one  was  unimproved.  He  asserts  that  hay-fever  or 
hay-asthma  and  perennial  or  bronchial  asthma  have  the  same  etiology — i.e., 
that  the  local  exciting  cause  is  always  in  the  nose.  He  therefore  calls  the 
first  vaso-motor  rhinitis  and  the  latter  vaso-motor  bronchitis,  lie  subse- 
quently reported  88  cases  of  asthma  with  intranasal  lesion,  of  which  \'2 
were  cured  (or  nearly  52  percent.),  '■>'■'>  improved,  and  '2  unimproved.  This 
corresponds  closely  with  the  reports  of  Schmiegelow  and  Heyman.  Bos- 
worth'- view  of  the  etiology  of  asthma  has  been  strongly  combated  by 
1).  Robinson,  Shurly,  [ngals,  -I.  X.  .Mackenzie,  and  others  in  the  discussions 
which  followed  the  reading  of  hi-  papers.  It  is  the  belief  of  the  writer 
that  Dr.  Bosworth  ha-  enunciated  the  proper  theory  in  drawing  close  analogy 
between  hay  fever  and  asthma  ;  hut  in  saying  that  a  local  nasal  lesion  always 
enter-  into  the  chain  of  causes,  he  seems  to  have  overshot  the  mark  in  each 
case.  While  thi'  writer'-  experience  is  much  less  extended  than  Dr.  Bos- 
worth's,  he  certainly  has  -ecu  cases  in  which  no  nasal  lesion  was  present,  and 
\\-w  cases  of  the  trouble  in  which  an  entire  and  permanent  cure  resulted  from 
intranasal  operations  on  existing  lesions.  A  rhinologist  cannot  from  his 
own  experience  alone  discuss  thi-  question  intelligently,  because  the  cases  of 
asthma  that  seek  him  are  those  especially  which  have  intranasal  symptoms. 
\\  e  see  thi-  exemplified  in  the  statement  of  Lublinski,  who  -aid  that  of  143 

-  of  asthma  with  nasal  and  pharyngeal  lesions  treated  by  operation,  27 
(less  than  '_'<>  per  cent.)  were  eiired  and  1  .">  improved.  Thi-  experience  was 
gained  in  a  general  medical  clinic  Heyman,  on  the  other  hand,  in  a  nose- 
and-throat  clinic,  saw  53  cases  and  cured  29  (more  than  50  per  cent.)  and 
improved  L4 ;  10  were  unimproved.  According  to  Schmiegelow,s  tables 
there  were  among  50  patient-.  '-\2  cured.  11  improved,  and  in  7  no  result. 
<  )nt  of  the  32  cases  reported  cured,  there  were  recurrences  in  17:  and  coin- 
cident with  the  return  of  the  asthmatic  attack-  there  was  a  recurrence  of  the 
nasal  lesion.  Schmiegelow  says  that  the  return  of  the  asthma  was  caused  by 
the  recurrence  of  the  nasal  lesion.  I  have  stated  my  reasons,  in  speaking 
of  hay-fever,  for  believing  thai  the  neurosis  is  frequently  the  initial  phenom- 
enon,and  the  polyp  or  hypertrophy  a  secondary  and  resultanl  lesion.  Schraie- 
stics  -how  that  hi-  material  was  made  up  of  517  cases  of  chronic 
rhinitis,  of  which  10  had  asthma  (8  per  cent.),  and  139  cases  of  nasal  polypi, 


REFLEX  NEUROSES  OF  THE  NOSE.  11  19 

of  which  31  had  asthma  (22  per  cent.).  These  proportions  certainly  seem 
very  high. 

Briigelman  distinguishes  5  kinds  of  asthma,  according  to  their  etiology  : 
I.  Nasal  asthma.  2.  Intoxication-asthma  (carbonic  oxid).  .*;.  Pharyngo- 
Iaryngeal  asthma.  4.  Bronchial  asthma.  5.  Neurasthenic  asthma.  Bollin- 
ger relates  a  case  in  which  asthma  apparently  was  caused  l>\  the  presence  of  a 
rhinolith  in  the  nasal  chambers,  and  ceased  after  the  expulsion  of  it.  Roquer 
y  Casadesus  reports  a  case  of  asthma  from  an  enlarged  lingual  tonsil  cured 
by  its  abscission.  Glasgow  relates  a  curious  instance  in  which  a  case  of  spas- 
modic asthma  was  cured  by  the  accidental  application  of  a  50  per  cent,  solu- 
tion of  carbolic  acid  to  the  larynx.  From -this  and  other  experiences  he 
believe-  that  the  larynx,  as  well  as  the  nose  and  other  organs,  may  be  the 
starting-point  of  the  reflex.  We  have  already  quoted  the  remark  of  Dr.  I". 
I.  Knight,  that  he  had  seen  a  case  of  hay-fever  cured  by  the  patient's  break- 
ing his  leg.  Cases  have  been  brought  forward  to  show  the  connection 
between  various  manifestations  of  neurosis  of  the  skin,  as  urticaria,  and 
circumscribed  edema  and  asthma. 

Treatment. — From  this  short  review  of  the  subject,  whatever  may  be 
the  reflex  path  from  the  nose  to  the  bronchioles,  whatever  may  be  the  pro- 
portion of  the  nasal  reflex  to  other  reflexes  in  the  causation  of  asthma,  it  is 
clear  that  when  lesions  do  exist  in  the  upper  air-passages,  they  should  be 
thoroughly  and  carefully  treated;  but  whether  such  lesions  exist  or  not,  the 
patient's  other  organs  should  be  examined  with  care.  Systemic  dyscrasia, 
lithemia,  gout,  rheumatism,  and  the  general  neurotic  tendencies  musl  all  be 
considered.  The  nose  is  only  one  wheel  with  many  cogs  in  a  complicated  and 
mysterious  mechanism. 

An  instance  of  the  coincidence  of  marked  naso-pharyngeal  adenoids  with  severe 
asthmatic  attacks  which  I  treated  several  years  ago,  has  taught  me  not  to  be  t •  »< •  sure  of 
the  dependence  of  asthma  on  the  nose  for  its  origin.  The  patient  was  a  young  woman 
of  considerable  personal  attractions,  but  with  a  most  disagreeable  "dead  voice."  She 
complained  of  violent  attacks  of  asthma,  somewhat  dependent  upon  the  climate  and 
environment,  and  of  constant  nasal  occlusion  not  dependent  on  either.  The  nose  waa 
narrow  and  the  naso-pharyngeal  vault  filled  with  a  mass  of  lymphoid  tissue.  I  was 
cautious  enough  to  make  a  guarded  prognosis  in  regard  to  the  asthma;  but  I  was  sure  in 
my  own  mind  that  I  would  cure  her  of  it.  I  removed  the  adenoids  perfectly  clean  from 
the  naso-pharynx,  and  incidentally  had  a  copious  secondary  hemorrhage.  She,  of 
course,  was  greatly  relieved  of  many  symptoms,  but  not  other  asthma;  for,  after  a 
somewhat  lengthyinterval,  it  returned.  I  saw  little  chance  of  benefitim:  the  nose,  and 
refused  further  nasal  treatment.  She  went  for  a  long  time  to  a  very  skilful  colleague, 
who  burned  and  cut  the  nasal  mucous  membrane.  This  was  five  years  ago.  Since 
then  she  has  been  married  and  has  had  a  child,  and  although  her  general  health  has 
been  fairly  good,  her  asthma  still  troubles  her  at  irregular  interval-.  A  gynecologist 
has  also  tried  his  skill  successfully  on  some  sensitive -pot.  hut  she  had  a  particularly 
bad  time  with  the  asthma  last  summer.     Her  nose  is  in  as  good  a  condition  as  possible. 

To  know  the  ultimate  result  of  these  nerve-shocking  operations,  one 
must  compare  the  conditions  of  a  long  time  before  with  those  of  a  long  time 
after  them. 

Paroxysmal  sneering  may  be  claimed  by  the  rhinologists  as  their 
reflex,  since  the  physiological  act  usually  receives  it-  impulse  from  the  nose. 
Sam  Weller,  it  will  be  remembered,  when  asked  by  the  footman  if  he  took 
snuff,  replied,  " Not  without  sneezing";  but  we  must  remember  that  bright 
sunshine,  through  the  eyes,  0r  erotic  emotion-,  through  the  genital  tract,  may, 
in  a  physiological  state,  -tart  the  reflex.  Lennox  Browne  reports  a  case  of 
paroxysmal  sneezing  during  pregnancy,  beginning  at  the  third  month  and 
lasting  till  term;  while  Herron   reports  a  case  from  eye-strain.     A  case  is 


1150  NEUROSES  OF  THE    UPPER  AIR-PASSAGES. 

reported  where  manipulation  tit'  a  diseased  eye,  preliminary  to  extirpation, 
caused  violent  sneezing  in  chloroform-anesthesia.  TRe  sneezing  was  only 
avoided   by  dropping  cocain   in  the  eye. 

Ringer  and  Morrell  have  gone  over  the  literature  of  the  subject  and 
reported  many  cases;  while  Crickniay,  Balfour-Graham,  Hurley,  William-, 
and  "F.  R.  C.  S./' in  a  series  of  shori  notices,  make  various  suggestions 
as  to  treatment. 

era]  year-  ago,  a  young  woman  applied  at  one  of  my  clinics  fur  relict'  from  pro- 
longed  and  frequently  recurring  attacks  of  sneezing.  The  middle  turbinal  on  the  left 
side  was  hypertrophied  and  pressed  against  the  septum,  and  there  was  a  large  spur 
which  occluded  the  nostril  on  the  right  side.  As  she  complained  of  irritation  in  the 
left  nostril,  and  palpation  of  the  middle  turbinal  with  the  probe  excited  severe  sneezing, 
the  mucous  membrane  with  some  <>t'  the  bony  structure  was  removed.  The  operation 
was  a  rather  severe  one.  She  returned  in  about  three  months,  saying  that  she  had  been 
entirely  free  of  tin'  trouble  until  the  hist  few  weeks,  when  it  had  begun  again  and  was 
becoming  as  had  as  ever.  The  spur  was  removed  by  trephine  and  saw  from  the  other 
side.  Both  nostrils  were  now  fairly  free.  The  cautery  was  also  used  to  reduce  the  vas- 
cularity of  the  inferior  turbinal  bodies.  Another  period  of  several  months  passed 
without  any  sneezing.  It  then  began  again  and  became  worse  than  ever.  She  said  that 
the  paroxysms  would  sometimes  last  for  an  hour,  and  she  would  be  so  exhausted  that 
she  would  have  to  take  to  her  bed.  She  was  apparently,  but  for  her  distressing  trouble, 
in  very  fair  general  health.  The  paroxysms  seemed  to  hear  some  relation  to  her  cata- 
menial  periods,  and  I  suggested  that  she  should  goto  the  gynecologist  for  an  examina- 
tion.     She  refused,  and  1  did  not  see  her  again. 

I  remember  a  hoy  playmate,  with  congenital  heart-trouble,  it  was  said,  who  would 
be  seized  with  uncontrollable  tits  of  sneezing  lasting  many  minutes.  This  would  excite 
our  hilarity  to  a  high  pitch.  When  his  tit  had  left  him  he  would  join  in  the  fun,  and 
his  paroxysm  of  laughing  would  also  he  prolonged  and  apparently  uncontrollable. 
Another  peculiarity  about  him  was  his  liability  to  drop  suddenly  to  sleep,  even  while 
standing.  His  mental  capabilities  were  not  limited,  although  rather  below  the  average. 
Twenty  years  afterward  1  heard  of  him  as  alive  and  well  ;  hut  I  do  not  know  whether 
hi-  reflexes  are  still  as  active. 

Cough  lias  been  repeatedly  found  dependent  upon  intranasal  disease 
alone;  although  the  usual  extrapulmonary  sites  of  the  reflex  (seepage  701)) 
are  in  the  pharynx  and  larynx,  set  up  by  the  various  lesions  of  these  regions. 

Glycosuria.  —  Bayer1  relates  the  history  of  a  ease  in  which  nasal  ob- 
struction and  post-nasal  catarrh  were  accompanied  by  glycosuria,  which  dis- 
appeared un  the  relief  of  the  intranasal  condition. 

Two  years  ago  I  operated  on  a  hoy  of  fifteen  for  an  adhesion  of  the  inferior  turbinal 
to  the  bony  septum  throughout  its  entire  length.  The  operations  occupied  three  or  four 
different  Bittings,  with  intervals  of  a  week  or  ten  days,  lie  was  previously  in  good  health, 
except  for  the  distre-s  ,,f  nasal  obstruction,  which  was  increased  hv  the  presence  of  post- 

I  adenoid-.  Large  pieces  of  hone  and  mucous  membrane  and  the  lymphoid  tissue 
from  tie-  na-o  pharynx  were  removed.  The  hoy  bore  the  operations  wit h'grcat  fortitude, 
and  they  were  successfully  and  satisfactorily  performed.  For  a  month  or  six  weeks  he 
had  to  wear  a  gutta-percha  plate  in  his  nose  to  keep  the  hare  bony  surfaces  apart. 
Bi  fore  all  the  lymphoid  tissue  was  removed  from  the  pharynx  he  began  to  be  languid 
and  pale,  and  complained  of  frequent  urination.  Examination  of  the  urine  by  his 
family  physician,  a   distinguished  and  skilful   man.  revealed   the  presence  of  a  small 

amount  of  3Ugar  and  that  he  wa-  passing  large  amount-  of  urine  daily.  Local  treat- 
ment was  suspended,  and  \t<-  wa-  pul  on  tonics  and  sent  to  the  country.     After  two  or 

three  week,    the  SUgar   h  a<  I  d  i  -a  i  >pea  r.  si  I  ;    and    after  two  or  three  months   the  urine  came 

hack  to  it-  normal  amount  and  his  general  health  was  restored.  I  believe  that  here  wc 
had  a  glycosuria  due  to   nervous  depression  from  the  -hock- of  repeated  operations, 

which,  while    not  very  painful,  were    trying   to    the    general    nervous   system. 

Salivation  i-  referred  to  by  Bosworth  as  having  been  cured  by  intra- 
nasal treatment  in  two  cases  of  elderly  people.  The  li-t  of  neuroses  occa- 
sionally ascribed  t<>  lesions  of  the  nasal  cavities  includes  esophageal  spasm, 

1  /.'■<       I    I  <  yng        ■ .  No.  19,  <  >ct.  1,  1894. 


ShWSORY  XKUROSES  OF  THE  PHARYNX.  1  1 :,  I 

hiccough,1  spasmodic  croup,  aphonia,  asthenopia,  strabismus,  blepharospasm,* 
migraine,  chorea,  epilepsy,  vertigo,  aprosexia,  dyspepsia,  exophthalmic  goiter, 
acne,  erythema  of  the  skin,  neurasthenia,  and  melancholia.  This  by  no 
means  exhausts  the  array  of  distant   ills  charged   to  the  nose. 

If  the  nose  is  such  a  fertile  organ  in  the  production  of  the  misfortunes 
of  its  brother  organs,  it  also  has  to  bear  troubles  which  are  transmitted  to  it 
from  the  gastro-intestinal  and  the  genito-urinary  tract-,  causing  vaso-motor 
disturbances,  post-nasal  catarrh,  epistaxis,  and  sneezing. 

SENSORY  NEUROSES  OF  THE  PHARYNX. 

Anesthesia  of  the  pharynx  is  occasionally  observed  in  cerebral  apo- 
plexy, tumors,  gummata,  scleroses,  general  paralysis  of  the  insane,  etc.,  and 
in  similar  bulbar  lesions.  It  is  also  present  in  a  marked  degree  in  extreme 
debility  from  anemia,  phthisis,  chorea,  etc.,  and  after  epileptic  convulsions. 
Certain  drugs  (chloral,  bromids,  cocain)  produce  it.  Schmidt  has  noted 
unilateral  anesthesia  of  the  pharynx  and  larynx  combined  with  anesthesia 
of  the  skin  in  a  case  after  exposure  to  severe  cold.  McBride  speaks  of 
cases  of  carcinoma  of  the  base  of  the  skull  in  which  there  was  hemi- 
anesthesia of  the  pharynx  and  larynx.  Schech  speaks  of  its  occurring  after 
influenza,  and  he  refers  to  a  report  by  Jurasz  of  its  occurring  after  pneu- 
monia. All  these,  however,  are  the  exceptional  causes  of  pharyngeal  anes- 
thesia. It  usually  presents  itself  as  a  sequel  of  diphtheria  or  as  one  of  the 
manifestations  of  hysteria. 

Besides  these  abnormal  instances  of  the  occurrence  of  anesthesia,  we  have 
a  widely  varying  degree  of  sensitiveness  of  the  pharynx  in  healthy  individ- 
uals. Some  patients  bear  surprising  manipulations  in  their  throats  without 
evidence  of  pain  or  discomfort,  although  these  great  differences  depend  prob- 
ably more  upon  differences  in  reflex  excitability  than  in  the  real  susceptibility 
to  tactile  or  painful  impressions.  Women,  as  a  rule,  have  more  tolerant  if 
not  more  anesthetic  throats  than  men  ;  and  it  has  certainly  been  impressed 
upon  me  that  neurotic  people,  those  of  nervous  temperament,  when  once  their 
first  timidity  is  allayed,  are  more  tolerant  than  others  of  the  use  of  the 
laryngoscope. 

Hyperesthesia  is  more  common  in  men.  They  not  only  bear  pain  less 
stoically,  but  they  evidently  feel  it  much  more  than  women.  Fat  persons  of 
both  sexes,  but  especially  men,  have  more  sensitive  throats.  Drinkers, 
especially  of  malt  liquors,  even  when  not  excessive  in  their  libation-,  are 
difficult  subjects  to  examine  or  to  operate  on.  The  naso-pharynx  is  much 
more  sensitive  than  the  lower  pharynx.  Hyperesthesia  is  rarely  a  symptom 
of  central  lesions,  but  always  accompanies  local  inflammations,  such  as 
pharyngitis  or  tonsillitis.  The  tongue  is  frequently  hyperesthetic  in  spots. 
Careful  inspection,  if  necessary  with  a  magnifying  glass,  will  usually  disclose 
a  swollen  papilla.  This  will  frequently  give  rise  to  great  apprehension  on 
the   part   of  the    patient    that   lie   has  a   beginning  malignanl    growth. 

All  these  hyperesthetic,  as  well  as  paresthetic,  symptoms  are  observed  in 

1  ibramson,  Journ.  of  Laryng.,  1890,  p.  216,  reports  two  cases  of  hiccough,  apparently 
dependent  upon  granular  pharyngitis.  These  are  the  only  cases  that  I  can  find  in  literature  in 
which  the  origin  of  the  reflex  seemed  to  !»■  in  the  respirator}  tract,  [ndeed,  the  oro-pharyni 
may  !>••  considered  as  lieIonLrinLr  t<>  both  the  respiratory  .■mil  tin-  digestive  tracts.  Hiccough  in 
severe  forms  is  usually  sii|>i»>si-i|  to  originate  in  the  latter  Benedict,  Atlanta  .!/»./.  Weekly, 
Mar.  •".   L895). 

I  or  tin-  literature  of  ocular  reflexes,  see  the  full  bibliography  given  by  White  I  Burnetii 
System,  etc.,  vol.  ii.  p.  129). 


1152  NEUROSES  OF  THE  UPPER  AIR-PASSAGES. 

ill.-  habitual  |KTi:-> ire  »t'  newspaper  advertisements  of  quack  nostrums  and 
the  execrable  Lucubrations  of  the  imaginative  reporters  of  the  public  press. 

Paresthesia. —  While  the  hyperesthesia  and  anesthesia  of  the  pharynx 
are,  as  a  rule  of  little  clinical  interest,  paresthesia  are  not  only  of  exceed- 
ingly common  occurrence,  but  very  frequently  baffle  the  skill  of  the  diag- 
nostician and  disappoint  the  hopes  of  the  operator.  They  are  frequently 
due  to  tonsillar  disease  (not  necessarily  hypertrophy),  to  abrasions  from  the 
ti.od  or  the  foreign  bodies  in  it,  which  leave  no  visible  mark  of  injury  to  the 
mucous  membrane  as  they  pass  over  it  ;  but  they  are,  above  all,  more  fre- 
quently observed  at  the  time  of  the  menopause  in  women,  and  in  those  who 
have  slighl  or  marked  hyperplasia  of  the  so-called  lingual  tonsil.  Now  it 
IS  an  undeniable  fact  that  many  persons  have  a  large  amount  of  lymphoid 
material  at  the  base  of  the  tongue  which  rubs  against  the  epiglottis  and  the 
side  of  the  pharynx,  who  present  uo  clinical  manifestation  of  the  condition  ; 
perhaps  the  larger  number  give  no  symptoms.  We  must  therefore  admit 
other  and  more  important  factor-.  These  are  supplied  by  the  hyperexcita- 
bility  of  the  sympathetic  nervous  system.  An  elongated  uvula  is  a  common 
cause  of  abnormal  pharyngeal  sensations,  and  its  abscission  affords  the  most 
satisfactory  result-  of  any  operative  treatment    for  the  affection. 

Granular  pharyngitis  of  the  posterior  wall,  so  far  as  my  observation 
goes,  never  by  it-ell"  gives  rise  to  any  symptoms.  It  is,  however,  an  irreg- 
ular lymphoid  hypertrophy  of  the  mucous  membrane,  and  when  this  extend- 
to  the  lateral  walls  and  invades  the  movable  posterior  pillars  of  the  fauces 
it  produces  an  attrition  of  surfaces,  which  frequently  gives  rise  to  the  most 
marked  of  the  symptoms  under  consideration.  The  "  globus  hystericus,"  the 
feeling  of  a  hard,  round  bodymoving  in  the  throat  ami  an  irresistible  inclina- 
tion, vet  an  inability,  to  swallow,  is  not  infrequently  seen  at  the  menopause  or 
in  voung  women.  I  have  seen  it  once  in  a  young  man.  It  is  not  necessarily 
an  indication  of  hysteria.  A  feeling  of  eold  or  a  burning  heat  is  sometimes 
experienced  by  the  patients  :  a  feeling  of  a  foreign  body,  a  hair  or  a  bone,  a 
tickling  <»r  itching  sensation  i-,  however,  the  usual  complaint.  Occasionally 
tin-  i-  so  marked  as  to  induce  distressing  cough  and  esophageal  or  laryngeal 
spasm.  This  is  also  to  be  sharply  distinguished  from  hysterical  manifesta- 
tions. It  is  seen  in  neurotic  states  which  nowadays  we  like  to  call  neuras- 
thenia. Rheumatic  and  gouty  diatheses,  and  especially  dyspepsia,  are  fertile 
sources  of  these  neuroses.  They  may  be  due  to  nasal  obstruction,  and  may 
accompany  and  aggravate  cough  from   laryngeal  or  pulmonary  disease. 

Treatment. — Careful  search  must  be  made  for  local  causes,  and  when 
found  they  must  be  removed.  The  crypts  of  the  faucial  tonsils  must  be 
destroyed  bv  the  gal vano-eauterv.  If  large  enough  to  cause  attrition  of  sur- 
face-, the  lingual  tonsil  must  be  reduced  in  size  by  the  guillotine  or  cautery. 
I  must  confess  to  many  disappointments  in  this  treatment  of  the  trouble. 
Applications  to  the  base  of  the  tongue  of  nitrate  of  silver — gr.  x  :  3j — has 
been  perhaps  the  m<»-t  successful.  This  should  be  done  twice  or  thrice  a 
week.     An  astringent   gargk — 


Jfy.  Tr.  kino, 

Tr.  catechu, 

( ilye.  tannin, 

ad  5j ; 

<  )l.  gaultheriae, 

5J" 

used  with    cold  water,  and    half  -wallow  <d   and  brought  up  with  a  gulp,  so  as 

to  give  the  throat  a  course  of  gymnastics,  will  often  benefit  these  patients. 


MOTOR  NEUROSES  OF  Till:  PHARYNX,  L153 

This  is  a  method  of  gargling  urged  by  Swain,  following  v.  Troltsch,  and  is 
really  the  only  efficacious  way.  Hygienic  and  tonic  treatment  are  indicated 
in  the  neurotic  cases.  Uvulotomy  should  always  be  performed  when  ii  is 
seen  thai  the  tip  of  the  uvula  rests,  when  relaxed,  upon  the  epiglottis1  or 
base  of  the  tongue.  Frequently  its  tip.  formed  exclusively  of  the  mucous 
membrane,  will  he  folded  or  curled  up,  at  the  time  of  the  examination,  in 
such  a  way  that  the  use  of  a  probe  will  alone  disclose  the  condition.  Lateral 
pharyngitis  must  he  treated  by  cauterizing  or  cutting  nil'  irregularities  of  the 
surface.  Usually,  however,  the  mucous  membrane  in  this  situation  is  dif- 
fusely and  uniformly  infiltrated.  The  treatment  of  diseased  faucial  tonsils 
below,  and  of  the  pharyngeal  tonsil  or  nasal  obstruction  above,  will  fre- 
quently cause  this  lateral  pharyngeal  infiltration  or  congestion  to  subside. 
Sometimes,  however,  it  persists.  Linear  superficial  cauterizations  ma)  be 
of  benefit;  hut  they  always  cause  great  dysphagia,  and  should  be  resorted  to 
only  after  other  treatment  has  been  tried  unsuccessfully.  In  middle-aged 
women  it  is  well  to  explain  to  them  the  dependence  of  their  symptoms  upon 
the  menopause,  and  tell  them  frankly  not  to  expect  much  relief  from  local 
measures  or  medicines,  but  from  time.  Many  will  he  satisfied,  hut  some  will 
seek  advice  elsewhere.  A  vigorous  local  treatment  in  these  cases  always 
results  in  disappointment  to  the  patient  and  ultimate  loss  of  prestige  to  the 
doctor.  The  patients  are  frequently  importunate  in  their  demands  and 
obstinate  in  their  belief  of  some  pathological  condition  which  exist>  only  in 
their  imagination. 

Neuralgia  of  the  pharynx  is  a  Greek  term  for  a  pain  in  the  throat  for 
which  the  observer  can  find  no  visible  or  tangible  explanation.  It  i-  some- 
times called  myalgia.  J  have  frequently  had  patients  complain  of  great 
dysphagia  and  give  every  evidence  of  suffering,  in  whom  I  could  discover 
no  pharyngeal  lesion.  These  cases  are  seen  more  frequently  in  cold  weather, 
when  throat  inflammations  are  rife.  I  am  under  the  impression  that  in  some 
of  these  cases  at  least  we  have  a  condition  analogous  to  what  is  known  as 
muscular  rheumatism.  Although  there  is  constant  pain,  there  is  usually 
little  tenderness  to  pressure  unless  it  excites  muscular  contractions. 

A  saline  purge  and  a  gargle  of  bicarbonate  of  soda,  one  dram  to  a  half 
ounce,  in  a  glass  of  hot  water,  often  gives  some  relief.  The  trouble  usually 
passes  off  of  itself  in  a  few  days.  It  is  sometimes  ascribed  to  a  gout)  or 
rheumatic  diathesis.  Morel!  Mackenzie  refers  to  more  chronic  cases  occur- 
ring in  young  women.  Some  of  them  suffered  from  anemia  or  chlorosis; 
hut  many  were  healthy  and  usually  not  hysterical.  He  recommend-  the 
local  application  of  the  tincture  of  aconite  twice  or  thrice  daily.  Massei 
recommends  the  galvanic  current. 

MOTOR  NEUROSES  OF  THE  PHARYNX. 

Spasm. — Tetanus, hydrophobia, tabes  dorsalis,and  hysteria  are  the  usual 

causes  of  this  rare  affection.  It  i-  said  to  he  occasionally  -ecu  in  acute  and 
chronic  inflammations.  Lennox  Browne,  in  hi-  paper- on  pharyngeal  tenes- 
mus in  1891,  seems  to  refer  to  cases  which  we  arc  accustomed  to  include 
among  the  paresthesia;,  giving  prominence  a- a  cause  to  the  lingual  varices, 
about  which  we  have  read  so  much  in  English  journals  recently.  Spasm  of 
the  pharynx  has  been  reported  by  Bewley  in  a  case  of  lesion  of  the  fourth 
cerebral   ventricle,  in    which   there   was  apparently  also  a  paralysis  of  thi' 

1  The  uvula  should  not  touch  the  laryngeal  Burface  of  the  epiglottis  of  Fig.  53  I 

2  Archives  de  Laryngologie,  Feb.,  1891. 

73 


1154  NEUROSES  OF  Till:   UPPER  AIR-PASSAGES. 

esophagus.  Seifert  speaks  of  having  seen  clonic  >|kisih  of  the  soft  palate 
with  subjective  tinnitus  aurium  in  a  case  of  hypertrophic  rhinitis;  while  the 
same  symptom  was  observed  by  Spencer  in  a  case  of  cerebral  tumor. 

Pharyngeal  Paralysis. — Diphtheria  causes  the  majority  of  the  paraly- 
f  the  palate  and  pharynx  ;  but  it  is  occasionally  -ecu  as  a  resull  of  a 
simple  acute  inflammation,  as  mentioned  by  Jurasz,  who  also  speaks  of  three 
cases  in  which  the  cause  was  unknown,  one  in  which  it  was  due  to  a  bulbar 
paralysis,  and  one  in  which  it  followed  cervical  glandular  swelling.  I  have 
seen  one  case1  in  which  it  was  due  to  a  syphilitic  lesion,  evidently  of  the 
floor  of  the  fourth  cerebral  ventricle.  It  was  unilateral  and  accompanied  by 
lingual  paralysis  and  atrophy  and  posticus  laryngeal  paralysis.  J  have  also 
seen  it  in  a  fatal  case  of  peripheral  neuritis  a-  the  initial  symptom  of  the 
involvement    of   the   muscles  of  deglutition   and   respiration. 

Besides  the  case  of  Jurasz,  cases  are  referred  to  by  Morel!  Mackenzie 
and  others,  which  were  reported  before  we  depended  upon  bacteriology  for 
our  diagnosis,  in  which  it  was  supposed  to  he  caused  by  simple  hut  severe 
angina.  Bourges  lately  reported  it  altera  case  of  membranous  pharyngitis, 
in  which  bacteriological  examination  had  not  revealed  the  diphtheria-bacillus, 
and  refers  to  it-  occasional  occurrence  after  other  diseases  (typhus  and  pneu- 
monia). He  says  it  may  he  produced  in  animals  by  injection  of  strepto- 
coccous  and  pneumococcous  toxins.  1  have  also  seen  a  ease  in  which  it  was 
.-aid  the  bacillus  of  Loffler  could  not  be  found.  However,  a  negative  bac- 
teriological report  is  seldom  conclusive.  The  symptoms  are  those  of  nasal 
speech  and  the  regurgitation  of  food  into  the  naso-pharynx.  An  examination 
shows  the  palate  and  pillars  of  the  fauces  relaxed  and  unable  to  respond  to 
tickling  witli  a  probe.  Mucosities  may  cover  the  posterior  "wall  of  the 
pharynx  and  cause  the  patient  great  annoyance.  The  prognosis  is  had  when 
due  to  central  lesions,  except  in  recent  cases  due  to  syphilis,  when  the  vigor- 
ous administration  of  the  iodid  of  potash  may  restore  power  to  the  muscles. 
Cases  of  peripheral  pharyngeal  paralysis  nearly  always  get  well  of  them- 
selves. Strychnin  and  galvanism  are  the  therapeutic  measures  employed; 
hut  I  am  not  sure  that  they  hasten  matter-  at  all,  except  that  strychnin  is 
an  efficienl  tonic. 

For  a  full  account  of  the  neuroses  of  the  soft  palate  Rethi's  excellent 
work  -'  may  be  referred  to. 

NEUROSES   OF  THE  LARYNX. 

Sensory  Neuroses. — Anesthesia  of  the  larynx  arises  from  the  same 
causes  a-  anesthesia  of  the  pharynx,  and  is  usually  accompanied  by  it. 
Schnitzler  -peak-  of  it   as  occurring  especially   in  anemia  of  the  larynx. 

Hyperesthesia,  as  in  the  pharynx,  i-  usually  present  in  the  various  forms 
of  acute  and  chronic  inflammation. 

Paresthesia  manifests  it-elf  usually  by  a  tickling  sensation,  a  feeling  of 
a  hair  or  other  foreign  substance  in  the  larynx.  It  is  commonly  due  to  some 
abnormality  of  the  laryngeal  mucous  membrane;  hut  very  frequently  sensa- 
tions are  referred  to  the  larynx  by  the  patient,  which  have  their  origin  in 
some  slighl  lesion  of  the  pharynx  (Jurasz).  All  these  sensor)  neuroses  of 
the  larynx  are  observed   in   hysteria. 

Neuralgia  of  the  larynx  ha-  been  reported  by  Chapman   in   four  cases 

due    to    malaria,    and    cured    by    anti-malarial    treatment;     hut     from    his 

1  .v   y.   1/../  Joum.,  Sept.  28    I 

-  Motilitdi  ■  'A--  weiclien  Qaumens,  eim  klinisdu  Studie,  Vienna,  1S93. 


.\7-.7  7.'o>/>   OF  THE  LARYNX.  1155 

account  of  the  eases  the  diagnosis  seems  to  be  a  little  uncertain.  It  i-  said 
also  to  be  due  occasionally  to  goul  or  rheumatism  ;  but  we  may  safely  con- 
jecture that  in  such  case-  it  is  really  due  to  some  slighl  involvement  of  the 
crico-arytenoid joint.  One  such  case  I  have  seen,  when  in  a  normal-appear- 
ing larynx  pain  was  produced  by  pressure  on  the  cricoid  cartilage.  In  this 
case  the  exhibition  of  salol  for  a  few  days  gave  entire  relief.  Bosworth 
report-  a  case  of  his  own  in  which,  in  a  neurotic  patient,  severe  pain  in  the 
larynx  was  due  to  an  acute  uaso-pharyngitis.  He  refers  t"  a  report  by 
Schnitzler  of  excruciating  pain  of  the  larynx  and  pharynx  following  an 
angina.  Bosworth's  case  was  cured  by  aconitin,  gr.  J,,,,  and  Schnitzler's  by 
local  application-  of  chloroform  and  morphin. 

Motor  neuroses  of  the  larynx  are  to  he  divided  into  spasm  (hyper- 
kinesis),  paralysis  (hypokinesis),  and  incoordination  of  the  laryngeal  muscles. 
Space  does  not  allow  here  of  a  consideration  of  the  anatomical  action  ami 
physiological  function  of  the  laryngeal  muscles,  nor  of  their  innervation,  nor, 
indeed,  of  a  full  review  of  the  somewhat  acrimonious  discussion  of  the  patho- 
genesis of  the  various  motor  neuroses,  which  for  several  years  produced  such 
a  voluminous  literature  of  the  subject. 

Spasm  may  affect  any  of  the  laryngeal  muscles,  and  cases  are  occasion- 
ally reported  in  which  there  was  spasmodic  contraction  of  the  abductors 
alone;  hut  it  is  probable  that  this  is  always  accompanied  by,  if  not  always 
the  result  of,  paralysis  of  the  adductors  of  the  larynx. 

Spasm  of  the  adductors  is  sometimes  divided  into  phonatory,  deglutitory, 
and  respiratory.  Phonatory  spasm  is  a  rare  affection  in  which  the  spasm  of 
the  adductors  comes  on  only  with  attempts  at  phonation,  preventing  it.  hut 
not  materially  interfering  with  respiration.  Deglutitory  spasm  of  the  laryn- 
geal adductors  is  that  form  which  supervenes  whenever  attempt-  are  made  to 
swallow,  sometimes  only  fluid,  sometimes  only  solid  food,  while  in  other  cases 
the  spa-m  is  produced  by  any  attempt  at  swallowing. 

Usually  by  spasm  of  the  larynx  is  understood  the  contraction  of  the 
adductors,  producing  a  closure  of  the  glottis  which  interferes  more  or  less 
seriously  with  respiration.  The  most  important  and  the  most  frequent  "f 
these  cases  present  the  well-known  phenomena  of  spasmodic  croup  in 
children. 

Laryngismus  stridulus  occurs  most  frequently  in  poorly  nourished,  if  not 
always  rachitic,  children.  The  percentage  of  cases  in  which  rachitis  is  an 
etiological  factor  is  variously  estimated  by  different  author-  from  50  to  90 
per  cent.  Various  theories  have  been  advanced  to  account  for  the  connection 
between  the  affections.  Pressure  on  the  medulla  from  softening  of  the 
cranial  hone-,  or  the  presence  of  enlarged  bronchial  glands  pressing  upon  or 
irritating  the  vagus  or  recurrent  nerve,  do  not  satisfactorily  account  tor  it. 
Heredity  seems  to  have  some  influence.  It  i-.  however,  not  infrequently 
observed  in  apparently  perfectly  healthy  children  a-  the  result  of  catching 
cold  or  disturbances  of  the  stomach  and  bowels.  Enlarged  naso-pharyngeal 
and  faucial  tonsils  occasionally  seem  to  he  the  sole  cause  of  attacks  which 
differ  in  no  way,  except  in  severity,  from  those  -ecu  in  rachitic  children,  and 
removal  of  the  tonsils  promptly  relieve-  the  symptoms.  Occurring  most 
frequently  in  male  children  from  six  months  to  three  years  of  age,  it  is  also 
-en  both  before  and  after  this  period.  It  usually  occurs  in  the  winter 
months,  and  the  attack-  come  on   more  frequently  at    night. 

Symptoms. — The  little  patient  suddenly  starts  up  from  hi-  sleep,  gasping 
for  breath,  the  face  becomes  livid,  for  many  seconds  respiration  stops,  and  the 
child  may  become  unconscious  and  death  may  at  once  ensue  :  hut  usually  the 


LI 56  ZV E UJRt )S ES  OF  Til  E   UPP E R  AIR-PA  ss.  I  ( ; ES. 

respiration  begins  again  in  gasps  and  gradually  becomes  normal.  Cold  sweat 
stands  out  on  the  face  and  the  heart's  action  is  much  reduced.  The  whole 
attack  may  be  over  in  a  few  minutes,  or  it  may  be  prolonged  and  repeated 
several  times  in  one  night  ;  and  there  is  usually  recurrence  for  several  nights 
in  succession. 

Treatment. — The  physician  rarely  gets  to  the  patient  in  time  to  apply  rem- 
edies, and  the  parents  or  attendants  are  usually  too  frightened  to  follow  any 
directions  that  may  have  been  given.  Tne  application  of  cloths  wrung  out 
of  very  hot  water,  or  out  of  ice-water,  to  the  anterior  cervical  region  may 
shock  the  laryngeal  muscles  into  good  behavior  for  a  time.  A  hypodermic 
injection  of  morphin,  or  the  injection  of  a  few  drops  of  chloroform  into  the 
rectum,  may  cut  short  the  attack.  If  possible,  an  efficient  emetic  may  he 
given,  as  the  yellow  sulphate  of  mercury.  The  prophylactic  treatment  is 
proper  hygiene,  the  administration  of  cod-liver  oil,  and  the  removal  of 
lymphoid  hypertrophies  from  the  lances  and  naso-pharynx. 

Bosworth  sharply  differentiates  the  cases  occurring  in  rachitic  children 
from  other-.  The  death-rate  is  high  among  the  former  and  low  in  the  latter 
cases.  He  claims  that  in  the  latter  cases  we  have  a  glottic  or  sub-glottic 
inflammation  of  the  mucosa.  This  may  be  so,  but  the  condition  has  been 
found  post-mortem  in  the  former  cases;  while  the  laryngoscope  cannot,  as  a 
rule,  be  used  to  establish  the  diagnosis  in  any  of  the  cases  during  life.  The 
symptoms  which  give  gravity  to  the  affection  are  not  inflammatory,  but  spas- 
modic. Sickly  children  cannot  stand  the  sudden  strain  thrown  on  the  lungs 
or  heart  bv  the  spasm  SO  well  as  robust  children.  I  presume  this  is  at  the 
bottom  of  the  apparent  difference  in  the  gravity  of  the  cases. 

laryngeal  Spasm  in  Adults. — While  laryngeal  spasm  in  children 
presents  a  fairly  uniform  clinical  picture  and  is  due  apparently  to  a  limited 
number  of  causes,  the  opposite  holds  true  in  adults.  Notwithstanding  its 
comparatively  infrequent  occurrence,  we  find  cases  reported  as  due  to  hys- 
teria, to  various  local  lesions  of  the  nose  and  throat,  to  reflexes  from 
other  organs,  and  to  lesions  of  the  nerve-trunks  and  centers.  It  may  occur 
at  any  time  of  the  night  or  day  or  under  various  conditions  of  health  and 
disease.  It  may  be  phonatory,  deglutitory,  or  respiratory.  The  following 
remarkable  case  is  reported  for  the  first  time,  I  believe,  although  it  occurred 
many  years  ago  in  the  New  York  Hospital. 

The  patient  was  an  unmarried  woman  of  thirty-two.  Her  father  died  of  spinal 
meningitis.  She  had  had  a  left  pneumonia  twice,  inflammatory  rheumatism,  and  seme 
disturbances  referable  to  her  stomach,  bowels,  and  kidneys.  Since  the  last  attack  of 
pneumonia,  five  years  previously,  she  had  had  a  slight,  persistent  cough.  Six  years 
previously  she  had  had  a  small  tumor  removed  from  some  part  of  her  throat,  and  after 
two  years  two  more   were   removed.     She   knows   nothing  of  their  nature  or  situation. 

had  had  at  time-  some  shortness  of  breath,  but  never  any  excessive  dyspnea  or 
aphonia  until  a  few  week-  before  her  admission.  She  had  used  morphin  hypoder- 
mically  for  neuralgia,  but  was  not  an  habitue.     Four  weeks  ago  she  had  caught  cold, 

and  since  then  the  cough  had  been  troubles* .and  -he  had  occasional  dyspnea  and 

aphonia.  On  the  day  of  admission,  after  a  hearty  meal  she  had  started  for  a  walk  feel- 
ing as  well  as  usual ;  hut  booh  experienced  a  feeling  of  constriction  of  the  throat,  and 
breathing  became  difficult.  Being  mar  the  hospital  she  came  directly  there.  She  was 
restless  and  excited.  Her  breathing  became  more  involved  in  spite  of  morphin  by  the 
mouth,  inhalation-  of  amyl  nitrate  and  ether,  and  "  Faradization  ofthe  pneumogastric." 
She  became  unconscious  three-quarters  of  an  hour  after  admission;  respiration  was 
practically  suspended.  She  was  cyan osed,  and  her  pupils  contracted.  Artificial  respi- 
ration being  "i  no  avail,  laryngo-tracheotomy  was  done.  The  introduction  of  the  tube 
was  not  followed  by  any  signs  of  tracheal  irritation  or  spasm,  hut  after  a  few  moments 
oioii  began.  At  first,  if  was  only  six  to  the  minute.  She  remained  unconscious 
for  -i.\  hour-,  when  the  respiration  having  arisen  to  sixteen  and  being  "  Cheyne-Stokes " 
in  character,  -he  had  a  severe  attack  of  coughing  ami  became  conscious,     fifteen  ounces 


NEEROSKS  OF   THE   LARYNX.  1157 

of  urine  were  drawn  by  catheter  and  found  to  be  pale,  1008,  albumen  2  per  cent.,  no 
casts.  For  two  weeks  she  suffered  from  sepsis  due  to  a  hypodermic  abscess  with  slough- 
ing. Her  general  condition  finally  became  normal,  excepl  thai  die  was  hysterical  in 
many  ways.     No  pulmonary  signs  of  importance  were  noted;  Inn  she  had  considerable 

gastric  disturbance.  The  albumen  soon  disappeared  from  tin  urine.  About  tour  weeks 
after  admission  she  had  a  very  severe  attack  of  coughing  combined  "apparently  with 
bronchial  spasm;"  and  tor  several  week-  had  such  attacks  lasting  from  thirty  seconds 
to  a  minute,  during  which  she  struggled  for  air  and  became  cyanotic.  They  would  sub- 
>ide  as  suddenly  as  they  came  (hysterical?).  After  a  time  her  condition  improved  and 
she  had  no  more  attacks.  Dr.  Letterts  examined  her  larynx  and  pronounced  it  absolutely 
normal.  She  was  discharged  from  the  hospital  after  the  removal  of  the  tracheotomy- 
tube. 

Five  or  six  years  afterward  this  patient  came  under  my  observation  for  attacks  of 
aphonia,  evidently  of  hysterical  origin.  In  the  meantime  she  had  no  return  of  any 
laryngeal  spasm. 

I  can  offer  no  explanation  of  this  case.  Certainly  we  do  not  exped 
hysterical  spasm  to  persist  when  the  patient  becomes  unconscious  and  as  near 
death  as  this  young  woman  was ;  and  vet  hysteria  was  the  salient  feature  in 
the  laryngeal  and  other  manifestations.  Leo  relates  a  case  in  which  death 
ensued  in  a  young  man,  which  he  thought  was  due  to  hysterical  spasm  of  the 
larynx  ;  although  the  history  of  the  ease  leaves  the  reader  in  doubt  as  to  the 
correctness  of  the  diagnosis.  Chaput  reports  a  case  of  hysterical  laryngeal 
spasm  cured  by  tracheotomy  ;  and  Landgraf,  one  cured  by  catheterization  of 
the  trachea.  All  these  cases  were  in  men.  Irwin  relates  a  case  where  laryn- 
geal spasm  occurred  in  an  adult,  arising  by  reflex  action  from  a  bullet  lodged 
in  the  arm.  Removal  of  the  ball  cured  the  case.  Foreign  bodies  in  the 
nose,  nasal  tumors,  gastric  disturbances,  irritation  of  the  recurrent  or  vagus 
by  tumors,  are  noted  among  the  causes  of  respiratory  laryngeal  spasm.  I 
have  seen  several  cases  in  which  an  aneurysm  of  the  arch  of  the  aorta  pro- 
duced dyspnea,  evidently  rather  by  involvement  of  the  recurrent  causing 
laryngeal  spasm  than  by  pressure  on  the  trachea  or  bronchi.  Epilepsy, 
chorea,  tetanus,  and  hydrophobia  are  the  general  nervous  affections  of  which 
laryngeal  spasm  is  the  more  or  less  constant  accompaniment.  A-  I  rottstein 
remarks,  it  occasionally  occurs  in  cases  in  which  no  explanation  can  be 
found. 

.Moure,  in  describing  laryngeal  spasm,  divides  the  etiology  into  functional, 
directly  irritative,  peripheral,  central,  reflex,  and  associated  with  general  affec- 
tions. The  form  of  laryngeal  spasm  we  are  most  familiar  with  results  from 
the  impact  of  foreign  bodies  and  local  applications  in  the  treatment  of  laryn- 
geal affections. 

Symptoms. — Long-drawn   whistling  inspirations  and  short   expirations, 

with  anxious  face,  drawn  features,  and  eyanosed    lips    make   a uni-takable 

picture  of  obstruction  of  the  air-tube  ;  while  its  sudden  advent  and  inter- 
mittency  indicate  its  spasmodic  character.  The  obstruction  is  rarely  so  greal 
as  to  completely  -top  the  respiration,  as  in  the  cases  narrated  above.  The 
attack  may  be  a  .-ingle  one,  or  often  repeated  for  days  or  month-.  The 
patients  usually  recover;  but  some  of  the  diseases  thai  give  rise  to  it, 
as  tetanus,  hydrophobia,  tabes  dorsalis,  are  in  themselves  fatal.  It  is  nol 
often   possible  to  observe  the   larynx  during  one  of  these  attack-,     in   the 

examinations    that    have    been    made    there    has    been    noted    - time-   only 

closure  of  the  true  cord-,  but  sometimes  of  the  false  cords,  which  hides  the 

condition    below. 

Treatment. — Tracheotomy  or  intubation  ma)  be  necessary  to  avoid  im- 
mediate suffocation  ;  but  others  ise  therapeutic  measures  nui-t  depend,  as  does 
the  diagnosis,  upon  the  cause  of  the  affection. 


1158  NEUROSES  OF  THE  UPPER  AIR-PASSAGES. 

Nervous  cough,  or  chorea  of  the  larynx,   \i  an  associated  tonic 

-u  of  the  glottis  and  of  the  other  respiratory  muscles,  resulting  in  a  more 
or  less  rhythmical  and  continued  cough  or  bark,  which  is  only  regularly 
absenl  during  sleep.  It  has  been  mosl  frequently  noted  in  girls  al  the  time 
or  shortly  after  the  advenl  of  puberty  ;  but  it  has  also  been  noted  before  this 
period  and  at  a  more  advanced  age.  In  one  case  reported  by  Holden  it 
occurred  in  a  man  of  fifty-seven.  I".  1.  Knight  recorded  a  case  in  a  woman  of 
forty-two;  other  cases  have  been  noted  by  Lefferts,  Roe,  Morgan,  Schnitzler, 
Wheeler,  Mandel,  Porcher,  Furundena-Labat,  Tamburini,  Krnnicutt,  Masucci, 
and  Clark.  Gottstein,  Massei,  Schmidt,  and  Schrotter  have  discussed  the 
nature  and  etiology  of  the  affection  thoroughly  in  their  works.  Some  cases 
seem  to  have  been  due  to  reflex  causes;  but  since  the  majority  of  the  cases 
a-  to  age  and  sex  are  grouped  around  the  period  of  the  advent  of  puberty 
in  women,  we  may  conclude  that  the  phenomenon  is  usually  due  to  the  ner- 
vous developments  peculiar  to  that  time.  Hysteria,  as  usual  at  this  period, 
i-  a  prominent  factor  in  some  of  the  cases.  These  cases  are  usually  reported 
under  the  head  of  laryngeal  chorea  :  hut  it  is  exceedingly  doubtful  if  it  has 
any  close  relation  to  this  affection,  since  very  few  of  the  eases  were  accom- 
panied by  any  of  the  other  choreic  twitchings.  The  cases  reported  have 
excited  the  interest  of  physicians  and  the  wondering  curiosity  of  friends. 
Many  have  been  known  as  " barking  girls,"  and  the  incessant  aoise  has  ren- 
dered them  a  auisance  to  their  companions  and  made  their  own  lives  miser- 
able. Fortunately,  after  a  varying  Length  of  time  the  trouble  disappears. 
The  cough  or  bark  may  be  repeated  at  intervals  of  a  few  seconds  or  minutes 
throughout  the  entire  day  or  be  only  present  for  a  short  time,  or  there  may 
he  periods  of  days  or  weeks  in  which  it  is  absent,  [t  is  always  absent  during 
sleep.  ( )n  laryngoscopic  examination  the  vocal  cords  are  seen  to  be  driven 
toward  the  median  line,  apparently  by  an  uncontrollable  spasm  of  the  adduc- 
tors. Knight  states  that  in  a  case  observed  by  him  he  could  distinctly  hear 
the  click  of  the  cords  as  they  met.  The  air  is  driven  out  through  the  nar- 
rowing glottis  by  a  corresponding  contraction  of  the  diaphragm,  producing  a 
short,  sharp  yelp  or  hark,  terminating  abruptly  from  the  firm  closure  of  the 
glottis.  This  is  repeated  at  intervals  varying  from  a  few  seconds  to  ten  or 
fifteen  minutes. 

Treatment. —  Local  treatment  is  of  little  avail,  and  the  bromids  and  nar- 
cotics have  no  curative  value.  The  moral  effect  of  authority,  fright,  galvan- 
ism, the  mind-cure,  faith-cure,  or  any  of  the  other  so-called  hypnotic  influ- 
ences may  suddenly  terminate  the  neurosis.  Of  course,  the  general  hygienic 
treatment  by  tonic-,  outdoor  life,  proper  diet  and  sleep,  and  relief  from  any 
nervous  strain,  must  all  be  insisted   upon. 

Inco-ordination  of  the  laryngeal  Muscles.— i  Dysphonia  or  Apho- 
nia Spastica;  Aphihcmgia  Laryngea  (Gottstein) ;  Phonqtory  Spasm). — This 
is  a  curious  laryngeal  neurosis  which  has  occasionally,  although  rarely,  hern 
noted.  It  seems  to  be  in  some  cases  a  manifestation  of  hysteria;  and  in 
some  cases  has  occurred  from  overfatigue  of  the  larynx  in  preachers.  Any 
attempt  at  phonation  results  in  a  more  or  less  c plete  closure  of  the  glottis, 

lal  not  a  sound  comes  forth;  and  with  it  may  be  associated  some  respi- 
ratory spasm — that  i-.  iIm- adduction  of  the  vocal  cord-  lasts  long  enough  to 
can-.-  inspiratory  dyspnea.  In  other  cases  there  come-  a  high-pitehed,  shrill 
tote  from  the  larynx,  possibly  articulated,  but  not  Long  sustained.  A  familiar 
pie  of  this  inco-ordination  of  the  phonatory  muscles  is  the  changing 
at    puberty. 

With  the  Laryngoscope  no  abnormalit}  is  to  be  observed  until  the  patient 


NEUROSES  OF  THE  LARYNX.  1159 

attempts  to  phonate,  when  the  vocal  curd-  are  seen  to  be  firmly  apposed   in 
the  median  line. 

Functioned  inspiratory' spasm  of  the  glottis  is  sometimes  associated  with 
the  phonatory  spasm,  or  il  mayexisl  withoul  the  trouble  in  phonation.  When 
attacks  of  inspiratory  dyspnea  occur,i1  is  seen  on  examination  thai  the  glottis 
is  narrowed  on  expiration.  The  cords  may  be  in  apposition  except  al  their 
posterior  end,  where  there  exists  a  three-cornered  opening,  from  which  we 
may  suppose  thai  the  interarytenoideus  muscle  is  nol  involved  in  the  spasm. 
We  may  look  upon  these  cases  as  evidences  of  perverse  innervation — i.  <.. 
the  inspiratory  impulse  starts  along  its  accustomed  path  to  the  abductors  and 
i-  switched  off  to  the  adductors;  but  the  cases  have  ool  been  numerous 
enough  to  furnish  data  for  study,  and  no  theory  satisfactorily  explains  them. 
Schnitzler  first  fully  described  the  affection,  and  it  has  been  discussed  in  the 
works  of  Schrotter,  Gottstein,  Moure,  Bosworth,  and  Mackenzie;  while  cases 
have  been  reported  by  Onodi,  Jendrassik,  Jonquiere,  Meyer,  Schnitzler, 
Landgraf,  Sanctis,  and   others. 

It  occurs  in  adults,  both  men  and  women.  In  the  latter  it  frequently 
depends  upon  hysteria,  but  in  many  eases  no  cause  can  be  assigned.  Mac- 
kenzie, Gottstein.  Schrotter,  and  others  have  met  with  cases  that  have 
lasted  for  years  without  relief;  but  most  of  the  hysterical  cases  have 
recovered. 

Treatment. — Reflex  causes  must  be  sought  for  and  remedied  it'  they 
exist.  The  general  health,  if  faulty,  must  be  improved.  Hysterical  cases 
have  been  cured  by  suggestion,  faradization,  etc.  Jonquiere  and  Meyer  cured 
some  cases  in  hysterical  women  temporarily  and  others  permanently  by 
pressure  on  the  ovaries. 

Ataxia,  nystagmus,  and  rhythmic  movements  of  the  vocal  cord-  have 
been  observed  in  tabes  dorsalis,  chorea,  hysteria,  cerebro-spinal  meningitis, 
and   paralysis  agitans. 

Mogiphonia  is  a  term  used  by  Frankel  to  describe  laryngeal  phenom- 
ena induced  by  overuse  or  -train  of  the  voice.  It  may  be  of  a  spastic  form 
— phonatory  spasm  of  the  larynx — a  tremulous  form,  or  a  paralytic  form. 
The  last-named  has  been  noted  by  Frankel  and  Bresgen  in  singers,  preachers, 
and  teachers.  It  is  peculiar  in  that  the  voice  may  be  used  for  other  purposes, 
but  phonation  fails  when  they  attempt  to  use  the  voice  in  the  accustomed 
way — singing,  preaching,  teaching,  etc.  I  do  not  find  that  others  have  used 
the  term. 

laryngeal  Vertigo. — Lctus  laryngea,  laryngeal  epilepsy,  laryngeal 
crises,  laryngeal  syncope,  or  lipothymia  laryngea  are  synonyms  for  an  affec- 
tion which  has  nol  as  yet  been  satisfactorily  classified,  although  it  has  been 
recognized  for  twenty  year-.  I  have  chosen  the  name  laryngeal  vertigo  as  a 
heading  because  that  is  the  term  under  which  mosl  of  the  cases  have  been 
described  in  the  English  language,  ictus  laryngea  being  the  name  under 
which  the  affection  is  usually  noted  in  other  tongues.  It  is,  however,  neither 
a  vertigo  nor  an  epilepsy  ;  since  the  cases  reported  have  rarely  suffered  from 
the  former  and.  except  in  two  cases  (<  rra)  and  Bianchi  .  ha\  e  ne\  er  presented 
any  other  manifestation  of  the  latter.  After  a  careful  stud}  of  the  reports 
it  would  seem  thai  laryngeal  syncope  (lipothymia  laryngea),  the  term  used 
by  Km/,  is  the  leasl  objectionable.  Laryngeal  vertigo  was  firsl  described 
in  1876  by  Charcot,  under  thai  name.  Since  then  there  have  been  numerous 
reports  in  French  and  English,  but  there  are  fev  accounts  of  cases  in  Ger- 
man. Garel  and  Toilet  have  given  the  besl  and  mosl  exhaustive  description 
of  it.  reporting   23  cases  of  their  own.     With  the  exception  of  two  or  three 


1100  NEUROSES  OF  Till-:  UPPER  AIR-PASSAGES. 

caseSj  all  have  been  in  men  ;  and  the  majority  of  thens  were  between  forty 
and  fifty  years  of  age. 

The  patients  feel  a  tickling  in  the  larynx,  cough  once  or  twice,  and 
become  suddenly  unconscious.  This  last-  for  less  than  a  minute,  with  quiet 
respirations  and  a  feeble  pulse,  when  they  as  suddenly  regain  consciousness 
and  feel  as  well  as  ever — often  laughing  at  the  alarm  the  attack  has  excited 
in  their  companions.  The  lace  becomes  Hushed  and  congested  at  the  begin- 
uing  of  the  attack  and  is  pale  on  recovering.  There  may  We  a  single  attack 
or  a  number  of  them  at  shorl  intervals  or  at  intervals  of  years.  In  some 
cases  there  has  been  evidence  of  bronchitis  and  emphysema  or  of  an  enlarged 
and  fatty  heart.  Alcoholism,  diabetes,  and  nephritis  have  been  occasionally 
noted  in  these  patients,  hut  not  frequently  enough  to  make  them  of  much 
importance  in  the  consideration  of  the  etiology.  The  patient  may  have  had 
laryngeal  irritation  and  cough  for  years,  and  only  once  an  attack  of  syncope. 
He  may  cough  only  once  slightly  or  many  times  violently  before  he  becomes 
unconscious.  Frequently  he  has  been  sitting  quietly  or  the  attack  has  come 
on  in  bed.  At  other  times  he  has  been  walking  or  driving.  In  some  cases 
there  has  been  excessive  bronchial  secretion.  Usually  there  has  been  no  con- 
vulsive muscular  action  during  the  attack  ;  but  in  some  there  has  been 
twitching  of  various  muscles.  It  is  exceedingly  probable,  as  urged  by  Garel 
and  Collet,  that  these  attacks  often  occur  without  the  patients  remembering 
them   in  their  accounts,   or  without   their  being  noted   by  their  companions. 

Various  theories  have  been  advanced  to  account  for  the  attacks.  Charcot 
supposed  them  analogous  to  Meniere's  disease,  the  superior  laryngeal  nerve 
being  involved  in  the  intracranial  irritation,  instead  of  the  auditory.  Garel 
and  Collet  suppose  it  due  to  arterial  anemia  of  the  brain,  there  being  an 
obstruction  to  the  venous  circulation  and  an  insufficiency  of  arterial  blood 
in  the  vessels  due  to  a  temporary  weakening  of  the  heart's  action.  This 
cardiac  failure  they  suppose  to  be  brought  about  by  the  involvement  of  the 
sympathetic  aerves  in  the  irritation  of  the  superior  laryngeal  at  the  time  of 
the  cough.  In  only  two  cases  was  the  attack  observed  by  the  reporter. 
Kurz  found  his  patient  in  syncope;  while  Schadewaldt  was  looking  at  his 
<-a-<'  when  one  of  the  attacks  began.  This  case  subsequently  died  in  one  of 
the  tit-  ;   but.  as  a  rule,  this  has  not  been  noted,  nor  does  it  appear  necessarily 

to    be   an    indicati >f  disease   of   a    vital    organ.      Gleitsmann's   case    had 

enlarged  lingual  glands,  and  the  treatment  of  these  abolished  the  attack. 
Adler  attained  the  same  result  by  clipping  an  elongated  uvula,  and  Charcot 
by  cauterizing  a  granular  pharyngitis. 

The  cases  are  really  more  curious  and  interesting  than  instructive  or 
important,  since  we  arc  unable  to  classify  them, and  since  they  apparently 
are  only  exceptionally  broughl   to  the  notice  of  the  physician. 

Treatment. — Local  abnormalities  must  be  sought  for  and  removed,  and 
the  systemic  diseases  which  maybe  present  musl  receive  their  appropriate 
treatment.     Drugs  have  lireel    influence  on  the  attacks. 

laryngeal  Paralysis  (Hypokinesisi. — Pathology  and  Etiolog-y. — 
Central  paralysis  of  voluntary  motion  in  the  majority  of  cases  is  caused  by 
3ome  lesion  of  the  cerebral  cortex.  Paralysis  of  involuntary  motion  in  the 
majority  of  cases  has  it-  origin  in  the  spinal  cord  or  the  medulla.  Phonation 
is  the  producl  of  voluntary,  ami  respiration  is  the  product  of  semi-involun- 
tary, motion.  Aphasia  musl  be  entirely  separated  from  aphonia  in  the  con- 
sideration of  ii-  etiology.  Shortly  after  interesl  was  firsl  aroused  in  the 
location  of  areas  of  the  origin  of  motor  impulses  in  the  cerebral  cortex, 
Krause,  in  1884,  showed  that  stimulation  of  the  gyrus  prefrontal^  in  animals 


NEUROSES  OF  THE  LARYNX.  II  til 

produced  muscular  movements  of  the  larynx,  palate,  and  pharynx.  There- 
upon Garel,1  in  1886,  reported  a  case  of  laryngeal  paralysis  in  which  autopsy 
showed  a  lesion  of  this  area.  Lewin  had  previously  noted  the  occurrence 
of  laryngeal  paralysis  in  a  case  of  hemiplegia  ;  bul  Garel's  was  the  firsl  case 

that  had  come  to  autopsy  in  which  a  laryngoscopic  examination  had  pre- 
viously been  made.  In  1889  Semon  and  Horsley2  published  the  results  of 
their  experiments  on  animals,  by  which  Krause's  statements  were  confirmed. 
They  showed  that  the  area  was  one  of  bilateral  representation — i.e.,  a  stim- 
ulation  of  either  side  at  the  lower  part  of  the  gyrus  prefrontalis  would  pro- 
duce adduction  of  both  vocal  cords.  They  also  showed  that  extirpation  of 
one  or  both  of  these  areas  produced  no  laryngeal  paralysis.  These  results 
have  been  confirmed  by  all  observers  with  the  exception  of  Massini,  who 
claimed  that  faradization  with  weak  currents  produced  movement  of  out- 
side only  of  the  larynx.  Several  observers  have  repeated  Massini's  experi- 
ments, with  negative  results.  Garel  and  Dor  later  returned  to  the  subject  and 
reported  further  cases,  and  cited  several  from  literature  in  which  a  cortical 
lesion  was  accompanied  by  laryngeal  paralysis;  but  in  none  of  these  cases 
were  they  able  to  exclude  a  possible  lesion  of  the  pons,  of  the  nerve-trunks, 
or  of  their  peripheral  distribution.  Hunter  Mackenzie's  recent  ease  is  open 
to  the  same  criticism.  Semon  and  Horsley  showed  that  the  fibers  from  this 
cortical  area  passed  through  the  corona  radiaia  and  internal  capsule  to  the 
bulb.  They  showed  also3  that  the  respiratory  cortical  center  in  animals  does 
not  exactly  correspond  to  the  phonatory  center,  and  that  laryngeal  move- 
ments were  observed  independent  of  thoracic  movements  of  respiration. 
"Acceleration  is  obtained  by  exciting  the  precrucial  gyrus;  intensification, 
most  commonly,  from  the  region  around  the  lower  end  of  the  crucial  sulcus  : 
and  inspiration  we  have  already  localized  in  the  cat  just  above  the  olfactory 
sulcus."  The  manifestation  produced  in  a  cat  by  stimulation  of  this  area 
was  persistent  abduction  of  the  vocal  cords,  while  thoracic  respiratory  move- 
ments continued.  As  to  phonation,  they  say  that  "there  is  in  each  cerebral 
hemisphere  an  area  of  bilateral  representation  of  <i<l<lii<-tm-  movement  of  the 
vocal  cords  situated,  in  the  monkey,jus1  posterior  to  the  lower  end  of  the 
precentral  -ulcus  at  the  base  of  the  third  frontal  gyrus  :  and  in  the  carnivora, 
in  the  precranial  and  neighboring  gyri."  The  fibre-  from  these  run  directly 
through  the  eorona  r<t<l!<tf<i  to  the  internal  capsule,  where  "the  fibers  which 
subserve  the  function  of  respiration  are  contained  at  firsl  in  the  anterior 
limb  and  lower  down,  more  especially  in  the  region  of  the  */,,/"."  "The 
fiber-  which  subserve  the  function  of  phonation.  and  excitation  of  which 
produces  adduction  of  the  vocal  cords,  are,  in  the  carnivora,  grouped  at.  or 
just  posterior  to,  the  genu,  and  also,  according  t<>  the  level  of  the  section, 
continued  into  the  posterior  limb.  In  the  monkey  they  ate  concentrated  as 
a  small  bundle  in  the  posterior  limb,  among  the  fibers  for  the  movement  of 
the  tongue  and  pharynx,  from  excitation  of  these  fibers  we  have  always 
obtained  bilateral  effects."  They  also  described  laryngeal  respiration  ;i-  rep- 
resented in  the  medulla  oblongata  by  an  area  in  the  upper  pari  ot  the  floor 
of  the  fourth  ventricle.  Here  also  unilateral  stimulation  produces  bilateral 
effect,  the  prevailing  movement  being  abduction  ;  while  adduction  or  phona- 
tory movement  (bilateral)  i-  excited  by  irritation  of  the  "/"  <■/, nr<u  and  the 
upper  part  of  the  calamus  scriptorius  at  the  lower  border  of  the  fourth 
ventricle,  [rritation  of  one  of  the  external  borders  of  the  restiform  bodies 
prod iic-.  unilateral  adduction  of  the  vocal  cord-.     The  authors,  in  conclusion, 

1  Rev.  de  LaryngoL,  May,  L886,  p.  248.  -  Brit.  Med.  Journ.,  :  i;   I  tec.  21, 

;  DeutecA.  Med.  Woch.,  1892,  p.  672. 


1162  NEUROSES  OF  THE  UPPER  AIR-PASSAGES. 

admit  thai  they  have  indicated  only  the  more  prominent  highways  of  nervous 
impulse,  and  that  there  may  be  other  contributing  paths. 

-.  (  modi,  an<l  Klemperer  have  confirmed  these  statements,  and  shown 
tliar  not  only  may  these  cortical  center-,  be  destroyed  in  animal-  without 
affecting  the  innervation  of  the  larynx  after  the  wound  has  healed,  bul  they 
and  others  have  proved  that  the  whole  of  both  cerebral  hemispheres  may  be 
cut  away  with  the  cerebellum,  leaving  nothing  but  the  pons,  without  affecting 
the  movements  of  adduction  or  abduction  in  the  larynx.  These  facts  have 
hem  established  by  experimentation  on  animals.  How  far  they  are  applicable 
to  man  it  is  impossible  to  say,  although  it  is  probable  that  owing  to  the 
larger  evolution  of  the  brain  in  man.  especially  that  part  of  it  having  to  do 
with  speech,  variations  would  he  noted  in  important  particulars  from  the 
h.wcr  animals.  As  a  matter  of  fact,  however,  there  has  been  no  case  re- 
ported in  man  of  cortical  lesion  accompanied  by  laryngeal  paralysis  in  which 
tin-  possibility,  and  feu-  in  which  the  probability,  of  involvement  of  the 
nervous  tract  below  could  he  excluded.  We  must,  therefore,  in  view  of  the 
positive  evidence  in  animals  and  the  negative  evidence  in  man,  admit  that 
Semon's  declaration  of  the  non-occurrence  of  cortical  laryngeal  paralysis  in 
man   is  probably  correct. 

In  1873  Schech  and  Schmidt,  by  experiment-,  apparently  established  the 
fact  that  the  vagus  gets  the  motor-filaments  which  supply  the  larynx  from 
the  upper  filaments  of  the  spinal  accessory  nerve.  This  view  ha-  obtained 
until  lately,  when  Grabower  and  Grossman, by  separate  investigations, showed 
in  1800  that  this  was  not  the  case,  but  that  the  motor  innervation  of  the 
vagus  was  obtained  through  it-  lower  filaments  from  the  dorsal  vagus  nucleus 

in  the  lower  part  of  the  fl ■  of  the  fourth  cerebral  ventricle.     I  >arksche^  itsch, 

in  1885,  -tated  that  the  dorsal  nuclei  of  the  vagus  and  the  spinal  accessory 
nerves  were  coterminous,  arising,  therefore,  from  the  same  tract  of  gray 
matter.  Grabower  and  (iro— man  in  1  S!»  t,  au'ain  separately,  in  a  -cries  of 
microscopic  sections,  have  shown  that  the  motor  nucleus  of  the  accessory  and 
that  of  the  vagus  are  not  coterminous,  hut  that  the  latter  begins  above 
where  tin-  former  leaves  off — in  the  medulla  oblongata  ;  and  .-till  more  re- 
cently Grabower  ha-  reported  a  case  which  goes  far.  by  clinical  and  patho- 
logical evidence,  to  establish  the  fact  which  he  had  previously  announced 
from  experimental  and  microscopic  investigations.  A  bulbar  lesion  causing 
laryngeal  paralysis  we  must,  therefore,  expeel  to  involve  the  dorsal  motor 
nucleus  of  the  vagus  nerve,  which  lie-  near  the  median  furrow,  at  the  lower 
part  ami  beneath  the  II ■  of  the  fourth  ventricle. 

The  anatomy,  course,  and  distribution  of  the  laryngeal  nerves  in  general 
have  been  well  understood  for  a  longtime;  and  .-pace  does  not  allow  us  to 
dilate  upon  well-known  data.  There  are  several  point-,  however,  upon 
which  it  is  necessary  to  say  a  few  words,  as  they  have  of  late  been  the  sub- 
ject of  important  investigations.  Notwithstanding  the  fact  thai  Exner  has 
shown  that  in  certain  animal-  the  superior  laryngeal  nerve  participates  in  the 
innervation  of  certain  of  the  intrinsic  laryngeal  muscles,  subsequent  investi- 
gations show  pretty  clearly  thai  this  arrangemenl  dor-  not  obtain  in  man; 
hut  that  the  external  or  smaller  branch  of  the  superior  laryngeal  nerve  alone 
contains  motor  filaments,  and  these  supply  the  crico-thyroid  muscle  only,  the 
other  branches  of  the  superior  laryngeal  nerve  being  exclusively  composed 
ry  filaments  (Onodi)  which  supply  the  laryngeal  mucous  membrane. 
I '•  les  the  nerve-supply  derived  from  the  superior  laryngeal  nerve,  the  crico 
thyroid  muscle  ha-  been  shown  by  Exner,  Onodi,  and  others  u>  receive  by 
;i  communicating  branch  (middle  laryngeal  nerve)  motor  impulses 


NEUROSES  OF  THE  LARYNX.  1163 

from  the  pharyngeal  branch  of  the  pneumogastric.  This  has  been  a  subjecl 
tit'  considerable  controversy  ,  but  in  a  later  communication  Exner  has  re- 
asserted the  fact.  The  other  internal  laryngeal  muscles,  adductors,  abductors, 
and  tensors  are  supplied  by  one  nerve — the  inferior  or  recurrent  laryngeal 
nerve.  The  vagus,  runningfrom  the  jugular  foramen  with  the  blood-vessels, 
dips  into  the  thoracic  cavity  and  gives  off  the  recurrenl  laryngeal,  which 
winds  around  the  arch  of  the  aorta  on  the  left  and  the  subclavian  artery  on 
the  right  and  returns  to  the  larynx. 

Rosenbach  and  Semon  at  about  the  same  time  1 1 88<  I  1  88  1  drew  attention 
to  the  fad  thai  in  laryngeal  paralysis  the  abductors  are  usually  the  first,  and 
sometimes  apparently  the  only,  muscles  to  suffer  as  the  resull  of  central  or 
nerve  lesions.  In  hysterical  aphonia,  however,  it  i-  the  adductors  which  are 
affected.  Attention  being  drawn  to  this  factof  the  preponderance  of  abductor 
paralysis,  great  curiosity  was  excited  as  to  the  cause  of  thi>  phenomenon. 
in  1884  Kxause,by  a  number  of  experiments  on  animals,  was  convinced  that 
this  apparent  paralysis  of  the  abductors,  resulting  in  the  immobility  of  the 
vocal  cord-  in  the  median  line,  was  really  due  to  a  contracture  of  all  the 
laryngeal  muscles  from  irritation  caused  by  pressure  on  the  nerve-trunks  or 
nerve-centers,  or  by  their  involvement  in  disease.  This  raised  a  point  about 
which  for  many  years  much  acrimonious  discussion  prevailed.  Semon  was 
the  most  persistent  and  the  most  successful  of  the  opposers  of  this  vi  \\  :  and 
his  papers  and  reference-  to  the  question  have  been  voluminous  and  frequent. 
Although  I  was  inclined  at  the  time  to  believe  that  Krause's  experiments 
had  established  his  contention,  and  so  expressed  myself,1  the  weight  of  evi- 
dence has  so  preponderated  against  it  in  the  last  five  or  six  year.-,  that  I  can- 
not but  admit  that  Semon's   view  is  more  nearly  correct  ;  yet,  as  the  latter 

has  said,  one  cannot  deny  that  contracture casionally  is  the  cause  of  median 

position  of  the  cord-.  Various  explanations  have  been  advanced  to  account 
for  the  greater  proclivity  of  the  abductor-  to  loss  of  power.  Although 
Mackenzie  and  Rieuel  had  -n-u'ested  the  existence  of  separate  filaments  in 
the  recurrent  nerve  supplying  the  different  muscles,  it  remained  for  Onodi 
and  Risien  Russel  to  demonstrate  the  fact  ;  but  their  position  in  the  nerve. 
as  suggested  by  Mackenzie  and  Rieuel,  could  not  account  for  the  frequency 
of  abductor  paralysis.  Hooper,  in  a  valuable  paper,  showed  that  ether  has  a 
peripheral  and  differential  effect  upon  the  laryngeal  muscles,  the  abductors 
being  the  first  to  suffer  in  their  function.  Jeanselme  and  Lermoyez  showed 
that  the  abductor-  lose  their  contractility  first  post-mortem.  Frankel  and 
Gad  showed  that  freezing  the  recurrenl  nerve  caused  firsl  a  paralysis  ol  the 
abductors.  The  experiments  of  Ma— ini  showed  the  same  effect  from  appli- 
cation of  chromic  acid  to  the  nerves.  Mackenzie  suggested  that  the  greater 
exposure  of  the  posterior  crico-arytenoids  to  the  passage  of  food  and  air  made 
them  more  liable  to  injury,  owing  to  their  position,  from  these  facts,  it 
geems,  as  Semon  says,  thai  the  greater  proclivity  of  the  abductors  to  the  loss 
of  power  is  probably  due  to  the  characteristics  of  the  muscles  themselves  ; 
but  it  inn-t  be  confessed  thai  the  evidence  in  this  regard  is  not  complete.8 
From  what  has  preceded,  it  i-  not  necessary  to  dwell  long  upon  the  causes 
of  laryngeal  paralyses.  We  have  seen  thai  we  may,  in  the  present  stated  our 
knowledge,  disregard  the  few  cases  thai  have  been  reported  oi  lesions  ol  the 
cerebral  hemispheres.      Various  affections  <>f  the  medulla  oblongata  nol   in- 

'   V.  )'.  1/.-/.  Joum.,  Sept.  -'.  1889     /  lm.    YL      A       ,  Oct.  8,  1892. 

s  Grabower  has,  since  the  preparation  of  this  chapter,  adduced  evidence  to  show  thai  the 
greater  vulnerability  may  be  dne  ton  difference  in  the  method  of  termination  of  the  nerve- 
hber»  in  the  mus  I     h.  f.  Laryngologie,  Band  v..  Heft  L.  , 


1164  NEUBOSES  OF   THE   UPPER   AUi-PASSACES. 

frequently  produce  laryngeal  neuroses,  together  with  other  peripheral  mani- 
festations. Out  of  1  •_'•_'  cases  of  tabes  dorsalis  observed  in  Gerhardt's  clinic, 
paralysis  of  the  laryngeal  muscles  was  observed  in  17.  Of  these,  11  were  of 
the  posticus  or  abductor  muscle  of  the  glottis,  5  were  bilateral,  4  upon  the 
right  hand,  and  li  on  the  left.  There  were  •">  cases  of  paralysis  of  all  the 
muscles  supplied  by  the  recurrent  —  1  bilateral  and  -J  on  the  right  side.  Of 
the  other  ."»  cases,  there  was  1  each  of  recurrent  paralysis  and  of  crico-thyroid 
(superior  laryngeal),  and  once  paralysis  of  the  recurrent  of  one  side  and  of 
the  posticus  muscleof  the  other.  In  2  cases  paralysis  of  the  thyro-arytenoid 
was  noticed.  In  2  of  the  L22  cases  ataxic  movements  of  the  vocal  cords,  and 
in  4  laryngeal  crises,  were  observed.  For  a  further  account  of  laryngeal  affec- 
tion in  tabes  dorsalis,  see  the  paper-  of  Burger,  Van  Gieson,1  and  Dreyfuss. 

Two  cases  of  unilateral  posticus  paralysis  have  been  observed  in  syringo- 
myelia by  Weintraud,  and  1  by  A.  Schmidt.  Paralysis  and  tremor  of  the 
vocal  cords  have  been  noted  in  multiple  sclerosis  by  Leube,  Bennett  Lori, 
Collet,  Speneer,  Krzywicki,  and  others.      In   one  of  Collet's  cases  the  lesion 

was  in  th rebellion.      Laryngeal   paralysis  is  one  of  the  symptoms  caused 

by  the  progressive  lesion  of  the  gray  nuclei  of  the  bulb,  which  we  call  glosso- 
labio-pharyngeal  paralysis,  and  is  said  to  distinguish  it  from  the  pseudo- 
bulbar paralysis. 

The  lesions  causing  these  symptoms  are  usually  softening  of  the  nervous 
matter  caused  by  atheroma  of  the  vertebral  artery  or  its  branches.  As  is 
readily  understood,  the  sequel  of  symptoms  varies  somewhat,  depending 
upon  the  vessel  affected.  Syphilis  may  set  up  similar  changes  in  the  blood- 
vessels; and  the  vigorous  administration  of  iodid  of  potash  may  stop  the 
progress  of  the  disease,  and  to  some  extent  restore  function  to  the  paralyzed 
vessels:  but  of  course  only  a  moderate  degree  of  restoration  is  to  be  ex- 
pected. Brain-tissue  in  this  situation  is  not  regenerated, although  congestion 
and  the  pressure  of  inflammatory  syphilitic  products  maybe  relieved.  The 
small  laryngeal  muscles,  when  once  atrophied,  are  not  usually  restored  to 
function.  ( !ases  have  been  reported  by  Senator,  Eisenlohr,  Delavan,  Wright,2 
Scheiber,  and  others. 

Cases  of  bilateral  laryngeal  paralysis  are  rarely  due  to  bulbar  lesions; 
but,  as  will  be  -ecu  by  reference  to  tin'  above  instances,  a  number  of  cases  of 
unilateral  laryngeal  paralysis  have  been  found  to  be  due  to  lesions  of  the 
medulla.  This  doe-  not  entirely  correspond  to  the  evidence,  cited  from 
Seraon  and  Horsley's  experiments,  of  the  existence  of  ;i  bilateral  representa- 
tion of  laryngeal  movements  in  the  nuclei  of  the  bulb  in  the  lower  animals. 
Evidently  the  last  word  has  not  been  said  concerning  the  central  innervation 
of  the  larynx. 

Tumors  of  the  pons  and  medulla  have  been  rarely  reported  ;i-  causing 
laryngeal  paralysis.     Gottstein   reviews  the  subjeel  and  refers  to  the  report 

<»f  several  cases  of  glj m  and  one  case  of  aneurysm  of  the  basilar  artery  by 

<  )llivier  d'A  ngers. 

All  the  cases  reported  of  laryngeal  paralysis  due  to  bulbar  Lesion  have 
presented  similar  c litions  in  the   regions  supplied  by  the  facial,  acusticus, 

jso-pharyngeal,  spinal  accessory,  or  other  branches  of  the  vagus  nerve, 
;i rding   to  the  extenl   of  the  lesion. 

Many  cases  of  laryngeal  paralysis  have  been  reported  due  to  the  involve- 

menl  of  the  trunk-  of  the  vagus  or  larj  ngeal  nerves  in  tui 's,  traumatism, 

and  other  pathological  condition-  ;it  the  base  of  the  -hull.  As  these  condi- 
tions  may  simultaneously  involve  the  other  nerves  referred  to,  it   is  often  a 

1  Tht  •/  I  Mental  Disease,  July,  l  396.  *  Loc  cit. 


NEUROSES  OF  THE  LARYNX.  1165 

matter  of  some  difficulty  to  distinguish  them  from  bulbar  Lesions.     Such  are 
the  cases  reported  by  Remak,  McBride,  and  Tiirck. 

Lesions  involving  the  trunk  of  the  vagus  on  its  way  down  the  neck  and 
of  the  recurrent  as  it  winds  around  the  greal  vessels  in  the  thorax  and  travels 
back  along  the  esophagus  to  the  larynx,  are  the  mosl  fertile  causes  of  laryn- 
geal paralyses.  Enlarged  glands,  traumatism  from  wounds  and  operations, 
goiters,  aneurysms,  tumors  of  the  mediastinum,  esophagus,  and  pharynx, 
pleurisy,  and  tuberculosis  at  the  pulmonary  apices,  pericarditis,  scoliosis  of 
the  cervical  vertebra,  have  all  Ween  reported  as  causing  paralysis  of  the 
abductors  alone  or  of  all   the  muscles  supplied   by  the  recurrent. 

In  aneurysm  of  the  arch  of  the  aorta,  laryngeal  paralysis  maybe  tin- 
first,  and  for  a  long  time  the  only,  sign  of  dilatation  of  the  vessel.  A.gain, 
cases  arc  not  infrequently  met  with  in  which  no  cause  can  !><•  assigned  for  the 
recurrent  paralysis,  and  we  are  compelled  to  make  a  tentative  diagnosis  of 
simple  neuritis. 

We  musl  suppose  the  rare  instances  of  the  paralysis  of  separate  muscles 
to  be  due  either  to  lesions  of  the  nerve-twigs  supplying  them,  or  to  involve- 
ment of  the  muscle-substance  itself.  As  we  have  seen,  paralysis  of  tin 
abductors  is  said  by  Mackenzie  to  be  due  in  some  instances  to  their  exposure 
to  traumatism  from  the  passage  of  boluses  of  food  through  the  lower 
pharynx  to  the  esophagus,  or  of  cold  drink.  Several  year-  ago  I  treated  a 
case  in  which  there  was  apparently  a  paralysis  of  the  thyro-arytenoid 
muscles,  with  a  paresis  of  the  crico-thyroid  and  interarytenoid  muscles  on 
each  side.  Besides  the  elliptical  opening  in  the  glottis  on  adduction,  the 
cords  had  the  peculiar  rounded  outline  described  by  Storck.  This  latter 
soon  disappeared,  but  the  laxness  of  the  cords  continued  for  some  time.  This 
condition  supervened  on  the  pharyngeal  inflammation  caused  by  swallowing 
carbolic  acid.  Besides  in  diphtheria,  cases  have  been  reported  in,  or  as  fol- 
lowing, scarlatina,  typhoid  fever,  influenza,  measles,  anemia,  chlorosis,  and 
psychical  disturbances,  cholera,  trichiniasis,  malaria,  icterus,  pneumonia,  and 
poisoning  from  atropin,  morphin,1  arsenic,  lead,  and  chronic  alcoholism. 

The  very  valuable  recent  paper  by  Heyman 2  comes  too  late  to  hand  for 
a  thorough  analysis  of  the  case-  of  toxic  paralysis  of  the  laryngeal  muscles. 
Hi-  list  of  the  poisonous  agents  include-  lead,  copper,  antimony,  phosphorus, 
arsenic,  alcohol,  atropin,  morphin,  and  cocain. 

In  the  same  issue  Lazarus  reports  paralysis  of  the  abductors  of  the 
larynx  in  a  case  of  gonorrhea  in  which  no  other  morbid  influence  w;i-  evi- 
dent. Occurring  in  connection  with  these  affections,  the  situation  "I'  the 
lesion  has  usually  been  unknown  ;  although  from  the  symptom-  in  some  it 
was  referred  to  the  bulb  ami  the  nerves,  as  well  a-  to  their  peripheral  dis- 
tribution. 

Some  cases  of  laryngeal  paralysis  due  to  reflex  causes  in  the  nose  and 
elsewhere  have  already  been  alluded  to  in  this  work,  mid  other-  are  to  be 
found  in  literature. 

Diagnosis  and  Symptoms. — Before  confining  ourselves  strictly  t<> 
laryngeal  manifestations,  something  musl  he  -aid  in  regard  i"  the  phenomena 
which  accompany  laryngeal  paralyses  due  to  lesion-  of  the  medulla  and  the 
vagus  nerve. 

1  Pneumonia  and  malaria   (Schecb    are  included  in  the  list  of  diseases,  and  atropin  and 
morphin  among  the  poisons  which   have  caused  laryngeal  paralysis,  bill  I  can   find  no  • 
references  to  cases  in  the  textrbooks  of  Sajous    p.  362,  ed.  1889),  Schecb    /'•   K   ■     heib 
Kehlkopfes,  etc.,  1897),  and  Gerhardt. 

2  Frankel's  "Archivfiir  Laryngol.  wnd  Rhinol."  Band  v.,  1896, 


1166  NEUROSES  OF  THE  UPPER  AIR-PASSAGES. 

In  lesions  of  the  medulla  oblongata  concomitant  manifestations  arc  almost 
always  found  elsewhere.  The  tongue  may  be  paralyzea,  atrophied,  and  pro- 
trude toward  the  affected  side.  There  is  usually  a  paralysis  of  the  soft 
palate,  causing  nasal  speech  and  the  occasional  regurgitation  of  food  and 
drink  into  the  nose.  Difficulty  in  swallowing,  from  paresis  of  (he  pharyn- 
muscles  and  anesthesia  of  i  lie  pharynx  and  larynx,  may  lie  present. 
There  may  he  facial  paralysis,  deafness,  and  vertigo.  Acceleration  of  the 
heart'-  action  and  of  the  respiration  are  of  occasional  occurrence.  Some- 
times the  manifestations  of  bulbar  disease  arc  bilateral,  in  which  case  it  is 
almost  always  the  abductors  alone  which  are  affected;  but  usually,  though 
not  so  frequently  as  in  the  other  lesions,  the  laryngeal  paralysis  is  unilateral. 
There  is  no  well-authenticated  case  of  paralysis  of  the  adductors  alone  from 
any  essential  lesion.  A  few  bulbar  lesions  have  been  reported  by  Jackson, 
Proust,  Senator,  and    Eisenlohr  as  causing  bilateral  laryngeal   paralyses. 

Many  of  these  bulbar  cases  die,  especially  those  in  which  there  is  a  double 
laryngeal  paralysis,  from  the  extent  of  the  disease  in  this  region  which  pre- 
sides over  the   most    vital   functions  of  the   organism. 

Lesions  Of  the  VagUS  Nerve. — The  involvement  of  other  nerves  in 
bulbar  disease  establishes  the  diagnosis,  as  a  rule  ;  but  occasionally  lesions  at 
the  base  oi*  the  skull  may  simulate  it  by  Involving  the  trunks  of  several 
nerve-  besides  the  vagus.  Such  are  the  cases  reported  by  McBride,  and  by 
Schech,  Bernhardt,  and  Nothnagel.1  Baiimler,  Johnson,  McCall  Anderson, 
and  Whipman  have  published  eases  in  which  pressure  upon  one  vagus  has 
caused  laryngeal  paralysis  of  both  sides.  This  Johnson  explains  by  stating 
that  a-  the  vagus  contain-  centripetal  libers  the  ensuing  degeneration  extends 
to  the  medulla  and  there  by  decussation  involves  the  motor  area  of  the  other 
side.  Such  seemed  to  be  the  explanation  of  a  fatal  case  of  double  abductor 
paralysis  reported  by  the  writer2  in  1892.  Krause's  contention  that  the 
recurrent    laryngeal   nerve  contains  centripetal  libers  has  not  been  sustained. 

Paralysis  of  all  the  Muscles  Supplied  by  the  Recurrent 
Laryngeal  Nerves. — The  vocal  cord  assumes  the  "cadaveric  position,"  a 
term  first  \\>cd  by  v.  Ziemssen,  and  since  then  generally  adopted  to  denote  a 
position  half-way  between  the  median  line  (phonatory  position,  adduction) 
and  the  lateral  wall  of  the  larynx  (deep  inspiration  or  extreme  abduction). 
When  the  paralysis  is  complete  and  bilateral  the  voice  is  entirely  extin- 
guished, ami  it  is  only  by  a  great  effort  of  expiration  that  the  lax  vocal 
cords  are  thrown  into  vibration  and  a  hollow,  whispering  note  is  produced. 
Forcible  respiration  causes  the  arytenoid  cartilage-  to  tip  inward  at  their 
summits,  which  produces  :i  stridulous  sound.  When  there  is  no crico-thyroid 
paralysis,  or  only  partial  paralysis  of  some  of  the  muscles,  these  symptoms 
are  variously  modified. 

Bilateral  paralysis  of  the  recurrents  is  occasionally  caused  by  the  involve- 
nieiit  of  both  recurrent  nerves  in  cases  of  thyroid  or  esophageal  cancer  or 
aortic  aneurysms,  as  noted   b\    Mackenzie  and  others. 

Unilateral  paralysis  .-it  first  causes  entire  aphonia,  but  after  a  time  tin; 
unaffected  cord  will  be  seen  to  make  more  or  less  extensive  excursions  across 
the  median  line  to  meet  its  fellow,  with  the  result  of  producing  a  more 
audible  whisper  or  even  some  rough  phonatory  sounds.  There  is  no  dyspnea 
'•ither  in  bilateral  or  unilateral  recurrent  paralysis  when  complete ;  or  when 
partial,  except  in  cases  of  bilateral  abductor  paralysis.  Bilateral  recurrent 
paralysis  may  :it  lir-t  be  mistaken  for  the  functional  paralysis  of  the  adduc- 
tors in  hysteria,  but  a    more   careful  examination  will    -how   that    the  cords  do 

1  Histories  quoted  bj  Gottateiu,  '  Luc.  cil. 


.V/.77,'o,s7:,v  OF  THE  LARYNX.  1167 

not  move  on  forced  inspiration  ;  while  in  hysterical  paralysis  there  are 
jerky  movements  of  extreme  abduction,  or  in  some  cases  the}  maj  be 
immovable  against  the  external  laryngeal  wall,  leaving  a  much  wider  open- 
ing of  the  glottis  than   that    left    by  the  cadaveric   position  of  the  cords. 

Paralysis  of  the  Abductors  of  the  I^arynx. — When  bilateral,  both 
posterior  crico-arytenoid  muscles  being  completely  paralyzed,  the  patient 
withoul  immediate  help  dies  from  suffocation.  It  seems  to  me  exceedingly 
probable  that  many  sudden  deaths  from  cerebral  apoplexy  might  be  explained 
in  this  way.  The  stertorous  breathing  in  apoplectic  coma  lends  probability 
to  this  suggestion. 

The  eases,  however,  in  which  bilateral  paralysis  has  been  observed  laryn- 
goscopically,  have  been  those  principally  in  which  the  disability  came  on 
gradually  in  one  or  both  cords.  The  vocal  cords  are  seen  almost  in  apposi- 
tion throughout  their  length.  There  may  be,  however,  a  narrow  elliptic  slit 
between  them;  while  at  the  posterior  commissure  an  isosceles  triangle  is 
formed  on  inspiration.  This  is  due  to  the  relaxation  or,  when  present  on 
both  inspiration  and  phonation,  to  the  paralysis  of  the  interarytenoideus 
muscle  and  the  tensors  of  the  vocal  cords.  Notwithstanding  the  great  dyspnea 
in  these  cases,  phonation  is  not  materially  interfered  with,  because  the  vocal 
cords  are  constantly  in  the  phonatory  position. 

Treatment. — Tracheotomy  in  these  cases  is  indicated  to  avoid  impending 
suffocation.  In  my  case  and  in  others  procrastination  on  the  part  of  the 
patient  resulted  fatally.  Where  it  becomes  evident  that  the  patient  is  liable 
to  live  a  long  time  with  a  tracheotomy-tube,  the  question  arises  as  to  the  ex- 
cision of  the  vocal  cords.  This  has  been  suggested  by  Hope  and  strongly 
condemned  by  Semon.  It,  of  course,  should  only  be  done  as  secondary  to 
tracheotomy,  when  it  becomes  evident  that  there  is  to  be  no  recovery  of 
function.  The  patient  should  have  to  choose  between  the  extinction  of 
voice  and  the  necessity  of  wearing  a  tracheotomy-tube  indefinitely.  Judging 
from  examples  familiar  to  all  laryngologists,  we  might  expect  some  restora- 
tion of  voice  without  vocal  bands.  So  far  as  I  know,  this  procedure  has 
never  been  carried  out  in  man,  although  adopted  with  advantage  in  horses  as 
a  cure  for  roaring.  Division  of  one  recurrent  nerve  has  been  done  by  Ruault 
in  a  case  of  bilateral  abductor  paralysis,  in  the  hope  that  the  cord  would 
fall  back  to  the  cadaveric  position  ;  but  this  did  not  occur.  Probably  in  all 
these  cases,  after  a  varying  time,  the  adductors  become  atrophied  from  disuse 
a-  well  as  the  abductors;  but  the  arytenoid  joint  become-  stiffened  also  from 
disuse,  and  the  cord  is  immovable. 

Unilateral  abductor  paralysis  is  the  most  common  of  all  the  hypo- 
kinetic disturbances  of  the  laryngeal  muscles.  When  uncomplicated,  it  pro- 
duces neither  dyspnea  nor  dysphonia.  It  is  not  infrequently  a  surprising 
discovery  in  a  routine  laryngoscopic  examination — giving,  it  ma}  be,  the 
first  hint  of  a  thoracic  aneurysm,  or  possibly  proving  an  unsolvable  puzzle  to 
the  observer  when  he  seeks  its  causation. 

Paralysis  of  the  Adductors  of  the  Vocal  Cords  ( (  Hco-arytenoidi  i 
Laterales). — Bilateral  :  This  is  the  usual  manifestation  of  hysteria  in  the 
larynx.     It   is  distinguished  by  its  sudden  onset,  as  a  rule,  and   by  the  fact 

that  it  occurs   in  a  patient  who  nearly  always  presents  so other  sign  of 

hysteria  than  the  laryngeal  one.  Aphonia, occasionally  the  inability  to  whisper 
(apsithyria),  the  history  of  previous  attacks  which  suddenly,  from  some 
trifling  incident  or  from  no  assignable  cause  ceased,  make  the  condition  ;i 
tolerably  easy  one  to  recognize.  Sometimes  the  patient  i>  able  to  3ing,  bin  not 
to  use  a  conversational   tone;  and  various  other   phenomena  which  it  is  im- 


[168  NEUROSES  OF  THE   UPPER   AIR-PASSAGES. 

possible  to  reconcile  with  the  idea  of  an  essential  paralysis  are  helps  in  the 
diagnosis.  Various  theories  have  been  advanced  to  accounl  for  the  pathol- 
ogy of  the  affection.  Thus  Gerhardl  supposes  ii  to  be  of  cerebral  or  nerve 
(vagus  origin  because  it  is  occasionally  unilateral,  and  hence  beyond  the  con- 
trol of  the  will  ;  1  >ut  all  theories  to  explain  special  phenomena  in  hysteria 
are  of  little  value  until  an  acceptable  explanation  with  demonstrable  material 
proof  can  be  formulated  to  accounl  for  the  general  condition.  The  vocal 
cords  are  seen  to  be  widely  abducted,  so  trial  the  glottis  is  constantly  in  the 
inspiratory  position.  Sometimes  there  seems  to  he  a  concomitant  spasm  of 
the  abductors,  so  that  the  vocal  cords  disappear  in  the  lateral  larynx  walls. 

Paralysis  of  one  lateral  adductor  has  been  noted  by  .Mackenzie,  Donald- 
son, Stewart,  and  others.  Usually  this  rare  affection  is  caused  by  hysteria  or 
lead-poisoning.  Some  cases  are  recorded  as  due  to  reflex  trouble  in  the  nose. 
These  cases  have  not  been  sufficiently  studied  to  arrive  at  any  conclusion  in 
regard  to  differentiating  between  the  functional  cases  (hysteria)  and  those 
probably  due  to  some   material   lesion. 

Paralysis  of  the  arytenoideus,  the  transverse  or  central  adductor, 

usually  occur--  in  connection  with  that  of  the  other  muscles,  hut  is  sometimes 
noted  a-  occurring  alone,  when  larynu'oscopie  examination  shows  that  the  vocal 
cords  are  in  apposition  throughout  their  anterior  three-fourths  on  phonation, 
with  a  triangular  space  posteriorly.      Aphonia  is  more  or  less  complete. 

While  these  cases  usually  occur  in  connection  with  hysteria,  a  number  of 
cases  have  been  reported  where  they  seemed  to  result  from  acute  or  chronic 
catarrhal  affections  of  the  larynx.  Proust  and  Tissier's  monograph  has  the 
bibliography  to  L890.      few.  if  any,  cases  have  been  since  reported. 

Paralysis  of  the  Tensors  and  Adjusters  of  the  Vocal  Cords 
ith'-  external  tensor — crico-thyroideus ;  the  internal  tensor — thyro-arytenoi- 
deus  interims i. —  Paralysis  of  l/i<  superior  laryngeal  nerve  supplying  motor 
filaments  to  the  crico-thyroid  muscle  and   sensory  filaments  to   the   mucous 

membrane  is  a  ran currence.     Sometimes  only  the  external  or  muscular 

branch  seems  involved,  when  it  is  said  that  the  examining-finger  will  note 
the  relaxation  of  the  muscle  by  palpation  of  the  crico-thyroid  space.  This 
has  been  caused  by  traumatism  and  operations,  but  more  frequently  results 
from  diphtheria  (v.  Ziemssen).  When  resulting  in  total  anesthesia  of  the 
larynx  and  of  the  epiglottis,  greal  danger  arises  from  the  food  and  secretions 
entering  the  larynx.  When  this  i<  accompanied  by  paralysis  of  the  recur- 
rent, tin-  danger  is  -till  further  increased.  Mackenzie  relates  a  case  in  which 
suppurative  inflammation  of  the  cervical  glands  caused  paralysis,  apparently 
of  the  superior  laryngeal  nerve  alone  ;  while  Johnson  reports  a  case  following 
typhoid  fever.  According  to  the  account  given  by  Mackenzie,  the  vocal 
cords  when  adducted  assumed  at  their  line  of  junction  a  wavy  appearance 
with  :i  depression  ;it  the  center.  When  only  one  cord  is  affected,  it  is  seen 
;it    a    lower   level    than    the   other   side.       Hoarseness   and    aphonia    result. 

Mackenzie,  in  hi-  definition,  *ays  "  Paralysis  of  the  superior  laryngeal 
nerve  gives  rise,  when  complete  and  bilateral,  to  anesthesia  of  the  larynx 
and  loss  of  power  of  the  crico-thyroid,  thyro-epiglotHe,  mid  ary-epiglottic 
must-/,.--."  lie  further  says,  "  When  these  muscles  arc  paralyzed  the  closure 
of  the  larynx  during  deglutition  docs  nol  take  place,  the  glottis  remaining 
erect  and  againsl  the  rout  of  the  tongue."  'flu-  i-  incomprehensible,  a-  these 
latter  muscles,  so  far  as  I  have  been  able  to  gather  from  authorities  (Gray,Quain, 
Onodi),  are  intimately  associated  with  the  arytenoideus  muscle  and  supplied 
by  the  recurrent  nerve;  and  so  far  a-  I  remember  my  own  observations  of 
laryngeal   paralyses,  1  have  -ecu  this  position  of  the  epiglottis  in  connection 


Plate  i^. 


1.  Forced  inspiration. 


I 


position. 


l.  Moderate  adduction. 


5.  Phonatory  apposition 


6.  Bilatera]  paralysis  of  external 
tensors  i  Macken 


rpr 


7.  Bilateral   paralysis  of  internal 
thyro-arytenoids  and  arytenoid. 


I 


Paralysis  of  left  posterior  crico  9.   Bilatera]  para     •-■■!' l.-it- 

arytenoid,    inspiration.  era!  crico-aryienoids. 


10    I  eft  recurrent  paralysis 
Adduction. 


1 1    Bilatei  al  i  ecurrent 
y  si  s 


\li.i 


Semi-schematic  illustrations  of  the  glottis  in  health  and  in  di  • 


HYSTERIA    OF  THE  NOSE  AND   THROAT.  1169 

with  paralysis  of  other  muscles  supplied  by  the  recurrent.  The  passage  of 
food  into  the  larynx  in  connection  with  superior  laryngeal  paralyses,  I  should 
suppose  to  depend  more  upon  the  anesthesia  than  upon  the  loss  of  power  in 
these  muscles,  as  intimated  by  him.  This  is  a  point  to  which  I  have  been 
unable  to  find  any  reference  in  other  authors,  and  I  hesitate  to  make  the  criti- 
cism of  an  almost  faultless  text-book. 

Paralysis  of  the  thyro-arytenoidei  interni  muscles  alone  occurs  frequently 
as  the  result  of  -train  and  local  inflammation.  It  is  seldom  complete.  An 
elliptical  opening  of  varying  transverse  diameter  is  seen  on  adduction. 
Hoarseness  or  complete  aphonia  results.  Usually  resl  and  local  applications 
after  a  few  days  restore  the  function  of  the  cord-;  although  Mackenzie 
reports  a  case  in  which  it  was  paralyzed  for  three  year.-,  and  cured  in  three 
weeks  by  faradization. 

While  laryngeal  paralyses  have  been  treated  seriatim  and  separately,  it 
must  be  understood  that  in  the  peripheral  manifestation  various  combinations 

may  exist  which  alter  and  complicate  the  laryngoscopy  image,  due  to  the 
influences  of  synergistic  or  antagonistic  muscles. 

An  error  in  diagnosis  may  frequently  arise  in  mistaking  for  paralysis  the 
ankylosis  of  a  crico-thyroid  joint  due  to  inflammation,  or  the  inability  or 
limitation  in  a  vocal  cord  due  to  infiltration  of  the  muscle-  or  stroma  by 
tubercular,  syphilitic,  or  cancerous  disease,  or  to  the  existence  of  librous 
cicatricial  bands. 

Prognosis. — AVe  have  only  to  consider  the  prognosis  as  it  relates  to  the 
recovery  of  power  in  paralyzed  muscles.  Loss  of  function  due  to  essential 
lesions  is  rapidly  followed  in  the  small  laryngeal  muscles  by  fatty  degener- 
ation and  atrophy.  Complete  laryngeal  paralysis  from  these  causes,  when  it 
has  existed  for  several  months,  is  rarely  recovered  from,  as  pointed  out  by 
Elsberg1  many  years  ago.  Aside,  therefore,  from  irreparable  changes  in  the 
nerve-trunks  and  centers,  peripheral  changes  soon  render  a  cure  of  essential 
paralysis  unlikely. 

Treatment. — Indications  must  he  met,  as  they  arise,  to  preserve  the 
patient's  life  by  tracheotomy  or  intubation.  In  pareses  or  partial  paralyses, 
and  in  functional  paralyses  faradization  by  an  intralarvngeal  electrode  may 
be  of  advantage.  Prompt  removal  of  causes,  such  as  pressure  on  nerves 
or  inflammatory  processes,  may  re-tore  action  to  immobile  muscles  when  the 
trouble  has  not  resulted  in  too  much  degenerative  change.  The  -aim-  may 
be  said  of  central  syphilitic  lesions. 

HYSTERIA   OF   THE  NOSE  AND  THROAT. 

The  manifestations  of  hysteria  in  the  nose  and  throat,  as  elsewhere,  are 
of  such  infinite  variety  ami  shade  oil'-,,  gradually  into  essential  neuroses  and 
so-called  neurasthenia,  that  an  orderly  or  complet<  account  of  them  could  no! 
be  given,  if  every  case  reported  were  reviewed  ami  every  case  observed  were 
reported. 

Persistent  or  intermittent  complaint-  of  anosmia  or  parosmia  arc  made 
by  women  in  whose  noses  little  can  be  observed  that  is  abnormal.  How  to 
distinguish  these  cases  from  those  in  which  there  i-  essential  disturbance  of 
the  olfactory  apparatus  is  often  a  matter  of  greai  difficulty.  W  hen  I  see  a 
neurotic  woman  with  a  nasal  raucous  membrane  which  is  tolerably  healthy, 
and  yet  who  complain-  of  anosmia    persistently,  so  as   to   bring   it    to  my 

1  Phtia.  Med.  Times,  July  30,  1881. 

71 


11,1'  &EUBOSES  OF   THE   UPPER  AIM-PASSAGES. 

especial  notice,  I  always  think  it  i-  a  case  of  hysteria;  because  true  anosmia 
is  usually  complained  of  incidentally  by  patients  who  come  for  relief  of 
other  nasal  symptoms.  Reference  1  ia-  already  been  made  to  cases  who  com- 
plain "t*  subjective  sensations  of  obstruction  or  irritation  in  the  nose.  Here 
again  it  is  difficult  to  separate  the  elements  which  are  neurotic  it'  noi  h\  sterical. 
While  typical  cases  of  hysteria  differ  entirely  from  typical  cases  of  neuras- 
thenia, there  arc  so  many  on  the  border  line  between  the  two  that  one  fre- 
quently  hesitates  as  to  their  classification  exclusively  in  either  category. 

Hysterica]  affections  of  the  soft  palate  and  pharynx  are  mosl  frequently 
those  of  a  sensory  nature.  Occasionally  cases  will  be  observed  to  simulate 
paralysis;  but  essential  paralysis  involves  such  a  complex  series  of  disturb- 
ances in  deglutition,  respiration,  and  speech,  that  flaws  may  he  easily  detected. 

Hysterical  aphonia  has  attracted  more  attention  than  any  other  manifes- 
tation of  functional  trouble  in  the  larynx  ;  yet  we  find  simulation  of  almost 
every  form  of  neurosis.  Treupel  '  enumerates  laryngeal  spasm,  nervous 
cough,  inspiratory  functional  spasm  of  the  glottis,  phonatory  functional 
spasm  of  the  glottis,  hysterical  aphonia,  and  apsithyria,  or  hysterical  mutism. 
All  these  have  been  mentioned  in  the  preceding  pages,  and  lack  of  space 
forbids  any  more  extended  notice  of  them.  Local  disease  of  trifling  char- 
acter in  any  part  of  the  upper  air-tract  is  frequently  noted  as  a  cause  con- 
tributory to  the  general  neurotic  tendency.  While  it  is  usually  observed  in 
young  women,  it  is  by  no  means  unknown  in  children  or  in  people  of  advanced 
age,  and  i-  occasionally  observed  in  men.  Treupel's  work  deals  exhaustively 
with  the  subject  :  and  he  asserts  that  all  the  laryngeal  manifestations  which 

have  1 ii   observed   in  hysteria    may.  by  practice  in   the  healthy  person,  be 

reproduced  at  will.  Of  course,  patients  cannot  he  aware  of  the  positions  of 
the  vocal  cords  taken  in  response  to  their  impulses,  hut  they  can  reproduce 
by  their  sensations  states  in  which  these  phenomena  occur.  It  is  difficult, 
however,  to  explain  all  the  laryngeal  manifestations  by  this  hypothesis. 
Laryngeal  spasm  persisting  after  loss  of  consciousness  so  thai  death  ensues, 
i-  difficult   to  reconcile  with  the  idea  of  exclusive  control  by  the  will. 

Treatment. — Hysterical  affections  of  the  nose  and  throat  can  more  fre- 
quently  he  cured  by  suggestion  than  by  any  other  treatment.  The  methods 
of  doing  this  are  so  various,  and  each  one  so  often  fail-,  that  no  one  pro- 
cedure can  lie  considered  of  any  exceptional  value.  Ostensible  operations 
with  forceps  or  cautery,  or  application-  or  mere  examination-,  accompanied 
by  the  confident  statemenl  of  the  operator  a-  to  it-  immediate  efficiency,  will 
frequently  bring  about  a  prompt  disappearance  of  the  local  affection.     These 

maneuvers  will   v  frequently  succeed   in   the  unsophisticated   patient   on 

whom  similar  tricks  have  not  been  played  before.  Galvanism,  thai  magical 
tir-t  con-in  t<>  charlatanry,  is  a  potent  device  to  bring  aboul  the  desired 
impression  on  the  patient.  S«.  far  as  my  observation  goes,  all  such  phe- 
nomena are  more  frequently  benefited,  as  to  the  local  trouble,  by  individuals 
who-.'  faith  exceed-  their  scientific  attainments,  or  whose  effrontery  supplants 
their  scruples.  However  brilliant  may  he  the  immediate  results  of  a  decep- 
tion, condoned  by  the  ethic-  of  Plato,  it  i<  only  successful  a-  concerning  the 
immediate  form  of  the  neurosis,  and  doe-  nothing  for  the  general  vice  which 
lie-  behind,  and  I-  in  no  way  a  preventive  of  recurrence  of  the  same  trouble. 

The  treatment  must  he  on  the  broad  grounds  of  improving  the  general 
health  .nid  the  moral  tone  of  the  individual,  with  an  elimination  of  vicious 
influences — physical,  social,  and   psychical. 

K  hlktip/i  I'li   II  •    i,  Jena,    1895;  also  /.''  iin.   Klin. 

I'll'-  former tains  a  very  full  bibliography  of  laryngeal  hysteria. 


THE  VOICE— ITS    PRODUCTION    AND  HYGIENE. 

By   G.  HUDSON   MAKTJEN,  M.  D., 

OF    PHILADELPHIA,  PA. 


Voice  may  be  defined  as  a  moving  column  of  breath  set  in  vibration  In- 
ks own  impact  with  the  vocal  bands  and  reinforced  by  its  diffusion  through 
the  various  resonators  into  the  surrounding  atmosphere.  According  to  this 
definition  there  are  three  important  elements  to  be  considered  in  relation  to 
voice — namely,  the  moving  column  of  breath,  the  vocal  bands,  and  the  reso- 
nators.    We  shall  consider  these  elements  in  their  order. 

The  Moving  Column  of  Breath. — This  column  may  he  regarded 
as  having  the  diaphragm  for  its  base,  and  as  being  set  in  motion  by  the  re- 
spiratory muscles.  This  motor  process  has  been  called  the  breathing  of 
voice-production,  and  it  differs  from  ordinary  so-called  natural  breathing  in 
that  the  one  is  active  and  voluntary,  while  the  other  is  passive  and  auto- 
matic. Ordinary  breathing  is  simply  for  the  purpose  of  aerating  the  blood. 
The  breathing  of  voice-production  performs  this  function  only  incidentally, 
its  main  purpose  being  something  far  more  complicated  and  difficull  of 
execution.  The  large  thoracic  and  abdominal  muscles,  some  of  them  among 
the  strongest  in  the  body,  must  be  controlled  with  precision  and  accuracy. 
They  work  to  a  great  extent  in  pairs,  and  of 
these  pairs  the  one  muscle  opposes  the  other. 
For  instance,  the  contraction  of  the  diaphragm 
results  in  a  protrusion  of  the  abdominal 
wall-  (Fig.  n'<>4),  and  the  strength  of  this 
protrusion  depends  upon  the  force  of  the  con- 
traction, which  may  be  made  very  great.  This 
outward  motion  of  the  abdominal  walls  is 
checked  by  the  contraction  of  the  abdominal 
muscles,  which  oppose  in  their  action  that  of 
the  diaphragm.  In  a  similar  way  the  costal 
muscles  oppose  each  other,  one  set  tending 
to  elevate  the  ribs  and  the  other  to  depress 
them.  Tims  the  vocalist  utilizes  in  breath- 
ing the  principle  of  opposition  of  forces,  by 
means  of  which  perfect  equilibrium  of  the  va- 
rious organs  is  maintained,  and  ureal  strength 

1> imc-    compatible    with    greal    delicacy    of 

action. 

Very  little  breath  is  required  for  the  pro- 
duction of  tone,  and  the  function  of  the  re- 
spiratory   muscles     i-     not     SO    much    to    force 

breath  out  of  the  lung-,  :i-  to  -n-tain  and  con- 
trol the  breath  in  the  lungs  and  to  give  (<>  the 
thorax  a  certain  drum-like  ten-ion   which  i-  very  i  ssential  i"  ■■>  >,  sonanl  and 
well-balanced    voice.      Jusi    a-    the    drm ir    tighten-    hi-   drum-strings, 

1171 


•  h  ami 
phragm 
'iii>  abdominal  mm    i  - 


1 1  72 


THE    VOICE— ITS  PRODUCTION  AND   HYGIENE. 


so  tin1  vocalist  contracts  his  thoracic  and  abdominal  muscles.  This  may 
be  best  explained,  perhaps,  by  describing  the  muscular  action  in  the  pro- 
duction of  a  single  prolonged  tone.  There  are  two  distinct  processes  :  first, 
that  of  preparation,  and  second,  that  of  actual  tone-making.  The  preparatory 
process  is  similar  to  that  which  naturally  takes  place  just  prior  to  any  other 
muscular  act,  as,  lifting  a  weight  <>r  striking  a  blow.  There  is  a  slight  inspi- 
ratory movement  caused  by  the  contraction  of  those  muscles  the  function  of 
which  is  to  elevate  the  ribs.  The  diaphragm  should  have  no  part  in  this 
action,  for  it-  contraction  depresses  the  ribs,  and  therefore  it  must  he  con- 
sidered as  an  expiratory  muscle.  The  second  process,  or  that  of  production 
of  tone,  now  follows,  and  consists,  not,  as  many  would  have  us  suppose,  in  a 
complete  relaxation  of  these  inspiratory  muscles,  allowing  the  ribs  to  fall  to 
their  original  position,  hut  in  a  continuation  of  this  tension  and  a  simultane- 
ous and  stronger  contraction  of  the  expiratory  muscles.  The  strength  of 
this  latter  contraction  should  he  proportionate  to  the  strength  of  the  desired 
tone  and  to  the  amount  of  breath  which  it  requires. 

Thus  we  have  to  deal  with  two  distinct  sets  of  muscles;  one,  the  inspira- 
tory, tending  to  elevate  the  ribs,  and  the  other,  the  expiratory,  tending  to 
depress  them.  It  is  the  nice  adjustment  of  these  opposing  forces  that  gives 
to  the  thorax  that  degree  of  tension  upon  which  the  accuracy  of  breath- 
control  and  the  consequent  equilibrium  and  smoothness  of  the  voice  so  much 
depend;  and  it  is  the  education  of  these  muscles  which  constitutes  the  first 
-tip  in  the  cultivation  of  either  the  speaking  or  the  singing  voice.  So  tar  as 
possible,  each  muscle  must  be  brought  under  perfect  control  and  trained  to 
respond    promptly  and  accurately  to  an  intelligent   volition. 

The  Vocal  Bands  (Fig.  665). — These  hands  correspond  to  the  strings 
of  the  violin.  They  arc  composed  of  small  elastic  threads  of  yellow  fibrous 
tissue,  and  are  from  otic-half  to  three-quarters  of  an  inch  in  length,  longer 
in  the  male  than  in  the  female,  and  situated  in  the  larynx,  or  voice-box, 
SO  culled  because  it  encloses  and  protects  these  essential  organs  of  voice 
(Fig.  o4l2).      The  framework  of  this  box  is  composed  of  cartilage,  a  material 

more  flexible  than  hone,  yet  more  rigid 
than  muscular  or  ligamentous  tissue. 
These  cartilages,  nine  in  number — the 
thyroid,  the  cricoid,  the  two  arytenoids, 
the  two  eornicitla  larynges,  the  two  cune- 
iform cartilages,  and  the  epiglottis — artic- 
ulate with  one  another  by  means  of  freely 
movable  joints,  and  they  arc  held  to- 
gether by  numerous  ligaments  and  con- 
trolled by  still  more  numerous  muscles. 
It  is  the  motion  imparted  to  the  carti- 
lages by  these  muscles  which  serves  not 
only  to  place  the  vocal  bands  in  the 
phonating  position,  bu1  also  to  give  them 
the  necessary  degree  of  length,  weight, 
and  tension.  The  arytenoid  cartilages, 
to    which    the    vocal    bands   are   attached 

teriorly,  are  freely  movable  al   their  point-  of  articulation  with  the  cri- 
coid cartilage,  and  they  are  made  to   rock   and  revolve  upon  these  points 
666)   l>\    means  of  various   -<t-  of   muscles.     The  same   principle  of 
opposing  forces  applies  here  :i-  in  the  management  of  the  muscles  controlling 
the  column  of  breath.     The  contractu f  one  sel  of  muscles  tend-  to  revolve 


^jS&fe? 


A/ujcularTtocei} 
Arytenoid 

Meat  ^^^-V^HH 


TJLyro.  Viytenoih} 


i  the  larynx,  siinw  trig 

the  vocal  cordB  in  relal ion  l< 

ctor,  abductor   and  tensor  mus- 


77//';   VOCAL  BANDS. 


1 1 73 


the  cartilages  in  an  inward  direction,  thus  approximating  the  vocal  band-  ; 
and  the  contraction  of  the  opposing  set  tends  to  revolve  them  in  an  outward 
direction,  retracting  the  hands  and  opening  the  glottis. 

The  lateral  crico-arytenoids  and  the  arytenoid  combine  in  their  action  to 
close  the  glottis,  and  their  opposing  muscles,  the  posterior  erico-arytenoids, 
tend  to  dilate  the  glottis;  and  it  is  by  the  nice  adjustment  of  these  forces 
that  the  vocal  bands  may  be  made  to  assume  any  position  from  that  of  close 
apposition  to  the  sides  of  the  larynx  to  that  of  close  approximation  in  the 
median  line,  or  even  partial  overlapping  of  the 
posterior  edges,  thus  shortening  the  vibrating  sur- 
face. When  the  vocal  bands  thus  approach  approx- 
imation, with  only  a  narrow  chink  between  the  thin 
edges,  their  degree  of  tension  is  determined  in  the 
following  manner  :  The  thyroid  cartilage,  to  which 
the  vocal  bands  are  attached  anteriorly,  is  freely 
movable  at  its  points  of  articulation  with  the  cri- 
coid, and  its  tilting  forward  upon  the  cricoid  tends 
to  remove  it  farther  from  the  arytenoids  (Fig.  tiiio'), 
and  thus  to  make  tense  the  vocal  bands  and  also  to 
elongate  and  attenuate  them  (Fig.  504).  The  forward 
tilting  of  the  thyroid  cartilage  is  accomplished  in 
part  by  the  crico-thyroid  muscle,  but  chiefly  by  a 
muscle  extrinsic  to  the  larynx,  the  sterno-thyroid. 
The  muscles  opposing  this  downward  and  forward 
movement  of  the  thyroid  cartilage  are  the  thyro- 
hyoid and  thyro-arytenoid  (intrinsic  muscles)  and  the 
styh-hyoid  and  digastric  (extrinsic  muscles).  The 
importance  of  these  extrinsic  muscles  of  the  larynx 
is  not  generallv  understood.  In  addition  to  controlling  the  degree  of  ten-ion 
of  the  vocal  bands,  they  serve  to  fix  the  larynx  firmly  against  the  cervical 
vertebra?  during  the  emission  of  strong  resonant  tones. 


Fig.  666— Diagram  of  the 
thyroid  cartilage  tilting  upon 
th.<  cricoid  and  stretching  the 
\  oca!  cords. 


Fig.  667.-  Seel  Ion  of  the  larynx  a1  right 
angles  to  the  vocal  bands:  01.  glottis;  Th, 
thyroid;  If, thyro-arytenoid   (Mucki 


Fig.  668.  Schematic  representation  of 
band,  showing  the  thyro-arytenoid  muscle 
ii  send*  11    i>i,.  i    Into  the  bodj  ofthe  band  " 


and  " haw 
(Muckey). 
u  hen  it  is 
finally,  tor 


When  this  muscle  Is  bu1  slightly  contracted  the  band  maj  ?il  backasr;  bul 

more  ami  more  contracted  the  extent  of  a  Ibration  Is  limited  first  to  the  poinl    ,  then  to  (,  until 
the  highest  notes,  only  the  pari  between  u  and  the  edge  Ql  Is  allowed  ; 

The  thyro-arytenoid  muscles  also  serve,  by  means  of  their  intimate  rela- 
tion with  the  vocal  bands,  to  limit  the  amounf  of  their  lateral  vibrating 
surface  and  to  adjust  the  lips  of  the  glottis  (  Figs.  667,  668). 


117  1  THE    YOKE—ITS  PRODUCTION  AXD  HYGIENE. 

Id  the  untutored  larynx  and  throat  these  muscles  are  practically  invol- 
untary, and  may  perform  their  function  very  imperfectly  ;  but  in  the  process 
of  the  cultivation  of  the  voice  many  of  them  may  be  brought  under  control 
of  the  will  and  thus  trained  to  perform  their  function  with  greater  efficiency. 
A  laryngoscopic  image  of  the  larynx  -hows  the  vocal  hands  to  be  slightly 
separated  posteriorly  during  ordinary  breathings  and  widely  separated  and 
flattened  out  againsl  the  sides  of  the  larynx  during  deep  breathing  (Fig.  541). 
The  extent  of  the  separation  depends  upon  the  action  of  the  abductor  mus- 
cles, which  turn  the  arytenoids  outward.  When  the  adductor  muscles — those 
which  turn  the  arytenoid  cartilages  inward — contract  and  the  abductors  re- 
lax, the  hands  come  together  in  the  median  line  and  shut  off  all  communica- 
tion between  the  trachea  and  the  pharynx.  This  always  takes  place  immedi- 
ately before  the  act  of  coughing  or  clearing  the  throat.  But  when  the 
abductor  muscles  contract  in  conjunction  with  the  adductors,  the  arytenoids 
become  nicely  poised  upon  their  pivots,  turning  one  way  or  the  other  by  a 
minute  traction  of  an  inch,  as  the  vocal  bands  are  required  to  be  separated 
or  approximated.  It  has  been  estimated  that  as  slight  a  change  as  one-seven- 
teen-thousandth of  an  inch  is  necessary  to  produce  the  wonderfully  minute 
variations    in    pitch   of  which    some  of  our   noted   singers  are   capable. 

The  Resonators. — Strictly  speaking,  the  whole  body  is  a  resonator 
of  the  voice;  and  not  only  so,  but  the  platform  upon  which  the  speaker  or 
the  singer  stands,  and  the  house  in  which  that  platform  is  built,  are  all  in  a 
certain  sense  resonators  of  the  voice.  The  chief  resonators,  however,  and 
those  which  contribute  mosl  to  the  individual  characteristics  of  the  voice  and 
to  it-  reinforcement, are  the  thorax,  the  trachea,  the  larynx,  the  pharynx,  and 
the  oral  and  oasal  cavities  with  their  contiguous  structures. 

The  thorax,  although  not  always  so  regarded,  is  one  of  the  important 
resonanl  organs.  The  column  of  breath,  resting  as  we  have  shown  upon  the 
diaphragm,  receives  vibrations  from  the  vocal  bands  in  the  same  way  that 
the  aii-  above  the  band-  receives  vibrations;  and  when  the  ribs  are  slightly 
elevated  and  the  muscles  taut,  the  thorax  becomes  tensioned  like  a  drum,  and 
add-  in  the  voice  a  peculiarly  characteristic  and  pleasing  quality. 

fhe  trachea  is  also  an  important  resonator,  and  it  is  so  constructed  that 
the  trained  vdcalist  can  increase  or  diminish  its  size  both  longitudinally  and 
transversely,  thus  making  it  equivalent  to  a  series  of  organ-pipes.  It  is  for 
this  reason,  and  because  of  the  bellows-like  function  of  the  lun^s,  that  the 
Vocal   mechanism  i-  -aid  to  resemble  that  of  the  pipe-organ  (see  page  843). 

The  larynx  it-elf  probably  has  more  to  do  with  determining  the  quality 
of  voice  than  any  other  pari  of  the  mechanism.  Its  size  varies  greatly  in 
different  individual-,  ami  thi-  variation  is  the  chief  cause  of  the  wide  differ- 
ences in  the  qualities  of  voices.  One  illustration  of  this  fact  may  be  found 
in  the  marked  change  which  takes  place  iii  the  male  voice  at  puberty.  With 
the  iin  rea-.'  in  size  and  density  of  the  various  parts  of  the  larynx  we  have  a 
sudden  change  in  the  quality  of  voice.  The  thin,  childish  treble  grows  into 
the  heavy  baritone  or  bass ;  and  the  transition  stage  is  an  important  one,  and 
should  be  treated  with  greal  care.  Many  a  voice  is  injured  irreparably  by 
overwork    at    thi-    period.       Another    illustration  of   the  manner    in   which   the 

of  the  larynx  determines  the  quality  of  voice  is  found   in  comparing  tin' 
ami    female    Iarynge8   and  voices.       In    almost    exact    proportion    as   the 

female  voice  i-  lighter  and  more  flexible  than  i  he  male  voice,  will  the  various 
par  of  the  female  larynx  be  found  to  be  lighter  ami  more  flexible  than 
those  of  the  male  larynx.  (  M'  course,  the  differences  in  the  other  resonators 
contribute  somewhat    t<>  these  distinguishing  characteristics,  but    the  chief 


THE  RESONA  TONS. 


1  I  75 


cause  exists  in  the  laryngeal  variations.  The  ventricles  of  the  larynx — two 
depressions  immediately  above  the  vocal  bands  and  parallel  with  them — and 
the  ventricular  bands  situated  immediately  above  the  ventricles,  influence  the 
voice  mainly  by  governing  and  directing  the  stream  of  vocalized  breath  after 
it  leaves  the  glottis.  The  ventricles  unite  to  form  a  little  vestibule,  the 
entrance  to  which  is  the  chink  of  the  glottis,  or  the  space  between  the  lips  or 
edges  dt'  the  vocal  bands;  and  the  exit  is  the  .-pace  bounded  by  the  corre- 
sponding thicker  edges  of  the  ventricular  hands.  During  its  entrance  into 
the  vestibule  the  breath  is  set  in  vibration  or  vocalized;  this  vocalized 
breath  transmits  its  vibrations  to  the  air  already  in  the  vestibule;  and  these 
vibrations  are  directed  out  through  the  ventricular  exil  into  the  upper  larynx, 
the  pharynx,  and  the  mouth.  The  position  of  the  larynx  also  has  much 
influence  on  the  voice.  It'  it  be  held  firmly  fixed  againsl  the  spine  by  the 
extrinsic  muscles,  the  vocal  resonance  will  be  greatly  increased.  The  entire 
spinal  column   may   thus   become  a   resonator  of  the   voice. 

We  now  come  to  a  consideration  of"  the  pharynx  as  a  vocal  resonator.  It 
is  a  funnel-shaped  muscular  bag  with  seven  openings,  and,  like  the  mouth,  it 
forms  an  important  part  of  the  alimentary  canal,  with  the  opening  into  the 
esophagus  at  its  lower  and  posterior  portion.  The  size  and  shape  of  the 
pharynx,  however,  and  its  general  physical  condition  are  important  elements 
in  the  formation  of  voice.  The  posterior  wall  of  the  pharynx,  a  portion  of 
which  may  he  seen  by  direct  inspection  through  the  mouth,  is  well  adapted 
in  its  construction  to  gather  the  sound- 
waves as  they  are  reflected  from  the 
epiglottis,  and  project  them  forward 
beneath  the  soft  palate  against  the  firm 
sounding-hoard  formed  by  the  hard 
palate  and  the  teeth.  ( Joveringthe  solid, 
bony  framework  of  the  posterior  wall 
of  the  pharynx  we  have  the  constrictor 
and  palatopharyngeal  muscles,  which 
by  their  numerous  contractions  serve 
so  to  shape  the  reflecting  surface  that 
the  vocalized  breath  may  he  directed 
toward  any  desired  point.  The  train- 
ing of  these  pharyngeal  muscle-  forms 
a  very  important  [tart  of  the  work  of 
the  vocal  teacher;  ami  the  care  of  the 
mucous  membrane  in  this  region  is  of 
the  utmost  importance  to  the  voice. 
Inflammatory  adhesions  and  thicken- 
ings act  in  various  way-  to  injure  the 
voice.  They  encroach  upon  the  size 
of  the  pharyngeal  space, they  interfere 
with  the  free  action  of  the  muscles 
which  have  been  mentioned,  and  they 
transmit    to    the    larynx   and    trachea 

their  deleterious  influence  both  by  force  of  gravity  and  by  continuity  of'  struct- 
ure. That  the  condition  of  the  pharyngeal  vaull  is  an  importanl  factor  in 
the  resonance  of  the  voice  is  shown  bv  the  marked  change  which  take-  place 

in  the  character  .,1'  tune  whenever  tlii-  -pace  i-  encroached   upon  l>\    glandular 

or  other  hypertrophy.  A.denoid  vegetations,  for  instance,  on  accounl  of  their 
peculiar  moist   and  spongy  consistency,  serve  to  damp  the  voice  and  destroy 


Pig.  669.    Diagn f  the  course  of  Bound- 

uu\ ea  reflect  i  piglottis  to  the  pharynx- 

wall,  1 1 1 >  to  the  palate,  and  thence  out  "i  the 
mouth. 


1176 


THE    VOICE— ITS  PRODCCTIOX  AM)   HYdlENE. 


the  resonance  that  comes  from  this  region.     The  posterior  pharyngeal  wall 
(Fig.  670)  ascends  vertically  to  a  point  about  on  a  level  with  the  floor  of  the 


Fig.  670.— Section  of  the  parts  concerned  in  phonation,  and  the  changes  in  their  relations  in  sound- 
in-  thevowels  A  .  /  ee),  U{oo)  (after  Landois  and  Stirling):  T,  tongue ;  p,  palate ;  e,  epiglottis  ;  g, 
glottis  ;  h,  hyoid  bone;  1,  thyroid;  2,  3,  cricoid  ;  i.  arytenoid  cartilage. 


nose,  and  then  gradually  inclines  forward,  making  a  graceful  curve  over  to  a 
point  ju-t  above  the  choanae.  The  shape  of  this  portion  of  the  pharynx  has 
been  imitated  in  nearly  all  the  artificial  sounding-boards,  whether  constructed 
for  the  reflection  of  the  voice  or  of  the  sounds  of  other  musical  instruments. 

h  is  the  function  of  the  soft  palate  and  the  uvula  to  act  as  a  kind  of  valve 
controlling  the  sound-waves  and  directing  them  either  up  through  the 
pharyngeal  vault  into  the  nostrils  when  the  palato-glossi  muscles  contract 
and  diminish  the  size  of  the  fauces,  or  out  through  the  fauces  into  the  mouth 
when  the  palato-pharyngei  muscles  contract  and  draw  the  palate  hack  toward 
the  pharyngeal  wall,  diminishing  or  cutting  off  entirely  the  passage-way  to 
the  post-nasal  -pace.  These  to-and-fro  and  up-and-down  movements  of  the 
soft  palate  during  articulation  are  well  demonstrated  by  a  very  ingenious  in- 
strument devised  by  the  late  I>r.  Harrison  Allen.  It  consists  of  a  moderately 
stiff  wire  passed  along  the  floor  of  the  nostril  until  the  distal  end,  which  is 
slightly  curved  downward,  rests  upon  the  soft  palate.  The  proximal  end  is 
placed  againsl  a  revolving  cylinder,  and  upon  its  prepared  surface  the  up-and- 
down  movements  of  the  palate  are  accurately  traced.  This  device  furnishes 
a  valuable  aid  to  the  study  of  an  important  part  of  the  oral  mechanism. 
The  nasal  chambers  themselves  and  their  communicating  cavernous  hones 
contribute   much  to  the  agreeable  quality  of  the  speaking  voice,  the   nasal 

element   being  essential  to  the  fullesl  and  richest  t is.     For  the  sustained 

tones  of  th<'  singing  voice  the  palatal  and  pharyngeal  muscles  are  tense,  and 
the  soft  palate  i-  held  fixed  againsl  the  pharyngeal  wall,  the  sound-waves 
being  directed  entirely  through  the  mouth.  This  tense  condition  of  the 
palate  is  necessary  in  order  that  the  palato-pharyngei  and  other  extrinsic 
muscles  of  the  larynx  may  perform  their  function.  It  is  these  variations  in 
the  size  and  shape  of  the  vocal  organs  which  determine  the  character  or 
timbre  of  tone  and  distinguish  one  voice  from  another.  There  are  no  two 
voices  alike,  any  more  than  there  are  two  faces  or  two  leaves  on  the  trees 
alike.  People  are  recognized  by  their  voices  as  they  are  by  their  faces,  and 
there  are  certain  distinguishing    characteristics  in  both  which  may  not    be 

■  _v'l.      Not   all  voices  may  become  great  voices  any  more  than  all  faces 

ma;   be< e  beautiful  one-;  bul  all  voices  may  be  improved  by  training,  as 

all  faces  may  be  improved  by  care  and  cultivation. 

of  these   resonators  of  the   voice,  such  as  the  lip-,  the  teeth,  the 

tongue,  the  soft  palate,  the  pharj  nx,  and  even  the  upper  part  of  the  larynx. 

rded  as  belonging  to  an  entirely  different  mechanism — viz..  thai 


Till:  HYGIENE  OF  THE    VOICE.  1177 

of  articulation.  We  have  considered  the  voice-producing  organs \  these  are 
the  speech-producing  organs.  The  organs  of  voice  manufacture  the  sound, 
and  the  organs  of  speech  articulate  it.  The  mechanism  of  articulation  is  as 
important  as  thai  of  phonation  to  the  singer  as  well  as  to  the  speaker;  and 
these  two  mechanisms  musl  work  together  in  perfecl  harmony  it'  we  would 
have  good  speech  au>l  good  song.  The  articulation  of  the  singing  voice 
liffers  in  no  respect  from  that  of  the  speaking  voice.  It  consists  simply  in 
the  moulding  of  sounds  into  syllables  and  words  which  mean  something  to 
the  ear,  whether  they  be  the  sounds  of  speech  or  of  song. 

The  palate  is  probably  the  most  important  organ  of  articulation.  Fairly 
intelligible  speech  has  been  shown  to  be  possible  without  a  tongue,  but  the 
lip-  and  teeth  could  more  easily  be  dispensed  with.  Furthermore,  the  larynx 
and  lungs  are  not  absolutely  indispensable  to  the  production  of  tone,  as  has 
been  proved  by  at  least  one  person  who  can  -peak  and  even  singwithout  any 
larynx  and  with  the  lungs  entirely  cut  oil*  from  the  pharyngeal  and  oral 
cavities.  Not  all  persons,  however,  would  learn  to  speak  without  a  tongue 
"1-  without  a  larynx.  Endeed,  most  people -peak  badly  enough  who  are  not 
thus  handicapped;  and  it  is  interesting  to  uotice  how  slight  a  deviation  from 
the  normal  in  some  of  these  organs  will  result  in  the  most  glaring  defects 
of  speech.  All  irregularities  of  the  vocal  and  speech  organs,  whether 
acquired  or  congenital,  should  be  corrected  a-  early  in  life  a-  possible,  before 
the  habits  of  speech  are  fully  formed. 

The  Hygiene  of  the  Voice. — The  hygiene  of  the  voice  include-  the 
hygiene  of  the  whole  physical  organism,  for  there  is  scarcely  any  portion  of 
the  body  which  is  not  related  directly  or  indirectly  to  the  mechanism  of  the 
voice.  Disease  of  any  kind  is  reflected  in  the  voice  as  clearly  and  a-  unde- 
niably as  in  the  face,  and  the  cheerful  ringing  tones  of  exuberant  health  are 
known  to  us  all.  Therefore,  whatever  contributes  to  the  well-being  of  the 
physical  organism  contributes  also  to  the  well-being  of  the   voice. 

It  is  a  mooted  question  among  specialists  whether  catarrh  of  the  stomach 
is  the  cause  of  catarrh  of  the  upper  respiratory  and  vocal  passages,  or  whether 
catarrh  of  these  passages  is  the  cause  of  catarrh  of  the  stomach.  This  much 
we  know,  that  the  pharyngeal  and  oral  cavities  are  continuations  upward  of 
the  alimentary  canal,  and  are  lined  with  the  same  membrane ;  that  the 
color  and  general  condition  of  the  tongue  are  clear  indication-  of  the  condi- 
tion of  the  stomach  below.  A  coated  tongue  mean-  .1  coated  stomach,  and, 
if  I  may  use  the  expression,  a  coated  voice.  The  care  of  the  digestion,  then, 
i-  'if  the  first  importance  to  the  vocalist,  both  because  of  its  direct  influence 
upon  the  organs  of  voice  and  because  of  its  indirect  influence  through  the 
circulatory  and  nervous  systems.  Strong  healthy  nerves  are  essential  to  a 
good  voice.  .-Hid  these  nerves  are  dependent  upon  good  blood  properly  circu- 
lating; and  this,  in  turn,  is  dependent  upon  good  digestion,  and  this  upon 
good  food  thoroughly  masticated.  Article-  of  food  affect  the  voice  also  by 
direct  contact  with  the  organs,  and  therefore  highly-seasoned  and  stimulating 
food  should  be  avoided.  Tea,  coffee,  liquors,  and  the  after-dinner  cigar  may 
injure  the  voice  in  the  same  way,  and  can  be  beneficial  only  when  they  offsel 
these  deleterious  effects  by  assisting  in  the  digestion  of  nourishing  foods. 
\o  absolute  rule  can  be  laid  down  regulating  the  diet  of  individuals,  for 
what  i<  food  for  one  i-  poison  for  another.  Someone  ha-  well  -aid  thai  ev<  r\ 
man  over  forty  years  of  age  should  be  his  own  physician  a-  fur  a-  diet  i- 
concerned,  and  I  would  place  the  age  limit  ten  years  earlier.  The  man  who 
cares  more  for  hi-  stomach  than  for  hi-  voice  will  never  make  a  greal  singer 
or  a  great  speaker.     The  vocalist  musl  eat  to  live,  ami  u<\  live  only  to  eat  ; 


1178  THE    VOICE— ITS  PRODUCTION  AND   HYGIENE. 

and  no  little  self-denial,  in  this  and  in  other  respects,  ts  the  price  which 
must   be  paid  for  a  well-preserved  voice. 

Madame  Patti  has  said  that  a  draught  of  air  has  always  been  the  dread 
of  her  life.  The  cutaneous  surface  of  the  body  should  be  classed  among  the 
organs  of  respiration.  Indeed,  ii  has  been  called  the  "outer  lungs,"  on 
nit  of  it-  absorbing  and  eliminating  capacity.  The  skin  should  be  kept 
active,  therefore,  by  suitable  exercise  and  judicious  bathing.  General  exer- 
cise should  never  be  carried  to  the  point  of  fatigue,  lesi  it  result  in  the  need- 
le— expenditure  of  thai  vital  energy  which  is  so  necessary  to  the  working  of 
the  vocal  mechanism,  and  in  the  abnormal  development  of  certain  muscles, 
which  prevents  that  harmonious  action  and  nice  adjustment  and  co-ordination 
so  essentia]  in  the  management  of  the  vocal  machinery.  The  matter  of 
bathing  should  also  receive  careful  attention.  Many  people  bathe  too  much, 
and  many  more  bathe  too  little.  It  should  he  remembered  that  the  hot  hath 
extract-  heat  from  the  body,  and  heat  is  onlj  another  word  for  energy.  Only 
the  very  vigorous  should  take  frequent  hot  baths,  and  they  should  he  taken 
only  upon  retiring.  The  cool,  daily  plunge  may  he  indulged  in  to  advantage 
by  many;  but  perhaps  the  cold  hand-  or  sponge-bath,  both  morning  and 
evening,  is  fetter  for  the  average  person.  The  feet,  the  tipper  chest,  the 
neck,and  the  face  should  he  hardened  by  frequent  cold  douches.  These  parts 
arc  the  vulnerable  ones  in  the  singer  and  speaker. 

A-  t>>  the  matter  of  dress,  I  am  inclined  to  think  that  the  less  dress  the 
better.  As  some  one  has  said,  "  .Man  is  not  by  nature  a  clothed  animal." 
Whole  races  have  been  swept  from  the  face  of  the  earth,  with  not  one  left  to 
tell  the  tale,  because  they  were  compelled  by  their  conquerors  to  wear  clothe-. 
I  leavv  winter  flannels,  which  may  not  be  changed  to  suit  the  conditions  of  the 
moment,  arc  positivel}  contraindicated  because  they  interfere  with  the  breath- 
ing of  the  outer  lungs.  In  other  word.-,  they  interfere  with  the  natural 
functions  of  the  skin,  throwing  its  work  upon  the  mucous  membrane  or 
"inner  skin,"  as  it  has  been  called.  The  natural  result  of  this  overwork 
of  the  mucous  membrane  i-  congestion,  with  all  its  deleterious  effects  upon 
the  voice.  We  say  we  have  "taken  cold  ;"  but  "cold1'  doe-  not  express  it 
any  more  than  would  "  heat  "  or  "  indigestion,"  for  either  is  probably  a  more 
frequent  cause  of  the  condit ion. 

Voice-training. — This  brings  us  to  the  training  of  the  voice,  which  is, 
after  all,  the  most  practical  pari  of  our  subject.  "There  are  method-  and 
method-,"  as  some  one  has  said,  "and  there  is  good  in  every  one  of  them, 
but  no  one  of  them   has  ;i   monopoly  of  the  good." 

Method-  have  their  origin  in  the  necessities  of  certain  cases.  We  are  too 
apt  to  reason  in  this  way  :  My  method  eradicated  my  faults  in  vocalization 
ami  developed  my  voice  to  it-  present  magnificent  proportion  ;  therefore  it 
will  eradicate  your  fault-  and  develop  your  voice, — forgetting  that  no  two 
of  ii-  are  exactly  alike,  ami  that  my  faults  arc  not  necessarily  your  faults, 
nor  i-  my   voice  your  voice. 

I  <1< t    believe,  therefore,  in  so-called  methods  for  the  training  of  the 

voice,  any  more  than  I  believe  in  iron-clad  rule-  for  the  treatment  of  disease. 
Quinin  i-  a  good  thing  for  miliaria,  but  not  every  case  of  malaria  may  take 
quinin.  The  vocal  teacher  should  use  methods  just  as  the  skilled  physician 
H-.  -  emedies.  He  should  Btudy  the  necessities  of  the  case,  he  should  make 
a  thorough  diagnosis,  if  you  please,  of  the  conditions  a-  they  exist,  and  then 
decide  upon  hi-  plan  of  procedure,  thus  putting  \ocal  training  upon  ;i  scien- 
tific basis.  This  necessitates  a  thorough  knowledge  of  the  organs  involved,  and 
of  their  function-,  both   natural  ami  special.     The  physical  training  of  the 


VOICE-TRAINING.  1179 

voice,  reduced  to  its  final  essence,  consists  in  the  development  and  specializing 
of  certain  definite  muscles.  This,  of  course,  can  be  carried  to  its  highesl 
perfection  only  when  there  is  a  corresponding  psychical  development.  Tin- 
one  stimulates  the  other,  and  it  is  a  question  which  takes  precedence  in  the 
evolution  of  the  singer  or  speaker.  Written  rules  for  the  training  of  the 
voice  are  impracticabli — one  must  have  the  living  teacher,  the  choice  of 
whom  should  be  made  with  great  care,  for  more  harm  than  good  is  often  done 
by  bad  teaching. 

The  ear  is  also  an  important  factor  in  the  training  of  the  voice.  It  must 
be  taught  to  stand  guard  over  even-  tone,  to  become  a  fair  and  unprejudiced 
critic,  exacting  to  the  last  degree.  Defective  hearing,  therefore,  is  one  of  the 
greatest  obstacles  to  vocal  development.  The  man  who  cannot  see  his  faults 
will  rarely,  if  ever,  eradicate  them  ;  and  every  man  must  perceive  his  vocal 
imperfections  through  the  medium  of  the  ear.  Therefore  the  greatest  care 
should  be  taken  to  preserve  the  functions  of  this  organ.  Acute  inflamma- 
tions of  the  ear  should  be  promptly  attended  to  by  the  -killed  aurist  ;  and  at 
the  first  intimation  of  uneasiness  in  the  ear,  or  beginning  deafness,  profes- 
sional advice  should  be  sought — for  then,  if  ever,  can  the  hearing  be  saved. 
An  ounce  of  prevention  at  this  time  is  worth  a  ton  of  cure  later  on.  The 
cause  of  deafness  is  often  traced  to  some  catarrhal  trouble  in  the  nose  or 
throat  ;  and.  fortunately,  the  vocalist  generally  discovers  this  trouble  before 
the  ear  becomes  seriously  affected. 


OPERATIONS  UPON  THE  AIR-PASSAGES. 


By  JOHN  O.  ROE,  M.  D., 

OF    ROCHESTER,    N.    Y. 


DEFORMITIES  AND  DEFECTS  OF  THE  NOSE. 

N  \>ai.  deformities  arc  generally  divided  into  idiopathic  or  congenital  and 
traumatic  or  acquired.  The  former  are  usually  regarded  as  mere  accent- 
uations of  certain  racial  types;  but  no  special  deformity  can  be  said  to  be 
governed  merely  by  racial  influences.  Congenitally-deformed  noses  may, 
however,  vary  from  a  mere  rudimentary  knob  to  a  very  large  and  greatly 
distorted  organ.  Traumatic  or  acquired  deformities  sustain  little  or  no  rela- 
tion to  the  natural  conformation  of  the  nose,  and  therefore  may  assume  any 
form  in  which  accident  or  disease  happens  to  leave  them. 

From  a  surgical  point  of  view,  nasal  deformities  are  to  be  divided  into 
those  in  which  the  normal  parts  are  present,  hut  distorted  from  their  natural 
position,  and  those  in  which  there  is  a  partial  or  complete  absence  of  these 
parts.  The  firsl  comprise  those  which  affect  the  bony  portion  of  the  nose 
and   those   which   affect   the  cartilaginous  and   soft   parts. 

Deformities  of  the  bony  portion  may  be  subdivided  into  the  vertical,  in 
which  the  dorsal  profile  is  distorted,  being  too  convex  or  too  concave,  and  the 
lateral,  which,  when  viewed  from  the  front,  present  abnormal  contour,  whereby 

the  bony  porti lay  he  either  spatulated  or  deflected.     Deformities  of  the 

cartilaginous  portion  include  excess  or  deficiency  in  the  tissue  of  the  tip  of 
the  nose,  or  it-  distortion  from  normal  direction,  and  collapse  or  abnormal 
expansion  of  the  wings  of  the  nose. 

TREATMENT. 

The  treatment  of  nasal  deformities  differs  in  those  in  which  the  normal 
parts  are  present,  bu1  distorted  from  their  natural  position,  and  those  in 
which  there  is  .1  partial  or  complete  absence  of  these  parts. 

In  t he  former, treatmenl  consists  merely  in  restoring  the  parts  to  their  nor- 
mal position  ;  whereas  in  the  second  class  the  deficiency  musl  be  supplied  by 
tissues  taken  from  some  other  pari  of  the  body,  or  by  artificial  or  mechanical 
supports.  In  all  cases,  however,  after  securing  or  maintaining  full  respira- 
tory patulency,  the  main  cosmetic  indication  is  <<>  re-tore  the  symmetry  of 
the  nose.  A  nose  which  was  originally  proportionate  to  the  face  will,  if 
deformed,  appear  very  unsightly;  while  tin-  same  nose,  although  made  one 
or  two  sizes  - 1 1 1 .- 1 1 1 < t.  will  have  ;i  more  or  less  handsome  appearance  if  its 
did' •■nt   parts  are  perfectly  symmetrical.     So  symmetry,  ana  not  size,  is  to 

-ider.-d. 

In  the  correction  of  deformities  of  mere  displacemenl  all  operations 
should  '  lone  fjubcutaneously  and  without  wounding  the  -kin,  in  order  to 
avoid  scars  which  mighl  lie  :i-  unsightly  .-i-  the  original  deformity.     In  some 


CONVEX  AND  CONCAVE  DEFORMITY  OF  THE  NOSE.    MM 

instances  fracturing  of  the  nasal  bones  and  of  the  septum  also  may  be  acces- 
sary in  order  to  restore  the  part.-  to  their  normal  position. 

In  all  intranasal  operations  full  asepsis  of  the  instruments  and  bands  is 
essential,  and  of  the  nasal  vestibules,  where  the  vibrissa  form  a  natural  Bieve 
to  -train  out  all  foreign  matter  from  the  inspired  air.  Mild  antiseptic  spray- 
ing and  mopping  of  the  accessible  portions  <>|'  the  nasal  chambers  and  naso- 
pharynx should  follow,  and  may  be  repeated  after  operation  if  clearly  de- 
manded :  lint  rather  better  nasal  results,  with  far  Less  danger  i<>  the  ear,  have 
followed  the  abandonment  of  ton  much  after-spraying  and  svringing. 

The  Convex  Vertical  Deformity  of  the  Bony  Portion  of  the 
Nose. — In  correcting  this  deformity  the  skin  is  first  raised  from  the  de- 
formed or  projecting  portion  by  incising  within  the  nostril  through  to  the 
under  side  of  the  skin.  The  opening  is  then  enlarged  sufficiently  to  admit 
the  instrument  required  for  the  removing  of  the  redundant  tissue,  which  may 
be  bone-scissors,  rongeur  forceps,  a  slender  saw,  or  a  chisel,  according  to 
the  nature  of  the  tissue  to  be  removed.  Care  musl  he  exercised  not  to 
remove  too  much  of  the  redundant  tissue,  lest  a  depression  more  unsightly 
than  the  original  deformity  be  left  in  the  top  of  the  nose.  This  accident 
more  readily  happens  when  the  vault  of  the  nasal  passage  extends  all  the 
way  up  into  the  projection,  for  the  nasal  chamber  is  mix  easily  opened  into 
on  removing  the  projecting  angular  portion.  After  this  redundant  t i ~~i i* ■ 
has  been  removed,  a  gentle  compress  should  be  placed  over  the  dorsum  so  as 
to  maintain  the  integument  coaptated  against  the  nose,  and  worn  from  four 
to  six  days  or  until  the  skin  has  united  to  the  tissue  beneath. 

Concave  Vertical  and  Spatulated  Deformity. — The  operation 
consists  in  filling  in  the  depressed  and  lowering  the  unduly  prominent 
portions.  As  the  depressed  or  saddle-back  deformity,  as  it  i-  termed,  i- 
usually  the  result  of  injury  causing  displacement  of  the  tissues,  it  is  not  often 
that  the  nose  can  be  made  as  large  as  it  originally  was  ;  hut  it  can  be  made 
symmetrical  by  filling  in  the  low  places  with  tissues  taken  from  the  elevated 
portions.  This  i-  done  by  raising  the  skin  from  the  dorsum  by  incising  from 
the  inside  of  the  nostril,  as  before,  and,  if  the  nose  is  flattened  out.  removing 
to  the  top  of  the  nose  the  displaced  tissue  found  at  the  sides,  by  making  flaps 
and  turning  them  upward.  Bony  ridges  or  projection-  are  in  this  manner 
to  he  u~n\  by  car*  fully  -awing  them  off  with  a  sharp  slender  -aw.  It'  the 
displacement  of  the  tissue  is  into  the  naves,  it  can  be  utilized  in  the  -ante 
manner  by  turning  the  flaps  made  from  it  up  under  the  skin  upon  the 
dorsum  of  the  nose. 

When  it  i~  necessary  to  refracture  and  raise  the  depressed  nasal  bones, 
this  i-  done  according  to  a  method  which  I  have  devised  by  an  incision,  as 
before,  sufficiently  large  to  admit  one  blade  of  a  pair  of  -tout  forceps,  which 
is  slipped  under  the  skin  raised  from  the  nasal  bone;  while  the  other  blade, 
covered  with  a  rubber  hood  or  adhesive  plaster  to  avoid  lacerating  the  mu- 
cous membrane,  remain-  in  the  nasal  passage.  Sufficient  force  i-  tin  n  exer- 
cised to  fracture  the  hone,  assisted  by  slightly  rotating  or  twisting  the  Mad—. 
when  it  can  he  raised  to  the  desired  position.  The  hone  on  the  opposite  -idc 
is  then,  if  necessary,  fractured  in  the  same  manner,  and  they  are  held  in  the 
desired  position  by  an  internal  support,  a-  described  in  the  Treatmenl  of 
Fractures  of  the  Nose  (page  111'"-').  If  the  end  of  the  nose  -till  projects 
above  the  line  of  the  central  portion,  it  can  he  lowered,  a-  later  described. 

Many  plan-  for  the  making  of  a  new  nose,  as  will  he  presently  described, 
have  been  used  for  correcting  these  minor  defects.  There  i-  no  advantage  in 
nor  necessity  for  performing  external  operation-  when  we  can  work  subcutane- 


1182 


OPERATIONS   UPON   THE  A  I R-I'ASSAGES. 


ously  to  avoid  wounding  the  skin  and  also  utilize  the  normal  tissues  instead 
of  resorting  to  mechanical  supports  for  the  correction  of  these  deformities. 

Deflection  of  the  Bones  of  the  Nose. — In  correcting  this  deformity 
it  is  usually  necessary  to  fracture  the  nasal  bones,  and  on  one  side  force  the 
bone  outward,  on  the  other  side  inward.  It  may  be  also  necessary  to  fracture 
the  nasal  septum,  more  or  less,  and  to  overcome  the  distortion  of  the  cartilag- 
inous portion.  After  fracturing  the  bones  they  should  be  held  in  the  desired 
position,  as  in  the  treatment  of  fracture  of  the  nasal  hones.  Great  care  must 
be  exercised  in  the  performance  of  these  operations,  and  they  are  only  to  be 
undertaken  under  the  mosl  favorable  conditions  (see  page  1119). 

Excessive  or  Deficient  Development  of  the  End  of  the  Nose. 
— The  operation  for  excess  (commonly  termed  pug-nose)  consists  in  turning 
back  the  mucous  membrane  and,  from  the  interior  of  the  nostril,  removing 
enough  of  the  redundant  tissue  at  the  end  to  make  the  nose  symmetrical  and 
to  bring  the  end  down  on  a  line  with  the  dorsum.  The  mucous  membrane  is 
then  replaced  and  supported  by  a  light  antiseptic  compress  in  the  interior  of 
the  nostril.  Any  associated  expanded  condition  of  the  wings  should  be  dealt 
with  as  will  presently  be  described.  After  the  operation  the  nose  is  to  be 
held  in  the  desired  shape  by  the  metallic  form  (Fig.  641),  applied  to  the  out- 


71.— 0]»niti"ii  fur  li-ii'jtlii-iiing  and  narrowing  t  lie  tip  of  t  lie  nose  (Linhart). 

3ide  of  the  nose  for  several  days,  until  healing  in  the  exact  position  has  taken 
place. 

Deficiency  ofthetip  is  corrected  by  raising  the  skin  and  filling  in  the  defect 
by  mean-  of  plastic  operation  according  to  the  conditions  found.  Where  the 
frenum  i-  shori  or  defective,  this  can  be  rectified  by  taking  flaps  from  the 
floor  of  the  nose  or  upper  lip.  The  upper  portion  of  the  tip  can  be  filled  in 
with  tissue  taken  3ubcutaneously,  in  the  form  of  flaps,  from  the  sides  of  the 
nose  and  cheeks  (see  also  Fig.  <»71  ). 

Often  a  flattened  condition  of  the  end  of  the  nose  is  associated  with  a  lat- 
eral expansion  of  the  alse,  and  is  relieved  by  correcting  the  latter  condition. 

Deviation  of  the  Tip  of  the  Nose  from  the  Median  lyine. — As 
this  deformity  i-  almost  always  associated  with  deviation,  distortion,  or  dis- 
location of  the  triangular  cartilage  of  the  septum,  it   is  usually  necessary  to 

ighfc  n  the  -I'ptnin.  and  in  some  cases  this  will  be  found  to  be  all  that  is 
required  to  eorreel  the  deviation  of  the  end  of  the  nose. 

This  operation  is  performed  by  loosening  the  cartilage,  and  sometime-  the 

columna  also,  along  its  junction  with  the  superior  maxillae,  and  making  a  ver- 

incision  through  the  cartilage  al  the  bend  or  poinl  of  deflection.     The 

carti  then  placed  in  position  and   held  therewith  transfixion-pins  or 


STENOSIS  OF  THE  NASA1     VESTIBULE.  1183 

splints  or  hollow  plugs  placed  in  one  or  both  nostrils.  Sometimes  incisions 
are  necessary  to  overcome  the  elasticity  of  the  cartilage  al  other  points.  In 
most  cases  this  is  best  done  with  a  bistoury.  With  a  finger  i le  nasal  cham- 
ber we  ran  determine  when  the  cartilage  has  been  completely  incised  from  the 
other  side  without  cutting  through  the  mucous  membrane  beyond.  I!\  leaving 
the  membrane  intact  on  one  side,  it  serves  as  an  excellent  splint  to  maintain 
the  edges  coaptated  while  healing.  In  some  cases  the  end  of  the  nose  may  ap- 
pear to  be  deviated  by  reason  of  an  excessive  development  or  expansion  of  the 
shield  cartilage  on  one  side  alone,  the  other  side  being  straight  and  normal. 
Sometimes,  when  the  lateral  shield  cartilages  are  deformed  or  distorted  to 
one  side,  it  is  also  necessary  to  freely  incise  them  from  the  inside  or  loosen 
their  attachment  in  order  to  overcome  such  elasticity  as  may  tend  to  repro- 
duce the  deformity.  The  nose  should  then  lie  held  in  place  with  a  splint  on 
the  inside  (Fig.  644)  or  a  form  on  the  outside,  or  sometimes  by  both,  until 
it  becomes  fully  fixed  in  the  desired  shape  and  position. 

It  is  not  infrequently  the  case  that  distortion  of  the  end  of  the  nose  i- 
associated  with  a  deviation  of  the  whole  nose,  in  which  cases  it  i-  necessary 
to  eombine  the  operations  for  correeting  the  deviation  of  both  the  osseous  and 
cartilaginous  portions  of  the  nose. 

Collapse  or  Expansion  of  the  Alse.— Correction  of  the  deformities 
of  the  wings,  whether  collapsed  or  expanded,  consists  in  carefully  incising  in 
several  places  from  the  inside  the  lower  lateral  and  sometimes  also  the  upper 


a  b 

Fig.  672.— Operation  for  reducing  redundant  tissue  of  the  alse  (Linhart). 

lateral  or  shield  cartilages  (see  Fig.  645).  It  may  be  necessary  in  some  cases 
of  greatly  expanded  or  inflated  ahe  to  excise  a  V-shaped  portion  of  the  carti- 
lage to  permit  of  its  being  moulded  to  the  desired  shape.  The  parts  are 
then  to  be  placed  in  position  by  first  inserting  into  the  nostrils  an  internal 
support  of  the  desired  size  and  shape,  consisting  of  a  short  tube  of  suitable 
material,  and  should  be  held  there  by  an  external  shield  until  firmly  fixed. 

In  case  of  expanded  nostrils  it  will  generally  be  necessary  after  the  oper- 
ation to  apply  only  the  external  support  or  compress  t<>  maintain  the  parts 
in  the  desired  position  until  the  tissues  become  more  fixed ;  whereas  in  the 
collapsed  condition  of  the  wines  the  external  support  is  rarely  necessary,  the 
nostrils  requiring  simply  to  be  expanded  to  their  normal  size  and  shape,  and 
maintained  in  tin-  position  until  the  tendency  to  collapse  i-  overcome. 

Should  the  expansion  of  the  alae,  however,  be  due  t"  distention  from  an 
intranasal  growth  or  foreign  substance,  the  necessity  for  the  removal  of  the 
growth  or  body  is  self-evident  before  the  deformity  of  the  nostrils  can  be 
overcome,  and  further  intervention  may  be  unnecessary    see  also  Fig.  672). 

Stenosis  of  the  Nostril. — The  nostril  or  the  vestibule  of  the  nosi  may 
be  so  small  upon  one  or  both  sides  as  greatly  to  impede  proper  respiration. 
This  may  be  a  congenital  smallness  or  deficient  development  or  an  acquired 
lesion  due  to  cicatrization  after  burns,  lupus,  or  syphilitic  ulceration.  Acute 
inflammation  of  furuncular  or  other  nature  ma}  temporarily  close  the  nos- 
tril, but  this  would  call  only  for  evacuation  of  pi!-  or  similar  obvious  inter- 


1184 


OPERATIONS  UPON  THE  AIR-PASSAGES. 


vention.  For  the  simple  stenosis,  dilatation  by  frequently  forcing  in  the 
lubricated  finger  may  be  sufficient,  or  the  wearing  of  a  tube  for  a  time  may 
1„.  required.  When  the  constriction  cannol  be  thus  easily  overcome,  divulsion 
may  be  necessary,  care  being  taken  to  maintain  the  passage  well  dilated  until 
after  the  parts  have  healed.  Where  Loss  of  substance  precludes  success  by 
these  simple  methods,  plastic  operation  by  flaps  or  skin-grafts  will  supply 
the  deficiency. 

The  cutting  away  of  a  stenosis  where  the  mucous  membrane  i-  already 

fcOO    limited  in  extent  should  lint  he  attempted,  for  the  reason  that   the  surface 

will  invariably  grow  together  throughoul  the  extent  of  the  incision.  In 
these  cases  it  i-  best  to  raise  the  skin  or  mucous  membrane  from  the  con- 
tracted portion  and  remove  the  cicatricial  connective  ti>sue  from  beneath, 
then  replace  the  part-  and  dilate  the  uostril  to  its  fullesl  extent  until  healed, 
when  they  will  remain  in  place,  leaving  the  opening  of  the  vestibule  free. 


PARTIAL  OR   COMPLETE  ABSENCE  OF  THE  NOSE. 

There  are  two  principal  method-  by  which  defect-  and  deficiencies  of  the 
nose  may  be  supplied  or  corrected,  according  to  the  condition  of  the  ease:  by 
rhinoplasty,  using  only  living  tissues,  and  by  internal  artificial  supports. 

Rhinoplasty  may  be  complete  or  partial.  It  is  termed  complete  when 
the  whole  or  the  greater  portion  of  the  nose  is  supplied  by  tissue  from  some 
near  or  distanl  part  :  and  incomplete  when  a  small  portion  only  is  supplied. 

(1)  The  Indian  method,  which  takes  the  tissue  from  the  forehead,  was 
originated  in  Hindustan.  It  is  serviceable  only  in  supplying  nasal  defects 
in  which  there  i-  a  moderate  loss  of  tissue;   for  when  there  is  destruction  of 

the  entire  bony  framework  of  the  nose, 
sntlicient  material  is  not  obtainable  from 
the  forehead  to  fill  in  the  defect,  and  the 
transplanted  tissue  sooner  or  later  drops 
through  the  large  opening,  and  the  nose 
sink-  again  to  the  level  of  the  face. 

In  order  to  ascertain  the  size  of  the 
flap,  a  nose  as  desired  is  modeled  of  wax 
or  plaster  of  Paris,  and  the  portion  that 
has  been  destroyed  is  outlined  upon  this 
model.  Then  by  moulding  a  pattern  of 
paper  or  thin  leather  over  this  model  the 
exacl  size  required  is  accurately  deter- 
mined, which  should  he  made  about  one- 
third  larger,  in  order  to  allow  for  the 
shrinkage  of  the  tissues  mi  healing. 
This  pattern  is  then  turned  upward  and 
spread  out  upon  the  forehead,  the  part 
corresponding  to  the  lower  portion  of 
the  nose  uppermost,  and  outlined  w  ith 
ink  or  tincture  of  iodin  to  indicate  the 
pori  ion  of  the  -kin  to  he  cut  out.  I  f 
the  height  of  the  forehead  is  not  -uf- 
ficienl    for    the    -ize    of    the    Hap,    more 

room  can  he  obtained  by  cutting   it  out  obliquely  (as  shown  in   Fig.  673), 

Kercised  not  to  cul  to.,  near  tin'  eyebrow,  Lest  the  latter  be  drawn 

up  by  the  retraction  of  the  scar.     The  flap  should  be  cm   out   by  a  single 


■  .  by  Mh-  Indian  mi 
i      ■  ttiont 
lalgaigne) 


i..n^  for  building 


PARTIAL   OB  COMPLETE  ABSENCE  OF  THE  NOSE.      1185 

firm  stroke  of  the  knife,  so  as  to  afford  an  even,  smooth  edge.  The  flap 
is  then  raised  and  made  to  include  the  periosteum,  or  the  anterior  table  01 
bone  is  included  by  chiselling  it  off,  it'  desired,  aud  the  flap  brought  down 
and  stitched  into  place  by  very  fine  gut,  silk,  or  horsehair  sutures. 

In  making  this  Hap  the  pedicle  should  be  sufficiently  long  to  admit  of 
being  twisted  upon  itself,  usually  from  left  to  right,  so  as  not  to  compress  the 
vessels,  and  wide  enough  to  include  plenty  of  nutrient  vessels,  especially  the 
angular  artery. 

The  low  portion  of  the  nose  can  be  still  further  filled  out  by  a  Hap  taken 
from  the  root  of  the  nose,  made  after  the  frontal  Hap  has  been  cut  <>nt,  so  that 
all  the  skin  of  the  bridge  and  root  of  the  oose  between  the  flap  and  the  d<  feet 
can  be  utilized.  The  width  of  this  Hap  should  be  the  same  as  the  neck  of 
the  frontal  flap,  and  left  attached  along  the  upper  border  of  the  opening. 
This  supplementary  flap  is  first  stitched  into  the  opening,  the  integument 
looking  inward,  alter  which  the  frontal  flap  is  brought  down  over  it  and 
stitched  into  place. 

Before  these  Haps  are  made  the  nose  should  he  prepared  for  their  recep- 
tion by  freshening  the  edges  of  the  gap.  Any  cicatricial  tissue  that  should 
be  removed  from  the  borders  can  be  turned  into  the  center,  in  the  form  of  a 
flap,  to  assist  in  elevating  the  dorsum. 

The  twist  in  the  pedicle  usually  forms  an  unsightly  prominence,  which  can 
be  obviated  somewhat  by  cutting  one  side  longer  than  the  other,  and  after- 
ward rectifying  it  by  operation.  The  edges  of  the  hole  left  in  the  skin  of  the 
forehead  are  then  sutured  together  as  closely  as  possible  and  any  denuded 
space  should  receive  a  sprinkling  of  Thiersch  grafts,  so  as  to  leave  the  least 
amount  of  disfigurement  on  healing.  The  coaptation  of  the  edges  is  consid- 
erably facilitated  by  raising  the  skin  for  a  considerable  distance  on  either  side 
so  that  it  can  be  slid  toward  the  center,  care  being  exercised  not  to  constricl 
the  frontal  Hap.  The  new  columna  of  the  nose  may  be  formed  at  the  same 
time  from  a  tongue  from  the  forehead  included  with  the  Hap,  or  from  the 
upper  lip,  as  will   be  described   further  on. 

The  after-treatment  consists  in  maintaining  the  part-  aseptic  by  light  boric 
acid  and  bichlorid  dressing  very  carefully  applied.  The  dressing  should  not 
be  changed  oftener  than  required  ;  and  secondary  hemorrhage  should  be 
guarded  against  by  light  pressure  when  it  seems  imminent.  The  Hap  may 
remain  dark  and  edematous  for  some  time,  and  finally  unite  mosl  suc- 
cessfully. The  swelling  can  sometimes  be  relieved  by  leeches  or  slight 
scarification. 

A  number  of  variations  of  this  method  have  been  practised  by  different 
surgeon-,  and  nearly  every  operator  has  some  modification  peculiar  to 
himself. 

Yemeni!  made  one  incision  along  the  median  line  of  the  depressed  por- 
tion of  the  nose  and  two  transversely  at  the  base  and  tip  respectively,  and 
dissected  up  the  two  lateral  Hap-.  He  then  raised  an  oblong  flap  of  the 
requisite  size  from  the  middle  of  the  forehead,  leaving  it  adherent  between 
the  eyebrows  by  a  pedicle,  turned  it  directly  downward,  and  stitched  the  two 
lateral  Hap-  together  over  it  ;  the  skin  of  the  Hap  lying  inward,  so  that  the 
raw  surface  came  against  the  under  surface  of  the  lateral  Hap-. 

(2)  The  German  and  French  Method. — This  consists  in  the  formation 
of  the  nose  from  tissues  taken  from  the  side  of  the  face.  It  vras  firsl  pro- 
posed by  Dieffenbach,  and  later  modified  by  Nelaton,  to  avoid  the  frontal 
scar  left  after  the   Indian  operation. 

This  operation  consists  in   making  a  double  Hap.  one  from  each  side  oi 


li-.; 


o  /'A'/.'  J  Tlo.XS   I/'OX  Till-:  AIR-PASSAGES. 


Fig.  674.— Formation  of 
columns  Mini  alse  from  the 
.in  from  above. 


the  nose,  including  a  sufficieni  portion  of  tin-  cheek,  joined  together  by  a  com- 
mon pedicle  at  the  root  of  the  nose.  These  flaps  arc  then  united  in  the 
center  and  carefully  stitched  together.  A  pattern  of  the  desired  form  is 
made,  so  thai  the  flaps  are  accurately  cul  in  such  a  shape 
as  to  form  the  column  of  the  nose  and  also  sufficiently 
long  for  turning  in  to  form  a  double  edge  to  the  nos- 
trils (Fig.  r.7  1 1.  which  arc  kept  open  by  hollow  vulcan- 
ite tubes  until  the  healing  i-  complete  and  all  tendency 
to  cicatricial  contraction  i>  overcome. 

NYlatoii  modified  this  operation  by  making  addi- 
tional parallel  flaps  from  the  cheek  just  outside  of  the 
two  primary  lateral  flaps;  and  these  were  brought 
to  the  center  and  stitched  in  place  under  the  two 
primary  flaps,  which  were  then  united  along  the  median  line  of  the  nose. 
When  the  tissue  of  the  dorsum  of  the  nose  i-  gone  and  the  septum  is  still 
in  place,  the  latter  can  he  utilized,  as  Mr.  Bell  and  Nelaton  suggest,  and 
held  in  place  by  transfixing  the  septum  and  both  the  flaps  at  their  outer 
lower  edges  witli  a  straight  needle.  The  wounds  in  the  cheek  may  be  par- 
tially closed  by  sutures,  but  are  usually  left  to  heal  by  granulation — the 
resulting  depression  adding  to  the  relative  prominence  of  the  new  nose. 

[.:!)  The  Italian  or  Tagliacotian  Method. — This  was  first  practised  by 
Branca  of  Sicily,  by  Bojani  of  Calabria,  and  Alexander  Benedetti,  professor 
of  Anatomy  at  Padua,  about  the  year  1  195  ;  but  it  was  Tagliacozzi  who,  about 
the  year  L587,  SO  popularized  the  method  by  his  skill  and  dexterity  that  it 
has  since  been  known  by  his  name.  It  consists  in  cutting'  from  the  biceps 
region  of  the  arm  a  thick  flap  for  the  formation  of  the  nose.  Parallel  incis- 
ion- are  made  about  four  inches  in  length  and  of  sufficient  width  to  allow  for 
the  subsequent  contraction  on   healing.     This  flap   is   raised   except  at  the 

attached  ends.  A  dressing  is  passed  be- 
neath to  prevent  reunion,  and  the  wound, 
as  practised  by  Tagliacozzi,  was  left  open 
to  granulate  ;  by  modern  methods,  how- 
ever, the  parts  are  maintained  aseptic  and 
the  edges  of  the  wound  stitched  together 
beneath  the  flap.  At  the  end  of  about  a 
week,  when  the  flap  has  become  suf- 
ficiently shrunken  and  hardened  by  ex- 
posure and  covered  with  granulations,  it 
is  liberated  at  the  upper  portion, and  then 
permitted  to  shrink  still  mo.v  i':<\-  another 
week  or  two   before   it    is  attached    to  the 

face. 

After    the   ct]>j;('<   of    the    nasal    tiss  lies 

have  been  scarified  and  fitted  for  its 
reception,  the  arm  is  placed  in  posil  ion 
and  the  upper  end  of  the  Hap  carefully 
shaped  ami  stitched  in  place.  The  arm 
i-  then  firmly  held  in  place  by  means  of 
the  cap-and-jackel  apparatus  shown  in 
Fig.  675  until  the  vascularization  between 

the    Hap    and    tic    QOSe    ha-    taken    place. 

I  hi-  usually  requires  about   ten  days,  when  the  pedicle  i-  Bevered  ami  the 
arm   released.     This  severed  end  of  the  flap  is  then  carefully  cut,  shaped, 


Fig.  675.— Italian   method  "f  rhinoplasty 
■   arm,  \\  hich  i-   Immovably  Becured 
i   intil  union  of  the 


PARTIAL  OB  COMPLETE  ABSENCE  OF  THE  NOSE.     1187 

and  stitched,  so  as  to  form  a  symmetrica]  end  to  the  nose.  Owing  to  the 
painful  nature  of  this  operation  and  the  distressing  position  of  the  arm.  it  ie 
not  frequently  resorted  to. 

Von  Graefe  made  a  flap  with  bul  one  pedicle,  and  implanted  it  at  once. 
This  is  inferior  to  the  original  plan,  as  it  does  nol  obviate  the  constrained 
position  of  the  head  and  arm  and  lessens  the  chances  of  union,  and  is  fol- 
lowed by  much  greater  shrinkage  of  the  nose  after  the  operation.  Warren 
of  Boston  took  a  flap  from  the  anterior  portion  of  the  forearm,  aboul  two 
inches  above  the  wrist,  transplanting  the  flap  at  once,  and  in  some  cases  suc- 
ceeded  in  separating  it  on  the  fifth  day. 

Partial  rhinoplasty  < •on: -i.-ts  in  supplying  minor  defects  of  the  differed 
portions  of  the  nose,  usually  of  the  alae,  of  the  tip  and  the  columna,  which 
have  been  destroyed  by  lupus,  syphilis,  by  injuries,  or  by  mutilation-..  While 
less  extensive,  these  operation-  are  often  more  important  to  the  function  of 
the  nose  than  the  complete  rhinoplasty. 

Eaeli  case  requires  a  special  study  and  ofttimes  the  greatest  .-kill  in  order 
to  adapt  the  operation  to  the  condition-  found. 

The  Restoration  of  the  Alae. — The  alae  when  destroyed  may  he  formed 
from   the  same  side  of  the  nose,  from  the  opposite  or  sound  side,  from  the 
cheek,  from  the  upper  lip,  or  by  the  jump- 
ing process.  ^-. 

The  lateral  flap  method  of  Denonvillier  \  ■ 

consists  in  dissecting  a  triangular  flap  from 
the  sound  tissues  above  the  defect,  which  can 
be  brought  down  on  a  line  with  the  normal 
wing  of  the  nose.  The  vertical  incision  is 
begun  just  above  the  end  of  the  nose,  leaving 
sufficient  tissues  to  nourish  a  Hap,  and  is 
carried  up  about  half  the  length  of  the  nose, 
as  required,  where  a  second  incision  is  made 
obliquely  downward  to  the  upper  and  outer         fig.  676.-Partiai  rhinoplasty  of 

-1       a     ,  .  l  1  and  columna  by  a  flap  lrom  the  bridge 

angle  01   the  ala.  of  the  nose  (Linhart  . 

The  flap  may  be  taken   lrom  the  bridge 
of  the  nose  (Fig.  (>7<i),  from  the  opposite  ala,  from  the  cheek,  or  from  the  lip. 
as  the  circumstances  of  the  case  dictate,  and  slid   into  place  or  carried  across 
untouched  surfaces  by  the  jumping  process. 

The  Restoration  of  the  Tip  of  the  Nose. —  Mere  shortness  of  the  tip 
i-  best  corrected  by  sliding  down  a  A-shaped  flap  (  Fig.  671  ).  Keegan's  oper- 
ation consists  in  makings  flap  on  each  side  of  the  bridge  and  base  of  the 
uose  and  extending  the  lateral  incision  downward  to  the  upper  border  of  the 
root  of  the  nasal  alae.  These  flap-  are  dissected  oul  from  above  downward, 
leaving  the  flap-  attached  at  the  lower  border.  These  flaps  are  to  be  cul  of 
the  -i/e  necessary  to  till  the  defect  at  the  end  of  the  no.-e  when  turned  down- 
ward, sufficient  allowance  being  made  for  contraction  while  healing. 

A  (lap  i-  then  taken  from  the  forehead  in  the  usual  manner,  twisted  and 
turned  downward,  and  stitched  into  the  place  from  which  the  other  flaps  have 
been  removed.  This  i-  made  sufficiently  long  to  form  the  columna  of  the 
septum  if  lacking,  the  opening  of  the  nostrils  being  maintained  l>\  hollow 

Splints   «>f  the    proper    -i/e   and    shape. 

In  Oilier'-  operation  the  incision  i-  carried  from  a  point  near  the  center 
of  the  forehead  to  a  point  on  a  level  with  the  lower  border  of  the  alae.  The 
-kin  only  i-  dissected  up  from  one  -ide  ;  while  mi  the  opposite  -ide  i-  included 
the  periosteum,  which  underlies  the  upper  portion  of  the  flap,  and  the  left 


[188  OPERATIONS   UPON   THE  A  IR-PASSAd  KS. 

nasal  bone,  which  is  separated  by  means  of  a  chisel.  This  entire  flap  then 
rried  downward  sufficiently  far  to  form  the  contour  of  the  end  of  the 
nose  and  stitched  there,  the  bony  portions  being  secured  with  wire  sutures. 
The  space  left  l>v  the  removal  Is  filled  by  a  bony  outgrowth  developed  from 
the  periosteum,  -lid  down  from  the  forehead  to  cover  the  opening. 

In  some  of  these  cases  it  is  possible  to  supply  the  whole  defect  at  one 
operation,  but  quite  often  secondary  operations  are  necessary  to  form  the 
colmnna  and    improve  the  opening  of  the  nostrils. 

Restoration  of  the  Columna  of  the  Nose  ;  Utilization  of  the  Upper 
Lip. — Many  method-  have  been  employed  for  the  restoration  of  the  colmnna. 
The  Italian  method,  though  not  frequently  employed,  consists  in  taking  a 
tlap  from  the  palmar  surface  of  the  hand  and  suturing  it  in  place  so  as  to 
form  the  column  of  the  nose,  the  hand  being  held  firmly  in  place  until  the 
flap  has  become  united  to  the  nose,  which  is  similar  to  the  Tagliacotian 
method  of  restoration  of  the  nose.  In  llenter's  method  the  colmnna  is 
formed  from  the  skin  covering  the  dorsum  of  the  nose.  The  flap  is  cut  out 
obliquely,  to  facilitate  it-  rotation  into  position,  and  so  cut  that  the  rotation 
take-  place  at  the  tip  of  the  nose,  which  render-  it  thicker  at  that  point  and 
thereby  assists  in  elevating  the  tip  of  the  nose.  For  the  purpose  of  render- 
in--  the  columna  more  rigid  he  recommends  that  the  upper  portion  of  the 
flap  should  include  the  periosteum  covering  the  nasal  hones,  so  that  the 
formation  of  osseous  tissue  will  afford  a  more  rigid  support. 

Wood's  method  consists  in  making  a  flap  from  the  central  portion  of 
the  upper  lip,  between  the  cutaneous  and  the  mucous  surfaces,  extending 
downward  to,  but  not  through,  the  vermilion  borders  of  the  lip.  This  flap 
is  turned  upward  and  covered  by  flaps  taken  from  the  cheek  on  either  side. 

Dieffenbctch's  method  consists  in  making  two  vertical  incisions  through 
the  entire  thickness  of  the  upper  lip.  thus  making  a  tongue  about  one-fourth 
inch  in  width,  which  i-  entirely  i'vccA,  except  at  its  upper  attachment.  This 
i-  turned  upward  and  united  to  the  remains  of  the  old  eolumna  and  to  the 
alse  by  tine  sutures.  The  mucous  membrane  of  the  lip.  which  looks  outward 
in  its  new  position,  soon  become-  skin  on  exposure  to  the  air.  The  cut  sur- 
face- of  the  lip  are  then  brought  into  apposition  and  united  exactly  as  in  the 
operation  for  harelip. 

Utilization  of  a  Finger. — The  fir-t  to  make  use  of  the  finger  to  supply 
the  loss  of  a  nose  wa-  Ilanlie  of  Manchester,  England,  in  L875,  at  the  sug- 

:on  of  hi-  house-surgeon,  Mr.  Tyler,  and  it  was  next  employed  by  Prof. 
Sabine  of   \ew  York,  in   L879.1 

In  1893  the  writer  performed  a  similar  operation  on  a  lad  of  sixteen  years 
of  age,  whose  nose  hail  been  destroyed  by  hereditary  syphilis,  leaving  a  con- 

rable  aperture,  around  which  the  -kin  was  very  much  wrinkled,  since  it 
had  not  been  destroyed,  but  hail  lost  it-  central  support,  which  gave  the  lad 
a  very  repulsive  appearance.  The  incision  was  made  under  the  lower  border 
of  this  wrinkled  -kin,  which  was  dissected  out  for  the  insertion  of  the  finger. 
Tli-  hf't  ring-finger  was  prepared  by  removing  the  la-t  phalanx,  so  as  to  do 
away  with  the  nail,  wa-  denuded  of  it-  cuticle  as  far  up  as  it  was  to  be 
inserted  beneath  the  -kin.  and  the  remaining  portion  was  split  in  the  center 
■  mi  the  palmar  side  down  to  the  bone.  The  tissues  forming  a  double  flap 
were  turned  outward  and  stitched  to  the  edges  of  the  -kin  of  the  nose  after 
the  insertion  of  the  finger  in  the  place  prepared  for  it.  The  arm  was  then 
firmly  held  in  place  bv  plaster-of-Paris  bandages,  -imilar  to  the  Tagliacotian 
iod,  until  the   union    between   the  finger  and  nose  had  taken   place,  when 


PARTIAL   OB  COMPLETE  ABSENCE  OF  THE  NOSE.      1189 


the  finger  was  disarticulated  at  the  knuckle.  When  the  finger  had  become 
solidly  united  to  the  aose  a  portion  of  the  bone  of  the  finger  was  cut  out,  so 
as  to  leave  sufficient  redundant  skin  oul  of  which  to  form  the  columna  and 
the  nostrils,  the  latter  being  kepi  open  by  hollow  plugs. 

The  result  was  at  first  exceedingly  satisfactory  ;  bul  al  the  end  of  a  year 
the  nose  had  very  materially  diminished  in  size,  due  to  a  settling  of  the 
finger  down  through  the  aperture  between  the  nasal  hone,-,  which  was  too 
wide  to  give  it  support. 

This  method  would  be  exceedingly  serviceable  in  some  eases  where  the 
aperture  was  too  small  to  permit  the  hone  of  the  finger  to  drop  through  ;  but 
in  cases  where  this  aperture  is  too  large,  this  method  is  far  inferior  to  that 
of  inserting  mechanical  supports  beneath  the  collapsed  ti.-sues. 

The  Employment  of  Artificial  or  Mechanical  Supports. — The  use  of 
artificial  supports  is  required  in  those  eases  only  in  which  the  central  carti- 
laginous or  bony  supporting  frame  is 
wanting,  as  is  often  the  result  of  the 
ravages  of  syphilis.  This  method  was 
first  suggested  by  Letievant,  who  in- 
serted beneath  the  skin  of  the  depressed 
nose  a  supporting  framework  of  alumi- 
num. C.  Martin  improved  upon  this  by 
substituting  platinum.  The  device  as 
used  by  Martin,  which  is  the  one  most 
commonly  employed,  consists  of  a  trian- 
gular piece  of  platinum,  bent  in  the  shape 
of  the  nose,  the  upper  end  of  which  rests 
on  the  nasal  spine  of  the  frontal  bone, 
the  lower  wings  being  supported  by  two 
arms,  one  on  either  side,  the  ends  of 
which  are  embedded  in  the  superior 
maxillae  (Fig.  677).  The  dimensions 
must,  of  course,  correspond  to  the  size 
of  the  nose  to  be  supported. 

The  form  i-  introduced  by  first  per- 
forming the  Rouge  operation,  in  which 
the  upper  lip  and  nose  are  cut  loose  and 
turned  up  over  the  face  so  as  to  avoid 
wounding  the  skin,  and  also  to  gain  direct  access  to  the  superior  maxilla  for 
drilling  the  hole-  in  which  to  securely  anchor  the  artificial  bridge.  The 
holes  should  be  made  in  the  inner  side  of  the  canine  eminences,  aboul  on 
a  level  with  the  floor  of  the  nose,  care  being  taken  not  to  enter  the  antrum. 
The  location  of  the  holes  should  be  determined  by  the  most  careful  measure- 
ments, in  order  to  bring  the  artificial  bridge  in  the  median  line  of  the  face. 

This  apparatus  ha-  also  been  used  by  some  for  elevating  the  center  of  the 
nose  in  those  cases  of  depression  in  which  the  bony  framework  i>  present 
In  these  cases  it  invariably  end-  in  failure,  for  it  inu-i  necessarily  be  inserted 
between  the  -kin  and  the  osseous  structure,  leaving  a  closed  -pace  between 
the  metallic  bridge  and  the  bone.  No  drainage  i-  afforded,  and  sooner  or 
later  irritation  i-  excited,  the  contained  discharges  decompose,  and  ulceration 
results.     In  the  most  favorable  of  these  cases  the  device  has  been  retained 

from  one  to  five  year-,  bul  in  every  case,  sooner  or  later.  - accidenl  hap 

pens  to  the  nose;  or,  on  account  of  some  complication,  the  artificial  support 
must    necessarih    lie   removed,   leaving  tin    nose  in  a  worse  condition  than 


Fig.  677.-  II"    Martin  bridge  ;i-  used  In  Weii 
(N.  v.  Med 


1190  OPERATIONS   UPON  THE  AIR-PASSAGES. 

before.  This  method  of  support  is  only  successful  and  only  necessary  in 
those  cases  in  which  the  bony  support  is  gone  and  where  thorough  drain- 
takes  place  into  the  nasal  cavity,  thereby  reducing  the  irritation  to  a 
minimum. 

In  a  case  where  the  entire  central  support  of  the  nose  was  gone,  including 
the  entire  vomer,  together  with  the  nasal  and  lachrymal  bones,  the  nose  being 
completely  flattened  on  the  lace,  the  writer  inserted  a  support  according  to  the 
method  already  described.  The  bridge  was  made  of  hard  rubber,  with  arms 
made  of  a  gold  and  platinum  alloy.  The  arms  constituted  one  piece,  a  band 
running  over  the  form  in  a  groove  made  for  its  reception  and  securely  riveted 
to  it.  This  made  a  much  lighter  bridge,  quite  a>  strong  and  less  irritating 
than  platinum,  and  exceedingly  satisfactory.  But  whatever  form  of  bridge  is 
used,  it  should  be  prepared  as  far  as  possible  beforehand,  leaving  only  the 
position  and  width  of  the  arms  to  be  adjusted  to  the  situation  of  the  holes 
made  in  the  jaw  at  the  time  of  the  operation. 

It  is  important  in  these  cases  that  the  most  thorough  aseptic  precautions 
be  observed  on  inserting  the  bridge,  and  that  the  bridge  be  so  inserted,  so 
moulded,  and  so  smooth  as  to  prevent  any  friction  or  unequal  pressure  upon 
any  of  the  soft  parts;  and  it  is  also  important  that  the  supporting  arms  should 
lie  buried  deeply  in  the  maxillae,  so  that  they  are  not  easily  displaced.  Martin 
employed  a  bridge  with  attached  arms  for  insertion  in  the  maxillae  to  hold  the 
bridge  in  place;  but  the  plan  of  cutting  the  bridge  and  the  supporting  arms 
from  one  piece  of  metal  when  platinum  i<  used,  as  suggested  by  Hopkins,  is 

far  better. 

Before  undertaking  any  operation  for  the  restoration  of  the  whole  or  any 
portion  of  the  nose,  we  should  ascertain  if  the  disfigurement  is  the  result  of 
an  injury  or  disease.  If  the  latter,  we  should  be  certain  that  the  disease,  be 
it  syphilis,  Lupus,  etc.,  is  completely  arrested  or  cured.  Also  before  decid- 
ing on  the  operation  to  be  adopted,  we  must  thoroughly  investigate  the  con- 
dition of  the  different  parts  of  the  nose  and  also  of  the  face  in  order  to  deter- 
mine which  region,  the  forehead,  the  cheeks  and  face,  or  the  arm,  will  best 
supply  the  requisite  tissue  free  from  scars  or  disease  and  leave  the  least  dis- 
figurement. 

In  performing  these  operations  the  greatest  cure  and  skill  arc  required  to 
insure  the  best  results.  Each  case  requires  the  most  careful  study,  for  as 
Prof.  Gross  has  well  said  :  "  For  repair  of  these  various  defects  some  of  the 
nicest  processes  of  the  art  and  science  of  surgery  are  required,"  .  .  .  and  that 
"if  the  operation  is  entered  upon  heedlessly  or  withoul  due  preparation  of 
the  part  and  system,  failure  will  be  al -t  certain." 

DEFORMITIES  OF  THE  NASAL  SEPTUM. 

<)f  the  internal  structures  of  the  nose,  the  septum  is  1  he  part  most  fre- 
quently deformed,  presenting  deviations  from  the  median  line,  spurs,  ridges, 
hyperplastic  thickenings,  and  exostoses. 

Deviation  of  the  septum  (see  page  917)  may  affect  the  whole  septum  oi 

part  of  either  the  osseous  or  the  cartilaginous  portion.     It  is  most  fre- 
quently found  in  the  cartilaginous   portion,  and   next    in   point  of  frequency 

■  junction  of  the  cartilaginous  and  osseous   portions,  while  deviation  of 
the   posterior  portion  of  the   vomer  is  exceedingly   rare.     The  division  of 

tions   into  osseous,  cartilaginous,  and   osseo-cartilagi is,  as   suggested 

by  Jarvis,  is   by  fir  the   most  natural,  and  further  attempts  at   classification 
are  unnecessary.     Thickening  on  one  side  of  the  septum  i-  sometimes  decep- 


DEFORMITIES  OF  THE  NASAL  SEPTUM.  1191 

tive,  giving  the  septum  the  appearance  of  being  deviated  to  thai  side,  when 
the  plane  of  the  other  side  may  be  perfect.  Sometimes  the  septum  is  curved 
at  different  parts  in  such  a  way  as  to  give  it  the  shape  of  the  letter  S. 

In  some  cases  the  deformity  may  consisl  in  the  septum  being  located  to 
one  side  of  the  median  line,  although  ool  deflected  or  curved,  causing  one 
meatus  to  be  larger  than  the  other. 

Spurs,  ridges,  and  hyperplastic  thickenings  may  be  found  on  any  portion 
of  the  septum,  although  they  arc  most  frequently  found  located  :  First,  along 
the  line  of  junction  of  the  vomer  with  the  superior  maxilla  ;  secondly,  along 
the  line  of  junction  of  the  anterior  border  of  the  vomer  with  the  triangular 
cartilage  and  the  lower  posterior  part  of  the  perpendicular  plate  of  the  eth- 
moid ;  and  thirdly,  along  the  line  of  junction  of  the  anterior  border  of  the 
ethmoid  with  the  triangular  cartilage.  They  may  be  either  unilateral  or 
bilateral.  Those  located  along  the  junction  of  the  vomer,  triangular  carti- 
lage, and  superior  maxillae  are  more  often  bilateral  than  when  elsewhere. 

Deviations  of  the  septum  are  very  often  associated  with  deformities  of 
other  portions  of  the  nose,  and  also  of  the  superior  maxilla,  and  with  a  -mall 
high-arched  hard  palate,  approaching  a  scoliosis  of  the  whole  face. 

The  treatment  of  the  different  deformities  of  the  septum  consists  jn 
the  restoration  of  the  parts  to  their  normal  condition.  The  importance  of 
correcting  these  deformities,  which  almost  always  produce  more  or  less  nasal 
obstruction  and  reflex  disturbance,  can  scarcely  be  overestimated. 

The  treatment  is  palliative  or  radical,  the  palliative  measures  consisting 
in  the  removal  of  such  conditions  as  may  have  influenced  an  abnormal  growth 
of  the  septum,  such  as  the  removal  of  adenoid  growths,  enlarged  tonsils,  or 
of  any  conditions  which  may  interfere  with  the  proper  development  of  the 
nose  during  infancy  and  childhood,  and  the  reduction  of  hyperplastic  thick- 
ening by  medical  measures. 

The  radical  treatment  may  consist  in  forcing  the  septum  into  it-  proper 
position  without  the  employment  of  cutting  or  fracturing  instruments,  by 
exerting  pressure  upon  the  convex  side  by  the  introduction  into  the  nostril 
of  plugs  or  tent-,  -lowly  forcing  it  over  into  place  ;  these  method-  arc.  how- 
ever, usually  painful  and  unsatisfactory,  and  are  not  to  be  recommended. 

The  more  surgical  treatment  consists  in  the  forcible  straightening  of  the 
septum.  The  methods  employed,  according  to  the  condition-  found,  are: 
removal  of  the  prominent  portion  of  the  deflection  with  knife,  chisel,  -aw. 
scissors,  drill-,  needle  and  snare,  or  punch  ;  destruction  of  the  prominence  by 
can-tie-,  electrolysis,  or  galvano-cautery  ;  incising  the  septum  with  a  knife  or 
cutting-forceps,  and  restoring  it  to  position  by  finger  pressure,  by  the  employ- 
ment of  pin-,  or  of  forceps  having  flat  parallel  Made-  ;  fracturing  the  septum 
hv  means  of  comminuting  forceps. 

Deviation  of  the   septum   i-  almost  always  associated  with  spurs,  ri 

exostoses,  etc..  which  have  resulted  from  the  -; cause  a-  that  which  caused 

th,-  deviation,  and  these  should  lie  removed  before  the  septum  i-  corrected. 
If  the  spur  or  ridge  is  cartilaginous  it  i-  -t  easily  removed  with  a  carti- 
lage-knife, although  g 1  authorities  recommend  its  removal  with  the  gal- 
vano-cautery, and  some  by  the  use  of  electrolysis,  inserting  both  pole-  into 
the  outgrowth  at  the  same  time. 

Osseous  outgrowths  are  most  easily  removed  with  a  nasal  saw  or  drill,  or 
the  bone-scissors  or  rongeur-forceps  may  be  employed.  II.  Allen  lifted  the 
lip  after  Rouge's  method  and  chiselled  away  exostoses  of  the  floor.  I  he 
drill-  may  lie  burrs  of  various  forms  or  the  trephines  d<  \  ised  by  <  urti-.  and 
maybe  driven  by  the  dentist's  treadle-engine  or  an  electro-motor.     Good- 


1192  OPERATIONS   UPON   THE  AIR-PASSAGES. 

willie  and  oilier-  protect  the  soft  parts  with  a  shield  which  covers  the  outer 
side  of  the  burr  or  trephine. 

When  the  spur  is  associated  with  a  marked  thickening  of  the  vomer  on 
thai  side,  the  use  of  the  trephine,  as  proposed  by  Wright,  is  to  be  recom- 
mended in  some  instances.  A  hole  is  made  from  the  anterior  to  the  posterior 
end  ot*  the  deviation  in  such  a  manner  that  it  goes  as  close  to  the  mucous 
membrane  on  the  other  side  as  possible  without  perforating  it.  Into  this 
resultant  tunnel  a  slender  saw  is  inserted,  and  the  exostosis  i-  removed  l>v 
sawing  upward  and  downward  from  this  point  (see  Fig.  (>7!h. 

The  use  of  the  snare  and  transfixion-needle  for  the  removal  of  cartilagi- 
nous spurs  is  sometimes  to  be  commended.  The  portion  to  be  removed  is 
transfixed  with  the  needle,  and  the  wire  loop  of  the  e'eraseur  is  then  passed 
over  the  needle  (see  Fig.  680)  and  drawn  up  tightly,  and  the  engaged  por- 
tion cut   through. 

('an-tics,  electrolysis,  and  galvano-cautery  are  employed  in  some  cases  if 
the  cartilaginous  spurs  are  not  large  and  other  operative  measures  are  rejected 
by  the  patient.  Electrolysis  in  these  cases  is  very  warmly  advocated  by 
( lasselberry. 

Forcible  Correction  by  Forceps. — The  forceps  mosl  commonly  used  are 
those  devised  by  Adam-,  illustrated  in  Fig.  o72.  The  disadvantage  of  this 
instrument  used  alone  is  that  it  will  simply  force  the  septum  to  the  median 
line  without  correcting  the  usual  redundancy  ;  it  is  mainly  serviceable  in  the 
correction  of  osseous  deformities,  because  in  the  cartilaginous  portion  it  does 
not  in  any  degree  overcome  the  resiliency  of  t  he  cartilage.  In  still  ruder 
manner  Ilewet-on's  forceps  press  open  the  stenosed  naris,  crushing  the  weak- 
est   point.      Browne  claims  that  "the  crushing  of  the  turbinated   bodies  and 

I ■-.  and  fracture  of  the  outer  wall  of  the  nose,  which  must  take  place  in 

some  instances,  appear  to  give  rise  to  no  troublesome  symptoms/5 

A  number  of  modifications  of  Adams's  forceps  have  been  devised.  Jurasz 
made  them  with  detachable  handle-,  so  that  the  blades  could  be  left  Ml  xitu^ 
held  by  mean-  of  screws,  after  the  correction  was  made.    Garrigou-Desarenes, 

to  over ie  the  resiliency  of  the  septum, had  one  blade  convex  and  the  other 

correspondingly  concave,  and  tightened  with  a  screw. 

Hope  of  New  York  has  devised  a  forceps  to  be  used  in  connection  with 
the  Adam-  forceps  iii  operating  on  the  cartilaginous  portion  of  the  septum. 
One  blade  ha-  a  steel  pin  which  i-  received  into  a  corresponding  opening  in 
the  other  blade  (see  Fig.  678).  The  operation  is  then  marked  out  with  a  line 
of  puncture-  with  this  pin,  which  so  weaken  the  cartilage  that  it  is  easily 
fractured.  This  iii-trunieiit  may  be  used  in  the  thin  port  ion  of  the  bony 
septum. 

For  the  purpose  of  incising  tin-  cartilage  so  as  to  overcome  its  resiliency 

le  employed  a  stellate  punch  with  radiating  blade-  (see  Fig.  678),  and 
held  the  parts  in  place  by  mean-  of  pin--  inserted  into  the  previously  ob- 
structed nasal  chamber.     A-di  accomplishes  this  with  a  pair  of  curved  carti- 

-scissors,  similar  to  buttonhole-scissors  (see  page  918). 

•I.  B.  Roberts  uses  pin-  for  holding  the  deflected  portion  in   place  after 

the  resiliency  of  the  septum   is  overcome  with  a  knife.     This  same  plan  is 

adopted   by  Watson,  after  having  obliquely  cut    the  septum  along  its 

:<  -t    convexity   and  sel   it  over    in    the   center.      The    pin,  which  should  be 

•  lated  to  avoid  corrosion,  i-  inserted  either  through  the  dorsum  of  the 

nose  or  from   the  nostril   30  :i-   to  hold  the  flaps  together,  and  the   point  is 

emb(  tided  in  the  II ■  below  or  the  septum  behind  sufficiently  to  hold  the  pin 

in  place  until  tin'  part-  are  united. 


DEFORMITIES  OF  THE  NASAL  SEPTUM. 


L193 


Gleason  makes  a  horseshoe  incision  through  the  lower  side  of  the  deflected 
portion  and  pushes  the  flap  through  the  opening  thus  made.  A  dressing  is 
inserted  on  the  convex  side  of  the  septum  to  control  bleeding  and  to  hold  it 
in  place  until  the  pan-  are  united. 

For  the  correction  of  the  osseo-cartilaginous  deviation,  Fig.  678  repre- 
sents a  pair  of  fenestrated  forceps  devised  by  the  author  in  L891  for  the  pur- 
pose of  fracturing  the  septum.     One  blade  of  the  forceps  is  fenestrated,  while 


Fig.  678.— Roe's  septum-forceps, with  fenestrated  blade  fur  limited  comminution, am  1  interchangeable 
blades,  makings  Hope  or  Steele  or  Adams  forceps  as  desired. 

the  other  is  made  sufficiently  narrow  to  fit  loosely  into  the  fenestrum  of  the 
opposite  blade.  The  distance  which  the  second  blade  passes  through  the 
fenestrum  is  regulated  by  a  screw  in  the  handle. 

The  fenestrated  blade  is  inserted  on  the  concave  side  of  the  septum,  which 
is  fractured  sufficiently  to  overcome  the  resiliency.  The  advantage  of  these 
forceps  is  that  fracture  of  the  septum  can  be  accomplished  without  wounding 
or  lacerating  the  soft  parts.  The  parts  are  then  forced  into  the  median  line 
by  a  small  nasal  spatula,  and  a  dressing  is  inserted  on  the  convex  side  of  the 
septum  sufficient  to  hold  it  in  the  median  line  until  it  has  become  permanently 
fixed.  These  blades  are  detachable,  and  may  be  replaced  by  Adams's  plane 
blade  or  by  Hope's  pin  or  Steele's  stellate  punches — the  penetration  of  the 
latter  being  controlled  by  the  screw  so  as  to  spare  the  farther  mucous  mem- 
brane, if  desired. 

The  redundancy  of  tissue1  which  is  frequently  associated  with  the  devia- 
tion requires  removal  to  complete  the  procedure.  Such  projections  may  be 
removed  in  part  before  straightening,  or  at  a  subsequent  operation;  but  it  is 
still  better  to  determine  the  extern  of  needed  excision  and  to  have  this  form 
a  part  of  the  main  operation.  Older  operators  were  much  afraid  of  per- 
forating the  septum,  lest  a  permanent  hole  result  ;  but  with  neat,  clean 
operating  there  is  little  reason  to  fear  any  failure  of  the  mucous  membrane 
to  unite  unless  there  has  been  too  much  excision  of  tissue. 

In  all  these  cases  the  parts  should  be  rendered  aseptic  by  thoroughly 
cleansing  them  with  a  solution  of  bichlorid,  1  :  5000,  both  before  and  after  the 
operation.  The  most  aseptic  and  satisfactory  form  of  dressing  is  a  cotton 
plug,  made  by  winding  cotton  over  a  small  metal  plate  of  sufficienl  size  to  lit 
the  meatus.  Before  insertion  iodoform  i-  blown  into  the  nostril  with  a  pow- 
der-blower, and  the  plug  dipped  into  a  solution  of  bichlorid.  If  thorough 
aseptic  precautions  are  taken  it  usually  can  be  left  for  three  or  four  days 
before  removal.  If  further  support  is  required  the  nostril  should  be  re  irri- 
gated, cocainized,  and  a  fresh  plug  inserted. 

Hollow  splints  made  of  hard  rubber  (Fig.  573)  are  employed  by  A.sch  and 
others,  but  they  cause  much  more  irritation,  are  less  aseptic,  and  I  have  not 
found  them  so  satisfactory  as  the  cotton  plugs. 

1  [  It  i--  too  rarely  recognized  that  hyperplastic  redundancy  is  the  usual  cause  of  tin-  devia- 
tion.— Ed.] 


1194 


OPERATIONS   UPON   THE  AIR-PASSAGES. 


In  oearly  all  cases  if  the  operation  is  properly  performed  and  all  elasticity 
of  the  septum  overcome,  supporl  to  the  septum  is  required  for  three  to  five 
days,  until  the  provisional  exudate  is  thrown  out,  which  is  ample  to  keep  the 
fragments  in  situ  and  the  septum  in  the  median  line  without  any  return  of  the 
deflection. 

DEFORMITIES  OF  THE  TURBINATED  BONES 

are  of  not  infrequeni  occurrence.  Normally  the  turbinated  bones  project 
from  the  outer  wall  of  the  nasal  chamber  and  turn  downward  and  outward 
like  a  scroll,  as  shown  in  Fig.  679. 

In-tead  of  their  normal  bending  downward  and  outward  they  are  fre- 
quently twisted  and  distorted,  projecting  across  the  nares  into  contact  with 
the  septum. 

1  )eforinity  of  the  inferior  turbinated  hone  is  frequently  associated  with 
hypertrophy  of  the  turbinal  body  ;  while  that  of  the  middle  turbinated  bone 


679.— Transverse  section  intra  and  orbits,  showing  marked  deviation  and 

hyperplasia  of  the  septum,  with  synechia!  attachmenl  to  tin-  lefi  middle  turbinal.  The  dotted  lines  indi- 
cate Wright's  method  of  drilling  and  sawing  (Zuckerkandl). 

is  associated  with  a  marked  thickening  of  the  bone  itself,  which  obstructs  the 
passage  and  impinges  firmly  againsl  the  septum,  or  forces  it  over,  as  shown  in 
Fig.  545,  and  is  the  cause  of  much  irritation,  frequent  sneezing,  and  not  infre- 
quent ly  persistent  headaches. 

In  tin'  case  of  the  lower  turbinated  bones  being  distorted  without  hyper- 
trophy of  the  -oft   parts,  they  can  be  fractured  and  bent  backward,  usually 

with  a   pair   of   nasal   forceps.       I'.ui    the    middle    turbinated    bone  is    best  dealt 

with  by  sawing  off  the  projecting  portion  and   fracturing  and    forcing  the 

remaining  part  backward  againsl  the  outer  wall  of  the  nose  with  a  small  spat- 
ula, holding  it  in  place  by  a  light  antiseptic  cotton  dressing  until  the  bone 
becomes   sufficiently  fixed  and  the  passage  ia  permanently  free. 

Reduction  of  Hypertrophy  of  the  Erectile  Tissue. — The  inferior 
turbinal  bodies  are  more  frequent!)   found  hypertrophied  than  any  other  por- 


DEFORMITIES  OF  THE   TURBINATED   BONES. 


1  L95 


tion  of  the  intranasal  tissue,  owing  to  the  extreme  vascularity  of  this  tissue 
and  its  sensitiveness  to  atmospheric  changes.  The  nexl  in  poinl  of  frequency  ie 
the  middle  turbinal,  and  third,  the  erectile  tissue  covering  the  posterior  por- 
tion of  the  septum. 

The  principal  methods  employed  for  the  removal  or  reduction  of  these 
hypertrophied  tissues  are  cauterization  with  chemical  means  or  the  galvano- 
cautery,  and  removal  with  a  snare  or  cutting  instrument. 

Where  the  hypertrophy  is  small,  due  mainly  to  thickening  of  the  inter- 
stitial connective  tissue,  chromic  acid  i'\\>a\  on  the  end  of  a  small  flattened 
probe  gives  very  satisfactory  results.  The  pari  should  be  anesthetized  with 
cocain  and  then  thoroughly  dried  t<>  prevent  the  acid  from  liquefying  and 
running  down  on  parts  below.  After  the  acid  is  applied  the  part  should  be 
dried  with  cotton  and  sprayed  with  an  alkaline  wash. 

Trichloracetic  acid  and  strong  lactic  acid  may  be  substituted,  although 
less  effective.     The  former  is  claimed  to  give  a  specially  aseptic  eschar. 

In  those  cases  in  which  the  turbinal  swelling  is  mainly  of  a  vascular  char- 
acter,  linear  incisions  with  the  galvano-cautery  through  the  tissue  down  to 
the  bone,  so  as  to  obliterate  the  deeper  ves- 
sels, is  far  preferable  to  chemical  caustics  (see 
pages  888  and  910). 

Delavan  has  suggested  deep  submucous 
incisions  with  a  slender  knife  for  severing 
and  obliterating  these  vessels. 

When  there  is  a  large  amount  of  inter- 
stitial hypertrophy,  as  we  find  in  chronic 
cases  of  nasal  stenosis,  the  tissue  is  best  re- 
moved with  a  Jarvis  snare  (Fig.  080),  held 
in  place,  if  necessary,  by  a  transfixing  pin. 

When  this  tissue  cannot  be  engaged  by 
the  snare  it  may  be  removed  with  nasal  scis- 
sors. Care,  however,  should  be  exercised  in 
every  instance  not  to  remove  too  much  of 
the  turbinal  tissue,  lest  there  result  a  dry- 
uess  of  the  pharynx  from  lack-  of  sufficient 
moisture  imparted  to  the   inspired  air. 

Hypertrophy  of  the  vascular  tissue  on 
the  septum  is  best  destroyed  with  galvano- 
cautery  used  very  cautiously.      Masses  occur 

also  on  the  upper  portion  of  the  septum,  caused  by  the  irritation  from  contact 
of  the  turbinal.  These  when  small  in  amounl  may  be  removed  with  chromic 
acid,  or  it'  large  they  can  be  cut  away  with  a  nasal  knife.  In  operations 
in  the  nose  there  is  little  or  no  danger  of  the  mucous  membrane  failing  to 
cover  the  denuded  part,  even  after  the  removal  with  the  knife  of  quite  an 

extensive  portion  ;  while  if  destroyed  with  the  galvano-cautery,  the  d is 

membrane  is  replaced  with  connective  or  cicatricial  tissue.  1  hi-  i-  par- 
ticularly the  case  in  operations  on  the  septum. 

Synechia  of  the  nasal  passages  may  be  congenital,  bul  is  most 
frequently  found  after  disease  or  operation  in  the  nose  when  the  two  opposite 

surface-   have  been  denuded   al    the   same  time,  granulation-tissue   -I ting 

across  and  uniting  the  parts  during  the  process  of  healing.  Occasionally  a 
spur  grows  across  into  contact  and  becomes  attached  to  the  turbinal.  when  a 
synchondrosis  or  synostosis  may  take  place  (Fig.  679).  It  has  often  proven 
a  very  obstinate  condition  to  remove,  for  if  the  band  is  bodily  cut  away  it 


Fig  680  -  Hypertrophy  of  the  ante- 
rior '-ikI  of  the  right  lower  turbinal, 
transfixed  by  a  Jan  is  needle  and  en- 
cii  cled  with  a  sna  i  •  :mi. 


1196 


OP i: /.' ATIO NS   UPON  THE  „  1  TR- 1 '.  1 88. 1  Q E8. 


will  almosl  invariably  reform.  The  best  plan  for  preventing  its  return  I 
have  found  to  be  in  cauterizing  one  side  only  with  the  galvano-cautery,  after 
cutting  the  band  away,  for  the  reason  thai  cut  and  cauterized  surfaces  do  not 
readily  grow  together.  Previous  treatment  t<>  shrink  the  tissues  and  separate 
the  surfaces  greatly  facilitates  operation  and  cure. 

Any  granulation-tissue  thai  may  shoot  out  can  he  touched  with  chromic 
acid.  Another  excellent  plan  is  to  wear  a  small  metallic  plate  covered  with 
asepticized  cotton  until  the  parts  on  the  two  sides  are  healed.  This  method 
is  more  troublesome  and  disagreeable  to  the  patient  than  the  other. 

Removal  of  Neoplasms. — The  operative  methods  of  dealing  with 
these  formations  vary  as  much  as  the  structures  themselves.  Myxomata, 
or  nasal  polyps,  are  the  niosl  frequent  (see  page  1075).  They  may  constitute 
simply  small  polypoid  growths,  very  easily  removed,  or  they  may  he  multi- 
plied like  a  bunch  of  grapes  hanging  from  its  parent  stem,  or  they  may  con- 
stitute one  huge  growth,  occupying  the  entire  nasal  chambers  and  extending 
into  the  accessory  sinuses. 

Various  agents,  as  chlorid  of  zinc,  iodin,  carholic  acid,  alcohol,  have  been 
recommended  for  local  application  or  injection  into  the  growth  ;  hut  they  are 
rarely  effective  and  not   advisable  except    when  the  polyps  are  exceedingly 

small. 

Previous  to  the  invention  of  Jarvis's  snare  these  growths  were  usually 
removed  by  divulsion — grasping  the  polyp  with  a  stout  pair  of  forceps  and 


;  desa  tiding  from  the  Infundibulum  engaged  by  the  snare  loop,which  is  tightened  to 

ii  by  pushing  forward  tbe  cannula  (after  Zuckerkandl). 

twisting  it  oil'.    Bui  with  Jarvis's  3nare  and  the  use  of  cocain  these  operations 

have  I n  greatly  improved.    Fig.  681  represents  the  application  of  the  snare 

to  a  polyp  in  t he  nose. 

'I'he    snare,  armed    with    a    No.  5  piano-wire,  i-.    carefully  introduced    over 

the  growth,  then  l>\  :i  gentle  forward-and-backward  movemenl  it  i>  worked 
up  as  near  the  base  of  the  growth  as  possible  before  tightening.  This  i-  besl 
done  by  holding  firmly  with  thumb  and  index-finger  the  outside  tube  to  which 
the  wire  is  attached  while  the  cannula  is  forced  forward  by  the  middle  finger 


DEFORMITIES  OF  THE  TURBINATED  BONES.  1197 

pressed  against  the  nut.  Escape  of  the  growth  is  thus  avoided ;  and  after  it 
is  secured,  the  cutting  i>  done  by  screwing  down  the  nu1  as  fast  or  as  slow 
as  seems  best. 

The  return  of  the  growth  can  often  be  prevented  by  cutting  the  pedicle 
with  a  slender  knife,  taking  a  portion  of  the  periosteum  or  a  scale  of  the  bone 
with  it. 

in  case  the  polyp  involve-  the  whole  of  a  turbinated  bone,  it  may  be  neces- 
sary for  the  eradication  of  the  growth  to  remove  the  entire  bone. 

[f  the  growths  are  small,  I  have  found  the  interstitial  injection  of  a  satu- 
rated solution  of  Kiel i  ron iate  of  potash  into  t  lie  neck  of  the  growths  exceedingly 
effective  in  not  only  destroying  them  hut  preventing  their  return. 

When  the  ethmoid  cells  are  involved  they  require  curettement  in  order  to 
reach  the  deep  portions  of  the  growth. 

After  removal  of  the  growth  the  parts  should  he  kept  clean  with  an  anti- 
septic wash  and  carefully  inspected.  Any  recurrence  or  -mall  portion  thai 
escaped  removal  should  he  removed  or  destroyed.  The  patient,  at  frequenl 
intervals,  should  return  for  an  inspection,  to  insure  againsl  a  return  of  the 
growth. 

Fibroma  and  Angioma. — In  the  removal  of  myxomatous  growths  and 
nasal  polypi  very  little  hemorrhage  is  encountered;  hut  in  cases  of  the 
firmer  and  more  vascular  growths  it  is  often  profuse.  This  is  besl  avoided 
by  using  the  galvano-cautery  loop  or  the  cold-wire  snare.  In  the  use  of 
the  galvano-cautery  loop  care  should  he  taken  not  to  have  the  wire  too  hot. 
If  brought  to  a  dull-red  heat  only,  it  closes  the  vessel- as  it  passes  through 
the  tissue;  but  if  raised  to  white  heat  it  cuts  through  quickly  like  a  knife, 
and  leaves  the  vessels  open.  In  one  case  of  angioma  of  the  nose  the  writer 
removed  a  portion  with  the  galvano-cautery  loop  which  was  followed  by  pro- 
fuse hemorrhage,  requiring  plugging  of  the  nose  ;  whereas  a  very  much  larger 
portion  of  the  same  growth  was  removed  very  slowly  with  the  cold-wire  snare, 
and  all  hemorrhage  was  avoided. 

The  chief  difficulty  of  removing  from  the  nose  large  growths  with  the 
snare  is  in  engaging  the  growth  in  the  loop.  This  is  most  easily  accomplished 
with  a  -mall  flexible  copper  wire  having  a  shot  attached  to  one  end  and  a 
stout  silk  thread  to  the  other.  The  head  of  the  patient  i-  thrown  backward 
and  the  shotted  end  insinuated  along  the  upper  side  of  the  growth.  \\  hen 
the  shot  has  reached  the  posterior  wall  the  head  of  the  patienl  is  erected  and 
the  shot  is  slowly  pushed  down  into  the  pharynx. 

A  similar  one  is  passed  through  the  lower  meatus  below  the  growth,  when 
both  wire-  are  grasped  with  a  pair  of  forceps  and  pulled  out  through  the 
mouth.  The  copper  wire  is  then  removed  and  the  end-  of  the  thread  tied 
together,  when,  with  the  aid  of  the  linger  behind  the  soft  palate,  the  thread 
can  hi'  drawn  up  around  the  base  of  the  growth.  One  end  of  the  thread, 
preferably  the  upper  end,  is  then  attached  to  the  steel  or  platinum  wire  with 
which  we  wish  to  encircle  the  growth  and  drawn  round  it  and  attached  I"  the 
instrument  for  removal.  In  this  manner  some  of  the  largesl  growth-  ol  the 
nasal  passages  may  he  removed  with  little  risk  of  hemorrhage. 

In  some  cases  in  which  it  h  impossible  t<>  pass  a  loop  around  the  growth, 
before  recourse  is  had  to  the  knife,  electrolysis,  best  applied  by  the  bipolar 
method,  will  sometimes  he  successful  in  arresting  if  not  obliterating  the 
growth.  The  bipolar  needle  should  he  plunged  directly  into  the  base  of 
the  tumor,  and  the  current  employed  should  be  as  strong  as  the  patient  can 
comfortably  endure,  cocain,  of  course,  being  first  applied. 

Enchondroma  of  the  nose,  as  well  a-  the  Beptal  ecchondroses,  can  usually 


1198  OPERATIONS  UPON  THE  AIR-PASSAGES. 

be  removed  with  a  knife.  In  some  cases  it  may  be  removed  with  the  snare 
or  with  the  galvano-cautery.  Electrolysis  has  been  commended,  bul  seems 
to  the  writer  a  tedious  and  useless  procedure  when  the  outgrowth  can  be  so 
quickly  and  effectively  cut  away. 

Osteonaata  found  in  the  nose  are  of  two  varieties,  one  being  composed 
of  cancellous  and  the  other  of  ivory  structure.  They  are  usually  located  in 
the  upper  part  of  the  oares,  and  may  involve  the  accessory  sinuses,  often 
causing  fetid  discharges  and  pain  from  pressure.  They  are  usually  attacked 
with  the  saw  or  drill,  the  ivory  variety  being  often  removed  only  with  the 
greatesl  difficulty,  unless  the  point  of  attachment  yields  readily  to  the  chisel 
or  other  instrument. 

Malignant  growths  should,  if  possible,  be  totally  extirpated,  otherwise 
the  partial  removal  tends  to  increase  the  rapidity  of  their  growth.  Partial 
removal  may,  however,  in  some  cases  be  expedient.  In  sarcomatous  growths 
the  galvano-cautery  loop  will  sometimes  be  successful  in  arresting  the  advance. 
A  case  of  the  kind  was  reported  by  Lincoln, in  which  the  thorough  removal 
of  the  growth  with  the  galvanic  snare  caused  the  complete  arrest  of  the  growth 
for  years. 

In  the  ease  of  carcinoma,  it  is  only  through  complete  extirpation  of  the 
growth  that  success  is  attained.  The  most  radical  and  effective  method  of 
reaching  the  interior  of  the  nasal  chamber  is  that  devised  by  Rouge  of 
Lausanne,  which  consists  in  dissecting  up  the  upper  lip  close  to  the  supe- 
rior maxilla,  together  with  the  whole  soft  structures  of  the  nose,  and  turning 
them  backward  over  the  forehead,  when  the  nasal  chambers  come  plainly  into 
view  and  become  directly  accessible  for  any  operative  procedure.  Partial  or 
total  resection  of  the  bony  parts  may  be  temporarily  made,  or  the  superior 
maxilla  or  other  parts  may  have  to  be  excised. 

Coley  reports  many  eases  of  sarcoma  successfully  treated  with  serum  of 
streptococcus  and  bacillus  prodigiosus.  I  have  succeeded  in  destroying  a 
sarcomatous  growth  with  the  injection  of  a  saturated  solution  of  bichromate 
of  potash,  already  referred  to  in  connection  with  polypoid  growths 

EVACUATION  OF  ABSCESS  OF  THE  NASAL  CAVITY. 

Abscess  of  the  septum  may  result  from  an  injury  or  other  causes  (see 
pages  899  and   1117). 

The  treatment  consists  in  the  evacuation  of  the  pus  by  a  free  incision 
with  a  small  uasal  bistoury.  The  cavity  should  then  be  washed  out  with  a 
bichlorid  or  hydrogen-dioxid  solution  injected  into  it.  When  the  abscess  is 
bilateral  an  incision  is  required  in  one  side  only,  for  the  reason  that  the  two 
sides  abno-t  invariably  communicate.  The  cavity  is  then  kept  collapsed  by 
pressure  on  each  side  by  means  of  a  suitable  dressing  placed  in  each  nostril. 
This  should  lie  removed  and  the  part-  cleansed  and  dre— ed  daily  until  cured. 

This  condition  musl  not  be  mistaken  for  a  hyperplasia  on  the  septum  or 
an  ecchondrosis  of  the  cartilage.  The  question  is  quickly  settled  by  explora- 
tion with  a  probe. 

Abscess  of  the  turbinal  body  sometimes  occurs  as  the  result  of 

inflammati f  the  turbinated  bone  'joim:  on  t<>  necrosis.     Sometimes  these 

abscesses  are  chronic,  and  the  discharge  mi-taken  for  that  originating  from 
•  cessory  -inn-. 

The  operation  consists  in  the  free  opening  of  the  abscess  ami  the  removal 

5   necrotic  bone  that  may  be  present,  which  i-  besl  done  by  a  small  burr 

run  by  an  electric  motor.      The  dead  bone  can  be  eradicated  in  this  manner 


OCCLUSION  OF  THE  POSTERIOR  NARES.  1199 

without  cutting  away  the  turbinal,  which  should  be  removed  only  when 
entirely  diseased. 

BONY  AND  CICATRICIAL   OCCLUSION  OF  THE  POSTERIOR  NARES. 

Bony  occlusion  of  the  posterior  nares  is  often  congenital.     In  operating 

for  its  removal  the  size  and  extent  should  firsl  be  ascertained  by  the. ibined 

exploration  of  the  anterior  nares  with  a  curved  probe  and  with  the  finger  in 
the  posterior  nares.  When  this  is  determined  it  should  be  removed  with 
either  a  drill  or  bone-cutting  forceps.  Greal  care  musl  be  exercised,  for  the 
position  of  the  bony  formation  frequently  renders  the  operation  extremely 
hazardous.  In  the  case  of  a  child  thai  recently  . -Mine  under  the  care  of  the 
writer,  the  posterior  nares  were  completely  closed  with  a  firm  bony  formation 
which  had  existed  from  birth.  This  was  removed  with  a  Curtis  drill  passed 
along  the  floor  of  the  nose ;  when  an  opening  had  been  made,  one  blade  of 
a  small  right-angular  bone-cutter  was  passed  through  and  the  bone  chipped 
off  until  an  opening  of  the  requisite  size  had  been  made.  Cicatricial  tissue 
may  close  the  opening  secured,  and  must  be  removed  as  fast  as  it  forms. 
Trichloracetic  acid  has  been  praised  as  the  cautery  least  apt  to  be  followed  by 
return  of  the  occluding  tissue. 

Stenosis  of  the  naso-pharynx  due  to  the  adherence  of  the  sofl  palate 
to  the  pharynx  may  be  congenital  or  it  may  be  due  to  ulceration  resulting 
from  acute  inflammation,  as  in  diphtheria,  from  struma  or  tuberculosis  :  but 
is  most  commonly  the  result  of  syphilis,  which  in  children  may  be  hereditary, 
but  in  adults  is  usually  acquired.  The  stenosis  is  rarely  complete,  there  being 
nearly  always  a  small  opening  between  the  two  cavities.  Complete  stenosis 
in  the  case  of  a  child  recently  came  under  my  observation. 

The  readiness  with  which  severed  cicatricial  adhesions  reunite  renders 
these  operations  extremely  unsatisfactory;  accordingly  a  greal  many  devices 
have  been  resorted  to  to  prevent  reunion  of  the  part-  after  having  been  sepa- 
rated, such  as  the  insertion  of  rubber  tubes,  plates  of  hard  rubber,  metal 
rings,  air-bags,  and  mechanical  dilations.  The  most  successful  plan  i.-  that 
devised  by  Nichols,  who  with  a  curved  needle  passes  a  heavy  -ilk  thread 
through  each  side  of  the  cicatricial  tissue  and  ties  it  in  the  center.  The  knot 
i-  then  slipped  around  back  through  one  of  the  openings  so  ;i-  to  be  entirely 
out  of  the  way,  lying  in  the  naso-pharynx,  and  is  allowed  to  remain  there 
until  complete  cicatrization  has  taken  place  around  the  thread  in  a  manner 
similar  to  the  treatment  of  web-fingers.  The  string  is  then  removed,  and  by 
inserting  an  annular  knife  in  one  of  the  openings  the  adhesion  between  the 
two  openings  is  cut  away. 

The  best  plan  for  keeping  the  cut  surfaces  aparl  until  healed  i-  by  means 
of  a  -mall  flat  piece  of  hard  rubber  attached  to  and  held  in  place  by  a  string 

passed  through  each  nostril  and  tied  in  front  of  the  septum.     In  - e  cases 

daily  dilatation  of  the  part-  i-  necessary  to  maintain  the  proper  size  of  the 
•pening,  and   in   moderate  stenosis  only  such  dilatation   may   be  necessary. 

SURGICAL  INTERVENTION  IN  DISEASE  OF   THE  ACCESSORY   SINUSES 

has  been  dear!  with  earlier  (page  966),  and  but  few  points  need  be  here 
added. 

Maxillary  Sinuses.— The  disease  of  the  maxillary  -inn-  mosl  fre- 
quently necessitating  Burgical  interference  is  empyema.  There  are  five 
method-  for  gaining  access  to  tin-  cavity  :  ( I )  Through  the  natural  opening  ; 


1200  OPERATIONS   UPON  THE  AIR-PASSAGES. 

through  a  tooth-socket  or  alveolus;  (.">)  through  the  canine  fossa?  or  the 
canine  eminence  or  the  malar  ridge;  (4)  through  the  inferior  meatus;  (5) 
through  the  hard   palate. 

Acute  or  subacute  inflammation  of  the  antrum  can  frequently  be  treated 
successfully  through  the  natural  opening,  which  in  most  cases  is  easily  found 
with  Hartmann's,  or  preferably  with  Myles's,  silver  tubes  (Fig.  593).  The 
second  method,  however,  is  the  one  mosl  frequently  resorted  to,  because  it  is 
the  easiest  and.  as  a  rule,  causes  the  leasl  disturbance  to  the  patient.  In 
many  cases  the  floor  of  the  antrum  is  divided  into  separate  compartments 
by  septa.  It  is  therefore  important  that  the  internal  orifice  of  the  open- 
ing through  the  alveolus  should  be  wide  enough  to  include  and  cut  away 
any  septa  that  may  be  present  in  order  to  aiford  tree  drainage.  In  many 
cases  it  is  advisable  to  make  the  opening  long  and  narrow  and  wider  on  the 
inside  by  separate  insertions  of  the  drill  ;  or  the  two  outer  holes  can  be  made 
a  short  distance  from  each  other  and  the  intervening  space  sawed  out.  By 
making  an  oblong  opening  in  this  way  the  food  does  not  so  readily  enter,  and 
in  nearly  every  case  a  tube  can  he  dispensed  with.  When  a  tube  is  required, 
Myles's  soft-rubber  tube  (Fig.  590)  is  the  best. 

Some  authors  advise  making  a  very  small  opening,  which,  in  the  experi- 
ence of  the  writer,  is  unpractical,  as  it  does  not  afford  sufficient  room  for  the 
exploration  and  [\-rr  drainage  of  the  cavity  or  the  removal  of  growths,  which 
are  frequently  found  to  be  the  exciting  cause  of  the  discharge.  In  case  the 
premolar  teeth  arc  sound  or  a  very  large  opening  is  necessary,  it  is  best  made 
through  the  canine  fossa.  In  cases  of  growth  in  the  antrum,  it  is  frequently 
necessary  to  make  a  very  large  opening  to  permit  free  inspection  of  the 
interior  and   thorough   removal  of  the  growth. 

The  writer's  method  of  opening  the  antrum  through  the  canine  fossa  is 
first  to  incise  and  turn  back  the  soft  parts  where  the  opening  is  to  be  made, 
then  to  drill  a  small  hole  near  the  lower  side,  which  permits  a  preliminary 
exploration  of  the  interior  of  the  cavity  with  a  probe  to  determine  its  size 
and  shape.  A  slender  saw  i<  then  introduced  through  thi-  hole,  and  a  circu- 
lar button  of  bone  of  the  desired  size  is  sawed  out  of  the  anterior  wall.  It 
is  usually  desirable  to  make  the  opening  sufficiently  large  to  freely  introduce 
the  finger,  which  is  a  valuable  aid  for  exploration.     This  large  hole  also  affords 

ample  space  for  the  re val  of  growths  or  other  diseased  conditions  and  a  ready 

access  for  treatment.     This  method  of  removing  the  bone  with  a  saw  I    have 
found  to  be  far  superior  to  the  use  of  the  chisel  commonly  resorted  to.' 

When  the  outer  bony  wall  of  the  nasal  chamber  is  thin,  an  opening 
through  it  is  easily  made  with  a  -mall  curved  trocar  ami  cannula;  but  when 
this  wall  is  firm,  it  i-  besl  made  with  a  curved  spiral  drill  attached  to  an 
electric  motor.  This  method  has  often  been  found  serviceable  in  recent  cases, 
but  it  is  not  a  route  generally  to  be  recommended,  for  the  reason  that  the 
floor  of  the  antrum  i-  frequently  much  below  the  plane  of  the  floor  of  the 
nose,  and  discharges  from  the  nose  will  find  their  way  into  the  antrum.  It 
i-  also  impossible  through  this  opening  to  remove  growths  or  to  explore 
or  properly  treat  the  antrum  when  extensively  diseased. 

<  Opening  through  the  hard  palate  i-  sometimes  resorted  to,  and  conditions 
may  arise  where  it  i-  the  mosl  advisable  method,  although  generally  it  is  not 
to  be  recommended,  on  account  of  the  readiness  with  which  food  ami  other 

stances  may  be  forced  through  the  opening  from  the  mouth. 

Disease  of  the  Ethmoid  Cells. — Disease  of  the  ethmoid  cells  is  very 
-   associated  with    nasal    polyps,  and   in   these  cases  the  anterior  ethmoid 
['  Dr.  M  •  ]'■-'-  opening  further  back  ie  described  on  pnge  97  I.  | 


SUltdEliY  IX  DISEASE  OF  THE  ACCESSOR  SIM  WAW.       1201 

cells  are  most  frequently  affected  \  but  when  there  is  necrotic  condition  of 
the  turbinated  bone,  the  posterior  ethmoid  cells  and  also  the  sphenoid  cavity 

arc  also  very  frequently  involved.  When  unassociated  with  nasal  polyps, 
the  tissues  covering  the  middle  turbinated  and  ethmoid  mass  frequently  have 
a  boggy,  doughy  character  and  a  pale  color,  resembling  a  polyp.  In  other 
instances  the  enlargement  of  the  turbinal  consists  of  a  true  connective-tissue 
hypertrophy,  causing  pressure  on  the  septum  and  much  reflex  disturbance. 
In  some  cases  the  bone  is  denuded,  which  is  very  readily  detected  with  a 
probe,  and  has  been  termed  by  Woakes  ,-  necrosing  ethmoiditis."  This  con- 
dition is  usually  attended  with  purulent  discharge,  headache,  supra-orbital 
and  peri-orbital  neuralgia,  and  sometimes  the  vision  in  the  eye  of  that  side 
i>  interfered  with,  or  choked  disk  is  found  on  ophthalmoscopic  examination. 

The  only  effective  treatment  is  free  opening  of  the  cells  and  curettement 
of  the  diseased  portion.  In  order  to  reach  these  cells,  more  or  less  of  the 
turbinal  body  requires  removal.  A  boggy  hypertrophy  of  the  middle  tur- 
binal bodies  is  best  removed  with  a  Jarvis  snare,  which  is  frequently  em- 
ployed for  removing  the  turbinated  hone  ;  but  for  this  purpose  Myles's  cutting- 
forceps  is  preferable,  for  the  crushing  of  the  hone  by  the  snare  is  not  desira- 
ble. Burrs  and  drills  are  employed  by  some.  Bosworth  employs  a  burr  run 
by  a  hand  motor,  and  depends  largely  upon  the  sense  of  touch  with  the  in- 
strument to  locate  the  point  for  operation.  This  method,  however,  is  hazard- 
ous, except  for  one  thoroughly  skilled  in  these  operations.  When  the  cells 
have  been  freely  opened  and  sufficiently  curetted  to  break  down  all  the  dis- 
eased cell-walls,  the  cavity  should  be  thoroughly  washed  out  with  an  anti- 
septic solution  and  packed  with  iodoform  or  sublimate  gauze.  This  should 
be  renewed  as  often  as  required,  usually  daily,  and  the  healing  process  stimu- 
lated by  mopping  with  a  silver-nitrate  solution,  30  grains  to  the  ounce.  I  f 
the  purulent  discharge  continues,  it  indicates  that  all  of  the  diseased  cells 
have  not  been  reached,  or  that  the  discharge  comes  from  a  neighboring  sinus, 
which  should  be  investigated. 

Disease  of  the  Sphenoid  Cavity. — As  already  stated,  disease  of  the 
sphenoid  cavity  is  often  associated  with  disease  of  the  ethmoid  cells  and 
maxillary  sinus,  and  is  usually  determined  by  tracing  the  source  of  the  pus, 
aided  by  the  use  of  the  aspirating  needle,  or  exploration  with  a  probe.  The 
opening  in  the  cavity  can  sometimes  he  found  by  passing  a  probe  directly 
backward  along  the  lower  border  of  the  middle  turbinal  body,  using  that  as 
a  guide.  Often er  it  is  higher  and  more  lateral,  so  that  the  probe  must  curve 
outward  and  cross  the  posterior  third  of  the  turbinal  i  see  Fig.  682 1.  Empyema 
as  in  the  maxillary  -inn-  can  also  be  determined  by  the  effervescence  on  in- 
jecting into  the  cavity  a  small  quantity  of  hydrogen  dioxid.  Tin-  cavity 
sometimes  becomes  the  seat  of  polypoid  or  other  growths  and  degenerated 
tissue,  requiring  curettement.  In  simple  empyema  the  cavit}  should  be  washed 
out  and  medicated  with  a  syringe  having  a  long,  -lender  nozzle. 

Other  diseased  conditions  frequenl  ly  require  a  free  opening  of  this  cavity, 
which  can  he  made  by  drilling  through  the  anterior  wall.  This  can  Bafely 
he  done  by  firsl  ascertaining  the  distance  of  the  anterior  sphenoid  wall  from 
the  end  of  the  oose  and  marking  the  distance  on  the  drill  ;  then  by  allowing 
sufficient  for  the  penetration  of  the  wall  of  the  cavity,  we  kii"W  exactly  the 
distance  beyond  which  the  drill  should  not  he  passed.  <  >rdinaril}  the  enter- 
ing of  the  drill  into  the  cavity  is  at  once  perceived  by  the  operator.  W  hen 
a  sufficient  opening  has  been  made  by  the  drill  or  the  rongeur  3ee  pagi  98  l  . 
the  growths  or  other  diseased  tissues  are  removed  by  curettement,  the  cavity 
is  cleansed  with  an  antiseptic  solution  and  packed  with  iodoform  or  sublimate 


1202  O/'/.VM'/Vo.Y.v   UPON   THE  A  IB-PASS  AGES. 

gauze,  as  in  the  case  of  the  ethmoid.  Afterward  the  cavity  requires  frequent 
irrigation  with  a  medicated  solution  until  the  parts  art'  healed.  After  irriga- 
tion of  the  cavity  the  head  should  be  held  downward  in  such  a  position  thai 
the  cavity  will  be  entirely  drained. 

Disease  of  the  Frontal  Sinuses. — Disease  of  the  frontal  sinus  is 
almo.-t  invariably  associated  with  disease  of  the  nasal  cavity — most  commonly 
polypoid  growths  or  enlargement  of  the  middle  turbinal — obstructing  the 
infundibulum.  Empyema  of  the  frontal  sinus  is  most  frequent,  although  it 
may  be  the  -eat  of  growths  and  degenerations.  The  disease  of  this  cavity 
is  indicated  by  the  flow  of  pus  from  the  upper  portion  of  the  semilunar 
hiatus,  and  by  pain  and  tenderness  to  pressure  over  and  around  the  eye. 

The  treatment  of  frontal-sinus  disease  is  by  drainage  and  injections  of 
medicated  solutions  into  the  cavity.  This  can  be  reached  by  two  routes: 
through  the  infundibulum  or  natural  opening,  or  by  an  external  incision 
through  the  bony  wall.  Through  the  infundibulum  a  slender  silver  catheter 
may  be  passed  and  the  sinus  irrigated  and  medicated,  and  in  recent  eases  a 
cure  is  effected  in  a  short  time  ;  hut  in  chronic  cast's  it  must  he  reached 
throuffh  an  incision  in  the  outer  wall.  The  incision  should  he  made  along: 
the  eyebrow,  and  the  tissues  raised  and  turned  backward  a  short  distance  to 
give  room  for  opening  the  bone.  The  cavity  is  best  entered  just  above  the 
supra-orbital  ridge  with  a  small  drill  run  by  electric  motor,  controlled  by  a 
foot-switch.  Through  this  opening  the  cavity  can  he  explored  and  its  size 
and  the  relations  of  its  walls  ascertained.  A  larger  drill  can  then  he  em- 
ployed, or  a  button  of  bone  taken  out  with  a  trephine,  or  the  portion  of  the 
wall  -awed  out  with  a  slender  saw,  as  in  opening  the  antrum.  Luc  adopts 
the  plan  of  making  a  vertical  incision  from  the  root  of  the  nose  upward  and 
so  raising  the  sofl  parts  thai  the  opening  through  the  bone  is  made  under  the 
flapjusl  outside  the  median  line,sotha1  the  two  wounds  will  not  come  opposite 
each  other.  When  the  opening  has  been  made,  the  cavity  is  curetted  or  dealt 
with  according  to  the  conditions  found.  A  Bryan  soft-rubber  drainage-tube 
i-  then  inserted  through  the  natural  opening  into  the  nose,  the  flange  on  the 
head  of  the  tube  remaining  in  the  cavity  to  keep  the  tube  in  place,  and 
through  this  the  cavity  i-  irrigated  and  medicated  from  below.  The  external 
wound  i-  then  closed  in  the  usual  manner.  It  is  important  that  the  line  of 
the  incision,  when  horizontal,  be  made  along  the  line  of  the  eyebrow,  so  that 
the  -ear  will  be  obscured  bv  the  hair. 


TONSILLAR  OBSTRUCTIONS  IN  THE  NASOPHARYNX  AND  FAUCES. 

The  mosl  frequenl  obstructions  in  the  naso-pharynx  are  adenoid  growths 
or  enlargements  of  the  pharyngeal  tonsil  (see  page  952),  although  nearly 
every  known  variety  of  growth  is  encountered  in  this  region.  A  variety 
of  methods  is  employed  for  the  removal  of  these  growths,  as  curettement, 
the  use  "f  cutting-  or  divulsion-forceps,  scraping  them  out  with  the  finger- 
nail, or  burning  them  away  with  galvano-cautery.  These  methods  are  ap- 
plicable to  the  different  « •<  n  wl  i  t  ioi  is  of  the  growth.  When  it  i-  one  rounded 
massif  is  besl   removed  with    Lowenberg's  postnasal  adenoid   forceps,  having 

a   posterior  b< ped   projection,  as  shown  in    Fig.  682.     When  composed  of 

independent  vegetations  scattered  about  the  pharynx  (Fig.  583),  the  simple 
knife  or  Gottstein's  curette  ma)  be  chosen.     When  the  mass  is  sofl  and 

igy,  it  i-  very  easily  scraped  away  with  the  finger  (Fig.  683)  or  with 
Darby's  artificial  fingernail-attachment.  When  it  is  firm  and  more  or  less 
pedunculated,  it  i-  often  besl   removed  with  a  postnasal  snare  curved  to  pass 


TONSILLAR   OBSTRUCTIONS  TN  NASO-PHARYN2T,    ETC.    1203 

up  behind  the  soft  palate  In  children  the  use  of  a  general  anesthetic  is 
always  advisable  unless  there  is  some  counterindication  to  its  use.  Chloro- 
form or  Schleich's  mixture  is  the  most  satisfactory,  and  the  operation  as 
performed  by  the  writer  is  as  follows: 

The  child  is  anesthetized,  a  mouth-gag  introduced  —  with  it-  head  slightly 
dependent.  The  tongue  is  then  depressed  and  the  choseD  instrument  intro- 
duced behind  the  palate  and  the  growth  removed.  The  child  is  then  placed 
on  the  side,  preferably  the  right,  if  the  operator  is  right-handed,  so  as  to  allow 
the  free  escape  of  the  blood  without  the  danger  of  its  being  inspired  into  the 
larynx.  The  vault  should  then  be  digitally  explored  to  determine  if  every 
part  of  the  growth  has  been  removed,  which  should  be  done  before  the  oper- 
ation can  be  considered  completed.     After  the  operation  the  vault  of  the 


Fio   682— The  Gottstein  curette    it-  blade  shown  also  above  to  the  left)  applied  for  the  removal  .>t 
the  pharyngeal  tonsil,  the  mouth  being  held  open  by  a  gag.    A  -nan-  is  also  shown  engaging  a  w  - 
tnrbinal  hypertrophy  through  the  nans.    The  Hartmann  curette  is  shown  above  and  tl  rg  for- 

ceps below,  to  the  right. 

pharynx  can  be  irrigated  with  a  postnasal  syringe,  using  a  bichlorid  solution, 
1  :  5000,  for  the  purpose  of  removing  blood'  and  rendering  the  parts  aseptic. 

Further  treatment  than  this  is  unnecessary,  and  often  this  can  be  dis- 
pensed with  by  thoroughly  cleansing  the  part-  with  an  alkaline  solution  used 
before  the  operation. 

in  operating  on  adults  anesthesia,  except  by  cocain,  is  rarely  required. 
After  the  growth  is  removed  the  conditions  thai  may  have  resulted  from  the 
presence  of  the  growth,  such  as  deafness  and  the  imperfection  of  speech  in 
children,  must   be  properly  dealt  with. 

Formerly  the  galvano-cautery  was  frequently  employed  in  the  removal 
of  adenoid  growth-;  but  the  danger  of  middle-ear  complications  attending 
it-  use  in  the  postnasal  space  and  the  greater  or  less  difficulty  in  its  applica- 
tion, together  with  the  superiority  of  other  methods  has  caused  it  almost 
entirely  to  fall  into  disuse  for  this  purpose. 


1204  OPERATIONS   UPON   THE  MR-PASSAGES. 

Harrison  Allen,  Hooper,  and  others  raise  the  child  into  a  sitting  posture 
lor  operation  and  incline  it  forward  to  let  the  blood  flow  from  the  month  and 
nose,  Allen  using  generally  the  alligator-forceps  through  the  nose,  guided  by 
the  finger  in  the  pharynx,  which  is  able  also  to  squeeze  out  the  softer  masses 
as  well  as  tear  awav  the  firmer.  After  the  central  mass  has  been  removed, 
Hartmann's  Lateral-cutting  curette  (Fig.  682)  may  he  u>v<\  for  the  removal 
of  any  marginal  portion-  remaining  in  Rosen  miiller's  fossa'  or  elsewhere. 
When  there  i-  recurrence  of  the  growth  it  is  due  to  some  portion  of  this 


I--,,-  683  —Metal  finger-guard,  serving  also  as  mouth-gag  during  digital  examination  ami  erasion  in 
the  pharynx-vault,  its  bevelled  end  can  wedge  open  the  teeth  it'  set,  and,  while  fully  protecting,  it  per- 
mits sufficient  motion. 

lymphoid  tissue  which  has  escaped  removal.1  In  exploring  and  operating 
with  the  finger  a  guard  (Fig.  683)  is  useful,  and  can  sometimes  supersede  a 
mouth-gag. 

The  removal  of  the  faucial  tonsil  is  called  for  in  eases  where  it  is 
enlarged  sufficiently  to  project  beyond  the  pillars  of  the  fauces  and  eause 
obstruction  or  act  as  a  foreign  substance,  or  when  the  tonsil  is  not  hypertro- 
phied,  l>nt  so  diseased  as  to  cause  irritation  of  the  lances  and  more  or  less 
reflex  disturbance.  There  are  two  principal  methods  for  the  reduction  or 
removal  of  the  tonsil — destruction  by  means  of  caustic  substances  ami  ex- 
cision with  cutting  instruments. 

The  caustics  employed  are  Vienna  paste,  chromic  acid,  nitric  acid,  nitrate 
of  silver,  chlorid  of  zinc,  and  the  galvano-cautery. 

Before  the  application  of  the  caustic  the  tonsil  should  he  anesthetized  with 
COCain,  or  by  the  injection  of  Wilson's  local  anesthetic  around  the  base  of  the 
structure.     Where  the  Vienna  paste  is  used,  it  is  applied  by  mixing  it  with 

water  to  the  ( sistency  of  a  thick  paste  mid  rubbing  it  upon  the  tonsil  with 

a  -mall  glass  roil,  care  being  taken  that  no  paste  he  allowed  to  drop  into  the 
fail'  ■• 

Nitric  acid  is  besl  applied  with  a  very  small  pledgel  of  cotton  wound  on 
the  end  of  a  probe,  as  may  the  saturated  solution- of  the  other  caustics;  or 
crystals  of  chromic  acid,  silver  nitrate,  or  chlorid  of  zinc  may  be  picked  up 
or  fused  on  the  end  of  a  probe. 

The  galvano-cautery  is  most  effectively  employed  by  ignipuncture,  using 
a  -lender-pointed  electrode  (Fig.  568),  which  is  thrusl  into  the  tonsil  at  sev- 
i  ral  different  places,  rather  than  burning  away  the  tonsil  in  toto. 

None  of  these  processes  is  to  be  recommended,  however,  except  as  a 
substitute   for  the  knife  when   it-  use  i-  not   permitted. 

The  only  positively  satisfactory  and  effective  method  is  excision.     This 

1  [While  -nine  recurrence  is  possible,  thai  observed  i-  generally  due  to  the  growth  toward 
the  free  median  space  of  adenoid  tissue  left  at  the  iides      "Total  removal"  of  lymphoid  tis- 

monly  extends  into  the  Eu  tachian  tube,  is  neither  safely  possible  nor  desirable ; 
but  -ill  thai  is  obstructive  or  likely  t<>  become  so  should  be  removed,  preferably  by  expression, 

iy8  the  smallest  amount  of  mucous  membrane.     Ed.] 


TONSILLAR   OBSTRUCTIONS  TN  NASO-PHARYNXy    ETC.    1205 

maybe  done  with  a  bistoury,  with  the  tonsillotome,  with  the  cold-wire  snare, 
or  with  the  galvano-cauterj  ecraseur. 

The  bistoury  employed  should  be  slightly  curved  :m<l  havea  blunt  probe- 
point  to  prevent  the  wounding  of  the  pillars  of  thefaucesand  to  lessen  the 
danger  of  cutting  too  deeply.  The  tonsil  is  removed  by  grasping  it  with  a 
j»air  of  forceps,  dragging  it  from  its  base,  and  cutting  off  the  diseased  portion. 
In  cases  of  flattened  or  lobulated  tonsils  the  bistoury  is  a  very  practical  instru- 
ment for  the  removal,  especially  in  adults,  although  in  many  cases  the  writer 
gives  preference  to  the  cold-wire  snare. 

In  children  where  the  tonsils  are  found  plump  and  rounded  the  tonsil- 
lotome  of  Mathieu  or  Mackenzie  is  very  serviceable,  although  in  these  cases, 
also,  the  cold-wire  snare  is  preferable. 

in  the  use  of  the  tonsillotome  the  patient  is  seated  upright  and  the  head 
held  by  the  assistant.  The  tongue  is  depressed  and  the  ring  of  the  instru- 
ment is  passed  from  below  over  the  tonsil  and  well  in  behind  it    (Fig.  684  . 


Fig.  684.— Diagram  showing  the  method  of  applying  the  Mackenzie  tonsillotome  (after  Hovell). 

The  assistant  presses  with  one  finger  on  the  outside  of  the  neck  directly 
over  the  tonsil,  forcing  it  inward  toward  the  fauces,  so  that  it  may  the  more 
fully  enter  the  ring,  and  the  guillotine-knife  is  then  carried  through  the  tissue, 
cutting  off  more  than  a  surface  slice. 

Before  the  tonsils  arc  excised  they  should  he  thoroughly  liberated  from 
the  pillars  of  the  fances  by  a  curved  blunt  instrument.  This  I  regard  as  an 
exceedingly  valuable  procedure,  as  the  tonsils  are  so  frequently  adherent  to 
the  pillars  that  unless  liberated  there  is  danger  of  cutting  the  enlarged  blood- 
vessels of  the  pillar,  which,  if  wounded,  may  bleed  profusely  or  cause  the 
alarming   hemorrhages  that    occasionally   follow   tonsillotomy    in   adults.1 

When  portions  of  the  diseased  tonsil  escape  removal,  it  is  frequently 
necessary  to  finish  the  operation  by  grasping  these  portions  with  vulsellura 
forceps  and  removing  them  with  the  cold-wire  snare  <>r  1  >i -t < >t i ry. 

In  cases  where  hemorrhage  is  apprehended,  the  tonsil  is  best  removed  by 
mean- of  the  cold-wire  snare  or  galvano-cautery  6craseur,  as  in  do  instance 
has  hemorrhage  of  any  considerable  extent  followed  the  use  of  the  cold  snare. 

The  removal  of  the  tonsils  with  the  cold-wire  snare  or  the  galvano-cau- 
tery snare  is  done  in  the  same  manner  as  the  removal  with  the  tonsillotome, 
except  that  the  tonsil  is  drawn  outward  with  a  pair  of  vulsellum  forceps 
passed   through   the  loop. 

Luc  of  Paris  and  Farnham  of  Boston  have  devised  punch-forceps  for 
the  removal  of  enlarged  tonsils,  which  I  have  found  in  some  cases  service- 
able, particularly  in  removing  remnants  of  tonsils  that  have  escaped  excision. 
Bliss  employs  scissors  i"  dissect  away  the  entire  structure  and  l'\  achon  does 
this  with  the  galvano-cautery  knife. 

'J.  Wright  collected  from  literature  some   y<  I  cases  of  bleeding  after  tonsil- 

lotomy— 2  fatal ;  I. nt  this  was  out  of  a  t"t:tl  of  probably  100,000  operations. 


1206 


n per. i  y/o.v.v  rrox  Tin:  .1 //,-/■.  i.w.u/ i:s. 


In  the  removal  with  the  galvanic  snare  allowance  should  be  made  in  the 
adjustment  of  the  loop  for  the  portion  of  the  tonsil  that  will  slough  away  as 
a  result  of  the  burning. 

In  case  of  hemorrhage  following  excision  of  the  tonsils  the  instrument 
always  at  hand  and  generally  the  most  serviceable  is  the  two  large  fingers 
of  the  hand  corresponding  to  the  side  on  which  the  operation  is  performed. 
The  fingers  are  thrust  into  the  tonsil,  with  the  thumb  pressing  firmly  on  the 
outside  of  the  neck.  The  writer  has  never  seen  a  tonsillar  hemorrhage  that 
could  not  be  controlled  in  this  manner.  In  all  ordinary  eases  the  pressure 
for  a  short  time  will  suffice  for  the  complete  arrest  of  the  hemorrhage;  but 
it'  there  is  a  tendency  to  recur,  pressure  can  be  exerted  in  the  same  manner 
by   IVndiin's  instrument. 

With  our  present  knowledge  of  tonsillotomy,  the  wounding  of  the  deep 
hi l-vessels  of  the  fauces  sufficiently  to  give  rise  to  such  alarming  hemor- 
rhages can  only  be  justified  or  excused  by  an  anomalous  distribution  of  the 
arteries,  which  ought  to  be  recognized  beforehand  by  palpation  or  by  their 
visible  pulsation  on  careful  inspection. 

Operations  on  the  lingual  Tonsil. — When  the  enlargement  con- 
sists   stly  in  a  vascular  engorgement,  the  best  method  of  reduction  is  with 

the  curved  galvano-cautery  electrode  having  a  slender  point.  By  the  aid  of 
the  laryngeal  mirror  the  large  vessels  can  be  singled  out  and  destroyed  sepa- 
rately by  burning  deeply.  On  healing,  the  contraction  of  the  tissues  will 
cause  obliteration  of  the  intervening  engorgement.  For  this  purpose  caustic 
agents  are  also  used,  such  as  chromic  acid,  nitric  acid,  and  Vienna  paste. 
These,  however,  are  not  to  be  advocated,  as  the  use  of  them  is  painful  and 
unnecessary. 

Where  the  enlargement  consists  in  hypertrophy  of  the  interstitial  connec- 
tive tissue,  it  is  best  removed  by  excision.  When  the  mass  is  more  or  less 
rounded  and  projecting,  I  have  found  the  instrument  devised  by  myself  and 
termed  a   lingual  tonsillotome,  as  represented   in    Fig.  685,  exceedingly  ser- 


!■'!,,  >>  .     i it    Roi  '•  \ tlotome, 


viceable.  The  lower  portion  of  the  ring  is  caught  under  the  lower  edge  of 
the  growth  between  it  and  the  epiglottis,  and  l>v  pressing  forward  and  down- 
ward the  mass  i-  forced  through  tne  opening,  when  the  blade  is  shoved  down 
and  the  whole   mass  severed,  leaving  a  -i th  surface. 


EVACUATION  OF  FM'CIAL  AND   PHARYNGEAL  ABSCESS.    1207 

In  cases  in  which  the  hypertrophies  are  in  the  form  of  little  lobules  scat- 
tered iilxtut  the  base  of  the  tongue,  I  have  for  a  considerable  lime  used  the 
cold-wire  snare  having  a  curved  stem  to  pass  over  the  base  of  the  tongue. 
Bui  a  small  portion  can,  as  a  rule,  be  removed  al  ;>  time,  consequently  a 
number  of  efforts  arc  required  to  remove  the  entire  mass.  This  method  i-, 
however,  exceedingly  satisfactory,  causes  little  pain,  ami  bleeding  i-  rarely 
encountered. 

In  the  removal  of*  these  growths  it  is  important  to  adjusl   the  instr nt 

by  aid  of  the  laryngeal  mirror,  the  tongue  being  drawn  forward  by  the  patient, 
in  order  to  avoid  injuring  the  epiglottis.  Every  portion  of  the  growth  should 
be  removed,  for  if  one  or  two  small  lobules  remain  behind,  the  irritation  pro- 
duced may  be  nearly  as  great  as  that  caused  by  the  whole  mass. 

EVACUATION  OF  FAUCIAL  AND  PHARYNGEAL  ABSCESS. 

Quinsy  or  peritonsillar  abscess  is  rarely  if  ever  a  suppuration  of  tonsil- 
tissue,  as  it  was  formerly  considered,  although  generally  the  result  of  phleg- 
monous inflammation  from  tonsillar  infection.  Scarification  of  the  tonsil 
itself  is  in  most  eases  as  needless,  therefore,  a-  in  retro-pharyngeal  abscess. 
Fluctuation  i-  to  he  sought  by  palpation,  aided,  if  possible,  by  simultaneous 
ocular  inspection,  and  incision  should  he  made  as  soon  as  pus  i-  detected  or  is 
clearly  unavoidable.  Harrison  Allen  probed  carefully  each  tonsillar  follicle, 
seeking  a  boggy  point,  ami  could  often  thus  find  and  evacuate  the  lir-t  drops 
of  pus,  to  the  great  shortening  of  the  affection.  The  relief  to  the  patient  may 
be  great  even  before  pus  is  formed,  while  with  the  evacuation  of  the  absc<  iss 
most  of  the  pain  and  distress  of  the  condition  is  at  an  end.  The  thin  region 
of  pointing  may  perhaps  be  better  recognized  by  touch  than  by  sight,  and 
pulsation  is  to  be  felt  for,  both  as  to  its  indication  of  the  proximity  of  large 
arteries  and  because  an  aneurysm  might  be  opened  by  mi-take.  The  incision 
should  be  free,  usually  in  or  just  inside  of  the  anterior  half-arch  above  the 
tonsil,  entering  the  blade  nearly  half  an  inch  and  cutting  horizontally  in 
toward  the  median  line;  and  vigorous  use  of  the  probe  may  be  needed  to 
fully  enter  and  empty  the  flabby  sac.  Hot  syringing  with  mild  disinfecting 
solutions  is  usualy  advisable. 

Tn  the  retro-pharyngeal  abscess  it  is  easier  to  evacuate  the  cavity  ;  and 
lesl  it  should  deluge  the  air-passages  and  perhaps  be  drawn  into  the  lungs, 
some  open  at  its  upper  rather  than  at  its  mosl  dependent  portion.  In  these 
cases  the  possibility  of  extrinsic  origin  in  adjacent  lymph-gland,  mastoid  or 
vertebra]  suppuration  must  not  be  forgotten,  and  search  should  be  duly  made 
for  any  such  condition.  Where  the  retro-pharyngeal  pointing  is  merely  acci- 
dental and  external  operative  intervention  is  needful,  it  may  be  better  to 
drain  outward  without  pharyngeal  opening.  In  any  of  these  cases  thedanger 
of  wounding  the  large  blood-vessels  of  the  neck  is  much  greater  than  in 
tonsillotomy. 

UVULOTOMY. 

h  frequently  happen-  that  the  uvula  is  cut  away  because  it  is  the  sup- 
posed cause  of  irritation  which  in  reality  originates  from  diseased  conditions 
of  other  parts,  and  it  i-  -;ife  to  affirm  there  is  no  organ  in  the  bod}  which  is 
bo  often  abused  for  fancied  sins  as  the  uvula. 

It  occasionally  happens,  however,  that  the  uvula  requires  shortening,  and 
for  this  purpose  a   variety  of  instruments  have   been  devised:   fenestrated 


1208 


OPERATIONS    UPON   THE  AIR-PASSAGES. 


instruments  similar  to  the  tonsillotonie,  curved  scissors  with  the  cuds  coming 

bher  first  so  as  to  prevent  its  slipping  away,  and  others  having  a  pair  of 
claws  to  seize  the  cut  portion  to  prevent  it-  falling  into  the  larynx.  Some 
advise  the  use  of  the  snare,  in  order  to  avoid  any  danger  of  hemorrhage, 
which  sometimes,  although  very  rarely,  occurs. 

The  simplest  and.  as  I  consider,  the  best  method  of  removing  the  elon- 
gated portion  of  the  uvula  is  to  grasp  the  end  with  a  pair  of  mouse-toothed 
forceps,  pulling  it  gently  forward,  and  with  a  pair  of  grape-vine  scissors  cut 
it  on  the  slanl  so  that  the  cut  surface  looks  backward.  This  is  important 
for  two  reasons,  first,  it  prevents  food  from  coining  in  contact  with  the  cut 
surface,  and  it  directs  the  mucus  or  fluid-  from  the  nasal  space  forward  upon 
the  base  of  the  ton-ne,  thereby  preventing  it  from  falling  into  the  larynx. 

In  cutting  the  uvula  particular  care  should  be  exercised  not  to  cut  it  too 
short,  allowance  always  being  made  for  considerable  contraction  after  healing 
to  prevent  its  becoming  shorter  than  its  normal  dimensions. 

After  uvulotomy  some  cases  of  hemorrhages  have  been  reported.  .Morgan 
collected  a  number  of  such  cases  scattered  through  medical  literature,  and 
devised  a  clamp  which  can  he  applied  to  the  end  of  the  cut  portion.  This 
the  writer  has  found  in  some  cases  exceedingly  serviceable. 

INTRALARYNGEAL  OPERATIONS. 

Papillomata  and  polypoid  growths  of  the  larynx  are  best  removed  by 
mean-  of  forceps,  such  a-  Mackenzie's  (Fig.  686),  guillotine,  such  as  Stoerk's, 


>v 


[ackenzie  lateral  forci  pe  in  use  t..  bite  "it  »  polyp  of  the  ri^M  ventricle 

or  rongeurs,  such  as  Krause's.    The  choice  of  instrument  depends  much  upon 
the  form  and  -cut  of  the  growth  and  the  facility  of  the  operator. 

The  removal  of  foreign  bodies  is  often  :i  closely  similar  procedure,  both 


TNTRA  LARYNGEAL   OPERA  TIONS. 


L209 


being  guided,  as  a  rule,  by  the  mirror.  The  reversal  of  the  image  will  con- 
fuse an  inexperienced  laryngologist,  and  the  patienl  may  need  some  drill  to 
secure  steadiness  and  the  co-operation  sometimes  required  ;  so  some  prelimi- 
nary use  of  the  probe  is  ap1  to  be  useful.  Under  cocain  it  i-  nol  commonly 
difficult   to  have  the  needful  quiet  for  one  or  more  attempts;  bul    there  is 

room  for  the  exercise  of  the  highest  skill  if  pr pi  and  full  success  is  to  be 

attained.  Ample  illumination  is  requisite,  since  much  light  will  be  cul  oil'  by 
the  instrument,  which  is  sometimes  made  with  fenestrated  jaws  to  lessi  n  the 
obstruction  to  the  view  at  the  critical  moment  of  seizing  the  object.  Stoerk'a 
tube-forceps  with  its  pistol-grip  is  a  very  serviceable  instrument,  offering  the 
minimum  of  obstruction  and  irritation  by  reason  of  its  well-planned  curves. 
A  guarded  knife  is  sometime-  employed,  as  for  laryngeal  scarifications,  to  cut 
off  growths;  and  the  use  of  the  chemical  or  galvano-cautery  has  been  else- 
where described  (see  page  1004).  Preparations  for  a  tracheotomy  should  often 
be  made  before  intralaryngeal  operations  are  undertaken,  since  dangerous 
dyspnea  or  actual  suffocation   might  at  any   time  supervene.1 

Laryngeal  stenosis  can  often  be  dilated  from  the  mouth  by  the  passage  of 
a  suitable  catheter,  by  divulsion  with  instruments  like  the  author'-  dilator 


Fig.  687.— Roe's  laryngeal  dilator. 


(Fi£.  687),  or  by  cutting  and  dilating,  for  which  many  instrument-  have 
been  devised.     (For  Intubation  by  (THwyerV  method,  see  page  1029. 

EXTERNAL  OPERATIONS  ON  THE  LOWER  AIR-PASSAGES. 
Tracheotomy,  Thyrotomy,  and  Pharyngotomy.—Kxtei  nal  open- 
ing of  the  air-passages  may  be  required  for  a  number  of  conditions,  chiel  among 
which  is  the  prevention  of  suffocation  by  foreign  body.  false  membrane,  edema, 
abductor  paralysis,  or  neoplasm.  Asa  provision  againsl  the  entry  of  blood 
into  the  lungs,  i1  may  be  done  preliminary  to  operations  not  otherwise  requir- 
ing it;  ;m,|  it-  previous  performance  when  the  larynx  is  to  be  removed 
divides  the  shock  of  that  operation  and  anchors  the  trachea  to  the  external 
wound  in  a  way  that  avoids  some  of  the  complications  of  the  after-treatment 
The  need  for  it  may  be  so  sudden  that  little  preparation  is  possible,  an. I  use 
must  be  made  of  whatever  instruments  are  at  hand— even  a  penknife  having 

'The  multiplicity  of  carefully-designed  instruments  for  operation  within  the  larynx  are 
evidence  of  how  much  maybe  attempted  in  this  difficult  field  by  the  expert  laryngologist 
Yet  even  if  it  were  possible  here  to  refer  in  detail  to  these  procedures,  no  written  description 
could  materially  aid  the  practitioner  in  acquiring  the  dexterity  bj  which  success  has  been 
achieved.     For  detail  as  u<  tin-  removal  of  foreign  bodies,  Bee  page  1 133. 


1210 


OPERATIONS   UPON   THE  Alli-PASSAd  KS. 


been  successfully  employed  in  an  emergency.  Morell  Mackenzie  carried  an 
emergency  cannula,  the  split  obturator  of  which  contained  a  sterile  knife 
ready  for  immediate  use. 

Where  extreme  limitation  of  time  exists,  penetration  of  the  crico-thyroid 

membrane  is  usually  indicated,  for  this  structure  is  almost  subcutaneous  and 
generally  devoid  of  vessels  likely  to  cause  troublesome  hemorrhage.  Addi- 
tional space  may  be  gained,  if  required,  by  cutting  upward  into  the  thyroid 
or  downward  through  the  cricoid;  but  without  this  a  sufficient  respiratory 
opening  can  he  gained  for  the  emergency,  and  more  extensive  operation  in 
this  region  is  at  great  risk  of  permanently  impairing  the  voice. 

Tracheotomy  is  generally  to  be  preferred  it'  a  persistent  opening  and  the 
wearing  of  a  cannula  is  called  for  ;  and  the  opening  may  he  made  high  or  low, 
as  the  conditions  of  the  case  dictate.  The  presence  of  the  thyroid  gland  and 
its  vessels  generally  complicates  the  matter,  and  the  fatness  of  the  neck  in- 
creases the  annoyance  caused  by  the 
tube,  especially  if  the  opening-  is  low 
down,  where  the  trachea  is  deeper 
and  remains  of  the  thymus  gland 
are  present  in  the  very  young.  Yet 
the  low  operation  is  generally  pre- 
ferred because  the  space  above  the 
isthmus  of  the  thyroid  is  small; 
and  it  is  a  decided  complication  to 
have  to  secure  this  structure  with 
double  ligatures  and  divide  it  to 
make  room  (Fig.  688).  The  isth- 
mus generally  covers  the  second, 
third,  and  fourth  tracheal  rings, 
and  a  process  may  extend  up  to 
the  hyoid.  The  simplest  method 
of  hasty  tracheotomy  is  that  of 
Durham,  who  lightly  grasps  the 
trachea  between  the  thumb  and 
finger,  pressed  down  until  both  ca- 
rotids are  felt,  and  then  dissects 
down  upon  it  as  it  presses  forward 
into  the  wound.  The  veins,  en- 
gorged by  the  impeded  respiration, 
are  generally  easily  seen  and  pressed 
aside,  and  the  trachea  is  quickly 
laid  bare  and  opened,  either  directly 
or  after  fixing  and  lifting  it  with  a 
tenaculum.  By  Bose's  method  the 
median  skin-incision  is  crossed  by 
another  ;ii  the  level  of  the  erieo-t hy roid  membrane,  laying  this  bare,  and  the 
undivided  structures  in  front  of  the  trachea  are  peeled  down  sufficiently  to 
access  to  it.  A.s  it  i-  important  to  incise  the  trachea  in  the  median 
line,  greal  care  should  be  taken  to  place  the  patient's  neck-  and  trunk  straight, 

with  the  head  drawn  back  over  a  rolling-pin  or  other  linn  support  and 
immovably  held  there.  In  case  of  foreign  body  a  retractor  similar  to  a  nasal 
lum  may  be  used  to  hold  the  trachea  open,  or  a  suture  may  be  passed 
through  each  side  of  the  tracheal  wound  and  drawn  upon  whenever  cough- 
ing promises  to  expel  the  obstructing  object.     Such  thread-  are  a  very  great 


Fig.  688.— The  trachea,  larynx,  and  hyoid  region, 
with  tlir  divided  thyroid  gland  and  the  vein 

the  innominatea  an-  shown  emptying  into  the 
■id  receiving  Mm-  ana  inferior  (/,  / 

thyroid  vein-;  the  superior  {8,8)  and  middle 
thyroid  vein-  empty  into  the  jugular  (Faraboeuf). 


EXTERNAL   OPERATIONS  ON  LOWER  AIR-PASSAGES.      1211 

aid  in  placing  the  cannula  in  position  at  the  first,  and  -till  more  if  it  i-  to 
be  replaced  later  after  withdrawal  for  any  cause;  so  Bosworth  advises  them 
as  a  rule.      A  portion  of  one  or  more  rings  may  be  resected  in  order  to  secure 

a  gaping  wound,  and  the  margin  <>C  the  tracheal  and  cutau< -  wound  <m 

each  side  ran  he  stitched  together  and  a  tube  thus  dispensed  with. 

Usually  the  operation  can  be  performed  with  deliberate  division  of  suc- 
cessive layers  of  the  overlying  tissues  upon  a  grooved  director,  with  all  pos- 
sible blunt  dissecting,  until  the  trachea  is  bared  at  the  desired  poinl  and  all 
bleeding  vessels  secured  by  compression  or  ligation.  Then  with  ;i  tenaculum 
a  firm  and  central  hold  of  the  trachea  i-  secured  and  the  knife-poinl  entered 
and  the  needful  incision  made  upward  and  rather  from  within  outward. 
Turning  the  knife-blade  will  separate  the  lip-  of  the  wound,  while  the  finger- 
tip above  will  hold  wide  the  external  wound  and  prevent  Mood  from  being 
drawn  in  with  the  first  deep  gasping  inspiration.  The  cannula  may  now  he 
slipped  in  along  the  finger,  and  its  obturator,  if  used,  promptly  withdrawn  as 
soon  as  it  is  in  the  trachea.  The  tube  is  then  secured  in  place  by  tying  the 
tapes  attached  to  its  neck-plate  around  the  patient's  ueck  ;  and  the  external 
wound,  if  large,  may  he  narrowed  or  closed  around  the  tube  by  sutures. 

General  anesthesia  is  often  quite  unnecessary,  as  the  patient  is  sufficiently 
narcotized  by  the  semi-asphyxiation.  Chloroform  is  generally  preferred  he- 
cause  less  irritating  to  the  air-passages  and  le>s  liable  to  cause  vomiting,  with 
its  dangers.  Much  care  must  he  given  to  secure  due  warmth  and  moisture 
of  the  air  entering  by  this  shortened  route,  for  fear  of  pneumonia,  which  may 
supervene  from  this,  as  from  inspired  blood,  and  may  rob  the  operation  of 
its  life-saving  value.  [Steam-soaked  air  may  he  needless  or  even  harmful,  hut 
the  room  should  be  warm  and  certainly  not  too  dry.]  Artificial  respiration 
may  be  required  to  start  breathing  [or  to  continue  it  if  it  should  Ik-  interrupted 
after  the  first  free  inspiration,  as  will  occasionally  happen,  as  if  from  shock, 
on  the  free  entrance  of  air]  ;  and  the  patient  may  need  judicious  stimulation 
for  hours  or  day-  in  order  to  rescue  him  from  the  profound  carbonic-acid 
poisoning  which  has  taken  place  during  the  apnea.  The  inner  tube  must  be 
removed  and  cleansed  whenever  impeded  by  mucus  or  false  membrane,  and 
a  feather  may  be  passed  through  the  cannula  and  down  into  the  bronchi  to 
remove  collection-  and  to  stimulate  cough. 

The  operation  may  be  exceedingly  simple  and  easy,  or  may  be,  a-  charac- 
terized by  Billroth,  one  of  the  most  difficult  in  surgery.  Three  or  four 
assistants  are  desirable,  each  of  whom  must  give  full  attention  to  hi-  own 
duty,  although  it  be  the  simple  part  of  maintaining  the  head  and  oeck  in 
exact  position.  Full  illumination,  best  secured  by  the  concave  forehead- 
reflector,  i-  essential  to  the  most  skilful  work.  There  rausl  be  no  flurry  or 
clumsiness  at  the  crucial  moment  of  introducing  the  tube,  for  many  an  oper- 
ation ha-  failed  :it  thi-  point — serious  damage  being  done  t<»  the  tissues, 
bleeding  reawakened,  «>r  false  membrane  pressed  down  and  impacted.  The 
Trousseau  double  tube  with  it-  quadrant-curve  is  theoretically  inferior  to 
the  more  right-angled  and  adjustable  tube  of  Durham;  but  it  i-  the  one 
most  often  employed  by  A  lneriean-.  A  well-made  sofl  rubber  tube  can  have 
ample  lumen  and  be  much  more  comfortable  to  the  patient  and  less  likelj  t" 
cause  sloughing  from  pressure.     Fenestrated  tube-  maypermil  and  even  cause 

ingrowth  of  granulations,   with   troubles* •   resulting   erosion;   while  Buch 

construction  i-  aeedl< ince  ei gh  air  generally  passes  around  the  cannula 

to  furnish  sufficient  breath  for  phonation.  Where  bleeding  i-  to  be  especially 
guarded  against,  Trendelenburg's  or  Gerster's  dilatable  tube  maybe  used; 
but  a  tight-fitting  single  tube  can  serve  the  same  temporary  purpose,  and 


1  2 1  2  OPERA  TIONS   l  TPON  THE  . I  //.'- /'. 1 8SA  GES. 

one  of  better  size  at  the  close  of  the  operation.  Four  sizes  of 
tubes  should  be  available,  having  an  external  diameter  of  ten,  nine,  seven, 
and  five  millimeters  respectively. 

The  removal  of  the  tracheotomy-tube  alter  its  purpose  lias  been  served 
may  prove  quite  a  troublesome  matter,  for  the  patient  may  have  such  severe 
dyspnea  as  to  compel  it-  reintroduction,  and  this  may  be  difficult  or  even 
impossible  through  the  narrowed  wound,  necessitating  enlargement  of  it  or 
resort  to  intubation.  A.s  the  trouble  may  be  largely  hysterical,  there  is  room 
for  much  tact  in  forestalling  or  overcoming  it;  and  careful  laryngoscopic 
examination  should  be  made,  if  possible,  before  this  removal  is  attempted, 
to  make  sure  that  the  parts  are  in  condition  to  resume  their  function. 

Thyrotomy  '  or  laryngo-fissure,  often  with  preliminary  tracheotomy,  may 
be  needed  for  the  extirpation  of  broad-based  growths  or  for  foreign  bodies 
impossible  of  removal  by  intralaryngeal  methods.  The  cutaneous  incision  is 
to  he  made  as  for  a  high  tracheotomy,  from  the  hyoid  hone  to  the  cricoid 
ring;  the  rostrum  of  the  thyroid  is  laid  hare  and  divided  centrally  by  grad- 
ually deepening  cuts  or  by  sawing  if  calcified.  The  mucous  membrane 
should  be  exposed  and  all  structures  external  to  it  divided  and  bleeding 
controlled  before  it  is  incised  and  the  larynx  opened,  for  very  troublesome 
cough  will  he  excited.  Idie  larynx-cavity  should  he  entered  from  below 
under  good  illumination  with  the  forehead-mirror,  so  that  the  vocal  cords 
-hall  he  seen  and  injury  of  them  avoided.  The  purpose  of  the  operation  in 
extirpation  of  a  growth  or  other  step  is  to  be  then  carried  out  after  careful 
orientation,  and  the  parts  are  brought  together  with  all  possible  accuracy 
with  silkworm-gut  suture-,  the  -kin-wound  being  separately  stitched.  The 
voice  may  he  lost  or  permanently  impaired  by  the  operation,  or  not  regained, 
a-  it  sometimes  might  he,  after  consummate  intralaryngeal  work;  yet  if  this 
latter  i-  impracticable,  the  procedure  is  fully  justified. 

Subhyoid  pharyngotomy  may  he  needed  to  gain  free  access  to  the  supra- 
glottic  space  or  the  entrance  of  the  esophagus,  and  the  opening  may  he  made 
immediately  below  the  hyoid  hone  or  just  above  the  thyroid  cartilage.  The 
incision  i-  made  at  the  chosen  level  and  from  one  sterno-mastoid  to  the  other, 
and  carried  down  through  the  muscles  until  the  thyro-hyoid  membrane  is 
freely  exposed.  This  i-  entered  laterally,  and  the  epiglottis  brought  to  view 
and  drawn  out  of  the  wound  after  sufficient  enlargement,  when  the  region 
should  he  open  to  free  access.  If  found  requisite,  the  incision  can  he  carried 
down  along  the  sterno-mastoid  as  a  lateral  pharyngotomy  or  esophagotomy. 
(Iic.it  fear  was  at  one  lime  entertained  as  to  any  injury  or  removal  of  the 
epiglottis;  but  numberless  cut-throat  injuries  have  demonstrated  that  it  may 
he  lost  by  injury  n-  by  disease  with  little  serious  result.  Yet  feeding  should 
he  by  tube  (see  page  !<):;•_')  or  by  rectum  for  several  days  after  this  operation. 

Extirpation  and  Resection  of  the  larynx. — Malignant  growths 
of  the  larynx  rarely  admit  of  thorough  extirpation  by  endo-laryngeal  methods, 
mid  :i-  :i  speedily  fatal  result  with  great   suffering  is  the  only  natural  outlook, 

re  operative  measures  are  justified  in  their  removal.  [When  very  limited, 
it  may  be  feasible  by  laryngo-fissure  to  extirpate  the  growth  with  preserva- 
tion of  the  structure  and  the  voice  ;  but  partial  or  total  excision  is  generally 
needful  if  thoroughness  is  to  be  secured.  This  last  is  a  serious  measure, 
demanding  much  surgical  -kill  and   resource,  which  is  often  besl  done  hv  the 

facile  laryngoscopic  operator  will  employ  it  i •«•  rarely  than  one  lees  expert,  and 

ipl  to  decry  it  :i^  needless  and  unduly  risking  the  voice;  but  skilfully  done  it 
ntail  only  legitimate  risks,  due  rather  to  the  condition  calling  for  it  than  to  1 1  > . - 
Ed.  i 


PARTIAL   AND    TOTAL    LARYNGECTOMY. 


1213 


general  surgeon  rather  than  the  Iaryngologist  (see  page  1  1  13  i;  yel  many  are 
better  conversant  with  their  cases  than  another  can  quickly  become,  and  suf- 
ficiently versed  in  operative  technic  to  make  it  well  thai  they  should  direct 
if  not  perform  the  operation.] 

Preliminary  tracheotomy  is  generally  advisable,  and  the  patient  may  be 
allowed  to  recover  fully  and  become  habituated  to  the  change  before  the 
graver  intervention  ;  although  as  performed  by  Perier  and  by  Keen  tracheot- 
omy is  not  previously  done.  The  larynx  and  upper  portion  of  the  trachea 
are  sufficiently  bared  after  free  median  incision  and  the  grooved  director 
passed  behind  the  trachea,  through  the  front  of  which  a  strong  -ntnre  is 
passed  just  below  the  point  selected  as  the  lower  limit  of  the  excision. 
'fraction  upon  this  thread  holds  the  trachea  forward  while  it  is  cut  across, 
and  then  draws  it  out  of  the  wound  ;  and  a  tightly  fitting  curved  cannula  is 
inserted  and  secured  by  tying  the  suture  to  a  cleat  upon  it  |  Fig.  689).  The 
anesthetic  is  transferred  to  this  opening,  while  the  larynx  is  Lifted  by  a 
tenaculum  and  dissected  up  free  from  the  esophagus  and  its  upper  attach- 
ments, and  the  excision  completed  according  to  the  special  requirements  of 
the  case.     The  trachea  is  stitched  above  the  sternal  notch  into  the  wound, 


Fig.  689.— Extirpation  of  the  larynx  by  Perier's  method.    The  severed  trachea  is  plugged  with  a  tight 
cannula,  and  the  larynx  is  lifted  and  dissected  free  from  below. 

which  is  completely  closed  elsewhere  if  possible,  the  cannula  being  retained 
or  not  as  the  case  seems  to  require.  An  artificial  larynx  may  be  later  em- 
ployed, although  some  patients  have  been  able  to  talk  without  it. 

Partial  resection — e.  </.,  excision  of  one  side  of  the  larynx,  i-  regarded  as 
a  much  less  grave  procedure,  which  Bosworth  advises  as  a  first  step  after 
exploration  by  laryngo-fissure,  and  if  the  growth  appears  limited  to  that  side; 
while  J.  \.  Mackenzie  urge-  that  the  extirpation  should  be  as  total  as  of  the 
breast,  and  should  include  all  suspicious  neighboring  lymphatics. 

In  all  these  operations  placing  the  patient  in  the  Trendelenburg  position 
may  facilitate  the  procedure  and  greatly  reduce  it-  risks.  Shock  is  to  be  met 
by  full  employment  of  injection  or  transfusion  of  warm  neutral  salt-solution; 
and  in  case  of  carbonic-acid  intoxication,  simultaneous  venesection  with  free 
bleeding  has  been  employed  with  apparent  advantage. 


INDEX 


Abducens  nerve,  paralysis  of, 
511,  513 

paralysis,  511 

spasm,  511 
Abduction,  157,  497,  503 

associated,  503 

relation  of  adduction  to,  157 
Abductors  of  larynx,  paralysis 
of,  1167 

of  vocal  cords,   paralysis  of, 
1167 
Aberration.  107,  108.  230 

in  skiascopy,  206 

spherical,  88,  96 
Ablepharia,  241 

Abscess,  chronic  encysted  ton- 
sillar, 935 

epidural,  from  tympanic  in- 
flammation, 756.  See 
Pachymeningitis  externa. 

extradural,  from  tympanic 
inflammation,  756.  See 
Pachymeningitis  externa. 

intradural,  758 

of  auricle.  655,  693 
treatment,  693 

of  brain,  511 

from  ear  disease,  761.     See 
Brain-abscess. 

of  conjunctiva,  298 

of  cornea,  313 

of  evelids,  242,  546 

of  lachrymal  sac,  265,  267 

of  nasal  septum,  899,  1116 
diagnosis.  901 
etiology,  900 
evacuation  of,  1198 
prognosis,  801 
symptoms,  900 
treatment,  901 

of  nasal  wing,  901 

of  orbit.  526,  528 
operation  for,  599 

of  sclera,  330 

of  turbinal  body,  evacuation 
of,  1198 

pharyngeal,  evacuation  of, 
1207 

post-aural,  750 

prelachrymal,  268 

subdural,  from  tympanic  in- 
flammal  ion,  758 
Absence  of  nose,  operation  for, 

n-i 
Abstraction  of  blood    in  acute 

Otitis    media.  721 
Accessory  sinuses  of  nose,  anat- 
omy of,  966 
diseases  of,  966 
optic-nerve     lesions    from 

affect  ions  of,   151 
Accommodation,  94,  134,  155 
amplil  ude  of,  136,  155 
in  emmetropia,  136 


Accommodation,  amplitude  of, 
in  hyperopia,  1157 
in  myopia,  137 
effect  of,  on  pupillary  conl  rac 

tiou,  148 
Helmholtz's  theory  of,  134 
involuntary,  216 
mechanism  of,  95 
paralysis  of,    from  ptomain- 

poisoning,  465 
range  of,  136 
region  of,  155 

relation  of,  to  refractive  oph- 
thalmoscopy, 200 
relations  of  age  to,  138 
relative,  137,  155 
relaxed,  213 
spasm  of,  213,  216 
tone  of,  184 

Tscherniug's  theory  of,  135 
voluntary,  216 
A.  C.  E.  mixture,  542 
Acetauilid  in  chronic  suppura- 
tion of  middle  ear,  689 
in  laryngeal  tuberculosis,1048 
Acetic   acid    in    chronic    naso- 
pharyngitis, 952 
Achromatopsia,  457 
Aconite,  459 
in    acute    catarrhal   pharyn- 
gitis, 940 
in  acute  rhinitis,  893 
in      laryngeal      tuberculosis, 

mis 

tincture  in  acute  otitis  media, 
721 1 
in    neuralgia   of    pharynx, 
1153 
Aconitia  in  acute  naso-pharyn- 

gitis,  948 
Acoumeter,  668 
Acoustic  crest,  618 

hysteria,  symptoms,  776 
nerve,  atrophy  of,  769 
degeneration  of,  769 

diseases  of,  pathology,  70!» 

origin   and  distribution  of, 
621 
neurasthenia,  symptoms,  776 
treatment.  7-1 
Acromegaly,  138 

Actual  cautery.  252 

appiieat  ion   of,  567 
in  corneal  ulcers,  315 
\ in iiy  of  vision  of  peripheral 

part-  of  ret  ina.   L68 

Acute  affect  ions  of  laryns  and 

trachea.  985 
of  nose,  -:n 

of  tympanic  cavity.  715 
catarrhal    laryngitis,  985.   8ee 

Laryngitis. 

catarrhal       plia  ryngit  is.     939. 

See  Pharyngitis. 


Acute  catarrhal  tracheitis,  996 
ci  rcum  tonsillar       inflamma- 
tion, 925 

croupous  tonsillitis,  925 

edematous  laryngitis.  9SS 

lacunar  tonsillitis,  922.     See 
Tonsillitis. 

mastoiditis  interna,  749 

myringitis.  713 

naso-phai  >  ugit  is,  947 

otitis  media.   See  Otitis  media. 

parenchymatous      tonsillitis, 
923.     See  Tonsillitis. 

perichondritis  of  larynx,  995 
of  septum,  B99 

phlegmonous  laryngitis,  9ssi 

post-nasal  catarrh,  917 

purulent      inflammation      of 
middle  ear,  660 

rhinitis,  891.     See  Hit  in  it  is. 

sinusitis,  969,  972 

supraglottie  laryngitis,  986 

tonsillar  inflammations,  922 

ulcerative     tonsillitis,     927. 
See  Tonsillitis. 

uvulitis,  937 
Adam's  apple,  816 
Adams's  nasal  truss.  1122 

operation    for    deviated    sep- 
tum, -917 

operation  for  shortening  lid- 
In  i  rd er,  551 

septum  forceps,  1192 
Addison's  disease.  :;::<> 
Adduction,  157.  197.  503 

associated,  503 

relation  of  abduction  to.   157 
Adenoid    growths,    removal    of, 
1202 

hypertrophy,  etiology,  850 
examination  for,  867 

vegetations,    952.     Sir    Lym- 
phoid hypertrophy. 
ot itis  media  from.  7 L8 

Adenoma  of  caruncle,  304 
of  ciliary  body,  490 

Of  eyelids.  248 

of  lachrymal  gland.  263 

of  larynx,  i  108 

of  nose,  1085 

of  oro-pharynx,  1096 

Of  trachea.  1115 
Aditus  ad  antrum 
Advancement,  590 

accidents  and  complications, 

594 
of  capsule,  594 

to  correct    faulty  strabismus 
opera!  ions,  590 
liter-brain,  19 
After-cataract,  389 

After-images.    |o- 
\g>-    in   etiology  of  ear-disease, 
617 

1215 


1216 


INDEX. 


Agnew's  bident,  367 
Air.  index  of  refraction  of,  92 
Auction,  list ini:  of,  669 
Air-passages,  catarrhal   inflam- 
mation of,  8  1 1 
croupous     inflammation     of, 

B48 
diphtheritic  inflammation  <>f. 

848 
<li-<  asi  s  of,  sj  mptomatology, 

85] 
examination  of,  B55 
leprosy  of,  i « »i »« ; 
lupus  of,  1057.     See  Lupus. 
operations  npon,  1  180 
physiology  of,  835 
syphilis  of,  1067 
upper,  affections  of,  prognosis, 
889 
anatomy,  - 1 1 

diseases  of,  general    thera- 
peusis  of,  87 1 
local  treatment,  881 
gouty  affections  of,  general 

therapeusis,  875 
neoplasms  of,  1  <  >T-"> 
neurosis  of,  11 10 
rheumatic    conditions    of, 
t  reatment,  -7 1 
Ala  nasi,  abscess  of,  901 
retractor  lor,  Sb'O 
of  thyroid  cartilage,  H<> 
Ala-  uasi,  collapse  of,  operation 
for,  1183 
expansion  of.  operation  for, 

11-:; 
restoration    of   defects   of, 
1187 
Albinism,  351,  169,  520 
Albolene  in  empyema  of  maxil- 
lary sinus.  !»72 
Albuminuria,  390,  391,  116,  158 
Albuminuric  retinitis,  416.   See 

/.'.  tinitis,  albuminuric. 
Alcohol,  ill.  448,  159 
as  an  antiseptic,  540,  541 
in  aspergillus  of  ear.  686 
in  diphtheria,  994,  1020 
in      laryngeal      tuberculosis, 

I04fl 
spra; 
Alcohol-amblyopia,  l'i<> 
Allantiasis,  165 
Almn  in  atrophic  rhinitis,  964 
in  chronic  rhinitis.  909 
in  epistas  i 

spray  in    laryngeal    tubercu- 
losis, l""'11 
Amacrine  cells,  71 
Amaurosis,    17'.'.     See  also  Am- 
blyopia. 
from   quinin,    163 
partialis  fuga  ■-..  183 

traninat  ic,   360 
Ami. I>  opia,    r.7.    172.     See  also 

.  I  »/" 

nital,  157 

l",7.  50  I 
from  abuse  of  drugs,  159 
from  lead 

i  loss  of  hi 1.   159 

185 

oi  th<   -.  isual  held.  I7u 


Amblyopia,  toxic,  1 11.  1 18,  460, 
177 
etiology  and  pathologj  .  160 
treatment,  462 
traumatic,  360,  364 
uremic.   158 
American  catarrh.  !'  18 
Aunt  rometer,  '-'"7 
Ametropia,  212 
axial,   lengthening  or  short- 
ening of  eye  in,  17-,  20] 
frequency  of,  213 
Ammonia     in     catarrhal     tra- 
cheitis, 91 
in  laryngismus  stridulus,  995 
Ammonium  chlorid  in  chronic 

laryngitis,  L004 
Ammonol  in  acute  naso-pharj  n- 

gitis,  948 

Amplitude  of  sound-waves, 635 

Amy]    nitrite   in  embolism  of 

central     retinal     artery, 

108 

in    laryngismus    stridulus, 

995  ' 
in     subglottic     laryngitis, 
988 
Amyloid   degeneration   of   lar- 
ynx, 1  hi- 
disease  of  conjunctiva,  296 
Amyotrophic    lateral   sclerosis, 

177 
Anagnostakis-Hotz      operation 

for    entropion,   549 
Anemia.    1  19,  246,  339,  352,  372, 
399,  100,  12] 
of  labyrinth,  etiology,  770 
pathology,  766 
symptoms,  77  1 
treatment.  780 
Anesl  besia,  local,  542 
general,  542 
nasal.  11  13 
of  larynx,  1154 
of  pharynx,  1151 
Aneurism,  151,  406 
of  central   artery   of  retina, 
■IK) 
Angioid  streaks  in  retina.     127 

Angioma  of  auricle,  696 
operal ion  for.  783 

of  choroid.   193 

of  d  rumhead,  71  I 

of  eyelids,  248 

of  iris,  l-:i 

of  larynx,  1108 

of  nose,   removal  id',  1197 

of  orbit,  531 
Angle  alpha,  96,  128,   129 

beta,  96 

gamma,  !»;.  128,  129 

of  incidence,  104,  105,  106 
fraction,  104,  in."..  L06 

of  st  rabismus,  505 

visual,  138 
Angled    knives    for    intratym- 

panic  operations,  790 
Aniridia.  :;:::; 

traumatic,  362 
Anisocoria,  150 
Anisomel  ropia,  23] 

correct  i I',  232 

Ankyloblepharon,  256,  563 

.  ongenital,  2  1 1 
Ankylosis     of     foot-plat.-     of 
stapes  with  oval  \\  indow . 
(it  ;n 


Ankylosis,  stirrup-,  660 
Aimuliis  tympanicus,  622 
Anomalies      of      car-secretion, 

treatment.   684 
Anophthalmia.   1.",.",.  .",-.';; 
Anosmia,  1 1  in 
in  disease  of    upper  air-pas- 

sa.i.'i  - 
prognosis,  1 1  II 
treatment,  1111 
Anterior    chamber,    anomalies 
of.  343 
development  of.  '.'7 
foreign  bodies  in.  3 II 
irrigation  of,  after  cataract- 
extraction,  :!!»! 
nasal  aperture,  832 
pillar  of  fauces.  814 
Anthrax  pustule  of  tin  eyelids, 

242 
Antip.v  rin,   149,  460 
in  acute  rhinitis,  B93 
in  acute  tonsillitis.  925 
in  diphtheria.  1029 
in  epistaxis,  903 
in    sarcoma    of    soft    palate, 
1099 
Antisepsis    in    ocular   surgery, 

539,  540,  541,  574 
Antiseptics  used  in  ophthalmic 

work,  5  111,  oil 
Antitragicus  muscle,  G36 
Ant  itoxic  unit,  1025 
Antitoxin,  diphtheria,  dose  of, 
1024 
injurious  effects  of,  1023 
preparation  of,  1020 
site  of  injection,  1025 
testing  of,  1025 
in  diphtheria,  995,  1020 
in  dipht heria  of  conjunctiva, 

286 
in  membranous  rhinitis,  898 
Antitoxin-syringe,  1025,  1026 
Antrum,  function  of,  639 
irregularities    of     formation 

of,  793 
malignanl  neoplasms  of,  1090 
maxillary.        See     Maxillary 

a  nt  rii  in. 
of  Bighmore,  abscess  of,  438 
anatomy,  966 
empyema  of,  968 
of  mastoid.  632 
opening  of.  7!':; 
"p.  rat  ion.  793 
sarcoma  of,  1090 
Aortic  insufficiency  .  l  in 
Aphagia,  853 
Aphakia,  343,  395 
congenital,  397 
value     of     ophthalmometry 
in.  198 
Aphakial  hyperopia,  215 
Aphonia,  hysterical,  1170 
in      laryngeal     tuberculosis, 

1039 
in  nodular  larj  ngil  is,  1005 
spastica,  1 158 
Aphl  hongia  larj  ngea,  1 158 
Aprosexia  ft nasal  obstruc- 
tion, 852 
in    condensing     mastoiditis, 

in  lymphoid   hypertrophy  in 
pha rj  n \.  955 
Apsithyria,  1 167 


1 XI)  EX. 


121 7 


Aqua  calcis  in  diphtheria,  994 
chlorini,   280,   282,    285,   293, 
540 
intraocular,   injections    of, 
399 
Aqueduct,  vestibular,  o'-_>:; 

of  Sylvius.  19,  96 
Aqueous  lumior.  85,  87,  89 

index  of  refraction  of,   89, 
92 
Aqoocapsulitis.      See    Keratitis 

punctata. 
Arachnitis     from     ear-disease. 

operation  for,  B01,  803 
Arachnoid     sheath     of     optic 

nerve,  79 
Areas  senilis.  50,  326 

senilis  lentis,  389 
Area  Martegiani,  83 

olfactory,  B07 
Argamblyopia,  4">7 
Argyll-Robertson         svmptom, 
149,  150 
reversed,  150 
Argyll-Robertson's       operation 

for  senile  ectropion,  531 
Argyria.  conjunctival,  o"$ 
Argyrosis,  304 
Aristol.  252 

in  atrophic  rhinitis.  964 
in  chronic  myringitis,  714 
in  eczema  of  auricle,  693 
iu  inflammation  of  auditory 

canal,  705 
in  injuries  of  drumhead.  713 
iu     laryngeal      tuberculosis, 

1050,  1051,  1052 
in   polypi  of  auditory  canal, 

Tim; 
in    syphilis    of   air-passages, 

1074 
in  wounds  of  auditory  canal. 
708 
Arlt's  operation   for  cicatricial 

ectropion,  552 
Arsenate  of  iron    in    laryngeal 

tuberculosis,  1048 
Arsenic,  160 
in    affections   of   upper    air- 
passages,  886 
in  eczema  of  ear.  fi-r> 
in     laryngeal      tuberculosis, 

1048 
in  lupous  laryngitis,  1068 
in  lupus  of  pharynx.  1059 
in  nasal  and  pharyngeal  tu- 
berculosis,  L057 
Arteria  centralis  ret  inse,  78 

thyroidea  ima,  B25 
Arterial  pulsation  in  glaucoma, 
371 
sclerosis,   120,  1 1~> 
Arteries,  anterior  ciliary.  -6.  -7 
ciliary.  B6,  1  13 
hiiiL'  ciliary.  B6 
of  pharynx,  -1  1 

palpebral.  36 

posterior  ciliary,  36 
short  ciliary,  86 
Artery,      aberrant       choroido- 

retinal.    HMt 
cent  ml  ret  inal,  2 1.  86 
hyaloid.  _'t.     Sim-  Hyaloid   ar- 
tery. 
Articulation,  841,  117<; 
Artificial    eve.    introduction  of, 
599 


Artificial  eye.  operal  ion  for  sup- 
port of.  573 
larynx.  8  13 

ripening  of  cataract,  295 
Ary-epiglottic    folds,    develop- 
ment of,  809 
examination  of.  -7  I 
Arytenoid  cartilagi  s,  818 
development  of,  809 
muscle,  B22 

in  voice-production,  1 17-'! 
Arytenoideus,  paralysis  of,  1H>> 
Asch's  hollow  splint.  919 
operation    for  deviated    sep- 
tum, 918 
Aspergillus  fnmigatus,  ill  1'/ 

in  corneal  ulcers.  :;i  i 
Aspergillus-mycosis,  704 
pathology,  657 
treatment.  686 
Associated  action  of  pupils,  148 

movements  of  eyes,  500 
Asthenopia,  109,  510 
from  drugs,  466 
neurasthenic.  410,  485 
tarsal.   1  10 
toxic.  166 
Asthma  in  chronic  hypertrophic 
rhinitis.  907,  908 
Millar's.  986 
spasmodic,  1148 
treatment.  1149 
Astigmatic  eye.  principal  merid- 
ians of,  2'2-i 
eyes,  vision  of,  22 1 
pencil,   distribution    of   rays 

and  focal  lines  in.  1'27 
surfaces  and  pencils,  126 
Astigmatism.  50,  127,  212,  224, 
327,  333,  352,392,  109,  157 
after  cataract-extraction.  :;:•*; 
against  the  rule.  198,  226 
changes  in  cornea  caused  bv, 

226 
classification,  127 
combinations    of    lenses    for 

correcting,  228 
compound,  127 
compound  hyperopic,  227 
compound  myopic,  •.'■-'7 
correction  of,  '.''-'7 

determined  i>v    trial    lenses, 
208 

following  cataract-extraction, 
226 

following  iridectomy,  226 

from  pterygium,  297 

from  spasm  of  ciliary  muscle, 
365 

glasses  for,  •.'•.';» 

hyperopic,   127 

irregular,  224,  231,  324 
skiascopy  in,  207 

lenses  for  correct  ion  of,  128 

measured    with     ophthalmo- 
scope, 200 

mixed,  127,  227 

myopic,  127 

nervous  disturbance*   caused 
by,  226 

oblique,  227 

regular,  •.".'I 
determined    l>v   skiascopy, 
206 

rule  for  determining  amount 

of    the,     with    ophthal- 
mometer, 198 


Astigmatism,  simple,  127 
simple  hyperopic,  227 
simple  myopic,  227 
symptoms,  226 
transitory  .  U5 
variet  ies,  226 

with  the  rule,   l!i-.    _'•.>»; 

Astringents  in  chronic  laryn- 
gitis, 1002,  1003 

Asymmetry  of  nasal  chambers, 
831,  B34 

Atheroma,  391,  121 

Atmospheric  micro-organisms 
in    diseases    of   air-pass- 

3,   "il 

Atomizer.  882 

Atresia    of    external    auditory 
canal.  698 
of  meatus,  operation  for.  7-  1 
Atrium.  627 

Atrophic     rhinitis,     !•.". 
Rhinitis. 
sinusitis,  9711 
Atrophy  of  acoustic  nerve.  7o'!i 
Atropin.  209 

in  acute  otitis  media.  72] 

in    corneal    ulcers,   280,    283, 

315 
in  diphtheria.  1020 
in  iritis.  341 
Attic.  627 

inflammation  of,  7'.' 1 
Attollens  auriculae,  636 
Attrahens  auricula?,  636 
Auditory  canal.  625 

desquamative       inflamma- 
tion of.  7ul 
external,  atresia  of,  698 
circumscribed  inflamma- 
tion of.  702 
doubling  of.  699 
exostosis  of,  7<m; 
false  membranes  of,  7i>7 
foreign  bodies  in.  708 
furuncle  of.  702 
hyperostosis  of.  701; 
new  growths  of,  7n7 
polypi  in.  70.") 
syphilis  of,  7^7 
wound-  of,  708 

opic     appearance    of, 
675 
unduly  capacious,  699 
centers.  645 

meatns,  external,  s,  1    1/ 
1  xternal. 
pat hology,  o\">.~> 
internal,    development    of. 
621 
pit.  <il7 

sation,     perception      and 
judgment,  mechanism  of. 
>il  l 
Aural  fistula,  congenital.  692 

polypi,  pathology,  *  i« » 1 
Auricle.  625 
abscess  of.  •>•"•">.  up:; 
affections  of.  691 
angioma     of,    operation    for, 

congenital  malformations  of, 

691 
cysts  of.  655 

operation-  foi 
delect-  of.  operation  for,  7-'i 
diphl  heria  of.  655 

eczema  of.  655,  693 


1218 


TNDEZ 


Auricle,  eczema  of,  treatment, 

epithelial  carcinoma  of,  7-1 
epil  helioma  of,  <i!'7 
erysipelas  of,  693 
treatment,  685 
fibroma  of,  696 

fissures  <>!'.  operations  for,  783 
frost-bite  of,  696 
function  of,  636 
farancnlosisof,  treatment,  686 
hematoma  of,  655 
berpes  of,  i  reatment,  685 
herpes  zoster  of,  693 
horny  grow  i  hs  of,  i>07 
hyperemia  of,  i>~>! 
pal hology,  ,;"'  I 
treatment,  685 
inter!  rigo  of,  65  1 
keloids  of,  655,  696 
operal  ion  for,  789 
lupus  of,  695 

treatment,  686 
malignant  growths  of,  697 
muscles  of,  i>:;ii 
oew-growths  of,  696 
operations  on,  782 
pathology  of  diseases  of,  <>">l 
perichondril  is  of,  655,  694 
phlegmonous      inflammation 

of,  655 
projecting,  operation  for,  783 
syphilis  of,  695 

treatment,  686 
wounds  of,  697 
i  reatment,  7-:; 
Auricular  appendages,  removal 

of,  782 
Auscultation  of  middle  car,  i>7!) 
Auscultatory  sound  of  the  car. 

680 
Auto-ophthalmoscopy,  17!) 
Autoscopy  of  larynx.  873 
Axial  hyperopia,  215 
myopia,  125,  222 
5,   antero-posterior,  of  eye, 
100 
average  length  of,  201 
horizontal,  of  eye,  100 
optic,  95,  128 
visual.  96,  100 

Bach  i  i  -  coli  communis, 
chronic  tonsillitis  from, 
929 

diphl  hi  rise.   See  Kh  bs-  TJaffit  r. 

Klebs-Loffler,  281,  284,  614a, 
61  16,  991,  1011,  U»17 

Koch-Weeks',  01  In 

leprse,  301,  61  V> 

ozena,  61  1'/ 

of  diphtheria.  See  Klebs- 
ffler. 

of  influenza  ami  ear-disease, 

of  lepra,  "."l 

•  •i     Pea    and    Gradenigo    in 

at  rophic  rhinitis,  960 
of  tuberculosis 

of  "  :-i    61  1" 

■  ipsulati  'I.  <ii  i'/ 
lo  diphtheritic,  318, 

'■,)  V,,  1019 

81  l'' 

tidus,  614d 
■■I  I',,   1034 


Bacillus  xerosis,  296,  61  lb 
Bacteria   in  corneal  ulcers.  314, 
i;i  Ic 
in  membrauous  rhinitis,  B96 
in  ocular  diseases,  614a 
relat  ion  of,  to  ear-disease,  651 
Bacterium  coli.  (il  Id 
Balsam  of  Peru  in  lupous  laryn- 
gitis, 1066 
in  pharyngo-mycosis,  946 
Bandages,  54  l 
Bandaging   in    corneal    ulcers, 

316 
"  Barking  girls,"  1158 
Basedow's    disease,    534.      See 

Exophthalmic  goiter. 
Basilar  membrane,  619 

function  of,  Oh; 
Bathing  ami  affections  of  upper 

air-passages,  B78 
Baume   tranquille   in    furuncle 

of  auditorv  canal.  703 
Beat,  t ;:;:. 
Behring's  diphtheria-antitoxin, 

286 
Belladonna  in   acute    catarrhal 
pharyngitis,  940 
in    affections   of    upper    air- 
passages,  886 
Benign  neoplasms    of    larynx. 
1103 
symptoms,  1108 
treatment.  111)!) 
Benzoate  of  sodium  in  chronic 

laryngitis,  L003 
Benzoin  in  tracheitis,  997 
tincture    in    acute    catarrhal 
laryngitis,  986 
in  chronic  laryngitis,  1003 
vapor   in  chronic  catarrh   of 
middle  ear,  7-'ii! 
Benzoin-and-steam  inhalations 

in  laryngitis  sicca.  1005 
Benzosol  in  laryngeal  tubercu- 
losis, 1048 
Beri-beri,  436 
Bezold's  mastoiditis,  752 
Biborate  of  soda  in   laryngeal 

tuberculosis,  1050 
Bicarbonate   of    soda    for    im- 
pacted cerumen.  701 
in  perforation  of  tympanic 
membrane,  6HS 
Bichlorid  of  mercury.     See  also 
i/r ij  curie  chlorid. 
in   acute  croupous  tonsilli- 
tis, 925 
in     atrophic    rhinitis.    !)ii:'>. 

964 
in  chronic  myringil  is,  7 1  I 
in  diphtheria'.  994 
tablets,  886 
solution  in  acute  otit  is  lmdia. 
722 
Sing's  tesl 

Biniodid  of  mercury  in   syphi- 
litic throat,  -77 
Binocular    blindness,    tesl     for 
feigned,  107 
field  of  vision,  107.  171 
fixation,   199 

field  of.  502 

single  \  ision,  1  -— » « J .  199 

fit  Id  of,  502 
vision,  230,  499 
in  anisomel  ropia,  231 
Bismuth  in  chronic  rhinitis,  910 


Bjerrju m's  test-objects  formeas 
uring  field  of  vision,  163 

Miami  in's  operation  for  deviated 

septum,  920 
■•  Blanket,"  618 

Blepharitis,   245,  •_'.>,  275,  280, 
510,  61  \h 

etiology,  246 

from  eye-strain,  214 

hypertrophic,  240 

pathology,  246 

pediculosa,  247 

prognosis,  2 17 

simple,  245 

squamous,  245 

t  reatment.  217 

ulcerated,  245 

vaccine,  344 
Blepharo-adcnitis,  245 
Blepharophimosis,  256 

congenital,  2 1 1 
Blepharoplasty,  555 
Blepharoptosis.     See  rtoais. 
Blepharorrhaphy,  5 17 
Blepharospasm,  253,  306,  409 

clonic,  254 

from  eye-strain,  214 

tonic.  25 1 
Blepharotomj .  ~>\7 
Bleyer's  tongue-depressor,  872 
Blind  spot,  66,  97,  169,  195,  470 

enlargement  of,  1 17 
Blindness,  feigned,  466 

influence  of  Bontgen  rays  on, 
till 

tests  for   detecting    feigned, 
167 

unilateral  reflex,  150 
Blood,   state   of,    importance  in 
affections    of  upper  air- 
passages,  -7!) 
Blood  staining  of  cornea,  326 
Blood-upplv  of  fancial  tonsil, 
815 

of  larynx.  823 

of  naso-pharynx,  -1  1 

of  pharynx,  -1  1 
Blood-tumor  of  the  auricle,  655 
Blood-vessels  of  eyeball,  86 

of  nasal   mucous  membrane, 

Blue-vision,  468 

B I's  forceps,  n:i7,  1138 

Bone  caries  in  chronic  suppura- 
tion of  middle  ear,  742 

Bone    conduction,    testing    of, 
669 

Bonnet's    method    of   enuclea- 
tion, ~>7 1 

Bony  cysts  of  maxillary  sinus, 
1089 
of  nose,  1082 

examination,   L083 
literature.   1084 

microscopical  appearance, 

1082 
tri  atmi  nt,  1084 
labyrinth,  620 
fund  i"iis  of,  6  lo 
Borated  alcohol  in  furunculosis 

of  ear.  686 
Borax  in  chronic  rhinitis,  910 

in  pharyngo-mycosis,  946 
Boric  acid   in   aspergillns  mj 
cosis,  686 
in  chronic  myringil  i-.  7  I  1 
rhinitis.   909 


INDEX. 


1219 


Boric  acid  in  chronic  suppura- 
tion ot'  middle  ear,  689 
in  conjunctivitis,  275.  277, 

280,  285,  287,  289,  293 
in  eczema  of  auricle,  6!>:; 
in  empyema  of  maxillary 

sinus,  972 
in  furunculosis  of  ear,  686 
in    inflammation    of  audi- 
tory canal,  704 
in  injury  of  drumhead,  7K! 
in  polypi  of  auditory  canal, 

706 
in     wounds     of     auditory 

canal,  708 
insufflation  of,  in  laryngeal 

tuberculosis,  1050,  1052 
spray  in  laryngeal  tubercu- 
losis,  L050 
Boric  powder  in  acute  myrin- 
gitis, 713 
Borolyptol      in      acute      naso- 
pharyngitis,  948 
in  chronic   naso-pharyngitis. 
951 
Bosworth's  snare,  978,  979 

speculum,  859 
Botulismus,  405 
Bougard's  paste  in  lupous  laryn- 
gitis, 1066 
Bougie,  Eustachian.  682 
Bowman,  membrane  of,  51 
Bowman's  lachrymal  probes, 270 
membrane,  folding  of,  326 
operation  for  fistula  of  lach- 
rymal gland,  596 
operation   of  slitting  canalic- 
ulus, 269 
Brachyrnetropia.     See    Myopia. 
Brain-abscess,  150 
course.  762 
termination,  762 
from  ear-disease.  761 
operation  for,  803 
symptoms,  762 
Brain-diseases  from  diseases  of 

ear,  operations  for,  801 
Brain-tumors,  150,  151,  520 
a  cause  of   optic-nerve  atro- 
phy. Ill 
a  cause  of  optic  neuritis,  435 
mechanism    by    which    they 
produce    optic    neuritis, 
135 
Brain-vesicles.       See      Cerebral 

vesicles. 
Brandy  in  diphtheria,  994,  1020 
Breath,  moving  column  of,  1171 
Breathing  in  voice-production, 

1171 
Bridge-coloboma  of  iris,  332 
Brigbt's  disease.     See  Nephritis. 
Bromid  gargle  in  acute  ulcera- 
tive tonsillitis,  928 
of  ethyl,  542 
of  potassium  in  acute  inflam- 

mat  ion  of  luiilil  le  ear.  686 

nf  sodium  in  acute  inflamma- 

t  ion  of  middle  ear.  686 
Broinids   in  acute  suppuration 

nf  middle  ear.  688 
in   congestion    of  labyrinth, 

690 
Bromin  in  diphtheria,  994 
Bromofonn  in  laryngeal  tuber- 

culosis,  1052 
Bronchiti-.  394 


Bronchocele,  391 

Bronchotomy  fur  foreign  bodies 
in  trachea,  1 135 

Brncke's  muscle,  134 

Buckley's  method,  B80 

Bulbar  palsy,  150 
paralysis.  1 15 

Bulla  ethmoidalis,  830 

Buller's  shield,  279,  285 

Bullous  keratitis,  oil 

Buphthalmos,  385 

Burchardt's  dots,  140 
international  tests,  152 

Burns  of  nose.  111> 

Burnt  alum  in  chronic  suppura- 
tion of  middle  ear.  7  hi 

Burow's    operation    for    entro- 
pion, 551 

Bursa,  pharyngeal,  812,  ;»l!i 

Calcification    of   drumhead. 

714 
Calculi,  nasal,  1129 

of  tonsil,  935 
Calomel  conjunctivitis.  295 
in    acute     inflammation     of 

middle  ear,  686 
in     acute      suppuration      of 

middle  ear,  689 
in  eczema  of  auricle,  693 
in  subglottic  laryngitis,  !'Ss 
in  syphilis  of  auditory  canal, 

707 
powder  in  syphilis  of  auricle, 
686 
Calomel-sublimation    in    diph- 
theria, 1027 
Camera  obscura,  88 
Camphor  in  atrophic   rhinitis, 
964 
in  chronic  rhinitis,  910 
spray  in  laryngeal  tuberculo- 

sis,  1050 
vapor  in  chronic  catarrh  of 
middle  ear,  733 
Camphorated    steam    in    acute 

rhinitis.  894 
Campimeter,  163 
Canal,  auditory,  625 
hyaloid,  83  ' 
neural.  18 

of  Cloquet,  104.     See  Hyaloid 
canal. 

Of    Petit,   S5 

of  Schlemm,  55,  86,  -7 

of     Stilling.      See      Hyaloid 

Cltltlll '. 

Canaliculus,  division  of,  596 

knife.  27n 

lachrymal.      See     Lachrymal 
canaliculus. 
Canalis  reuniens,  617 

vestibular,  621 
Cantharidid    of    potassium    in 

laryngeal  tuberculosis,  L047 
Canthotomy,  5 18 

in  gonorrheal  conjunctivitis, 
281 
Canthus,  inner,  31 

outer,  :;i 
Capsular  ligaments  of  larynx, 

819 
< iapsulary  membrane,  23 
( lapsule  of  lens,  -11 
Of  Tenon.   13 
check  ligaments  of,  15 

Suspensory  ligament  of,    15 


Capsulo-pupillary     membrane, 

23 
Carbolic  acid,  159 

in  corneal  ulcers,  315 
in  diphtheria,  994 
in  lupus  of  pharynx,  1059 
in    nasal    and    pharyngeal 

tuberculosis,  1057 
spray  in  laryngeal  tubercu- 
losis, 1050 
Carbolized  oil    in    furunculosis 

of  ear.  686 
Carbon  disulphid,  159 
Carbonate  of  ammonia  in  diph 

theria,  994 
( iarbuncle  of  eyelids,  242 
( 'arcinoma  of  caruncle.  304 
of  eyelids,  251 
of  lachrymal  gland,  264 
of  larynx,  1109-1112 
of  meatus,  operation  for,  7-1 
metastatic,  of  choroid,  193 

of  ciliary  body,   191 
of  naso-pharynx,  1*>!»5 

Of  Hose.  1  <  >  — : * 

removal  of,  1198 

of  Optic  nerve,   1  l!» 

of  oro-pharynx,  1 102 
prognosis,  1103 
symptoms.  1 103 
treatment,  1103 
of  soft  palate,  1099 
treatment,  1100 
of  tonsils,  1101 
of  trachea,  1115 
primary,  of  ciliary  body,  490 
Cardinal  points,  90,'  92,  109 

of  a  three-index  system,  1 16 
of  human  eye,  125 
of  optical  surface,   graphic 
method  for  locating,  113 

Of  Schematic  eye.  92 

properties  of,  90 
Caries  in  acute  mastoiditis  in- 
terna. 751 

of  mastoid.  752 

of  orhit,  526 
Cartilage,  arytenoid,  818 

cricoid,  817 

of  Santorini,  SIS 

thyroid.  816 

triangular.  830 
Cartilages,  cuneiform,  816,  818 

of  larynx.  816 

of  nose,  fracture  of,  1123 

of  Santorini.  816 
examination  of,  -71 

of  Wrisberg,  B16,  B18 
examination  of,  -7 1 
Caruncle.  31 

adenoma  of,  ^>i 

affections  of,  304 

carcinoma  of,  30 1 

chalky  deposits  in,  304 

cysts  of,  304 

duplication  of,  27  1 

hyperl  rophy  of,  294 

papilloma  of,  30 1 

Ba  rcoma  of,  30 1 

telangiectasia  of,  304 

trichosis  of,  27  l 
<  tasselbt  rrj  'a  mel  hod  of  feeding 

after  intubation,  1031 
Cataract,  333,  385,  386,  104,  519 

alter-.   389 

after-treatment  of  opera: 
for,  5-i ; 


1  22i  l 


INDEX. 


•  i.  albuminuric, 
anterior  polar,  389 
artificial  ripening  of,  395 
black,  392 
capsular,  390 
capsulo-lenticular,  390 
central  lental,  390 
combined  extraction  of,  582 
complete,  of  young  persons, 

387 
complicated,  3>8 
concussion,  ■'; — 
conditions     influencing    the 

result  i'i'  operations  on. 

congenital,  387,  457 

cortical.  388,  389 

course,  393 

development,  393 

diabetic,  390 

diagnosis,  393 

discission  of,  395 

entopic     phenomena     as     a 

symptom  of.  l  1 1 
etiology,  391 
extraction  of,  347,  395,  580 

in  capsule,  582 

immature,  394 

monocular,  395 

operation  for,  ">80 

with  iridectomy,  582 
following      lightning-stroke, 

fusiform,  390 

glasses  for,  396 

glaucoma  alter  extraction  of, 
578 

glaucomatous,  377.  37'.' 

history,  386 

hypermature,  392 

immature,    ripening    opera- 
tions for,  58  l 

in  chromatic  asymmetry   of 
iris.  1  17 

incipient,  231,  392 
from  eye-s< rain.  214 

inflammatory,  '■'•  1 1 

juvenile,  387 

'lamellar.  387 

light  field  in.  394 

linear  extraction  of.  3<ir>.  ."-•.' 

mask  for.  586 

methods     of    extracting,    if 
vitreous  escapes,  582 
of  opening  capsule  in  ex- 
t ract ion  of.  581 

mistakes  and  accident-,  dur- 
ing extraction  ol 

Morgagnian,  392 

naphthalin,  392 

nuclear,  ::--    389 

ope  rat  ion-  for.  395,  579 

pathology 

period-,    of   development    of, 

posterior  polar.  •';-!'.  126 
process  of  ripening  of,  :,'.< :; 
prognosis 
punctata .  390 

tidal,  389 
raphanic, 

■  i    accommodative 
kin  to  the  developmi  nt 

nte   ami  chronic  dis- 

to  d<  ■■  ■  lop 


Cataract,  relation   of  heredity 
to  development  of.  391 
of  occupation   to  develop- 
ment of.  391 

of  sex   to  development   of. 
:;!H 
results    after    extraction    of. 

583 
secondary,  389 

opt  rat  ions  for,  585 

senile.   388 

simple  extraction  of,  395,  580 
soft,  operation  for,  582 
special  clinical  form-  of,  390 
starvat  ion-,  392 
suction    method  of  operating 

for,  395 
symptoms,  392 

traumatic.   317,  357,  384,  387, 
392 
operation  for,  582 
t  real  ment,  39  l 
varieties,  386 
zonular,  387 
Catarrh,  acute  middle-ear,    pa- 
thology, 659,  717 
acute  post-nasal,  9 17 
American,  948 
chronic  post-nasal,  948 
of  middle  ear,  chronic,  726 
sero-mucous,   of  the  middle- 
ear,  pat  hology,  659 
Catarrhal    inflammation  of  up- 
per air  pas-ages.  8  1 1 
etiology.  814 
pathology,  8 17 
laryngitis,    acute,    985.       See 

Laryngitis. 
pharyngitis,  acute.  939.     See 
Pharyngitis. 
chronic,  940.     Set-   Pharyn- 
gitis. 
tracheitis,  acute.  996 
Catheterization  of  the  ear,   679 
dangers  of,  681 
obstacles  to,  680 
substitutes  for,  681,  733 
Catoptric  test,  393 
Catoptrics,  102,  109 
( laustic  potash   for  ceruminous 
masses  in  ear,  685,  700 
in  lupus  of  auricle,  * ;  — ■* » 
Caustics  in  air-passages,  887 
in  diphtheria.  L028 

<  auterixat ion  in  chronic  laryn- 

gitis,  1004 
in  epistaxis,  903 
( 'aiiterv  ill  corneal  ulcers,  :;).", 

•  atlti  rv-poiiits, 

•  a\ ■. ■riit.iua  of  choroid,  193 

of  conjunct  iva,  27  I.  300 
Cavernous  sinus,  thrombosis  of, 
529,  759 
ani  iirv-mal  varix  of,  534 
Cavity,  drum.  626,  627 
tubo-1  ym  panic,  626 
Cellulitis  of  orbit,  527 
Center  of  opt ital  surface,  1<I9 
of  rotat  ion,  '■"'> 
optical,  117.  119,  120,  123 
of  a  lens,   1 18 

<  entered  opt  ical  bj  stems,  1 1  i 
< tenters,  auditory,  045,  77u 

C<  lit  ia<l.    133 

sj  stem  of  I  'emu  tt,  i:::; 
Centrum     ovale,     hemorrhage 
into,  L50 


Cephalic  visceral  arches,  H>9 

clefts,  B09 
Cerebellar  ataxia  in    brain-ab- 
scess, 763 
fossa,  623 
tumors.    135 
Cerebellum,    hemorrhage   into, 

150 
Cerebral  abscess  from    car-dis- 
ease. 7»il 
operation  for.  M>3 
origin  of  ear-disca-t  .   652 
peduncles,  hemorrhage   into, 

150 
softening.  150,  137,  145,  762 
tumors    in   etiology   of   ear- 
disease,  648 
vesicles,  primary .  18 
secondary,  19 
Cerebro-spinal  meningitis,  339, 
355 
relation    of.   to    ear-tl  iseasc, 
652 
sclerosis,    151 

Cerebrum.     See  Brain. 
Cerumen,  impacted,  699 

etiology,  700 
symptoms,  699 
treatment,  684,  700 
Cervical  ganglion.  97 
Chalazion.  2  1!' 
Chancre  of  eyelids,  247 

of  nose  and  throat.  1065 
Check  ligaments.  45 
Cheesy    ]>us    in    chronic    sup- 
puration  of   middle  ear, 
743 
Chemosis  of  conjunctiva,  298 
Cherry-red  spot,  407 
Chiasm,    optic,    438,     1 1">.    478. 
Sec  also  Optic  chiasm. 

diseases  of,  180 
Chloracetic    acid    in     laryngeal 
tuberculosis,  1050 
in  rodent  ulcer.  252 
Chloral.  459 

Chlorate  of  potassium.  :_>r>2,  886 
Chlorid  of  ammonium  in  affec- 
tions of  nose  and  throat, 
885 
in    larvngeal   tuberculosis, 

1049 
vapor,  883 
of  gold  ami  sodium  in  laryn- 
geal tuberculosis,  H 1 17 

in  nasal   and    pharv  ngeal 
i  uberculosis,  1057 
of  mercury  in  diphtheria,  994 
of  sodium  in  pachydermia  of 

larynx.  1008 
of  zinc  in  chronic  inflamma- 
tion   of    lingual    tonsil, 
934 
in  diphtheria,  994 
in    laryngeal     tuberculosis, 

1(117 
in  lupous  laryngitis,  1066 
-pia\  in  lai  j  ng(  al  tubercu- 
losis,  1050 
Chlorinated  soda  in  diphtheria, 

1028 
Chlorin-gas    in    diphtheria-dis- 
infect ion,  1015 
(  hlorin  water   in  lar\  ngeal    tu- 

berculosis,  1047,  1051 
in  nasal  and  pharyngeal  tu 
berculosis,  1057 


TNDEX. 


1221 


Chloroform,  542 

in  acute  otitis  media.  721 
in  spasm  of  larynx.   1156 
Chloroma  of  lachrymal  gland, 

264 
Chlorosis,  HO,  437 
Choana,  832 
Chocolate,  459 

Choked   di-k.      Sec   Optic  neu- 
ritis. 
Cholera,  538 

Cholesteatoma      <>f      auditory 
canal.    704 
of  drumhead,  714 
of  tar.  75:; 

of  middle-ear,  pathology,  061 
Chondroma  i>t"  larynx,  1 108 
of  mis.-.  1084 
nt'  trachea,  1115 
Chondromalacia  of  auricle,  <i!»l 
Chorditis   tuherosa,    1005.    See 

Laryngitis,  nodular. 
Chorea.   106,509,  511 
color  of  iris  in,  1  17 
from  eye-sl rain,  21 1 
of  larynx,  1 158 
Chorio-capillaris,  58,  59,  189 
Chorio-retinitis,  457 

striata,  128 
Choroid,  57,  301 
angioma  of,  193 
atrophy  of,  353 
calcareous    degeneration    of, 

357 
capillary  network  of,  57 
cavern oma  of,  193 
changes   in.  from  eve-strain, 

213 
changes  in.  from  myopia,  "221 
changes  in  visual  field  in  dis- 
eases of,  475 
circumpapillary  coloboma  of. 

15i  i 
colloid  degeneration  of ,  354 
coloboma  of,  192,  351,  157 
congenital  anomalies  of,  351 
contusion  injuries  of,  lit; l 
detachment  of,  357,  364,    191 

development   of,   27 

diseases  of.  351 
hemorrhage  of.  364,399,  428 
hyperemia  of,  352 
lamina  vitrea  of.  59 
layers  of.  57 
lymphatics  of.  59 
metastatic  carcinoma  of,  493 

metastal  ic  -ar< la  of.  193 

nerves  of,  59 

o--.iticuti.iii  of.  357 

rupture  of.  354,  357,  364,  392 

ina  of.    191 

senile  areolar  atrophy  of,  354 

solitary  tubercle  of.  356 

b1  ron t'-  58 

tuii  irculosis  of.  356 

tumors  of.  r.'l 
Choroidal  cleft,  22,  332,  333,351 

fissure,    26.      See    Choroidal 
deft. 

rin-.  66,  1-1 

str a.  58 

Choroiditis.    189,  oil.   352,  391, 
.  399,  hi:;.  175 

areolar,  353 

central,  35  I 

disseminated,  352,  126 

etiology, 


Choroiditis,  exudative.  352 
from  injuries,  354 
l: ut  tale,  354 
hemorrhagic,  354 
metastatic.  355,  398 
myopic,  35 1 

pathological  anatomy.  352 
prognosis,  355 

recent.  353 

suppurative.  355,  356 
symptoms,  353 
syphilit  ic,  353 
traumatic,  365 
treatment.  355 
unclassified  forms,  3.")  t 
Choroid.)-  retinal  aberrant 

artery.   190 
Choroido-i'et  initis.  357,  387 
sympal  hetic,  348 
syphilitic,  419 
•  Ihromatometer,  15 1 
<  'hromato-photo-optometer,  151 
Chromic  acid.  ss7 

in    chronic    follicular   pha- 
ryngitis, 943 
in  chronic  inflammation  of 

lingual  tonsil,  934 
in  chronic  laryngitis,  1004 
in  chronic  myringitis,  714 
in     chronic     naso-pharyn- 

gitis,  952 
in  chronic  rhinitis,  911 
in  condylomata  of  auditory 

canal,  707 
in  epistaxis,  903 
in  Lupus  of  pharynx,  1059 
in    new   growths  of  drum- 
head, 714 
in  nodular  laryngitis,  1006 
in  pachydermia  of  larynx, 

1008 
in  pharyngomycosis,  946 
in  polypi  of  auditory  canal, 
706 
Chromidrosis  of  eyelids.  259 
(  hroiiic  catarrh   of  middle  ear, 
726.     See  Middle  ear. 
catarrhal      pharyni;iti-.     940. 

s.e  Pharyngitis. 
conjunctivitis.    See  Conjuncti- 
vitis, chronic. 
enevsted      tonsillar      abscess. 

935 
follicular     pharyngitis,    942. 

S.e  Pharyngitis. 
hypertrophic  rhinitis.  905 
inflammation  of  lingual   ton- 
sil. 932 
lacunar   tonsillitis,   928 

Tonsillitis. 
laryngitis,   998.     See    Laryn- 
gitis. 
lingual  tonsillitis,  932 
mastoidil  is  interna.  751 
myringitis,  713 
naso-pharyngitis,    948.      See 

Va  o  pharyngitis. 
nonsuppurative        iullamma- 

t  ion  of  middle  ear.  72<i 
otorrhea.  660 

parenchymatous      tonsillitis, 
929 

isal  catarrh,  948 
purulent      inflammation     of 

middle  ea r,  660 
-inn-it  is,  :>?:; 
subglotl  ic  laryngitis,  1008 


Chronic  suppuration  of  middle 

ear,  739 
tonsillar  inflammations,  928 
tonsillitis  due  to  bacillus  coli 

communis,  929 
uvulitis,  938 
Chrysarobin,  295 
Cilia,  32 
epilation  of,  257 
reiiioN  al  of,  54  1 
Ciliary  arterii  -    86 
anterior,  B6,  87 

posterior.  86 

body,  59,  84 

adenoma  of,  490 

blood-vessels  of.  61 

contusion,  injuries  of,  364 

cysts  of,  191 

diseases  of,  :;i  t 

injuries  of,  346 

metastatic     carcinoma    of, 
191 

myoma  of,  190 

myosarcoma  of,  190 

nerves  of,  id.  190 

penetrating  wounds  of,  317 

primary  carcinoma  of,  490 

sarcoma  of,   I'.'l 

tumors  of,   190 
border,  scalping,  545 
congestion,  1  13 
glands,  86 
margin,    preparation    of,    for 

operations,  540,  571 
muscle,  60.  95,  bit 

relation  of,  to  accommoda- 
tion, 95,  L34 

traumatic  paralyses  of,  360 

traumal  ic  spasm  of,  -  ;*  i<  ► 

nerves,   97 

-nerve  theory  of  sympathetic 

ophthalmitis.  349 
neuralgia,  338 
processes,  60,  95 

development  of,  28 
ring,  59 

staphyloma.  330 
veins.  87 

vessels,  anterior,   1  13 
(  tlic-retinal  artery   in  relation 
to  embolism    ot'   central 
artery  of  retina,  189,  108 
vessels,  185,  1!"' 
in  embolism,  108 
( 'ilium-t'orcep-,  5  I  I 

<  iirculus  venosus  ciliaris.     Si  e 

Schlemm'8  ennui. 
( lircumtonsillar    inflammation, 
acute.  925,  926 

<  listerna  perilymphal  ica,  620 

Cleft    eyelid.   24] 

of  the  lobule.  698 
climacteric  319,  352,  120,  136 
Cloquet,  canal  of.    See  Hyaloid 
canal. 

<  loal-tar  products.  159 
Cocain,  1  19,  210,  459,  542 

and  atropin  in  diffuse  inflam- 
mat  ion  of  aud itory  canal. 
704 
in  furunculosis  of  auditory 
canal.  703 

effect  of,  on  corneal   epithe- 
lium, 326 
on  paraly  t  ic  myosis,  |5ll 
hydrochlorate  in  acute  otitis 

media.  721 


1222 


TNDEX. 


,ii  in  acute  catarrhal  pha- 
ryngitis, 940 

in  acute  inflammation  of  mid- 
dle car.  687 

in  acute  naso-pharyngitis,  948 

in  acute  rhinitis.  893 

in  acute  tonsillitis.  924 

in    acute   ulcerative    tonsilli- 
tis, 928 

in  chronic  catarrhal  pharyn- 
gitis, Mil 

in   chronic  inflammation  of 
lingual  tonsil,  934 

in  chronic  rhinitis.  1)10 

in  ciimeal  ulcers,  316 

in  diphtheria,  L028 

in  diseases  of  nose  and  throat, 
885 

in  enlargement  of  epiglottis, 
937 

in  examining i  rils,  B62 

in.    excision    of     conducting 
mechanism,  791 

in  herpes  of  auricle.  686 

in  lingual  tonsillitis.  927 

in  membranous  rhinitis,  898 

in  salpingitis,  72:: 

spray   in    laryngeal    tubercu- 
losis,  1050 
Coccidia,  259 

Cochlea.    621 

function  of,  643 
Cochlear  tube,  HIT 
t  lodein  in  acute  catarrhal  laryn- 
gitis, 986 

in  acute  rhinit  is.  893 

in     laryngeal     tuberculosis, 

lull. 
Cod-liver   oil    in    chronic    sup- 
puration   of  middle   ear, 
746 
in  lupous  laryngitis,  106(5 
in  lymphoid  hypertrophy, 

956 
in  spasm  "f  larynx.  1156 

Coffee,  159 

Colchicum  in  acute  catarrhal 
pharyngitis,  940 

Cold  applications  in  conjunc- 
tivitis, 280,  285 

Cold   in   acute  suppuration   of 

middle  ear.   688 
in  etiology   of  catarrhal    in- 
flammations, - 1 1 
in   the   head,  891.     See    Rhi- 
nitis, mull1. 
wire  snare,  912 
Colloid  bodies  of  optic  disk,  151 
■■.  t  lis  of'  larynx.   L108 

Coloboma  of  choroid,   I 
157 
circumpapillary,   of  choroid. 
156 
stalline  lens,  191,  397 
■  lid.  operal  ion-  for,  557 
is,  191,  :;:;■:.  169 
bull  .  operal  ion  I 
of  macula,  in:;.  35] 

I'M.  155,  157 
i  ath,  155 

'  100,  153,  451 


(    ..1,,, -field.    167 

( lolor-fields,  reversal  of,  186 
( lolor-h earing,  77? 
Color-measurer,  1">1 
Color-perception,  98,  99 
( lolor-scotomas,  99 
(  olor-seii-ai ions,  169 

Color-sense.    153 

in  optic-nerve  atrophy,  -1-13 
quantitative    estimation    of, 

inn 
subnormal,  157 
tests  for.  153,  154,  155 
( 'olor-\  ision,  l  11 

standard   of.  in  railway  serv- 
ice. iiii."» 
Colors,  complementary,  99 
congenita]     amblyopia     for, 

157 
measurement    of    vision   for, 

i;,:; 
mixed.  V'.i 
simple,  98 
spectral,  98 
Colnmna  of  nose,  restoration  of. 

1188 
Commotio  rel  inae,  364,  1 1  l 
( lommutor,  888 
Compressor  lent  is,  134 
Compsoinyia      mascellaria      in 

frontal  sinuses,  980 
Conch    of    middle    turbinated 

hone,  829 
Concussion  of  the  head,  effect 

mi  labyrinth,  776 
Condensing  mastoiditis,  751 
t  londylomata  of  drumhead,  71  1 
( 'mie  of  light,  676 
( 'one-visual  cell.  70 
(  ones,  number  of,  71 

size  of,  in  macula  lutea,  139 
( longenital  cataract.     See  Cata- 
ract, congenital. 
conus,  191 

fissure  of  lobule  of  ear,  692 
fistula  of  ear.  692 

operation  for,  783 
ptosis.  242,  -.'.".l 
Conical    crnea,    179.    222,   231, 
328 
keratoscopic      appearances 

of.  328 
operation  fir.  568 
treatment,  328 
Cohium,  25  1 

Conjugate,  definition  of.  124 
«le\  laiimi  of  eyes,  519 
foci,  m:;,  lu- 
ll lalion    of,    to     principal 
foci.  111 
Images,  1 1 1 
« onjunctiva,  30,  :;."i 
al.-c  --  of,  298 
acute  blennorrhea  oi 
amj  hud  disease  of,  296 
argyria  of,  304 
atrophy  ol 

benign  tumors  of.  300 
blood-vessi  I-  of.  i  13 
burns  of.  358 
cavern om a  of.  -.'7  1.  300 
chemosie  of,  298 
cical ricial  changes  in.  296 
CH  at  n    i  il  :ont  raci  ion  ol        '■- 
nital  anomalies  of.  27  I 
nital   tumors  and 
of,  300 


Conjunctiva,  cylindroma  of,  301 
cysticercus  cysts  of.  301 
cysts  of,  293,300 
dermoid  c\  sts  of.  -.'7  I 
dermoid  tumors  of.  274 
diseases  of,  274 
ecchyinosis  of.  :2!»S,  36(1 
echinococcus  cysts  of,  301 
eczema  of.  286 
emphysema  of.  299 
epithelioma  of.  301 
epithelium  of.  :;ii 
essentia]  atrophy  of.  296 
fibromata  of,  293.  301 
foreign  hndies  in.  3(58 
gumma  of,  300 

herpes  of,  287 

horny  granulations  of,  293 

hyperemia  of.  27  1 

hypert  rophy  of.  291 

injuries   of.    from    heat    and 

chemicals.  55,- 
lepra  of.  302 
lime  burns  of.  301 
lipoma  of,  27  l.  358 
litliiasis  of.  295 
lupus  erythematosus  of,  302 
lymph-follicles  of,  35 
lymphangiectasis  of.  299 
lymph omata  of.  293 
malignant  i  umors  of.  301 
mechanical  injuries  of,  359 
myxoma  of,  301 
operations  on.  561 
osteoma  of.  271,  301 
papilloma  of.  301 
pemphigus  of,  303 
pigment-patches  of,  27  l 
polyp  of.  517 
preparation  of.  for  operations, 

540.  571 
removal    of    foreign     bodies 

from.  561 
sarcoma  of,  :illl 

streptococcus-diphtheria     of, 

61  Ic 

syphilis  of.  300 

telangiectal  ic  patches  of,  274 

temperature  of.  1  1 1 
tuberculosis  of  302 
tumors  of.  300 
w  <ni  iids  of.  359 
xerosis  of,  296,318 
Conjunctival     hemorrhage     in 
nephritis,  298 
veins,  \arix  of.  248 
\  essels,  anterior,  1 1 1 
posterior,  l  13 
Conjunctivitis,    143,    219.   251, 
256,  266.  275,  510 

acute  contagious,  276 

catarrhal.     See  Conjunctivitis, 
simple. 

chronic.  216.  294 

cold  applications  in.  27? 

croupous,  283 

diphtheritic,  258,  284,  285 

diplo-bacillus,  61  Ic 

epidemic  catarrhal.     - 

junctivitis,     acute    conta- 
gious. 

follicular,  2-9 

from  calomel.  295 

from   eleel  rieity,     168 

from  •  ye-strain,  21  1 
from  mj  drial  ics,  295 
from  m vot  ics,  295 


INDEX. 


L223 


Conjunctivitis    from    Rontgcn 
rays,  168 
from  stings  of  insects,  296 
gonorrheal,  266,  278,  279 
granular.     See  Trachoma. 
hemorrhagic  catarrhal,  ".'77 
infectious,  of  animal  origin, 

614c 
lachrymal.  294,  6146 
lymphatic  286 
membranous,  283,  6146 
muco-purulent,  276 
neonatorum,  281,  282 
antepartum,  281 
corneal    complications    in, 
282 
Parinaud's,  61  k 
phlyctenular,  286,  287,  6146 
pneumococcus,  275,  *  J 1 1" 
purulent,  278 

ulcers  of  cornea  in,  316 
simple,  275 
tea-leaf,  278 
traumatic,  275 
toxic.  295 
ulcers  of  cornea  in  gonorrheal, 

279 
vernal.  287,  288 
Consensual  action  of  pupil,  148 
Constrictor   of    pharynx,   infe- 
rior, 81 1 
middle,  814 
superior,  813 
Contorsion,  500 
Contraction  of  pupil,  150 
Contusions  of  nose,  1116 
Con  us.  1-1.  1  !>■.'.  221 
atrophic,  193 
congenital,  1!'4 
underlying,  li'l 
Convergence,  500 

effect    (if.    on    pupillary    con- 
traction. 148 
exec--.  515 
insufficiency.  517 
movements  of,  502 
near-point,  503 
nerve-center  governing  move- 
ments of,  502 
paralysis,  517 
power  cf.  161 
Convergence-adduction   51  (3 
Convergence-reaction  <>f  pupil. 

148 
Convulsions,  391,  409 
Corectopia,  334 
Corelysis,  343,  579 
Corestenoma  congenitum,  334 
Cornea.  50,  89 

abscess  of,  313 

anterior    elastic     lamina    of, 
51 
epithelium  of,  51 
limit  ing  membrane  of,  51 

arcuate  fibers  of,  52 

blood-staining  of,  326 

blood-vessels  of,  52 

burns  of,  358 

cellular  element-  of,  52 

changes  in  form  of,  caused  by 
inllammat  ion,  323 

congenital  opacities  of,  329 
staphyloma  of,  329 

conical,  328.     See  Conical  cor- 
nea. 

connective-tissue  stroma    of, 
21 


Cornea,  contusions  of,  359 
creeping  ulcer  of,  313 
curetting  of,  567 
curvature  of,  196 
diameter  of,  1  1<> 

in  glaucoma,  376 
dendritic-  ulcers  of,  310 
dermoid  tumors  of,  -I'.'lt 
diseases  of,  305 
epit  helioma  of,  329 

epithelium  of,  21 

erosions,  of  359 
fibroma  of,  329 
fistula  of,  324,  384 
flattening  of,  323 

foreitin  bodies  on,  368 

form  of,  50 

geometrical  figures  in,  326 

herpes  of,  309 

index  of  retraction  of,  89,  92 

infiltration    of,    with    lymph, 

326 
inflammation    of.     .See   Kera- 
titis. 
injuries    of,    from    heat    and 

chemicals,  358 
inspection  of,  145 
lepra  of.  :;-J!i 
lime-burns  of,  358 
massage  of,  322 
mechanical  injuries  of,  359 
micro-organisms  in  ulcers  of, 

314,  614c 
morbid  growths  of,  329 
nerves  of.  52 
non-inflammatory  changes  in 

form  of,  327 
opacities  of.  322 

due  to  metallic  deposits,  326 
operations  upon.  566 
panel-like  opacities  of,  326 
papilloma  of,  329 
paracentesis  of,  567,  578,  584 
posterior    elastic     membrane 

of.  52 
posterior  endothelium  of.  52 
limiting  membrane  of,  52 
powder-grains  in.  368 
primary    transverse    opacity 

of,  325 
proper  substance  of,  51 
radius  of  curvature  of,  92 
removal     of     foreign    bodies 

from,  566 
removal      of      powder-grains 

from.  567 
result-,    of   inflammation   of. 

322 
rodent  ulcers  of.  313 
rupture  of,  362 
sarcoma  of.  :;■.'!• 
-.  risibility  of.  i  p; 
serpiginous  ulcer  of.  :;i  I 
staphyloma  of.  :;■_':; 

-tincture  of.  51 

suppurative  inllammat  ionsof. 
A',  ratitis,  suppurative. 
tattooing  of.  ::•_':;.  568 
transparenl  ulcer  of.  309 
t  ransienl  opacil  ies  of,  326 
transplantation  of.  ::■.':;,  569 

t  libel  elllo-i-  of,  :;i  - 
ulcer    of,     1  15.    -.'15.   2!'::.    313, 
::i  l.  ::15.  527 
alter  tenotomy.  594 
from    gonorrhea]    conjunc- 
tival 


Cornea,  ulcer  of,    in   small-pox, 
:;i7 
vaccinia!  abscess  of,  :;i- 
vertical  meridian  of,  197 
wandering  cells  of,  52 
widt  li  of,  1  15 
wounds  of,  568 
wrinkling  of,  324 
zonular  opacity  of.  325 
( lorneal  corpuscli  s,  52 
loupi  .    1  17 
microscope,  1  17 
refleel  ion.  size  of,  196 
reflex,  1-1 

section    during    cataract-ex- 
traction, 5-0,  582 
Corneo-scleral    juncture.       See 

Sclero-corneal  junt 
Cornicula  laryngis,  816,  818 
Cornu  cutaneum,  248 
Corpora  geniculate,  IT!* 

quadrigemina,  1  19,   17!' 
Corrosive    sublimate   in  condy- 
lomata of  auditory  canal, 
707 
Corti,    membraua    tectoria    of. 

ill!) 
Corti's  organ,  function  of,  644 

rods.  619 
Coryza,  891.   See  Rhinitis,  acute. 

fetida,  957 
Couchin.tr,  395,  5-0 
Cough,  nasal.  1150 

nervous.  1 158 
Counter-field.    110.  486 
Couper's  ophthalmoscope,  17:; 
('rede's  method  of  prophylaxis 
in  conjunctivitis   neona- 
torum, '-'-2 
Creolin   in    laryngeal    tubercu- 
losis, 1052 
spray  in  laryngeal  tuberculo- 
sis, 1050 
Creosote  in  laryngeal  tubercu- 
losis, 1047,  1048 
spray   in    laryngeal  tubercu- 
losis,  1050 
t  Irescent,  myopic,  221 
( 're-t.  acoustic,  618 
Cribriform  plate  of  ethmoid,  826 
Crico-arytenoid  ligaments,  819 

muscles,  lateral.  -21 
Crico-arytenoidea  laterales,  pa- 
ralysis of.  1167 
Crico-arytenoids    in    voice-pro 

duction,  117:; 
( 'rii'oid  cart  ilage,  -17 
Cricothyroid  artery.  825 
membrane,  -li' 
muscle,  822 
in  voice-production,  1 173 
Critchett's  operation  for  staph- 
yloma, 571 
of  tenotomy,  587 
I  .1  cylinders,  229 

lateral  deviation,  l  57 
paresis  in  brain  absci 
Croup,    990.        See    Laryngitis, 
croupous. 
false,  986 
Croupous   conjunctivitis.     See 
mnctivitis,  croupous. 
inflammation   of   upper    air- 
passages,  - 18 

laryngitis,  

rhinitis,  896 
tonsillitis,  acute,  925 


1224 


INDEX. 


i  Iras  1 1  rebri,  IT!' 
Crypto-glioma,  194 
Cryptophtbalmos,  241 
Crystalline  body,  operations  on, 
:.7i 
lens.     3  .  crystalline. 

Cuneiform  cartilag<  s,  816,  818 
Curare,  160 
Curettement      in       lupus      of 

pharynx,   L059 
Curetting     in    corneal    ulcers. 

315 
( 'urvature-hyperopia,  215 
Curvature-myopia,  222 
Cnrves,  study  of,  103 
Cushion  of  <  piulott  is,  Sl.-S 

Passavant's,  81 1 
Cutaneous  horns,  2 18 
Cyan  id   of   mercury    in    diph- 
theria, 995 
Cyanurel  of  mercury.  540 
Cvclitic  membrane,  345 
Cyclitis,  111.  1IT,  l'15.  344,  366, 
:;!••;.  492,  194,  495 
diagnosis,  '■'•  15 
etiology,  34  l 

pathological  anatomy,  345 
plastic.  :;i  l 
prognosis,  345 
purulent,  - 15 
serous,  34  I 
symptoms,  :;i  1 
t raumal ic,  -U  1 
treatment,  :ilti 

will)  capsulitis  after  cataract- 
extract  iun.  503 
Cyclophoria.      See   Insufficiency 

of  oblique  muse 
Cyclopia,  523 
( ycloplegia,  51 1 
traumatic,  360 
Cylinder,  crossi  d,  229 
Cylinders,  126,  128 
distortion  of   retinal   imagi  - 
by,  -.'::ii 
Cylindrical  lens.  207,  228 

testing  of.  -.mm 
Cylindroma     of     conjunctiva, 
301 
of  lachrymal  gland,  26  l 
Cysl  of  lachrymal  gland,  262 
Cystectomy,  586 
Cysticercu's,  :;i-.  128 
cysts  of  conjunctiva,  301 
in  anterior  chamber,  :;i  t 
in  \  it  reous,  102 
of  eyelids,  260 
subretinal,  131 

iid  cicatrix,  324,  383 
imata  of  no-  .  1084 
ime,  580 

di  i moid,  of  conjunctiva, 
274 

it  ion-  for,  783 
inch    "•'  1 1 

.   I'M 
onjunctiva,  293  ::"" 
of  in 

1  108 
try  -inn-,  l' 
neons   membrane, 

[082 

1096 


Daae's  tesl  for  color-sense,  154 
Dacryo-adenitis,  acute,  261 

chronic,  ■.'ill 
I  >acryo-cj  s1  it  i-.  265,  295 
acute.  267 
chronic,  266 
treatment,  263 
Dacryoliths,  262,  263,  265 
I  (acryops,  262 
I  >alrymple's  sign,  535 
Danger-signals  in  chronic  sup- 
puration  of  middle  ear, 
745 
Darby's    artificial     finger-nail, 

L202 
Daturin,  209 
I  >a\  [el's  spoon.  580 
Day-blindness  See  Hemeralopia, 
Deaf-mutism,  777 

treat  men!.  7-  1 
Deafness  from  otitis  media.  716, 
719 
in   acute   affections  of   tym- 
panic cavity,  716 
in  brain-abscess,  763 
in  chronic  catarrh  of  middle 

ear,  ~r"> 
operations  for.  7-9 

Defects    of    auricle,    operation 

tor.  7-.'! 
1  Reflection  of  nasal  bones,  treat- 
ment. I  I--.' 
of  nasal   septum    in  el  iology 

of  nasal  obstruction,  8  l!> 
Deformities   of    nasal    septum, 

operations  tor,  1190 
of  nose,   operative   treatment 

of,  1180 
of  turbinated  hones.  1 194 
Degeneration  of  acoustic  nerve, 

etiology,  77o 
Deglutition  in  diseases  of  upper 

air-passages,  853 
Delirium  in  diphtheria,  1016 
I  temours's  membrane,  52 
I  tench's  tuning-fork,  669 
Dendritic  keratitis.  310 
I  »enni  t  t's  tesl  -tj  pes,  1  10 

I  leiion  villier's  method.   1  1-7 
Dental  defects  in  cataract.  387 

disease,  151 
Deoi  -urn  version,  501 
I  (epression,  olfactory ,  807 
Dermoid  cysl  of  pharynx,  1094 
oi  orbil .  531 

Of  eyelid-.  260 
tumors    of    conjunct  iva,    27  I. 
:;nu 
I  dermoids,  lipomatous,  300 
Descemet's   membrane,  28,  52, 
55,  til.  336,  :;::7 
folding  of,  326 

perioral  ion   of,  31  I 
I  tescemet  it  i-       Si  i       Keratitis, 

punctata. 
Discission  tor  -oft  cataracts,  584 
Desquamated     epithelium      in 
chronic    suppuration     of 
middle  ea 
I  lesquamal  ive  otitis,  I 
1 1.\  iat  ion-angle      systi  m      of 

Jack 133 

Devial  ion  of  nasal  sepl  ura,  331 . 
915,  916 
forcible  corred  ion  bj  tor 
ceps,  1 192 

I  i  •  aim.  lit.  917,    1191 


Deviation  of  tip  of  nose,  treat- 
ment, L182 
1  >evia1  ions.   See  al-o  Strabismus, 
Ueterophoria,  Insufficiency, 
and  Ocular  mtiscli  ■*. 
associated  parallel,  519 
convergent,  515 
divergent,  517 
varieties  of.  504 
vertical.  518 
De   Wecker's    method    of    ad- 
vancement, 590 

of  capsule.  594 

operat  ion  for  staphyloma,  570 
I  'ext  roducl  ion,  502 
Dextrotorsion,  502 
Dexl  roversion,  500 
Diabetes;  222,  :;:::'.  391,  394,  419, 
121,  1 1."-.  I.".-,  nil.  511 
insipidus.   110.  445 
of  car.  685 
Diachylon  ointment,  244 
Dieffenbach's   method    of    ble- 
pharoplasty,  556 
operation  of  rhinoplasty,  1188 
for  deviated  septum,  917 
Diet  in  affections  of  upper  air- 
passages,  B80 
in  diphtheria,  L033 
1  tiffusion-circles,  94 
Digastric    muscle   in    voice-pro- 
duction. 1173 
Digitalis,  159 

in  diphtheria,  994.  10-20 
Dilatation  of  pupil,  I  1!' 
cerebral  origin  of,  150 
spinal  orisrin  of,  150 
Dilatator  pupilhe.  64,  96 

I  lilator  center,  97 
Dioptre,  the,  122,  123 
Dioptric  apparatus,  89 

system,  90 
Dioptrics,  L02,  109 
Diphtheria.  284,    136,  511,  991, 
1010 
-antitoxin.  286,  1020 
dose  of.  L024 
in    atrophic    rhinitis,    960, 

963,  9H5 
injurious  effects  of,  L023 
preparat  ion  of.   L020 
site  of  inject  ion,   L025 
testing  of,  L025 
bacillus  of.   991,    mil.    1017. 

See    al-o    h'li  lis   I.otjlrr    ba- 
rillas. 
in  meinhraiious  rhinitis,  H9<> 
diagnosis,  993,  L017 
from    membranous    croup. 
993 
diet  in.  1033 

disinfection  in.   101  1.   1015 
etiology  of.  991,  mi  i 
history,  1010 
intubation  in.  L029 
moil. i.l  anatomy,  1012 
nasal  feeding  in.  i"-:i 
of  auricle,  655 
of  eye,  1032 

ot  it  i-  mi  ilia  froi 

pathology,  992 

osis.  994,  L019 
prophj  laxis,  1013 

relat  ion  of.  to  ear  disease, 651 
symptoms,  992,  1016 

t  raeheotom  V    ill.    1031 

treatment,  994,  1020 


INDEX. 


1225 


Diphtheritic        conjunctivitis, 

S:  ;       (  :.:.' J  it  mill  ttlS 

diphtheritic. 
inflammation   of    upper  air- 
passages,  848 
Diplacusis,  777 
Diplo-bacillus,  <il  Ic 

conjunctivitis,  iil  Ic 
1  tiplococcns  in  oro-pharynx,  846 
in  labyrinth.  767 
of    Lowenberg    in    atrophic 

rhinitis.  960 
of  pneumonia  in  ear-disease, 

653 
pneumoniae,  n'l  I" 
Diplopia,  499,  509,  525 
a    best    for    insufficiency   of 
the  ocular  muscles,  156, 
157 
monocular,  in  cataracts,  392 
region  of,  157 
varieties.  500 
Direct   method  of  ophthalmos- 
copy, 17-"> 
measure  of  refraction  by, 
199 
reflex  action  of  pupil,  1  18 
Discharge,    aural,    as   a    symp- 
tom, 667 
Discission,  395,  584 

for  secondary  cataract.  585 
glaucoma  after,  573,  586 
of  cataract.  ol7 
Dislocation  of  nasal  bones,  1125 
Dislocations    of    cartilages    of 

nose,  1126 
Disseminated  sclerosis,  151,  145, 
447,  44,^,  520 
field  of  vision  in,  K>7 
Dissonance,  636 
Distichiasis.  257 
congenital,  241 
Distortion.  500 
Divergence,  500 

movements  of,  503 
Divergence-abduction,  503 
Divergence-insufficiency.  516 
Divergence-paralysis,  51  ti 
Dobell's  solution.  882,  883 

in    chronic    naso- pharyn- 
gitis, 951 
in  chronic  rhinit  is.  909 

in   sarcoma  of  soft  palate, 
1099 
Donder's  schematic  eye,  92 
Douches,  883 

Dover's  powder  in  acute  naso- 
pharyngitis, 9 I- 
in  acute  rhinitis,  893 
Drainage    of    frontal     sinuses. 
980,  981 
of  maxillary  antrum,  972 
Dn  ssings,  541 
Drum-cavity,  626,  627 
paracentesis  of,  786 
Drumhead,  629 
acute  primary   inflammation 

of,  713 
angioma  of,  71  l 
calcifical  ion  of,  71  I 
cholestea  toma  of,  7 1  l 
ch  roii  ic  i  nflammal  ion  of,  7  L3 
condylomata  of,  7  I  I 
development  of,  622 
direcl  injn  ries  of,  71 1 
•  pithelioma  of,  7  1  1 
■  i iij  of,  7  1  1 


Drumhead,  hemorrhage  in.  711 
hyperemia  of,  71 1 
infectious  diseases  of,  7 1  I 
injuries   and  diseases  of,  711. 

712,713 
myxoma  of,  71  1 
new  growths  Of,  71  1 

polypi  of,  714 
rupture  of,  712 
small-pox  of,  71 t 

syphilis  of,  714 
Druseii.    151 

Dry  heat  in  acute  otitis  media. 
721 
mouth.  936 
Duboisin,  209 
Duct,  endolymphatic,  f!17 

naso-lachrymal,  17 
Duplay's  speculum,  859 
Dura,  opening  of,  804 
Dural   sheath    of   optic   nerve, 

79 
Dust  in  affections  of  upper  air- 
passages.  880 
"Dutch     garden     symmetrv," 

1069 
Dynamic  strabismus,  156 
Dyschromatopsia,  458 
Dy scoria.  :;:!1 
Dysmenorrhea,  344 
Dysphagia,  853 
in  diphtheria,  1016 
in     laryngeal      tuberculosis, 
1039 
Dysphonia,  1158 
in     laryngeal      tuberculosis, 
1039 
Dyspnea  in  acute  phlegmonous 
laryngitis,  989 
in  chronic   subglottic  laryn- 
gitis, L008 
in  croupous  laryngitis,  991 
in  lupous  laryngitis,  1060 
in  subglottic  laryngitis,  987 
in  tracheitis,  997 

Ear,  abscess  of,  pathology,  655 
anatomy,  ni7 
anomalies     of     secretion     of, 

treatment.  68  I 
aspergillus-mycosis  of,  657 

treatment.  686 
auscultatory  sounds  of,  680 
blood-tumor     of,    pathology, 

655 
ca1  beterization  of,  <!79 
cholesteatoma  of,  75:; 
congenital  fistula  of,  692 
cj  sts  of,  655 

diphtheria  of,  pathology,  655 
discharge  from.  667 

d  iseases  of,  c plications.  7  i:» 

eczema  of,  pathology,  654 

i  real  ment,  685 
embryology  of,  017 
examinal  ion  of,  <>73 

external,  all'ectioiis  of,  691 

anatomy,  625 
functional     examination    of. 

668 
furunculosis    of,    t  real  mi  o1 

686 
herpes  of,  t  reatment,  685 
illuminat  ion  of,  »!73 
intertrigo  of,  t  reatment,  685 
keloids  of,  655 
lupus  of,  t  reatment.  686 


Ear,  menstruation  from.  650 

middle,  ij-.'o' 

inflation  of,  with  ausculta- 
tion, 679 
ossicles  of,  630 
osteology  of,  620 
perichondritis  of,  655 
physiology  of,  634 
syphilis  of,  treatment,  686 
Earache,  7 15 

as  a  symptom.  <i<>7 
Ear-disease,  etiology,  ^17 
.  668 
clinical  history  in,  665 
examination  blank  for,  683 
examination  of  patients,  665 
pathology,  65 1 
symptomatology    and     diag- 

aosis,  665 
therapeutics,  68  1 
Ear-forceps,  <>7 1 
Ear-scoop,  <>74 
Ear-speculum,  o'73 
Ear-syringe,  ii74 
Eburnation,  751 
Ecchondrosis  of  trachea,  iii5 
Ecchymosis  of  conjunctiva,  298, 
'  360 
of  eyelids,  :;7l 
Echinococcus  cysts  of  conjunc- 
tiva, 301  ' 
of  orbit,  531 
Echo,  634 
Ectoderm,  19,  20 
Ectopia  lentis,  396 
Eel  ropia  pupillse,  334 
Ectropion,  255,  258,  372,  526 
cicatricial,  of  upper  lid,  opera- 
tions for,  553 
congenital.  2  11 
operations  for,  551,  552 
organic.  258 
spasmodic.  258 
treatment,  258 
uvea'.  378 
Eczema,  2 16,  275 
of  auricle,  654,  693 

treatment.  693 
of  conjunctiva,  286 
of  car.  treatment.  685 
of  eyelids,  24  1 

from  eve-strain.  21  1 
si  borrhoeicum,  2 16 
Edema  of  larynx,  989,  990,  1139 
Edematous    polypi    of   larynx, 
1 1 1 15 
of  maxillary  Minis.  ios«t 
of  nose,  1076 
Egyptian  ophthalmia,  294 

ric  ophthalmia,  168 
Electricity,  126 
in    affections  of    upper    air- 
passages,  B86 
in  atrophic  rhinitis.  963 
in  cataract.  394 

in  chronic  laryngitis,  1  < m 1 1 
in  corneal  opacit  ies,  322 
iii  diseases  of  sound  pero  i\ 

inn  apparatus,  7-1 
in    insufficiencies    of   ocular 

muscles,  520 
in  opt  ic-nerve  atrophj  .  1 19 
in  vitreous  opacil  ies,  |im> 

Electro-cautery  .  248 
in  pterygium, 

Electrolysis.  248,  257.  561 

fOr    rellle-.,  HIL.'   I"  1  I  1   I  I 


1220 


TNDEX. 


Electrolj  ~i~  in  chronic  rhinitis, 
912 
in  deviation  of  septum,  920 
in    erectile   tumors  of  orbit, 

601 
in   fibroma  of  naso-pharynx, 

L093 
in  lachrymal  strictures,  27  I 
in  orbital  angiomas,  531 
in  retina]  detachment,  130 
in  trachoma,  564 
Electro-magnet,  369,  370 
Electrozone   in   diphtheria-dis- 
infection, 1015 
Elephantiasis  arabum,  252 
lymphangiectodes,  252 
telangiectodes,  n'^ 
Embolism  of  central  artery  of 
retina,  406,  107,  I'.M 
relation   of    cilio-retinal 
artery  to,  L89 
Embryo,  17 

Embryology  of  the  ear,  HIT 
Emmet  ropia,  212 
amplitude  of  accommodation 

in.  136 
determined  by  skiascopy,  205 
Empyema  of  anterior   mastoid 
cells    with     perforation, 
752 
of  apex  of  mastoid  with  per- 
foration     into    digastric 
fossa,  .■">■.' 
of    mastoid,     operation    I'm-. 

793 
of  maxillary  sinus.  ;h;>.    See 
Maxillary   si  mix,   empy 
ema  of. 
opi  rative  treatment,  1  !!>!> 
of    sphenoidal     cells,    treat- 
ment, 983 
Emphysema,  409 
of  conjunct  iva,  299 
of  eyelids,  371,  537 
of  orbit,  ">:;7 
Ems  pastilles  in  rheumatic  con- 
ditions    of    air-pas>a:_res. 
875 
Encanthis,  304 
Encephalocele,  533 
Enchondroma  of  eyelids,  248 
of  naso-pharynx,  1093 
of  nose,  removal  of,  1 197 
of  orbit,  531 
of  sclera,  330 
Endocarditis,   12] 
Endogenous  infect  ion,  355 
Endolymph,  function  of,  640 
Endolymphal  Lc  duct,  <H 7 
Endothelioma   of  optic   nerve, 
149 

Enophthal s,  I7u.  525,  538 

Entopl  ic  phenomena.  140 

study  of  macula,  L89 
Entropion,  257,  291,  293,  308 

con-,  nil:, 

opera!  ions  foi .  548 

inic  -.'.".7 
spasmodic,  257 
Enucleation,  38  i 
complical  ions  after,  572 
of  an  eyeball,  57 1 
in  panophthalmitis  356 

Ephidi  im  -  of  eyelids 
thus,  -.'ii 

for,  548 


Epidural    abscess,     756.       See 

Pachymeningitis  externa. 
Epiglottis,  B18 

cushion  of,  818 

development  of,  809 

diseases  of,  936 

enlargement  of,  937 

examinat  ion  of,  870 

incarceration  of,  933,  936 
Epilal  ion,  54  t 

of  cilia,  257 
Epilepsy,  L50,  151,  509,  511 

from  eye-strain,  2]  I 

influence    of,    on     the    ear, 
649 

laryngeal,  1 159 
Epiphora,  264 

Episcleral     congestion,    transi- 
tory, 330 

lymph-space,  >s7 

vessels,  l  13 
Episcleritis,  329,  330 

partialis  iugax,  XiO 
Epistaxis,  902,  903 

idiopathic,  902 

t  raumatic,  903 

vicarious,  902 
Epithelial  carcinoma  of  auricle, 
operation  for,  784 

implantation  tumors,  4Sft 
Epithelioma.     See  Carcinoma. 

contagious,  259 

of  an liclc,  me 

of  conjunctiva,  301 

of  cornea,  :!•_'!! 

of  drumhead,  714 

of  nose,  papillary,  10SH 

Of  sclera.  330 

Equilibrium,    disturbances    of, 

testing  of,  771 
Ergot,  459 
in   congestion   of   labyrinth, 

(Jiiii 

in  epistaxis,  903 
Ergot  ism,  392 

Eruptions,  antitoxin-.  1023 
Erysipelas,  275,  1 1 1.  528 
of  auricle,  693 

i  reatment,  685 
of  eyelids,  242 
of  nose,  901,  902 
Erythema  of  eyelids,  242 
Erythropsia,  468 
Escat's  tongue-depressor,  872 
Eserin    in   corneal    ulcers,  280, 
283,  316 
in  glaucoma,  38 1 
in  staphylomas,  324 
Esophagus,    foreign    bodies   in, 
L135,  1136 

iria,  L57,  L61,  500,  515 
i  reatment,  520 
Esot  ropia.     See  Strabismus,  con- 

■■  nt. 
Essent  ial   at  rophy   of  conjunc- 
tiva, 296 
pht  bisis  bulbi,  -".."7 
Ether,  542 

in  subglottic  laryngitis   988 
Ethmoid  bom  .  325   -  16 
cells,    disease    of,    operative 

tr<  atment,   1200 
disi  ase,  976  97  i 
IMul 

mucocele  of,  533 
sinus,  154 
sinuses,  neoplasms  of.  Hum 


Ethmoidal   cells,   anterior,   ex- 
amination of,  864 

c\  sis  of,  H7<) 
diseases  of,  !»7l> 
inflammation  of,  !»77 
polypi  of,  treatment,  !>77 
Ethmoiditis,  necrosing,  120] 
Ethyl  bromid   in   laryngeal  tu- 
berculosis, 1052 
Ethylenediamin,  465 
Eucain,  -.'1 1.  595 
Eucain  "'A,"  543 
Eucain  "  I'.."  543 
Eucalyptol    in   chronic   catarrh 

of  middle  ear,  7.'{."{ 
Eucalyptus  in  tracheitis,  !i<»7 
oil  in  laryngeal  tuberculosis, 
1050,  1051 
Europhen    in    laryngeal   tuber- 
culosis, L050,  in.".-.' 
Eustachian     bougie,    examina- 
tion of  car  with.  682 
bougies   in   chronic    catarrh, 

734 
catheter,     inflation      of     ear 
willi,  (i7!) 
in  salpingil  is,  7">.'! 
openings,  631,  809,  810 
tube,  630 
development  of.  621 
function  of.  (>:;!» 
inflammal  ion  of.  723 
isi  luiiiis  of,  626 
obstruction  of.  by  chronic 

catarrh.  7:i::.   7:il 
pathology  of.  663 
Eversbusch's   method   of  mak- 
ing an  eye-lid,  555 
operation  for  ptosis  559 
Evisceration,  324 
complications  after,  '<!■'• 
of  eyeball,  .">7-J 
with  insert  ion  of  art  ificial 
vitreous,  •',7-.' 
Examination  blank  for  ear-dis- 
ease. 683 
Exanthematous    eruptions    of 
eyelids,  -.Ml 

Excision    of  oxides    in    catarrh 
of  middle  ear,  7-'!7 
in  chronic  suppuration  of 
middle  ear.  7  IT 
of   sound-conducting   appar- 
atus, 788 
Exenteration,   572.      See    also 
/  'msceration. 
of  .obit,  600 
tympano-mastoid,  796 
Exophoria,  L57,  500,  517 
in    relat  ion   to  full  correction 

of  hyperopia,  219 
treatment,  520 
Exophthalmic  goiter,  170,  255, 

177,  534 
Exophthalmos,  -';I7.  525 

cardiac.  534 

pulsating,  534 

I  Ixostoses   carl  ila$  ineae  of  me- 
al us.  operal  ion  fur.  7-1; 
of   external    auditorj    canal. 

7111; 
of      meatus,      operation      for, 

of  orbit,  •">•'"! 
Exotropia.     See  Strabismus, 

i- 1  ■nil  nl. 

Exploratory  tympanotomy,  737 


INDEX. 


L227 


External  auditory  canal,  affec- 
tions of,  698 
circumscribed   inflamma- 
tion of,  702 
congenital  a1  resia  of,  698 
diffuse  inflammation   of, 

703 
doubling  of,  699 
exostoses  of,  706 
false  membranes  of,  To? 
furuncle  of,  702 
hyperostosis  of,  706 
ear,  affections  of,  69] 
anatomy,  625 
function  of,  <>3(> 
rectus.     Sec  Rectus,  external. 
Extirpation  of  larynx,  1212 
Extorsion,  I!'? 

Extraction  of  cataract,  395,  580 
after-treatment  of,  586 
combined.  582 
disturbances     of     healing 

process  after.  583 
execution  of  operal  ion  of, 

580 
in  capsule,  582 
mistakes  and  accidents  dur- 
ing operation  of,  582 
results  of,  583 
simple,  580 
suppuration  after,  583 
various  modifications  of  the 
operative    procedure    of, 
581 
with  iridectomy,  582 
of  immature  cataract,  394 
of  monocular  cataract,  395 
Extradural   abscess,    7~>(>.      See 

Pachymeningitis  externa. 
Eye,  a  living  camera,  88 
anatomy  of,  29 
animal's,  operation  on,  611 
antero-posterior  axis  of,  100, 

201 
cardinal  points  of  schematic, 

92 
center  of  rotal  ion  of,  !••! 
determination  of  position  of 
opacit  ies  in  media  of,  17!' 
development  of,  17 
development   of   fibrous  and 

vascular  coats  of,  ".'7 
diphtheria  of,  1032 
direct   inspection  of,  1  12 
examination  of  media  of,  1  78 
external  examination  of,  1  12 

fund  ional   test  ing  of,    1  1"-' 

general  plan  of  examination 
of  refract  ion  of,  2]  1 

horizontal  a  \  i-  of,  LOO 

human,  cardinal  points  of,  125 

hyperopic,  '.'I  I 

injuries  of,  358 

injuries  of  appendages  of,  358 

lengl  li  of  axis  of  emmet  ropic, 
L78 

lengtlieniii!.'  or  shortening  of, 
in  ;i  \ia]  .inn  i  ropia,  201 

methods  of  determining  re- 
fraction of  the,  196 

movements  of  each,  198 

muscles  of.  See  Oculai  muscles. 

myopic,  219 

opacil  ies  of  media  of,  1 83 

opera!  ions  oil.   539 

optical  defects  of,  95 
posil  ion  of,  170 


Eye,  primal. v  position  of,  101 

reduced,  93 

refraction     of,    at     different 

parts  of  retina,  200 
rotation  of,  100 
scbemat  ic,  92 

svmpat  bet  ic  affeel  ions  of,  3  I? 
Eyeball,  atrophy  of,  315,  356 

blood-Ve>sels  of,  86 
eollt  lision   of,  360 

dislocation  of,  537 

enucleal  ion  of,  571 

fibrous  tunic  of.  50 

foreign  bodies  in,  369 

injuries  of,  from  contusion, 
concussion,  and  com- 
pression, 360 

lymphatics  of,  s7 

macroscopical  anatomy  of,  48 

microscopical  anatomy  of,  48 

movements  of,  1  <M) 

nervous  tunic  of,  50,  65 

ossification  of,  348 

penetrating  wounds  of,  367 

principal  diameters  of,  49 

refractive  media  of,  50 

rupture  of,  361 

vascular  tunic  of,  50,  55 
Eyeballs,    anomalies   of    move- 
ments of,  497 
Eyebrows,  260 

cysts  of,  260 
Eye-glasses,  239 
Eye-ground.     See  Fundus. 
Eyelashes.     See  Cilia. 
Eyelid,  Eyelids,  30 

abnormal  shortness  of,  246 

abscess  of,  242,  546 

adenoma  of,  248 

angioma  of,  248 

anthrax  pustule  of,  242 

blood-vessels  of,  36 

border,  reconstruction  of,  550 

burns  of,  372 

carbuncle  of,  242 

carcinoma  of,  251 

chromidrosis  of,  259 

coloboma  of,  operation  for,  557 

congenital  anomalies  of,  241 

contusions  of,  372 

cutaneous  bonis  of,  248 

c\  s1  icercus  of,  260 

dermoid  cysts  of,  2bM 

development  of.  28 

diseases  of,  2 1 1 

ecchymosis  of,  371 

eczema  of,  24  I 

elephantiasis  of,  252 

emphysema  of,  37 l,  537 

enchondroma  of.  2 18 

ephidrosis  of,  -.'.Mi 

epithelioma  of,  invading 
orbit,  533 

erysipelas  of,  242 

eryl  liema  of.  2  12 

exant hematous  eruptions  of, 

244 
fibroma  of,  248 
furuncle  of,  242 

gumma  of,  2  I- 
injuries  of,  37  1 

integ nt  of.  32 

lepra  of,  252 

li| a  of,  248 

lupus  of,  invading  orbit,  533 

\  ulgaris  of,  252 
lymphatics 


Eyelid,     Eyelids,     met  bod    of 

e\  ell  ing,     I    13 

iii ilium  of,  '.Till 

molluscum    contagiosum    of, 

2:.!) 
nerves  of.  37 

neuroma  of.  248 

nevus  of,  invading  orbit,  533 

operations  lor  restoration  of. 
555 

operations  on,  . ,  I  1 

papilloma  of.  248 

rare  forms  .,f  carcinoma  of. 
252 

replacement  of  lacerated,  557 

rodent  ulcer  of.  251 

sarcoma  of,  250 

sebaceous  cj  -1  -  of,  259 

seborrhea  of,  258 

syphilis  of,  247 

third,  31 

transplantation  of  cicatricial 
skin  to  replace  integu- 
ment of,  55 1 

tumors  and  hypertrophies  of, 
".Ms 

ulcers  of,  1'  13 

vaccinia  of.  21 1 

veins  of.  3? 

wounds  of,  372 
Eyes,  associated  movements  of, 
1(11,  500 

associated  parallel  move- 
ments of.  500 

astigmatic.  221 

mobility  of.  L55 

nervous  mechanism  govern- 
ing associated  parallel 
movements  of,  502 

secondary  position  of.  mi 
Eye-speculum,  575 
Eye-strain,  213,  352 

•FACE,  examination  of.  in  affec- 
tions of  nose  and  throat, 
855 
facial  canal.  621,  755 
facultative  hyperopia,  215 
false  croup,  986 
membrane  in  diphtheria,  L012 
membranes  of  internal   audi- 
tory canal.  7u7 
vocal  cords,  816,  820 
Farlow's  tongue-depressor,  865 
far-point,  13  1,    155 
Far-sightedness.  See  Hyperopia. 
fascia,  oculo  orbital,  inllamuia 
tion  of.  529 
orbitalis.   12 
fascicular  kerat  it  is.  31  I 
fauces,  herpes  of,  946 

malignant  tumors  of.  hio- 
Faucial  abscess,   evacuation  of, 
12117 
lymphoid     tissue,    pathology 

,.f,  850 
tonsils,  815,  921 
pal  hology  of.  850 
removal  of,  L204 
Fauvel's  forceps,  11:17.  L138 

fenestra     ovalis,     function      of, 
640 
rot  unda.  fund  i"M  of,  6  in 
!  cli  ft,  L91 

1    (Mallei,  1.   I7!i 
of  Mulb  I 
of  Wernicke.    179 


1228 


INDEX. 


Fibroma  of  auricle.  (i.V..  696 
of  conjunctiva.  •_'!•:;.  :;ni 

of  drumhead,  714 

of  ej  elids,  248 

of  larynx.  L105 

of  lobule,  operation  for,  783 

of  middle  ear,  661 

of  naso-pharynx,  1091,  1092 

of  nose,  l"-" 

removal  of,  l  1!>7 
of  « >  i  >  t  i  t ■  uerve,  449,  530 
of  oro-pbarynx,  1096 
of  sclera,  330 
of  sofl  palate,  mitt; 
of  trachea,  1 1 1~> 
papillare  of  hum-.  1081 
Fibro-mucous   polypi   of    naso- 
pharynx, 1093 
Field  of  binocular  fixation,  502 
ut'  binocular  single  vision,  .">02 
of  fixation,  169,  198 
of  \  ision,  162,   I7<i 
absolute,  166 
amblyopia  of,  I7n 
anomalies  of,  IT-.' 
binocular,  li>7.  171 
changes  in,  in  affections  of 
optic  nerve.  47<i 
in  diseases  of  choroid,  I7~> 
in   diseases  of  retina.   17:; 
due   to  optic   hindrance, 
17:; 
contraction  of,  17'.' 
edict  of  refraction  on  size 

of,  166 
false  projection  of,  509 
for  colors,  1H7 
in  glaucoma,  '■•7'.k  176 
in  optic-nerve  atrophy,  1 1*;. 

117 
minimal,  166 
relative,  166 
size  of,  165 
Fifth  nerve.     See  Trigeminus. 
Filamentous  keratitis,  31 1 
Filaria    sanguinis    hominis   in 
anterior  chamber,  •';  1 1 
in  vitreous,  102 
Filtration-angle   in    glaucoma, 

Fissure,  « rlaserian,  625 
Fissures   of   auricle,   operation 

for, 
Fistula,  aural,  692 
lachrymal,  26S 
of  ear.  congenital,  692 

operation  for, 
of  lachrymal  gland,  262 

■  ion,  binocular,  499 
contraction  of  fii  Id  of,  199 
field  of,  169,  in- 
field of  binocular,  502 
line  of,  96,  128 
Flaccid  membram 

••  •  ption  <■! 
"  PI  i  in  nu  i  scotom,"  183 
.1  chambi  i 
brain,  19 
I  15 


Focal  points,  90,  92 
Foci,  in:..  108 
conjugate,  L03,  L08 

relation  of,  to  principal  tV »< ■  i . 
Ill 
principal,  121 
of  surfaces  measured  from  the 

surfaces,  1 1 1 
id'   systems     measured    from 
principal   (mints  of   sys- 
tems, 1 11 
Focus,  102,  124 
first  principal,  109,  110 
principal,  1 1  1 
second  principal,  109,  110 
virtual,  of  concave  lens.  L24 
I   lerstei  soper  mm  for  ripening 

cataract,  584 
Folliculosis,  289,  292 
Fontana,  spaces  of,  28,  55,  86, 

-;,  :;77 
Foramen  lacerum,  624 
Forci  ps,  ear  .  674 
Fauvel's,  1137,  1138 
for  deviation  of  nasal  septum, 

1192 
<  rarrigou-1  lesarenes,  1192 
Mackenzie's  tube-,  1143 
line's  tracheal.  1 134 
Fore-brain,  19 
Fore-gut,  808 

Foreign     bodies     in    auditory 
canal,   708 
in  cornea  and  conjunctiva, 

368 
in  esophagus,  1 135 
in  eyeball,  369 
in  larynx,  11".'!» 

and'  trachea.  1130   1132 
removal  of,  1209 
in    meatus,   operation    for, 

786 
in  nose,  861,  1127,  1128 
in  pharynx,  1 135 
in  tonsil,  !»:;i> 
in  trachea.  1 129 
Form     nf    upper    air-passages, 

alterations  of,  854 
Formaldehyde,  272,280,293,540 
in  corneal  ulcers.  315 
in  laryngeal  i  uberculosis,  1050 
in    nasal  and   pharyngeal  tu- 
berculosis, 1057 
Formaldehyde-disinfection      in 

diphtheria,  1016 
Formalin.     See  Formaldehyde. 
Formate  of  soda  spray  in  laryn- 
geal tuberculosis,  1050 
of  sodium  in  nasal  and  phar- 
yngeal i  uberculosis,  1057 
Form-field,  166 
Fornix  conjunctiva-.  :;."i 
Fossa,  cerebellar,  623 
patellar,  80 
posterior,  623 
of  Rosenmuller,  310 
Fourth  ventricle,  1!' 
188 
c  ntralis,  6( 

reflection  from,  182 
i  reflex,  H7.  L88,  106 
Fowler's    solution     in     lupous 

laryngil  is,  1066 
Fracture  of  bones  of  nose,  1119 
tn  atraent,  1 121 
of  carl  ilagi  1 123 

of  lachrymal  bones,  1 120 


Fracture  of  larynx,  1 139 
of  nasal  septum,  I L24 
of  petrous  bone,  77ii 
of  triangular  cartilage,  1 124 
of  vomer.  1 L24 
Frankel's  diplococcus  in    laby- 
rinth, 767 
tongue-depressor,  865 
Fran  kel -We  ichsel  hau  in     calcu- 
lated diplococcus,  61  In 
Fricke's   method   of   blepharo- 

l>lastv,  556 
Fright,  149 
Frontal  nerve,  :'>7 
disease.  980 
Frontal   sinus,   growths  in,  in- 
vading  orbit,  ■":;:; 
operation  for  distention  of, 
602 
sinuses,  diseases  of,  !»79 

operative  treatment,  6'02 
1202 
drainage  nf.  9,-0,  9-1 

neoplasms  of,  1090 
Fronto-nasal  process,  807 
Frost-bite  of  auricle,  696 
Fruehjahr's  catarrh,  287 
Fundus,  chanties  in,  caused  by 
eye-strain,  213 
caused  by  myopia,  221 
color  of,  189 

congenital-anomalies  of.  Is!) 
differences  of  level  in.  1-1 
normal,  171.  184 
physiological     variations    of, 
189 
!•  undus-details,  177 
Furcula,  309 

Furuncle  of  external   auditory 
canal.  7u-.' 
of  eyelids.  2  12 
of  nasal  wins,  901 
Furuncles  of  external  meatus, 

pathology,  655 
Furunculosis  of  auricle,    treat- 
ment  of.  « >  — ■  # > 

< :  w.r.ic  ACID  in  epistaxis,  903 

Galtou's  whistle,  669 

i  ralvanism,  310,  330.    See  also 

Electricity. 
Galvano-cautery,  309,  r>97,  887 
in   acute    follicular   pharyn- 
gitis, iU- 
iii     acute     naso-pharvngitis, 

948 
in  chronic   naso-phai  \  ngitis 

952 
in    chronic    parenchymatous 

tonsillitis,  932 
in  ch  ionic  rhinit  is,  !i|  1 
in  chronic   subglottic    laryn- 
gitis, inn!' 
in  corneal  ulc<  re,  567 

in  enlargement  of  epiglottis, 
937 

in   fibroma  of  naso  pharynx, 
1093 

in  lupous  laryngil i-.  1066 

in  lupus  of  pharynx,  1059 

in    neoplasms    of    nasal     sep- 
tum. 1080 

in  nodular  larj  ngitis,  L006 

in  singers'  nodes,  1 105 

m,  genii  ulatc,  626,  627 

retinae,  R7 

Bpiral,  619,  620 


INDEX. 


1229 


Gargles,  881 
in   acute    catarrhal    pharyn- 
gitis, 940 
Garrigou-  Desarenes        forceps, 

L192 
Gasserian  ganglion,  corneal  ul- 
cers of,  removal  <>t'.  317 
Gastric  disturbance  in  etiology 
of    catarrhal    inflamma- 
tion, B  15 
Gelle's   binaural  synergy   test, 
672 
test,  672 
< '<<  Isemium,  254,  159 

in  acoustic  neurasthenia,  781 
Geniculate  ganglion,  620.  ii\!T 
German  and  French  method  of 

rhinoplasty,  1 185 
Gerontoxon  lentis,  389 
Gifford's  reflex,  151 
Gland,  lachrymal,  45 
Glands,  ciliary,  86 

of  Moll,  :;:;.  35 
Glaserian  fissure,  625 
Glasgow's  operation   for  devia- 
ted septum,  917 
Glass,  index  for.  110 
Glasses.    See  also  Spectacles. 
for  astigmatism.  229 
in  hyperopia,  "JIT,  218 
in  myopia,  222 
mounting  of,  234 
period  of  adaptation  of.  235 
Glaucoma.    143.    1 19,    226,   311, 
357.    366,    373,    391,  396. 
421,  128,  157,  492 
absolute.  377 
acute,  377,  378 
after  cataract-extraction,  578 
after  discission.  578,  586 
anatomical  conditions  of,  373 
chronic.  1177 

inflammatory,  379 
complicated.  3-1 
congenital.  385 
congestive,  377.  379 
danger  of  mydriatics  in,  210 
diagnosis,  381 

from  iritis,  341 
differential  diagnosis  of  sim- 
ple,     from      optic-nerve 
atrophy,   382,   448 
excil  ing  causes,  376 
field  of  vision  in.  379  3-1 
fulminans,  379 
hemorrhagic,  38  l.  570 
inflammatory,    375,  377.  3-1. 

57i  i 
malignant,  383 
non-inflammatory,  ■  !7'.  • 
non-surgical  treal  ment,  38  I 
pathology,  370 
predisposing  causes,  375 
primary.  "7  I 
relal  ion  of  age,  race,  and  ses 

to,  375 
relat  ion  of  refract  ion  to,  375 
secondary,  321,  341,  384 
simple.  375,376,  379,  382,  II-. 

570 
subacute,  377.  379 
i  real  ment,  382 
true-  forms  of,  37fi 
varieties,  37 1 
visual  field  in,  170 
Glaucomatous       degeneration, 
378 


(  Haucomatous  exca\  al  ion,  373 
halo,  371 

Male.  378 

i  rlenoid  cavity.  625 
<  flioma  endophytum,  494 
exophytum,  194 
of  optic  nerve.  1 19 
of  retina.  356,  398,   I"".  494 
diagnosis,  I'M 
pathological  anatomy,  495 
prognosis,  195 
Globe  inhaler,  1049 
( {lobular  process,  807 
Glosso-epiglottic  folds,  median, 
819 
fossa,  examination  of,  -09 
ligaments,  818 
Glottis,  820 

spasm  of,  995 
Glycerite   of    boro-glycerin    in 
Lingual  tonsillitis,  927 
of    tannic    acid    in    chronic 
aaso-pharyngitis,  952 
Glycosuria,  nasal.  1150 
i  llycol  bymoline  in  acute  naso- 
pharyngitis, 948 
in  chronic   naso-pharyngitis, 
951 
Goiter,  exophthalmic,  534 
Golding-Bird's  double  retractor, 

1134 
Gonococcus  of  Neisser,  278,  281, 

314,  (ill" 
Gonorrhea,  278,  339,  437 
Gonorrheal  conjunctivitis,  266. 
See   Conjunctivitis,    gonor- 
rheal. 
inoculations  in  pannus,  309 
rheumatism,  279 
Gottstein's  curette,  1202,  1203 
Gout.    261,    319,    330.    339,   391, 
399,  400,  421,  136 
relation    of.    to    ear-disease, 
650 
Gouty  affections  of  upper  air- 
passages,   general    thera- 
peusis  <>t'.  875 
Gradenigo's  test.  672 
Graefe's  cataract-knife.  576 
equilibrium-tesl    for     ocular 

muscles,  157 
operation  of  tenotomy.  5-7 
sign,  535 
Granular     conjunctivitis.    See 
Trachoma. 
lids.     See  Trachoma. 
pharyngitis,  942 
Granulation  growths  in  chronic 
suppuration    of    middle 
ear.  742 
Granulations  of  meatus,  opera- 
t  ion  for,  7-5 
of   tympanum,     removal   of, 

79-.' 

Granuloma  of  conjunctiva,  301 
oi  iris,  340.  1-9 

Grattage,  565 

Graves's  disease.  See  Exoph- 
thalmic goiter. 

Gray  degeneration  of  acousl  ic 
nerve,  769 

(  ;  rii  ii  -1 .1  i  ml  1 1< — .  603 

( Ireen's  opera!  ion  forentropion, 

55 1 
( rrippe.     See  /,<  Cm 
Groenonw's  testa  forlight-w  use, 

L68 


i  ear-scoop,  671 
probang,  L138,  L139 
( Iruening's  operation  for  diver- 
si  rabismus,  589 
Guaiac       in       acute      catarrhal 
pharyngil  is,  9 10 
in  acute  tonsillitis,  92  I 
Guaiacol    in    acute    tonsillitis. 
921 
in     laryngeal      tuberculosis, 

1048 
in  lupus  of  pharynx,  1059 
in    nasal     and      pharyngeal 

tuberculosis,  1057 
spray   in   laryngeal  tubercu- 
Losis,  L050 
'  luaiacum  in  laryngeal  tubercu- 
losis,   1017 
Guillery's  dots,  1  10 
Gumma  of  conjunctiva,  300 
of  eyelids,  248 
of  optic  nerve,  150 
Gunn's  dots,  106,  122 
Gymnastic        exercises      with 
prisms,  520 

Haab's  electro-magnet,  370 

reflex,  151 
Hematoma  auris,  694 

treatment,  695 
Hairy  pharyngeal  polypi,  1093 
Hajek's  cannula,  B63,  86  I 
Handle  of  malleus,  tract u re  of, 

712 
Hard  cataract.      See    Cataract, 

senile. 
Haider's  glands.  31 
Harlan's  operation   for    cicatri- 
cial orbit,  600 
for  symblepharon,  563 
Harlan's  test  for  feigned  blind- 
ness. p;7 
Harmonic.  635 
Hartinann's  cannula.  863 
combined    probe    and    blunt 

hook.  67 1 
ear-forceps,  674 
speculum,  859,  B60 
Hasner,  valve  of,  1- 
llay  fever.   1111 

in      chronic    hypertrophic 
rhinitis,  907,  908 
Headache.  226,    I"!',  510 
from  eye  — train.  21  I 
in  brain-abscess,  763 
in      chronic        hypertrophic 

rhinitis, 
in  deviation  of  nasal  septum, 
916 
Hearing,  defect  of,  as  a  symp 
torn,  666 
qualital  ive  tests  of,  l 
quantitative  tests  of 
Heart-disease,   120,   121 
Heat-cold,  - 
Heating   in  affections  of  upper 

air-passagi 
Helicia  major,  637 

minor,  637 
Helix.  625 

Helmholtz's  formula,  l  L3 

opht  balmometer,  196 

ophthalmoscope,  172 

schema!  ic  eve.  92 

t  heory  of  accommodation,  134 

theory  of  color-percepl  ion,  99 
Hematemesis,  121 


1230 


ZXDIJX. 


Hematoma  of  septum,  899 
Hemeralopia,  460,  469 

-achromatopia,  182 
Hemianopia,  1  19,   170,  472.  480 
heteronymous,  180 
homonymous,  i-\ 
lateral,  181 
monocular,  182 
nasil.   180 
significance  of,  482 
spurious,  1 18 
temporal,  180 
transient,  183 
vertical,  182 
Eemianopic  pupillary  inaction, 

180 
Hemianopsia,     See  Hemianopia. 
homonymous,    in      brain-ab- 
scess, 763 
III  micrania,  21  l 
I [emophilia,  ">:'.7 
Hemophthalmia,  362 
Hemorrhage     after     glaucoma 
operal  ions,  383 
from  external  meatus,  655 
from  pharynx,  9 1 1 
in  diphtheria,  1<>17 
in  drumhead,  71 1 
in  opt i<-  nerve-sheath,  153 
into  choroid,  364,  399,  428 
into  labyrinth,  663 
etiology,  770 
pathology,  766 
symptoms,  71 1 
treatmenl ,  780 
into  opl  ic  im  r\  e,  153 
into  orbit,  1 1 1.  '<■'>' 
into  retina,  364,  117.  128,  420 
after  cutaneous  burns,  121 
pathology  of,  i-.m 

into  vit  nous.   1(11 
subhyaloid,  421 
Hemorrhagic     laryngitis,    944, 

996 
Hereditary  ataxia.  520 

Byphilis,  339,  387 
Heredity  in  etiology  of  ear-dis- 

■  .  6  17 
Hering's    theory   of   color-per- 

ception,  100 
Herpes  auricularis,  655 
conjunctivae,  287 
corm  bb,  309 

relapsing,  311 
febrilis,  310 
frontalis,  309 
labialis,  310 

of  auricle,  t  reatment,  685 
of  fauces,  946 
zoster  of  auricle,  693 
zoster  ophthalmicus,  '-'11 
Hi  rscbel'a  prism,  158 
Heterophoria,    161,    504.      See 
also    Insufficiency,    D 
in, its.  and  Ocular  muscles. 
etiological  classification,  505 
insertional,  510 
reflex-disturbances  from,  510 
tnral,  510 
ophthalmos,  331 
■  ropia.      8<  ■ 
and  D(  i  iations. 

Hind 

Hippus,  151,  334 
B  ii  hronic  subglottic 

laryngitis,  1008 


Hoarseness  in  laryngeal  tuber- 

culosis,  1038 

in  lupous  laryngitis,  1060 

in  nodular  laryngitis,  1005 

Holden's  tests   for  light  -si  nsi  . 

168 
Holmgren's   method  for  color- 
blindness, 603 
wools,  153 
Holocain,  54  1 
Homatropin,  209 
Homnicl's     method     of    aural 

massage,  736 
Homoreut  ric  rays,  89 
refraction  of,  90 
Homonymous  heminanopsia  in 

brain-abscess,  763 
Hook-cartilage,  630,  631 
Hope's  septum-forceps,  1 192 
Hordeolum,  243,  546 
Horner's    muscle.     See    Tensor 

tarsi. 
Horny  growths  of  auricle.  697 
Hot   applications  in  conjuncti- 
vitis, 280 
in  corneal  ulcers.  :;i(! 
in  irit  is,  342 
hath  in  subglottic  laryngitis, 

988 
fomentations     in     subglottic 

laryngitis,  988 
snare    in    chronic    parenchy- 
matous tonsillitis,  932 
Hot-eye,  330 

Hotz's  method  of  transplanting 
cicatricial  flap,  555 
operation  for  reconstructing 
lid-border,  550 
Hubbel's  electro-magnet,  371 
Humidity  in  etiology  of  catar- 
rhal inflammation,  845 
Huskiness  in   pachydermia  of 

larynx,  1006  ' 
Hutchinson's  teeth,  319 
Huyler's  operation  for  deviated 

septum,  917 
Hyaline  bodies  in  optic  disk, 

451,  196 
Hvalitis.  357,  398,   U0 
asteroid,  399 
punctata.  399 
suppurative,  398 
Hyaloid  artery,  24,  403 

persistent,  24,  190,  403,  194 
vestigial,    remains  of,  389, 
mi 
canal,  24,  83 

mi  ml. rane.  28,  82,  83,  84 
vessels,  28 
Hydrobromic  acid  in  tinnitus, 

738 
Hydrocephalus,  136,  146,  155 
Hydrochlorate    of     coniin     in 
laryngeal  tuberculosis,  1050 
Hydrochloric  acid   in  diphl  he- 
ria,  994 

en     dioxid      in     acute 
croupous  tonsillitis,  925 
in   chronic  suppuration  of 

middle   ear,   7  17 
in  diphtheria,  1028 
Hydrophthalmos,  823,343,  570 
anterior,  52 1 
i  nital,  385 
II 5  drops  of  i n t  ravaginal  space, 

134 
1 1;.  Li'  in-  of  the  voice,  1 177 


Hyo-£piglottic  ligaments,  819 
1 1  j  oid  bone,  816 
llxomandihular  (deft,  M>!> 
Hyoscin,  209 
1  [yoscyamin,  209 
Hyperacusis,  77<i 
Hyperemia   of  acoustic  nerve, 
769 
of  auricle,  pathology,  654 

t  real  ment,  685 
of  drumhead.  7!  1 
of  labyrinth,  etiology,  770 
pat  hology,  7n»i 
symptoms,  77  1 
treatment.  780 

Hyperesophoria,  161 
Hyperesthesia,  nasal,  1143 

of  larynx,   1154 

of  pharynx.  1151 
Hyperexophoria,  161 
Hyperkeratosis,  lacunar.  945 
1 1 5  permetropia.  See  Hyperopia. 
Hyperopia,    170,  212,  214,  333, 
343,  394,  395,  457 

absolute,  215 

amplitude  of  accommodation 
in,  137 

aphakial,  215 

axial,  215 

causes,  215 

course,  215 

curvature,  215 

determined   by   trial   lenses. 
2!  18 

determined  by  skiascopy,  205 

facultative,  215 

full  correction  of,  217 

index,  215 

latent.  215 

manifest.  215 

measured     with     ophthalmo- 
scope, l(ii» 

partial  correction  of,  218 

symptoms,  216 

total,  215 

t  reatment.  '.'17 

varieties.  215 
Hyperopie  astigmatism.  12>,  227 
llyperosiiiia.  1  1  12 

Hyperostosis  of  external  audi- 
tory canal,  706 

of  meatus,  operation  for,  785 
Hyperphoria.  161,  500,  518 

comitant,  518 

left,  500 

non-comitant,  518 

prism-tesl  for,  157 

right,  500 

treatment,  520 
Hypertrophic  rhinitis,  chronic, 

905 
Hypert  rophied  tonsils,  effeel  of, 

on  ear.  718 

galvano-cautery  in,  888 
H  vpert  rophy  .  adenoid,  etiology 
of,  850 
lymphoid,      in      pharyngeal 
vault,  952.    See  Lymphoid 
hypertrophy. 

Of  tonsil,   polypoid.  935 

of    turbinated    hones,   treat- 
ment, 1194 

of     Vascular    tissue    of    nasal 

sepllllli,      II!).") 

Hypertropia.     See    Strabismus, 

circumvergent. 
Hyphema.  344,  362 


TNDEX. 


1231 


Hypokinesia  of  larynx,  1160 
Hypopyon,  :;i  I,  355,  m  \l> 

in  cyclitis,  345 

in  iritis,  336,  337,  338 
Hypopyon-keratitis,  391 
Hysteria.  151,  254,259,  110,  466, 
185,  511,  .">li» 

acousl  ic,  776 

field  of  vision  in,  167 

influence  of.  on  the  oar.  til!' 

of  nose  and  throat.  1  L69 
i  reatment,  1170 

visual  field  in.  166 
H\  sterical  aphonia,  1170 

[ce  in  acute  catarrhal  pharyn- 
gitis, 940 
in  croupous  laryngitis,  - *i ' l 
in  epistaxis,  nit:; 
Ice-bag   in  acute  phlegmonous 

laryngitis,  989 
Ictus  laryngea,  1 159 
Ideal      points.      See      Cardinal 

points. 
Idiopathic  epistaxis,  902 
Ignipuncture  in  chronic  paren- 
chymatous tonsillitis.  932 
Illumination     in     ophthalmos- 
copy, 179 
minimum  stimulus  of,  153 
oblique,  146 

Uses  of.    146 

of  ear.  67.'5 
rmage,  103 
and  object,  111.  112 
magnification     determined 
by  properties  of  principal 
foci,  11 -J 
middle,  116.  L20,  123 
position  and  size  of,  114 
retinal.  >9 
in  ametropia.  139 
in  emmetropia,  139 
size  of.  1  •_'.""> 
Image-forming   optical    instru- 
ments, in:;.  105 
Images,  conjugate,  111 
formation  of,  in  reduced  eye, 
94 
on  retina,  90 
of  Purkinje,  98,  135 
real.  124 
virtual.  124 
Imbalance   of   ocular   muscles. 

See  Ocular  muscles. 
Impacted  cerumen,  699 
Incarceration  of  epiglottis,  9:;:;. 

936 
Incidence,  angle   of.    mi.    ior>. 

1(16 
Incision  of  drum-membrane  in 
chronic   catarrh    of   mid- 
dle ear,  735 
of    vocal    hands    in    chronic 
laryngitis,  1004 
ho-isor  crest,  -'-'7.  830 
Inco-ordinat  ion     of     laryngeal 

muscles,   1 158 
[ncudo-stapedial  joint,  disartic- 
ulation at.  ''.id 
In.  us.  i;:;u 
function  of,  638 

Index  for  air.   I  10 
for  glass.  1 10 
of  refraction.  In", 
of  air.  92 

of  aqueous  humor,  89,  9-.' 


Index  of  refraction  of  cornea, 

89,  9-.' 
of  crystalline  lens.  89,  92 
of  vitreous,  B9,  92 
[ndex-hyperopia,  215 
1 1 1 . 1 .  •  x  - 1 1 1  %  opia,  222 
Indian  method  of  rhinoplasty, 

11-1 
Indirect  method  of  ophthalmos- 
copy, 17i> 
measurement    of    refrac- 
tion by,  -iol 
reflex  action  of  pupil,  1  18 
Infect  ious  diseases  of  drumhead, 
71  I 
relation  of,  to  ear-disi  a  - 
650 
Inferior  constrictor  of  pharynx, 
-1  1 
oblique.      See  ( lli/it/iir. 
rectus,  :'>9.      See  Rectus. 

Iuliltrat ioti-anest besia,  5 14 
Inflammation  of  attic,  721 
of    auditory    canal,    circum- 
scribed, 702 
desquamative,  704 
diffuse,  703 
of  drumhead,  acute  primary, 
713 
chronic.  713 
of  Eustachian  tube,  72-"> 
of   meninges  from   tympanic 

inflammation,  7.">6 
of  middle   ear.      See    Middle 
ear,  inflammation  of. 
chronic      uon-suppurative, 
726 
Inflation      of     ear,      Politzer's 
method,  (i-1 
Valsalva's  method.  6-1 
of  middle  ear,  679 
Influenza,    -27."..    339,    391,    436, 
140,  r,ll 
and  ear-disease,  653 
middle-ear  disease  from,  718 
Infra-auricular    region,    exam- 
ination of,  672 
Ingals's  operation  for  deviated 

septum,  917 
Inhalations  in  laryngeal  tuber- 
culosis, 1019 
Injuries    in    etiology  of  ear-dis- 
eases, ill- 
Injury  of  drumhead.  711 
Ininr  wall    of    nasal    chamber, 

830 
Innominate  artery,  825 
I  nsanity,  1~>1 
Insects  in  auditory  canal,  708, 

710 
Instruments,      preparation      of, 

540 
Insufficiencies  of  ocular  mus- 
cles, 254 

etiological      classilieat  ion 

of,  .".or, 
Stevens's  classifical  ion  of, 

161 
treatment.  520 
Insufficiency  of  external   recti. 
157,  515 
of  interna]  reel i.  157,  517 
of  oblique  muscles,  tests  for, 

159 
of  ocular  muscles,  L56 

diplopia  a   teal    for,  156, 
157 


Insufficiency  of  ocular  muscles, 
hysterical,  185 
rod-tesl  for,  160 
screi  d  fcesl  for,  1">6 
of  vertical  muscles,  51  8 
Insufflations        in        laryngeal 

tuberculosis,  1050,  1052 
Interarytenoid  space.  820 

examination  of,  -7  1 
I  nterference  otoscope,  672 
Intermaxillary  process,  808 
Internal  auditory  canal,  pathol- 
ogy. 664 
ear,    diseases   of,   treatment, 
690 
fund  ions  of,  640 
syphilis  of,  t  reatment,  690 
Internal  rectus.     See  Rectus. 
Interstitial        keratitis.        See 

Keratitis,  interstitial. 
Intertrigo  of  auricle,  654 
treatment.  685 
intorsion,   197 
Intracranial    complications   of 
mastoidil  is,     differential 
diagnosis  of,  76 1 
of   purulent   otitis    media, 
7  •">•">,  756 
tumors.     S<  e  Brain  tumors. 
Intradural    abscess    from    tym- 
panic inflammation,  758 
Intralaryngeal  operation-.  1208 
Intra  ocular,      inject  ions.     399, 
124 
tension.     See  Tension. 

hemorrhage    from     sudden 
reduction  of,    121 
tumors,  384,  128,  189 
Intratympanic     operations    in 
chronic  catarrh  of  middle 
ear.  7^7 
instruments  for,  790 
Intra-vit  reous  inject  ions.   100 
Intubation  in  diphtheria,  1029 
lodid  of  mercury  tablets.  886 
of  potassium  in  acute   otitis 
media,  722 
in  labyrinthitis  exudativa, 

7-1 
in      labyrinthitis      hyper- 

plastica,  780 
in  laryngeal  perichondritis, 

996 
in  larync.it  is  sicca,  1005 
in  1  ii ( n i  —  of  pharyn \.  1059 
in  pachydermia  of  larynx, 

1 1  in- 
ill  syphilitic  throat.  -77 
Iodids   in   acute   inflammation 
•  it'  middle  ear.  687 
in  affections  of  upper  ai 

ages.  B86 
in  eczema  of  ear.  685 

in    9yphillS    Of    internal    ear. 

690 
Iodin     and     carbolic    acid     in 

pharyngo-mycosis.  9 16 
and      glycerin     in     chronic 

rhinitis,  910 
in  at  rophic  rhinit  i».  mi  1 
in  corneal  ulcers.  :;i  5 
in    hypertrophy   of    inferior 

turbinal,  91  I 
in     laryngeal     tuberculosis, 

1048 
in  lupous  laryngil is,  1066 
in  lupus  of  pharyn \.  1059 


1232 


INDEX. 


Iodiu  in  nasal  and   pharyngeal 
tuberculosis,  1057 
injections  in  retinal  detach- 
ment, 131 
spraj 

vapor  in  chronic  catarrh  of 
middle  ear,  7:::; 
Iodoform,  280,   159,  Ml 
gauze  in  epistaxis,  !'<»•'!.  904 
in  atrophic  rhinitis,  96 1 
in  chronic  rhinitis,  t *  1  i » 
in  corneal  ulcers,  315 
in    empyema    of    maxillary 

sinn-.  '.'7.'! 
m  injuries  <  i  drumhe  id    "1 
'  in     laryngeal     tuberculosis, 
L051,  L052 
in  lupus  of  pharynx,  1059 
in     nasal     and     pharyngi  aJ 

tuberculosis,  1057 
in     syphilis    of    air-passat,res. 
107  I 
[odoform-insufflation  in  laryn- 
geal i  nberculosis,  L050 
lodol  in  atrophic  rhinitis.  964 
Ipecac  in  diphtheria,  1028 
Iridic!. mi  v.   323,  324,   347,  :?G(i, 
385,  395,  568,  575,  584 
execution   of  the  operation, 

r>T7 
for  remoA  ing  tumors  ami  for- 
eign bodies  from  iris.  576 
for  secondary  cataract.  "»<> 
in  glaucoma,  382, 383,  576,578 

hemorrhage  after,  l-'l 
in  iris-prolapse,  ">T(i 
in  iritis.  .'Ml!.  576 
indications  for.  "'< 
methods   of  performing,   for 
-I.,  rial      morbid      condi- 
tions. 578 
optical.  395,  578 
preliminary    to    cataract-ex- 
traction, 582 
[rideucleisis,  579 
Irideremia,  '■'<■'•'■'< 

Irido-choroiditis,  324,  346,  384, 
:;-7.  391,  W0 
chronic  serous,  3  hi 
[rido-cyclitis,  311,344,391,  :;:»•.'. 
61  16.     See  also  Oyelitis. 
after  cataract-extraction,  583 
anterior,  376 
plastic,  348,  356 
Irido-cystectomy,  579,  586 
[ridodesis,  :!I7.  579 

Iri-lolll   ll\  :1  '■:-- 

Iridodonesis,  334 
Iridoplegia,  150,  -"1 1 
reflex,   i  50      -■  e  also  Argyll' 

Robertson  symptom. 
traumatic,  360 
unilateral  reflex,  150 
[ridotomv,  ~u'.> 
I 
angioma  o 

anterior  endothelium  of,  62 
anterior  limit i 1 1 ir  membrane 
of,  63 
■• 

atrophy  of,    1  I-.  377 

bloo  64 

id   in  chromatic  asym- 

Iliet  I  •      of      1   17 

i  -\ mini  t  ry  of,   117 
mia  of.  :;:;.". 
;    I    332,  169 


Iris,  color  of.  62,  l  17 

in  chorea,  1 17 
congenital  anomalies  of,  331 
contusion-injuries  of.  362 
e\  -t-  of,  189 

pigment  layer  of  the,  490 

stroma  of,  189 
development  of,  28 
diseases  of,  331 
displacements  of.  363 
epithelial  cysts  of.  189 
funi't  ions  ,,['.  96 
granuloma  of,  340,  489 
hyperemia  of,  33  1 
inflammation  of.     See  Iritis. 
lacerations  of.  362 
lesion  of  nucleus  of  sphincter 

of.  149,  L50 
lymphat  ics  of,  »>■"> 
melanoma  of.  190 
mobility  of.  1  18 
motor  disturbances  of,  334 
nerve-cells  of.  65 
nerves  of.  65 
operations  in.  574 
piebald,  117 
pigment-layer  of.  <>  1 
posterior  limiting  membrane 

,.f.  64 
prolapse  of.  315,  316,  -"7»; 

after      cataract-extraction, 

radial  lacerations  of.  363 
reactions    of,    148,    149.     See 
also    Pupil. 

retroflexion  of.  :;(;:; 
rudimentary  development  of, 

rupture      of     sphincter      of. 
363 

ruptures  of.  :;<;■_' 

sarcoma  of,  li'<i 

senile  changes  in.  334 

serous  cysts  of,  189 

sphincter  of.  1 18 

st  ructure  of,  62 

traumal  ic  spasm  of.  360 

tremulans,  ■;•'•  I 

tuberculosis  of,  340 

tumor-,  of.    189 

vascular  si  roma  of.  63 
[ris-forceps,  -"77 

[ritis,  1  13,  1  17,245,321,330,332, 
335,  381,  384,  391,  '■<'■'■-. 
:;<»;.  398 

after  cataract-extraction,  583 

catamenalis,  339 

chronic,  ■"•  11 

diagnosis,  340 

divisions,  "•:!■"> 

it iology,  '■'>'■'■* 

from    acute     infectious    dis- 
eases, ::::!' 

from  staphylococci,  337 

gonorrheal,  339 

goutj 

guramaton 

object i\e  symptoms,  336 

papulosa,  337 

parenchymatous,  336,  337 

pat hological  anatomy,  340 

periodic,  339 

plastic,  ::::>; 

prognosis,  341 

purulent.  338 

1 1  en 
rheumatic,  :::;:• 


Iritis,  scrofulous.  !?:{!) 

serous.  327,  336,  337 

simplex,  336.    See  Iritis,  plas- 
tic 

spongy,  :;;;•; 

subjective  symptoms,  338 

sympathet  ie  serous.  348 

syphilitic,  338,  :;::!' 

traumatic,  340,  343 

treatment,  oil 

tuberculous,  339 
Iron  in  croupous  laryngitis,  991 

in  eczema  of  ear.  <;-.""> 

in  epistaxis,  903 
Irritation-myili  ia-is.  L50 
[rritation-myosis,  150 
Isthmus  of  Eustachian  tube,  626 
Italian       method     of      rhino- 
plasty, 1186 
Itelberg's  test.  672 

.!  M'Ksux's  ophthalmoscope,  173 

Jacob's  ulcer.      See  Undent  nicer. 

Jacobson's  organ,  development 

of,  81 17 

Jaeger's  test-type.  137 
types  for  accommodation,  155 

Jaeschc-Arlt  operation  for  en- 
tropion. 551 

Jarvis's  operation  for  deviated 
septum.  917 
snare.  1196 

in     hypertrophic    rhinitis, 
912 

Javal-Schiotz  ophthalmometer. 
See  also  Ophthalmometer, 
196 

Jennings's  method  for  color- 
hlindness,  li(»l 

Jequirity  in  pannus,  309 

Johnson's  operation  for  tra- 
choma. 56 1 

Jugular  veins,  825 

June  cold,  1111 

Jurasz's  septum-forceps,  1 192 

K  i  i  .i,  \  \'s  operation.   I  1-7 
Keloiil  of  auricle.  655,  696 
Keratitis,  1  II.  245,  258,266,  305 
bullous,  :;n 

recurrenl  form  of,  :;il 
dendritic,  310 
,■  lagophthalmo,  ::i7.  536 
en  bande"lette,  311,  325 
fascicular j  -'il  1 
filamentous,  31  1 
from  BchizomycetaJ  infect  ion, 

til  Id 
harvester's,  oil 
interstitial,  :;i- 
atypieal  forms  "f.  321 
el  iology,  319 
pathology,  320 
prognosis,  •">•-'! 
B3  mptoms,  319 
treatment,  321 
v  essel-formation  in  corni  :i 
after,  321 
maculosa,  31  l 
m  uroparalyl  ie.  ::17 
nodosa,  327 
nummular,  31 1 
o\  b1  er  shuckers' .  31 3 
parenchymatous.     See    Kera- 
titis, interstitial. 
phlyctenular,  287      Bee   Ker- 
atitis, superficial. 


i.\ni:x. 


1233 


Keratitis,  punctata,  327,  336 
ribbon-shaped,  525 
sclerosing,  32  I 
striped,  325 

subepithelial  is  cent  nil  is,  :',1  1 
superficial,  305 
diagnosisand  prognosis,  301 
diet  in,  307 
etiology,  305 
micro-organisms  in,  306 
pathology,  :;<>: 
punctate,  311 
symptoms,  306 
treatment.  307 
suppurative,  312,  313 

etiology  and  pathology, 312 
syphilitic.  318 
vascular.  320 
vesicular.  309,  311 
with  hypopyon,  313,  311 
Keratocele,  316 

Keratoeonus.  See  Conical  cornea. 
Keratoglobu-.  323,  385 
Keratomalacia.  296,  318 
Keratometer,  1 45.  146,  1  18 
Keratometry,  145.   See  Ophthal- 
mometry. 
Keratonyxis,  580 
Keratoscope,  145 
Keratosis  obturans.  704 
Killian's  method.  872 
Klebs-Loffler  bacillus.  281.  283, 
284,  614rt,  848,  991,  1011, 
1017 
in  membranous  rhinitis,  896 
Knapp's   method    of   blepharo- 
plasty,  557 
roller  forceps,  561 
Koch*s  antitoxin-syringe,  1026 
Koch-Weeks  bacillus.  276,  614a 
Kopiopia    hysteric,   1-5 
Krameria   troches  in  acute  ca- 
tarrhal pharyngitis,  940 
Krause's  glands,  252 
Kroulein's  operation,  451,  601 
Kuhnt-Muller     operation      for 
shortening       lid-border, 
552 
Kyanopsia,  468 

Labordk's  dilator.  1131 
Labyrinth,  absence  of,  765 
anemia  of,  766.     See  Anemia 
of  labyrinth. 
treatment.  780 
bony.  620 

bony  and  membranous,  621 
deformities  of,  765 
hemorrhage    into,    6*63,    766 
See  Hemorrhage  into  laby- 
rinth. 
treatment.  780 
hyperemia  of,  766.  See  Hyper- 
emia of  labyrinth. 
micro-organisms  of,  767 
pathology,  663 
syphilis  of,  pal  bology,  66  1 
Labyrinthitis,    exudativa,    eti- 
ology, 771 
pathology,  766 
symptoms,  775 
treatment.  780 

hyperplasl  ica,  el  iology,  771 
pathology,  766 

symptom-.  775 
t  realm,  nt.  7-" 

Lachrymal  apparatus,  15 

78 


Lachrymal    apparatus,   diseases 
Of,  261 

diseases  of  drainage  system 
of,  264 

operat  ions  upon.  596 
bones,  fracture  of,   1  120 
calculi,  262 
caualiculi,  16 

atresia  of,  264,  265 

dacryolil lis  in,  265 

foreign  bodies  in,  265 

polypi  in,  265 
canaliculus,  double,  264 

slitting  of,  269 
conjunctivitis,  294 
disease  dependent  Upon  nasal 

catarrh.  272 
duct.     See  also  Nasal  duct. 

blood-vessels  of,    18 

nerves  of,   18 

stenosis  of,  in  newborn,  269 
fistula.  268,  272 
gland,  15 

adenoma  of,  263 

adenosarcoma  of,  531 

atrophy  of,  263 

carcinoma  of,  264,  531 

chloroma  of,  26  1 

cylindroma  of,  264 

cyst  of,  262 

development  of,  29 

diseases  of,  261 

dislocation  of,  262 

fistula  of,  262 

hypertrophy  of,  263 

lymphosarcoma  of,  264 

myxoma  of,  263 

myxosarcoma  of,  263 

operation  for  fistula  of,  596 

removal  of,  270,  596 

spontaneous  dislocation  of, 
262 

syphilis  of,  263 

traumatic     dislocation    of, 
262 

tumors  of,  263 
groove.  808 
papillae,  46 
passages,  46 

anomalies  of,  241 

injuries  of,  371 

tuberculosis  of,  269 
probes,  270 

introduction  of,  598 
puncta.  atresia  of,  264 

congenital     anomalies     of, 
264 

double.  261 

eversion  of,  265 
inversion  of,  265 
malposil  ions  of,  26 1 

t  nut  no  HI   of,  265 

sac,    17 

abscess  of,  265,  267 

destruction  of,  with   caus- 
tics, 270,  597 

excision  of,  597 

inflammation    of.    See  l>,i 
cryo-ci/stitis. 

polypi  of,  269 

sj  philis  of,  '.'on 

in  -      See    Nasal    duct, 
strictures  of 
l.aein  \  mo-nasal  duct,  st  ricture 
of.    See  Nasal  duct,  sti  id 

iirr  of. 

Lactal ion.  prolonged,  391,  137 


Lactic  acid,  889 

in  chronic  laryngitis,  1004 
in    chronic    na-o-pharvngi- 

tis,   952 
in  croupous  laryngitis,  991 
in  diphtheria.  994 
in  fibroma  of  naso  pharynx, 

1093 
in   laryngeal    tuberculosis, 

Ki5ll 
in  lupous  laryngitis.  1066 
Lactophenin     in     acute    naso- 
pharyngitis, 948 
Lacunar  hyperkeratosis,  945 
tonsillitis,  acute,  922, 928.  See 
Tonsillitis. 
Lacus  lacrymalis,  31 
Lievoduction.  502 
Lsevotorsion,  502 
La'Voversion.  500 
Lagophthahnos.  255 
congenital,  211 
non  paralytic.  255 
paralytic,  255 
Lamina  cribrosa,  79,  184 
fusca,  51 
spiral,  619 
suprachoroidea,  57 
vitrea,  59,  453 
Lamina]  1 1  bougies  in  de\  i  ifcion 

of  septum,  920 
La  n  dolt's  method  of  advance- 
ment, 593 
method  ofblepharoplasty,  556 
Lantern-test     for     color-blind- 
ness, 604 
Laryngeal  crises.  115!) 
epilepsy,  1 159 
muscles,    inco-ordination    of, 

1158 
nerves.  B23 
paralysis,  1160 
diagnosis,  1 165 

etiology.    1160 

pathology.  1160 

prognosis,  1169 

symptoms,  1 165 

treatment,  1169 
polypi,  1105 

stenosis,  dilatation  of,  1209 
syncope.  1  L59 

tuberculosis,  1034.    See  Tuber- 
culosis of  larynx. 
vert  igo,  1 159 
Laryngismus     stridulus,     995, 

1155 

t  real  ment,  995 
acute  catarrhal.  985,  986 
Laryngil  is,   acute  catarrhal,   in 
children.  986 
acute  edematous,  988 
acute  phlegmonous,  988,  989 
acute  supraglotl  ic,  986 
chronic,  998 

etiology,  998 

pathology,  1001 

prognosis,  1001 

symptoms,  1000 

treatment,  1002 
croupous,  990,  991 
bemorrhag  ii 
lupous,   1060 

diagnosis,  1065 

etiology,  1062 

pathology .  1064 

sympl 1060 

treatment,  1066 


1234 


INDEX. 


Laryngitis,  membranous,  990 
nodular,  1005,  1006 
phlegnionosa,  988 
sicca,  100] 
stridulosa,  986 
subglottic,  1008 

diagnosis,  987 

etiology.  !»ii,  1008,  1009 

symptoms,  98? 

treatment,  988 
Laryngo-fissure,  1212 
Laryn  go-pharynx,  anatomy  of, 

812 
Laryngoscopy,  869 
Larynx,  acute  affections  of,  985 
acute  perichondritis  of,  995 
adenoma  of,  L108 
amyloid  degeneration  of,  1108 
anatomy  of,  816 
anesthesia  of,   1 154 
angioma  of,  1 108 
autoscopy  of,  873 
benign  neoplasms  of,  1103 
symptoms,  1108 
treatment,  L109 
blood-supply  of,  823 
carcinoma  of,  l  L09 

diagnosis,  1111 

prognosis,  1112 

symptoms,  1 1 L0 

treatment,  11 L2 
cartilages  of,  816 
chondroma  of,  1108 
chorea  of,  1 158 
cysts  of,  1108 
development  of.  >08 
edema  of,  989,  990 
edematous  polypi  of,  1105 
examiiiat  ion  of,  869 
extirpation   of.  1212 
fibromata  of,  1 L05 
foreign  bodies  in,  1  L29 

removal  of,  L133,  1209 
fracture  of,  1 L39 
hyperesthesia  of,  1 1  ~>  I 
interior  of,  819 
in  voice-product  ion.  1 174 
ligaments  of,  819 
lipoma  of,  1108 

lupUS     Of,      1060.       >ee      l.iiri/n- 

gitis,  lupous. 
lymphatic  of,  823 
lymphoma  of,  L108 
malignanl  tumors  of,  L109 
mucous  membrane  of,  B24 
muscles  of,  321 
myxoma  of,   1 108 
nerves  of,  823 
neuralgia  of,  1154 
1154 
pachydermia  of,  L006 

etiology,  l L007 

papilloma  of,  1 106 

differential    diagnosis     of, 
1 107 

in  children,  1 106 

physical  appeari es,  1107 

removal  of,    1208 

paralj  sis  of,   1 160 
i c tors  of,  l  PIT 
i  of,  1154 
physiology  of, 

i  of,  I  1 13,  1114,  1115 

•    !  1 55 
Its,  ll"'. 
1 1 55 


Larvnx.    spasm    of,    treatment, 
1156 
stenosis  of,  1 139 

dilatation  of,  1209 
syphilis  of,  L071 
'  treatment,  1073 

t  ransillumination  of,  872 
tuberculosis    of,    L034,    1108. 
See  Tuberculosis  of  larynx. 
diagnosis,  loi  l 
etiology,  L034 

pai  hological  anatomy,  1037 
prognosis  and  course,  1045 
symptoms,  1038 
treatment,  loin 
veins  of,  823 
ventricle  of,  820 
Latent  hyperopia,  215 
Lateral  nasal  processes,  SOS 
ventricle.   1!>1 

Lead,  111.  459 
Lead-amblyopia,  L62 
Leeches,  355 
in  diffuse  inflammation  of  ex- 
ternal meatus.  686 
in  iritis,  342 
Leeching  in  acute  otitis  media, 

721 
Leiter  coil   in  acute  phlegmon- 
ous laryngitis,  989 
Lemon -juice    in      diphtheria, 

1029 
Lens.  122.     See  also  Lenses. 
binocular  magnifying,  147 
concavo-convex,  L25 
com  exo-concave,  125 
double  concave,  125 

convex.  125 
local  length  of,  123 
location  of  optical  center  of, 

240 
optical  center  of,  118 
periscopic,  228 

physical   relation   of,  to  con- 
jugate foci,  103 
plano-concave,  L25 
plano-convex,  L25 
spherical,  207 
strength  of,  123 
unit   to  estimate  strength  of, 

123 
virtual  incus  of  a  concave,  124 
crystalline.  80,  89,  L22 
acquired     dislocations    of, 

396 
capsule  of,  80,  81 
coloboma  of,  L91,  397 

genital     anomalies     of, 
397 
dislocation  of,  396 
conicity  of,  17M 
contusion  of,  :;<;? 
cont usion-injuries  of,  365 
depression  of,  580 
dc  \  elopmenl  of,  22 

of  capsule  of, 
discission    of.     See    i> 

si  I)  II. 

diseasi  -  of,  386 
dislocation  of,  366,  384,  396 
into    anterior    chamber, 

396 
into  vitreous,  366,  396 

■  1 1 1  •  l  ■  r     I n's    capsule, 

396 
epil he] iun  rior  cap 

sule  of,  -l 


Lens,  crystalline,  fillers  of,  81 
increase  in  size  of,  215 
index  of  refract  ion  of,  B9,  92 
operations  on,  574,  579 

on  capsule  of,  585 
radius   of  curvature  of  an- 
terior surface  of,  92 
of  posterior  surface  of, 
92 
removal  of,  for  cure  of  myo- 
pia. 224 
rupture  of  capsule  of,  365, 

367 
structure  of,  81 
subconjunctival  dislocation 

of,  366,  396 
subluxat  ion  of,  396 
suspensory  apparatus  of,  83 
ligament   of,   80,  84,  85, 
95 
thickness  of,  92 
treatment    of    dislocations 

of.  396 
vascular  sheath  of,  23,  494 
Lenses.      See  also    Glasses  and 
Spectacles. 
cylindrical,  126,  128,  207,228 
forms  of,  L25 
method  of  testing,  239 
spectacle,  123,  236 
spherical,  128 
sphero-cylindrical,  228 
systems  for  designating,  123 
toric,  126 
trial,  207 

use  of  trial  case  of,  208 
Lens-jut.  20 
Lens-stars.  23,  82 
Lens-vesicle,  20 
I  .i  n t  icouus,  3!>7 
Lepra  bacillus,  301,  (>Ub 
of  conjunctiva,  302 
of  cornea,  :'.•.'!» 
of  eyelids,  252 
Leprosy,  bacillus  of,  (1146 

of  air-passages,  L066 
Leptomeningitis,  purulent,  758 

operation  for,  801,  802 
Lcptothrix  buccalis,  265 
in  oro-pharyn \.  846 
in  pharyn x,  9 1 1 
Leroy    and     Dubois     ophthal- 
mometer, L96 
Letter-blindness        in        brain- 

abscess,  763 
Leukoma,  285,  322 

adherent,  279,  322,  323 
Leuko-sarcoma  of  choroid,  493 
Levator  palati,  631,  810 
palpebral,  33,  254 
contraction   of,  in   associa 
t  ion  with  external  ptery- 
goid, 255 
superioris,  41 
veli  palati  muscle,  631,  810 
Ligament  of  Zinn,  39 
Ligament,  suspensory,  of  crys- 
talline  lens.   84,  85,  95 
Ligaments,  check,  15 
of  larj  nx,  819 
palpebral,  :;:: 

ineiituin  pectin  at  um  iridis, 
-  55 
Light,  98,  102 
decomposition  <>f.   by  prism, 

98 
propagal ion  of,  103 


TNDEX. 


1  235 


Light,  quantitative  perception 
of,  152 
wave-theory  of,  102,  104 
Light-difference,  153 
Light-minimum,  l~>:; 
Light-reflex  "t'  tympanic  mem- 
brane, 676 
Light-sense,  152 
in  optic-nerve  atrophy,  143 
nf  periphery  of  retina.  168 
Lime-water    in     frost-bite    of 

auricle.  696 
Line  of  fixation,  96,  128 

jard.     See   Line  of  fixa- 
tion. 
of   vision.    128.     See    Visual 
axis. 
Linear  extraction   of    cataract. 

395,  582 
Lingual  quinsy,  927 
tonsil.  815 
chronic    inflammation    of, 

932,  933,  934 
examination  of.  -69 
inflammations  of,  926,  927 
operation-  on,  1206 
pathology,  850 
varix  of.  934.     See  Lingual 
varix. 
tonsillitis,  926 
chronic.  932 
tonsillotomy  Roe's.  1206 
varix,  934,  935 
Liuseed    oil    in    frost-bite    of 

auricle,  696 
Lipoma  of  auricle  696 
of  conjunctiva.  274,  301 
of  eyelids.  248 
of  larynx,  1108 
of  orbit.  531 
of  oro-pharynx,  1096 
Lipomatoii-    dermoid    of    con- 
junctiva. 300 
Lipothymia  laryngea.  1159 
Lippitudo,  245,  246 
Listerine  in  acute  naso-pharyn- 
gitis.  !<1- 
in  chronic    naso-pharviiiritis. 

951 
in  chronic  rhinitis,  909 
Listing,  !">.  92,  93 

schematic  eye  of.  122 
Listing's  reduced  eye,  '■'■'< 
Lithemic    diathesis    in    throat 
and    nose,    treatment   of. 
B75 
Lithiasis  conjunctiva-.  295 
Liver,  diseases  of,  121 
Lobule.  Cleft  of.  692,  l     - 
coloboma    of.   operation    for. 

7-2 
fibroma  of.  operation  for.  7-:; 
Localization  of  sound,  646 

motor     ataxia.     151,     1 17. 
11- 
Loffler's  bacillus,  61  l      - 
Klebs-Loffler  bacillus. 
in  croupous  tonsillitis,  925 
culture-mixture,  l"l- 

ation  in  membranous  rhi- 
nitis 
Longus  colli,  81  I 
l.oi  ing's  ophthalmoscope,  172 
Loupe,  corneal,  1  17 
Lowenberg's      diplococcua      in 

atrophic  rhinitis,  960 
Lozei 


■  method  of  aural  mass- 
age,  736 
Ludwig's  incus-hooks,  790,  TCii 
tntitoxin  syringe,  1026 
Lungs,  syphilis  of.  1073 
Lupous   laryngitis,    1060.      See 

Laryngitis. 
Lupus.  243,  258 
erythematosus    of    conjunc- 
tiva. 302 
of  larynx.  1060 
of  auricle.  695 

treatment  of.  6-6 
of  larynx,  1060.     See  Laryn- 

gitis,  lupous. 
of  nose,  1058 
of  pharynx,  in:,-.  1  < i._> ! t 
vulgaris,  252 
of  air-passages,  1057 
of  larynx,  1060 
Luschka's  tonsil,  hypertrophy 
of,   952.      See    Lymphoid 
hypertrophy. 
Lymph-sheaths  of  retinal   ves- 
sels, 87 
Lymph-space,  episcleral,  -7 
subarachnoid,  79 
subdural,  79 
Lymph-tract,  anteriur.  of  eve- 
ball.  -7 
posterior,  of  eyeball,  87 
Lymphangiectasia  conjunctiva-. 

299 
lymphangioma   of  orbit.    530, 

531 
Lymphatics  of  eyeball,  87 
Lymphatism.  942 
Lymphoid       hypertrophy       in 
pharyngeal  vault,  952 
causes,  952 
diagnosis.  955 
pathology.  952 
prognosis.  955 
symptoms.  954 
treatment.  956 
ring  of  pharynx.  Bll,  815 
Lymphoma  of  larynx,  1108 
of  orbit,  531 

M  Mckenzie's  condenser,  857 

forceps,  1208 

tube-forceps,  1133 

:a.  operation  for.  7-:; 
Macula,  tin-.  L88 

rub,!,,, ma  of.   193,  351 
lutea,  i>>;.  76 

size  of  cones  in.  139,  foot- 
note. 
symmetrical  changes  at,  in 
infamy.    12.'! 
ornea,  322 
vascularization  of.  188 
Macular  bundle,  75 
halo.  182,  188 
reflex,  1—.  W6 
Ma.lan.-i-.  2!  1.  216 
Maddox's  obtuse-angled  prism. 
159 
rod-test   for  insufficiency  of 

ocular   muscles,    l'i'i 
Magnet    for    removing   foreign 

I.. ..li.-  t'r corn i ... 

Magnifying  lens,  binocular,  1  17 
Maier,  sinus  of,  hi 
Malar  hone,  necrosis  of.  258 
Malaria.  310,  ■■■■'■>.  121.   136,  159 
Male-fern,   159 


Male-fern  amblyopia,  166 
Malignant   growths  of  auricle, 
697 
neoplasms  of  antrum.   1090 
pustule.    s,-e  Anthraa 
tumor-  of  fauces,  1098 
of  larynx,  l  L09 
of  nose,  in -5 
treatment.  L089 
Malingering,  166 

-  f..r  detecting,  167 
Malleo-incudal  fold,  632 

space,  632 
Malleus,  630 

-  on  of,  791 

fund  ion  of.  638 
Malleus-handle,  fracture  of.  712 
Mandl's  solution  in  acute  naso- 
pharyngitis, 948 
Mania,  acute,  150,  572 

after  cataract-extraction,  586 
Manifest  hyperopia.  215 
Manubrium  of  the  malleus,  630 
Marasmus,  392 
Mariotte's  blind-spot,  169,  170. 

See  Blind-spot. 
Marrow-sheath,    retained.     See 

MeduUated  nerve-fibers. 
Martin's  bridge,  1 1-!' 
Massage  in  affections  of  upper 
air-passages.  886 
in  atrophic  rhinitis,  964 
in  non -suppurative  dis 

mid. lie  ear.  689 
in  perichondritis  of  auricle, 

695 
of  cornea,  322 
of  eyeball  in  cataract.  ■'•'H 
in  embolism,  408 
in  glaucoma.  384 
of  ossicles  in  chronic  catarrh 
of  middle  ear.  736 
Mastoid,  caries  and  ne.  I 
752 
cell-,   anterior,  empyema    of, 
752 
function  of.  639 
emissary  vein.  624 
empyema    of    apex    of.    with 
perforation  into  digastric 
fossa,  752 
neuritis,  751 
operation   on.  through   skull, 

BOS 
opera!  ion-.  793 
pathology  of.  663 
periostitis,  7  !!• 

process, sclerosis  of.  in  chronic 
suppuration  of  the  mid- 
dle ear.  7  1 1 .  7-M     - 
region,  examination  • 
Mastoidil  i-.  Bezold's,  752 
condensing,  7-~»l 
interna,  acute.  7  1!'.  750  751 

chronic, 
profunda, 
purulent,    differential    diag- 

nosis,  Till 
superficialis,  7  19 
Mathieu's  iris-foi 
Maxillary  antrum,  examination 

of.    - 

exploratory     puncture    of, 

opening  of,  1200 
transillumination    ol 
970,  972 


1236 


INDEX. 


308 
sinus.   154 
benign  neoplasms  of,  10S9 
bony  cysts  of,  1089 
cysts  of  mucous  membrane 

of,  L089 
empyema  of,  968 
treatment,  97] 
growths  in,  invading  orbit, 

533 
osteoma  i>t'.  L090 
polypi  of,  1089 
polvpoid  degeneration    of, 

974 
syphilis  of,  976 
t amors  of,  975 
sinuses,  anatomy,  * »« i«  > 
empyema      of,      operative 

treatment,   1199 
physiology  of,  968 
Miivrr's  hollow  splint.  919 
Measles,  269,  275,  136 
middle-ear  disease  from,  717 
relation  of,  to  ear-disease,  652 
Meatus,    atresia    of,    operation 
for,  784 
carcinoma   <>t',   operation   for, 

7-1 
exostoses  carl  ilaginea  of,  op 

t  rat  ion  for,  786 
exostoses  of,  operation  for,  785 
externa]  auditory,  pathology, 

655 
external,    cholesteatoma    of, 
657 
diffuse     inflammation      of, 

treatmenl  of,  686 
furuncles  of,  655 
hemorrhage  from,  655 
neoplasms  of,  657 
foreign  bodies   in,  operations 

for,  786 
granulations  of,  operal  ion  for, 

7-.". 
hyperostosis  of,  operation  for, 

785 
interna]  auditory,  62] 
of  nose,  middle,  clinical  anat- 

y  of,  829 

examination  of,  861 
operal  ions  on,  7-  I 
M<  onanism  of  auditory  sensa- 
tion,     perception,      and 
judgment,  64  l 
Media  of  the  eye,  I'M 
determination  of  position  of 

opacil  ies  in,  179 
examination  of,  178 
location  of  opacil  ies  in,  L83 
opacil  ies  of,  183 
three,  separated  by  two  sys- 
tems, Btudy  of,  1 15 
Medulla  oblongata,  97 

lary  elate-.  17 
Medullated     nerve-fibers,    194, 
L95 
ilophl  halmos, 
Buphthaln 

468 
•    546.  See  ( 'hal- 

14    249,  252 
chalky  deposit  in,  5 17 

choroid,  193 
papillaris,  301 
ti,  619 


Membrana  tensa,  629 
tympani  secondaria,  620 

Membrane,  basilar,  619 
flaccid,  628 

hyaloid.  82,  83,  -1 
of  Descemet,  28,  55 
Reissner's,  619 
reticular,  620 
Ruysch's,  59 
Shrapnell's,  628 
t  \  mpanic,  629 
physiology,  637 
Membranous       conjunctivitis, 
283,  284,  6]  lb.     See   Con- 
junctivitis, membranous. 
labyrinth,  function  of,  640 
laryngitis,  990 
rhinitis,  HfMi.     See   Rhinitis. 
Meniere's  disease,  775 
Meningitis,  150,  151,  391,  436, 
195,  528,  572 
after  e\  isceration,  356 
after  enucleal  ion,  :'>•">'> 
from  tympanic  inflammation, 
756 
Meningocele,  533 
Meningo-encephalitis,  150 
Meniscus,  125 

Menopause.     See  Climacteric. 
Menorrhagia,  421 
Menstrual     disturbances.    330, 
352,  399,  420,  121,436,461 
Menstruation,    relation    of,    to 

ear-disease.  650 
Menthol     in      acute    catarrhal 
laryngitis,  986 
pharyngil  is,  !»lo 
in  chronic  catarrh  of  middle 

ear,  7:;:; 
spray   in    laryngeal   tubercu- 
losis,   1050 
Mercurials    in    syphilis   of    in- 
ternal ear,  690 
Mercuric  bichlorid  in  conjunc- 
tivitis, 275,  277,  280,  'J-:.. 
287,  293 
chlorid   in  diphtheria,    1020, 
1028 
in   laryngeal    tuberculosis, 

1051 
in  ocular  antisepsis,  540 
Mercury.   160 
in  at  rophic  rhinitis,  96 1 
in  croupous  laryngitis,  991 
in  diphtheria.  994 
in  irit  is,  342 
in    labyrinthitis     exudativa, 

781 
in    laryngeal    perichondritis, 

996 
protochlorid     in      laryngeal 
tuberculosis,  1051 
Meridian--,     principal,   of  astig- 

mat  ic  eye,  224 
Mesial  nasal  proc<  --.  -"7 

\|,  sodl  rin.   19 

Mi  so-pterygoid  fossa,  - 
Metamorpbopsia.  353,  364,  129 
Mi  tencephalou,  19 
Mi  ti  r-angle,  the,  L33 
Meynert's  fibers,  l  19,  180 
Micrococcus  lanceolatus,  6]  la 
Pasteuri,  6]  La 
'         organ  isms   in    acute    la- 
cunar tonsillitis 
in     conjunctival     affections, 
61  la 


Micro-organisms  in  corneal  ul- 
cers, :;i  I,  in  ic 
in  labyrinth,  7<i7 
in  membranous  rhinitis,  896 
in  ocular  diseases,  HI  1« 
in  sympathetic  ophthalmitis, 

349 
of  oro-pharvnmal  tract,  846 
Microphthalmos,  241,  329,  387, 

155,  l.".7.  524 
Micropsia,  412,  468 
Microscope,  corneal.  147 
M  i  c  ni  s  poron-trachomatosum, 

292 
Microtia.  691 
Mid-brain,  19 
Middle  constrictor  of  pharynx, 

81  1 

Middle  ear.     See  also  Tympanum 

and  Tympanic  cavity. 

acute    affections     of.    715. 

See  also  Tympanic  cavity. 

acute  catarrh  of,  pathology 

of,  659 
acute   catarrhal   inflamma- 
tion of,  tit  in 
acute      inflammation     of, 

treatment  of.  686 
acute   purulent    inflamma- 
tion of,  660 
acute  suppuration  of,  660 

treatment,  (jss 
anatomy  of,  (i'.'ii 
auscultation  of,  679 
cholesteatoma  of,  '>'>l 
chronic  catarrh  of,  726 

functional        examina- 
tion of,  731 
operal  ions  in,  7-'!7 
physical     examination 

in.  730 
treatment.  733 
chronic       n  on  -suppurative 
disease   of.  treatment    of, 
689 
chronic       non-suppurative 

inflammation  of,  7".'<i 
chronic    purulent     inflam- 
mation of,  660 
chronic  suppurat  ion  of,  7.'i!> 

treatment,  689,  7  15 
examinat  i f.  678 

fibroma  of,  661 

fund  ion  of,  637 

functions  of  appendages  of, 

639 
intlat ion  of,  679 
muco-purulenl     inflamma- 
tion of,  660 
progressn  e      non  suppura- 
tive    disease     of,     treat- 
ment. 690 
proliferous      inflammal  ion 

of,  pal  hologj  of,  659 
sclerosis  of,  727 
suppnral  ive    inflammal  ion 
of,  with  tuberculosis,  662 
Migraine,  21  I 
Military  ophthalmia.  294 
Milium  of  eyelid-.  259 
Millar's  asthma.  986 
Mineral     wat.  i  -    ii.     rheumatic 

nffecl  ions  of  air-passages, 

-:  ■ 
M  iner's  nystagmus,  520 
M  inister's  sore-1  broal ,  - 7G 

Mi t  ophl halmometer,  i!'s 


TNDEX. 


1237 


Mirror,  otoscopic,  673 

Mirrors,  129 

.Mixed  astigmatism,  127,  227 

colors,  99 
Modiolus,  development  of,  618 
Moe's  forceps,  1 138 
Mogophonia,  1 159 
Moist     applications     in     acute 

otil  is  media.  721 
Moll,  -land-  of,  33,  35 
Mollnscam  contagiosam,  259 
Monochloracetic  acid,  887 
Mouocular    vision     from    sup- 
pression of  image,  !!>!» 
Monophthalmus.  523 
Monoyer's  test-types,  1  10 
Morcellement  in  chronic  paren- 
chymatous tonsillitis,  931 
Mi    gagnian  cataract,  392 
Morgagni's  globules,  390 
Morphin    and  carbolic   acid    in 
herpes  of  fauces,  946 
formanilid       in       laryngeal 

tuberculosis,  L052 
in  acute  otitis  media.  721 
in  acute  rhinitis,  893 
in     laryngeal     tuberculosis, 

1049 
in  lingual  tonsillitis.  927 
in  spasm  of  larynx,  1156 
sprav   in    laryngeal   tubercu- 
losis. 1050 
Morton's  ophthalmoscope,  173 
Mouth,  development  of,  808 

physiology  of,  841 
Mouth-breathing,  general  treat- 
ment of,  880 
in       chronic       hypertrophic 

rhinitis.  907 
in    chronic    parenchimatous 

tonsillitis.  931 
in   etiology  of  catarrhal    in- 
flammation, -4n' 
palate  in.  852 
symptoms.  8.">1 
Mucocele.  266 

of  ethmoid,  ■".:::; 
Muco-puruleut  inflammation  of 

middle  ear.  660 
Mucous  membrane,  nasal,  B33 
Mules's  operation.  324,  572 
Muller's  fibers,  67,  71.  75 
muscle.    11.   134.     See   Palpe- 

h,-"l  m 
ring-muscle,  <>1 
Multiple  neuritis.   1 10 

sclerosis.   177 
Mumps,  261 
ami  ear-disease,  653 
of  lachrymal  gland,  262 
Muriate   of  ammonia    in    acute 
catarrhal  laryngitis,  986 
Muriated    tincture   of    iron    in 
acute  tonsillitis,  925 
in    chronic    suppuration 
of  middle  ear,  689 
Muscse  volitantes,  400.  HO 

Muscle,  ciliary.  60.  95,  134 
external  rectus.  39,  ]i»] 
Horner's,  17 
inferior  oblique,  11,  1"1 
inferior  palpebral,  3  I 
inferior  rectus.  :;!».  lul 
internal  reel  as,  39,  lul 
levator    palpebrse  superioris, 

U 
levator  palpebrarum,  254 


Muscle   Miiller's  ring-,  61 

of  Miiller,  11 

of  Riolan,  35 

orbicularis  palpebrarum,  253 

superior  oblique,  11,  101 

superior  palpebral,  31 

superior  rect  as,  39,  101 

tensor  choroidea,  60 

tensor  tarsi,  17 
Muscles  of  larynx,  82] 
Muscles,    ocular.       Se<     <>■      ■ 
must 

ocular  actions  of,  100,  L01 
Muscular  process  of  arytenoid, 

818 
M  asical  sound-.  635 
Musk  in  diphtheria,  994 
Myalgia  of  pharynx.  1153 
Mydriasis,  334.     See  also  Pupil, 
dilatation  of. 

irritation.  1">0 

paralytic  1  1!'.   150 

traumatic,  360 
Mydriatics.  L49,  209 

effect  of,  on  paralytic  myosis, 
150 

in    determination    of   refrac- 
tion of  eve,  210 

in  iritis,  342' 

sterilization  of,  542 

table  of,  211 

use  of,  196 
Myelitis.  440 

ascending.  137 
Myodesopsia,  lun 
Myoma  of  ciliary  body,  490 
Myopia,  170,  212,  219.  333,  343, 
352,  354,394,395,  399 

a  symptom  of  diabetes.  222 

amplitude  of  accommodation 
in.  137 

axial.  125,  222 

causes,  219 

complicated   with    glaucoma, 
385 

complications,  220 

course.  222 

curvature.  222 

determined  by  skiascopy,  205 

determined     by    trial-len-.-. 
208 

factors  active    in    production 
of,  220 

full  correction  of,  223 

index.  222 

malignant,  220,  128 

measured    with    ophthalmo- 
scope, l!*!i 

operative  treatment,  22  1 

ophthalmoscopic   changes  in, 
•.".'1 

partial  correction  of,  223 

progressive,  220 

removal   of  I  ransparent    lens 
for  relh  f  of,  585 

symptoms,  220 

tendency  of,  219 

treatment,  222 

variet  ies.  219 
Myopic  astigmatism,  127,  227 

eyes,  care  of,  223 
Myosarcoma  of  ciliary  body,  v»> 
Myosis,      150,    334.      See    also 
Pupil,  contraction  of. 

irritation.   150 

paralytic,  150 

spinal,  150 


Myotics.  i  p. 

effect  of,  on  paralytic  m\ osis, 
150 

in  glaucoma,  38  1 
Myringitis  acuta,  7b: 

chronica,  713 
Myxedema,  136 

of  throat.  -7". 
Myxoma  of  conjunctiva.  301 

of  drumhead,  71 1 

of  lachrymal  -land,  263 

of  larynx,  1 108 
Myxomata  of  nose,    1076.     See 
Polypi,  nasal. 
removal  of,    1  l!"i" 

Nagel's  meter-angle    system, 

L33,  131 
Naphthalin,  160 

insufflation       in       laryngeal 
tuberculosis,  1050 
NTaphthol-camphor    in   chronic 

myringitis,  71 1 
Nares,  examination  of,  B55 
Nasal  anesthesia,  11 13 
apertures,  832 

bones,    deflection    of,    treat- 
ment. L182 
calculi,  1129 


catarrh. 


See     Rhino- 


pharynx,  diseas< 

chamber,  apertures  of,  B32 

nerves  of,  834 

septum  of,  830 
chambers,  asymmetry  of,  831, 
834 

variations  in,  826 
cough.  1150 
duct,  size  of,  270 

stricture  of,  266,   268,   269, 
•J7o 
feeding  in  diphtheria.  1031 
glycosuria,  1 150 
hyperesthesia,  11 13 
lamina-.  808 
meatus.       middle.       clinical 

anatomy  of,  B29 
mucous  membrane,  -:;:; 

cysts  of,   1084 

neoplasms,  1076 
obstruction,     pathology     of, 

848,  851 
paresl  besia,  1 1  I" 

s,  tuberculosis  of,  1053 
treatment,  1057 
polypi.  1076 

removal  of,  1196 
probe,  860 
processes,  -"7.  808 
salivation.  1 150 
septum,  abscess  of,  899,  1 1  16. 

See   .  |  /in.  • 

evacuation  of,  1 198 
acute  perichondritis  of,  899 
deformities     of,    operations 

for,  1190 
deviation  of,  B31,  915 

treatment,  "17.  1191 
examinat  ion  of,  -id 
fractures  of,  1 124 
hematoma  of,  899 
papilloma  of,  1081 
removal     of     growths     on. 

I  191 

vascular  neoplasms  of,  1079, 

in-,  i 

specula,  859 


INDEX. 


Nasal  spine,  830 

tia,  removal  of,  1195 
i  chronic  rhinil  is,  910 
wing,  abscess  of,  901 
deformity     <>f.     operation, 

II-:; 
furuncle  of,  901 
■  ■lachrymal  duct,  17 
Naso-pharyngitis,  acute,  :U7 
treatment,  948 
chronic,  9 18 
treatment,  951 

tr\  n\.    809.      S<  i    also 
Rhinopharynx. 
carcinoma  of,  1095 
diseases  of,  9 17 
enchondroma  of,  1093 
examination    of,   in    ear-dis- 
ease, 678 
fibroma  of,  1091 

treatment,  1092 
fibro-mucous  polypi  of,  1093 
lymphoid  structure  of,  8]  1 
physiologj  of,  - 10 
removal    of     growths    from, 

1202 
sarcoma  of,  1094 
stenosis  of,  treatment,  1199 
tumors  of,  1091 
Near-point,  134,  155 
of  convergence,  503 


Neuritis,  acute  retrobulbar,  1 10 

ascending,  135 

chronic  retrobulbar,  1  ll 

descending,  132,  434 

fulminant  retrobulbar,  1 10 

interstitial.    134 

medullary,  135 

multiple,  17.ii 

optic.    See  Optic  neuritis. 

retrobulbar,  160,  177 
Neuro-epithelioma    bf     retina, 

I!'.", 

Neuro-epithelium  of  retina,  C>'.\ 

Neuroglia,  75 

Neuroma  of  eyelids.  248 

of  optic  nerve,  1  19 
Neuro-paralytic  keratitis.  :;i7 
Neuro-retinitis,    433,    136,    177. 
527 
from  lead-poisoning,  i::7 
Neuroses  of  larynx.  1154 

of  upper  air-passages,  1 1  10 
Neurotic  disturbances  of  sound- 
perceiving  apparatus,  77(> 
Nevus  of  ciliary  body,  190 
New  growths  of  auricle.  696 
of  drumhead,  71  1 
of  externa]  auditory  canal, 
7(17 
Nicol-prism,  154 
Nictitating  membrane,  ill 


Near-sightedness.     Sec  Myopia.    Night-blindness.  See  Nyctalopia. 


Nebula  of  cornea.  322 

\<  crosing  ethmoidil  is,  1201 

Necrosis  of  mastoid,  752 

of  orbit,  526 
Neoplasms  of  antrum,  1090 

of  ethmoid  sinuses,  1090 

of  external  meatus,  pathology, 
i  ;r>7 

of  frontal  -muses.  1090 

of  maxillary  sinus,  los't 

of  nasal  septum,  1079 

of  naso-pharynx,  1091 

of  nose,  1076 

removal  of,  1  196 

of  sphenoid  sinus,  1091 

of  i  rachea,  1115 

of  upper  air-passages,  1075 
Nephritis,   ii.  390,  394,  406,  U6, 
136,   137,  154,  158 

relation  of,  to  ear-disease,  6  19 
Nerve,  acoustic.  621 

frontal.  37 

oculo-motor,  -':7.  97 

optic.    See  (ij,ii,   nerve. 

supraorbital,  -':7 

sympathetic,  97 

third.    See  Oculo-motor  nerve. 
Nerve-head.     Si  e  Optic  disk. 
ciliary,  !»7 

of  nasal  chamber,  834 
Nervous  cough,  1 158 

i8es,  from  eye-strain,  .'i  I 
influence     on     ear-disi  as<  . 

tinnitus,  777 
canal,  18 

i>10 
toid   751 

1 1 54 

■ 
149,  I'd 


Night-terrors  in  chronic  paren- 
chymatous tonsillit  is,  931 
Nitrate  of  mercury  in  diphthe- 
ria. 994 
of  silver,  160 
in  abscess  of  auricle,  694 
in    acute   catarrhal    laryn- 
gitis, 986 
in  chronic  inflammation  of 

lingua]  tonsil,  934 
in  chronic  laryngitis,  1003 
in  chronic  myringitis,  71  1 
in  chronic  rhinitis.  909 
in  chronic  subglottic  laryn- 
gitis, L009 
in  chronic  suppuration  of 

middle  ear.  689,  746 
in  condylomata  of  auditory 

canal,  707 
in  conjunctivitis.  L'77.  2-0 
in  corneal  ulcers,  315 
in  diphtheria.  994 
in  eczema  of  auricle,  693 

Of  ear.  685 

in  epistaxis,  903 

in  inflammation  of  auditory 

canal.  705 
in   lupus  of  auricle.  686 

in   new  prow  t  hs  of  drum- 
bead,  7  1  l 
in  paresthesia  of  pharynx, 

1152 
in  -alpiiejit is,  7'.'.'; 
in  singi  rs'  nodi  s,  1 105 
solul  ion,  -- 1 

spray    in    laryngeal    tuber 
culosis,  1050 
Nitrite  of  amj  I.  106,  108,  160 
Nitrobenzol 
\  it  roglj  a  i  in.  i  pi 
m  diphthi  1 1  ;    1020 

I   point-.  90,  93,  114,  1 16 
119,  L20,  121,  123 
for    different     systems    ol 
Burfai  •   .  i  .'.: 


Noduli  cornea-.  ;;n 

Noises,  635 

Normals,  103 

Nose,  absence  of,  operation  for 

acute  affections  of,  891 

adenoma  of,  1085 

and     throat,    general     tliera- 

peusis  of,  -7  1 
angioma  of,  removal  of,  1 197 
bony  cyst-  of,  1082.    Se<  Bony 

cysts. 
burns  of,  1118 
carcinoma  of,   1089 
excision  of,  1  198 
chondroma  of,  1084 
chronic  affections  of,  905 
concave    vertical    deformity 

of,  treatment.  11-1 
contusions  of,  1116 
convex  vertical  deformity  of 
the     bony    portions     of, 
treatment.  1  1-1 
cystomata  of,  1084 
deficiency   of    tip   of,    treat- 
ment. 1182 
deflection   of  hones  of,   treat- 
ment,  1  I-'.' 
deformities       of,      operative 

treatment.   1  180 
deviation    of     tip    of,    treat- 
ment, lis:.' 
dislocation  of  hones  of,  1125 

of  cartilages  of,  1 126 
edematous  polj  pi  of,  1076 
embryology  of,  -"7 
enchondroma  of,  removal  of 

1198 
erysipelas  of,  901 
examination    of,   in    ear-dis- 
ease, 678 
excess   of    tip  of,   treatment, 
1182 
removal  of.  1  1!»7 
fibroma  of,  1080 
fibroma  papillate  of,  1081 
foreign  bodies  in,  1 127 

fracture  of  1 -  of,  1 119 

treatment.   I  121 
of  cartilages  of,  1 123 
fund  ions  of,  835 
h\  sti  ria  of,  1 169 
illuminal  ion  of,  s.v,.  858 
lupus  vulgaris  of,  L057 
malignanl     growths    of,    re- 
moval of,  1 198 
malignanl  tumor-  of,  1085 
treatment.   |ii-!i 

myxoma  of,  removal  of,  119G 
neoplasms  of,  1076 
osti  oma  of,  108  I 
removal  of,  1 198 

papillarx  epithelium  i  of.  Kisd 
papilloma  of.   ln-1 
physiology  of.  835 
plastic  surgerj  of,  1 180 
reflex  neuroses  of,  111'; 

restorati f    columna    of, 

l  1-- 

Of  tip  of.  11-7 
-arc.. ma  of,  1087 
scald-  of.   III- 

-i  ii-. r\  disturbances  of.  1 1  m 

syphilid  of,    1067 

treatment,  1073 
wounds  of,  1 1  16,  1 1 17.  1 1 1- 
\..-e  bleed,  902.     Bei    Epistaxis. 


INDEX, 


1239 


Nostril,  B32 
stenosis    of,    operation     for, 
llb3 
Nostrils,   expanded,    operation 
for,  11-:; 
testing  of  patency  of,  857 
Noyes's    method    of   advance- 
ment, 591 
trachoma-forceps,  56 1 
Nuclei,  ocnlo-motor,  1 1!) 

lesion  in,  150 
Nuclein  in   tuberculosis  of  lar- 
ynx, mi? 
Nucleus   of    sphincter   of    iris. 

lesion  in,  150 
Nux  vomica  in  affections  of  up- 
per air-passages,  B86 
in  exhausl  ion  of  t  hroat,  876 
Nyctalopia,   296,   318,   353,  122, 
425,  468 
visual  field  in,  473 
Nystagmus,  352,  445,  447,  519 
miner's,  320 

Object  and  image,  ill,  112 
Oblique  illumination,  146,  393 
examination  of  media  bv, 
178 
inferior,  41,  101,  497.  502 

paralysis  of,  511,  513 
muscles,  tests  for  insufficiency 

of,  159 
superior,  n.  101,  497,  502 
paralysis  of,  511,  513 
Obliquus  auriculae  muscle,  637 
Occlusion   of    posterior    nares, 
operation  for,  1199 
of  pupil,  337,  341,  343 
Occupations  in  etiology  of  ear- 

diseases,  648 
Ocular  antisepsis,  539.  540.  341, 
571 
blood-vessels,  rupture  of,  362 
deviations,  comitant,  507 
conversion  of  non-comitant 

into  comitant,  508 
differential    diagnosis     be- 
tween comitant  and  non- 
comitant,  507 
etiological  classification  of 

anomalies  of,  505 
non-comitant,  507 
subjective  symptoms,  508 
treatment,  520 
fissure.     See  ( 'horoidal  cleft. 
mask    for    cataracl  dressing, 

542 
muscles,  39 
actions  of,  11.  12,  100,  101 
advancement      in      insuffi- 
ciency of,  521 
affecl  ions  of  individual,  510 
associated  antagonists,  501 
associated  paralysis  of,  519 
associated  spasm  of,  519 
classification   of  anomalies 

of,  504 
common  tendons  of,  39 
diagnosis  of  affecto  d,  51  I 
diplopia   a   tesl    for   insuf- 
ficiency of,  156,  157 
distance    of    insertion    of, 

from  cornea,  10 
etiology  of  anomalies    of, 

504 
etiology    Of    deviations    of, 
5(  15 


Ocular  muscles,  general  symp- 
toms of  anomalies  of,  504 
Graefe's    equilibrium    tesl 

for,  157 
hysterical  insufficiency  of. 

'  185 
insufficiencies  of,  156,  254 
operations,  587 
physiological  action  of,  197 
reflex   disturbances   in   in- 
sufficiencies of,  510 
rod-tesl     for     insufficiency 

of,  160 
scheme    of  double    images 

in  paralysis  of,  513 
screen-test  for  insufficiency 

of,  156 
Stevens's    classification   of 

insufficiencies  of,  L61 
tenotomy   in    insufficiency 

of.  521 
testing    witb    prisms,    156, 

157 
treatment  of  insufficiencies 

of,  520 
varieties  of  anomalies  of,  504 
Oculo-motor  nerve,  37.  97 
center.  150 
effect  of  lesion  of,  on  pupil, 

149 
paralysis  of,  254,   511 
nuclei,  149 

lesion  in,  150 
paralysis.  511.  515 
recurrent.  512 
Oculo-orbital  fascia,  inflamma- 
tion of,  529 
Odontic  periostitis,  974 
O'Dwyer's  tubes.  1029 
Odynphagia,  853 

in     laryngeal      tuberculosis, 
1039 
Oil  of  cade  in  eczema  of  auricle, 
693 
of  cloves  in  laryngeal  tuber- 
culosis, 1D17 
of  eucalyptus  in  acute  catar- 
rhal laryngitis,  986 
of   pine    in    acute    catarrhal 
laryngitis,  986 
Oleate  of  morphia   in  furuncu- 

lo-is  of  ear.  * !  — ■  < ; 
01<  o  stearate  of  zinc  in  chronic 
catarrhal        pharyngitis, 
942 
Olfaction,  disturbances  of,   11  10 

physiology  of,  838 
Olfactometer,  858,  11 II 
Olfactory  area,  807 

depression,  -117 
Ollier's  operation.  1 187 
Opacities  in  transparent  media, 

local  ion  of,  183 
( Iperal  ing  masks,  612 
Operations,  539,  782,  l  180 

<  >  1 » 1 1 1  balmi  1.  See  >'  .•»»,   »r  >'  .  sites 

neonatorum.     See    Conjuncti- 
vitis neonatorum. 

nodosa,  296 

scrofulous,  286 
ophthalmic   artery,   aneurysm 
of,  534 

migraine,  recurrent,  512 

operations  on  animals'  eyes, 
•  ill 

<  Ophthalmitis,  sympathetic.  See 

Sympathetic,  ophthalmitis. 


<  tphthalmo  dynamometer,  1  ♦  j  1 
( (pht  balmo-leukoscope,  151 

•  >pht balmomalacia,  357 
Ophthalmometer,  1  15.  324,  328 

as  a  chromatometer,  151 

method  of  using,  197 

of  Eelmholtz,  196 

of  Javal-SchiStz,  196 

of  Leroy  and  Dubois,  196 
Ophthalmometry.  196,  231 

<  Ophthalmoplegia,      bilal  era! 

transient.  512 
externa,  51 ] 

from  ptomain-poisoning,  465 
interna.  51 1 
progressive,  ~<\-i 
totalis,  51 1 
Ophthalmoscope.  171 
measurement    of     refraction 

with.  199 
optical  principles  of,  173 

Use  of,    171 

Ophthalmoscopes  for  refraction, 

173 
Ophthalmoscopy,  171.  L96 
direct  method  of,  175 
illumination  in,  179 
indirect  method  of,  176 
measure      of     refraction    bv 
direct   method  of,    199 
by  indirect  method,  201 
position  of  surgeon    and    pa- 
tient in,  1~D 
refractive.   199 
Opiates    in    acute    myringitis, 
713 
in  acute  otitis  media.  720 
in  acute  suppuration  of  mid- 
dle ear.  688 
Opium  in  atrophic  rhinitis,  964 
in     laryngeal      tuberculosis, 
1049 
Optic  atrophy.     See  Optic  nerve, 
atrophy  of. 
axis,  95,  128 
canal,  hemorrhage  into,  1 1 1 

periostitis  of,  4 11 
centers,  primary.   179 
chiasm.  1  19 
cup,  20,  21 
disk.  tin.  77.  1-1 
anemia  of,    1 12 
atrophic  excavation  of,  1-7 
bands  of  connective  tissue 

on,  156 
crescents  at  margin  of,  193 
Cr  -cents  mar.  221 
e\  stic  growth  from,  191 
distorted,  1-7.  193 
dragged,  221 
excaval ions  in,  1  -7 
fibrous  growth  from.  1  * •  1 

glaui latOUS       excavation 

of,    1-7 
hyaline  bodies  in,  451,    196 
ischem  ia  of,  1 12 
physiological  excaval  ion  of, 

66,  7-.  1-7 
sarcoma  of,  \'.»> 
ent  ranee.     See  Optic  disk. 
foramen,  -\<K  39 
nerve.  79,   1  1!' 
arachnoidal  -heath  of,  79 
atrophv  of,    I  19,   35" 

385,  394,  442,  177.  527 
from  blows  mi  head.  I  I  1 
from  brain-tumor,   1  I  1 


1240 


INDEX. 


Optic  nerve,  atrophy  of,   from 
pelas,  1 1 1 

from  forceps  delivery,  I  i  * ; 

from     hemorrhage,     1 15, 
159 

from  injuries,  1 1 1 

from  Lead,  162 

from      lightning-stroke, 
146 

from    locomotor    ataxia, 
1 15 

from  pressure  on  chiasm, 
145 

from  sinus  disease,  r>l 

from  spinal  disease,  l  15 

from  spinal  injuries,  1 1 1 

with  excaval  ion,  :!?•! 
carcinoma  of,  I l!» 
changes  in,  from  eye-strain, 

213 
changes  in  visual   field   in 

diseases  of,  176 
coloboma  of,  191,  155,  r>7 
color-sense   in   atrophy   of, 

143 
concussion  of,  1 1 1 
congenital  anomalies  of,  455 
congenital  atrophy  of,  1  16 
diseases  of,  132 
dural  sheath  of,  79 
effeci  of  loss  of  conducting 

power  of,  1  19 
embolic  at  rophj  of,  1 13 
endothelioma  of,  1 1!» 
fibroma  of,  449,  530 
glaucomatous     excavation 

of,  373,  377,  381 
glioma  of,   1 l!» 
gray  al  rophj  of,  1 12,  446 
gumma  of,  150 
hemorrhage  into,  \~>'-'< 
hyperemia  of,  132 
injury  of,  537 
lesions  of,  from   affections 

of  accessory  sinuses,  15 1 
light-sense   in   atrophj    of, 

143 
lymph-clefts  of,  B7 
neuritic    atrophy    of,    133, 

143,    II? 
neuroma  of,  1 19 
physiological  excavation  of, 

382 
pial  sheath  of,  79 
progressive  atrophy  of,  178 
psammoma  of,  !  19 
removal  <  > l*  tumors  of,  601 

ii:i    Of,     I  19 

subarachnoidal  -pare-  of,  87 
subdural  lymph-spat  i 
supravaginal  -pace  of,  ~7 
theory  of  sympal  hetic  oph- 
thalmitis, 349 
tuberculosis  of,  150 
tumoi  -  of,  I  in 
tumors  of  inl  ra-ocu  lai  end 
196 

I  field     n  al  rophy  of, 
146,  117 

ith,     coloboma    of, 
155 
hemorrhage  into,    153 

192     109,    II-. 
432 

nsi    in 


Optic     neuritis     from     carious 
teeth,  138 
from  gonorrhea,  137 
from  hemorrhage,  159 
from  intranasal  operations, 

438 
from   lead.   163 
from  nephritis.  437 
from  physical  exertion,  138 
from    severe    hemorrhage, 

437 
from  Minis  disease,   15 1 
from  sun-Si  roke.    138 

in  brain-tu -s,   135,  136 

in  deformil  ies  of  skull,  436 
in  general  diseases,  436 

in  glauc a.  37  I.  377 

in  infectious  diseases,  lo<> 
in      intracranial      diseases, 

435,  136,  137 
in  tneningii  is,  436 
in  spinal  diseases,  137 
intra-ocular,  432 
intra-uterine,  455 
monocular.    136,  138 
pathology,  434 
prognosis,  438 
second  attach  of,  436 
simple,   132 
spurious.   138 
syphilitic.  137 
theories  of  pathogenesis  of, 

435 
treatment.    139 
trephining  for,  439 
vision  in.  433 
visual  field  in,  433,  177 

papilla.     See  Optic  disk. 

perineuritis,   135 

stalk,  lit 

thalamus,  47:' 

tract,  diseases  of,  4K1 

tracts,  l  in 
vesicles,  19,  20,  21 

Optical    center,    117,    119,    120, 
123 
Of  a  lens.  118,  240 

defects  Of  eye.  It.") 

inst ruments,   image-forming, 

103,  lur, 
principles,  general,  102 
surface,  109 
surfaces,    combined    systems 

of,  115 

SyStemS,  centered.     1  1   I 

Optico-ciliary  neurectomy,  574 

neurotomy,  38  I 
optic,  geometrical,  103 

physical,  103 

physiological,  102 
Optogram,  98 

<  Optometer,  207 
Optometry,   196 

Ora  serrata,  26,  65,  76,  -I 
Orbicularis     palpebrarum,    33, 
253 
paralysis  of,  .'H7 

<  (rbiculus  gangliosus,  61,  65 

<  nl.it.  abscess  of,  526,  528 

acute  eellulit  is  ,,f,  527 
acute   parietal   periostitis  of, 

angi b  of,  531 

blood-cysts  of,  531 

caries  of, 

...  ..i     ,.:i 
cellulitis  of,  527 


Orbit,  chronic  periostitis  of,  526 
congenital  anomalies  of,  523 
contents  of,  .'!7 
echinococcus  of,  531 
emphj  sema  of.  r.:;7 
enchondroma  of,  531 
erysipelatous  cellulitis  of,  527 
exenteral  ion  of,  600 
exostosis  of,  533 
fistula  of,  602 
foreign  bodies  in,  536 
hemorrhage  into,  1 1 1.  .-.:;7 
injuries  and   diseases  of,  523, 

536 
lipoma  of,  531 
lupus  of.  533 
lymphangioma  of,  531 
lymphoma  of,  531 
medullary    osteosarcoma    of 

walls  of.  :.:;i 
necrosis  of.  258,  526 
operation  for  abscess  of,  599 
operations  for  cicatricial.  500 
operations  on.  599 
osteoma  of.  5;;.'! 
palpation  of.  143 
periostitis  of,  525 
phlegmon  of,  527 
pulsating  angioma  of,  534 
removal  of  osteoma  of,  601 
removal  of  tumors  of,  600 
sarcoma  of,  531,  •">:;■_' 
sebaceous  cysts  id'.  531 
serous  cysts  of,  531 
spontaneous  hemorrhage 

into,  537 
thickening  of  periosteum  of, 

532 
tumor     arising     in     cavities 

close  to,  533 
tumors     arising     from    peri- 
osteum or  houv  walls  of, 

531 
tumors  arising  in  tissues  of, 

tumors  of.  255,  529 
Orbital  cellulitis.  438,  444 
fascia.  42 
margins,  injuries  to  hones  of. 

536 
veins,  thrombosis  of,  .'5(i5 
Orbits,  29 

axes  of.  'J! I 
Organ  of  Corti,  function  of,  (>44 
Oro-pharynx,  adenoma  of.  1096 

anatomy  of.  812 

carcinoma  of,  1102 

cysl  of,  1096 

fibroma  of.  1096 

lipoma  of,   1096 

papilloma  of,  1095 

sarcoma  of,   I  102 
Orthophoria,  16] .  505 
i  in  hopl  ic  exercisi  -        I 
« (ssicles,  excision  of.  79] 

in       chronic      catarrh      of 
middle    ear,  7.'!7 

fund  ions  of,  638 
of  the  ear,  630 
ctomy,  79] 
Osteitic     pyemia    with    sinus- 
phlebitis,  7<!1 

"stroma     of    conjunctiva,     274, 

:;ni 

of  maxillary  sinus,   1080 

of  nosi  .  in- 1 

removal  of,   I  1''- 


INDEX. 


1-241 


Osteoma  of  orbit,  533 

removal  of,  601 
Osteo-phlebitis     of     temporal 

hone.  701 

<  »i  hematoma,  655,  69 1 

<  >l  ic  vesicle,  617 

<  >ti  tic  brain-diseases,  ope  rat  ions 

for,  801 
(  Hitis,  desquamative,  753 
externa  diffusa,  7o:j 
pal  biology,  656 
media  acuta.  660,  715 

suppurativa    sen    perfora- 
tiva,  660 
media,  acute.  715 

deafness  in.  Til!.  Tlit 
pain  in.  71 1.  710 
treatment.  720 
media    catarrbalis    chronica, 

pathology,  659 
media  catarrbalis  sicca,  050 
purulent,  intracranial  com- 
plications of,  755 
sclerotica.  050 
serosa,  pathology  of,  050 
suppurativa  sen  perforativa 
chronica.  660 
operation  for,  793 

<  otoconia,  functions  of,  642 
Otoliths,  618.  G42 

<  (tomycosis.  7oi 

pathology,  657 

treatment.  686,  704 
Otorrhea,  chronic,  660 
otoscope,  679 

<  Moscopy,  073 

illumination  in,  673 
instruments  for,  1)73 
source  of  light  in,  675 
fcechnic  of,  675 
Outer   wall   of   nasal    chamber, 

828 
Oval  window.  620 
Oxid  of  zinc  in  eczema  of  aur- 
icle, tin:; 
in  erysipelas  of  auricle,  685 
in   inflammation   of   audi- 
tory canal.  704 
in  polypi  of  auditory  canal, 
706 
Oxycyanid  of  mercury.  540 
Oxygen-gas  in  atrophic  rhinitis, 

964 
Oyster  shuckei's'  keratitis,  313 

<  tzena,  957 

laryngis,  1001 

PA.I  BYDEBM1  \    of  larynx.   L006 
Pachymeningitis,  136,  111.  511 
externa  from  ei r-disease,  ope- 
ration for,  801 
from    tympanic   inflamma- 
tion, 756,  758 
relation  of,  to  ear  disease,  648 
Pagenstecher's  ointment.    See 

Yellow  oxid. 
Palatine  artery,  -l  I 

_■  lossus,  -I  I 
Palatopharyngens,  810,  Bl  I 
I  ':i  I  pebrse.     See  Eyelids. 
Palpebral  arteries,  36 
fascia,  3 1 

fissure,  operations  for  enlarg 
in!.'.  517 
operations   for  shortening, 
r.17 
ligament-.  :;:; 


Palpebral  muscles,  34 

Panas's    operation     for    ptosis. 

558 
l'ancreatin  in  diphtheria,  994 
Pannus,  291,  293,  308 
Panophthalmitis,  279,  315,  330, 
355,356,527,528,  583,  594 
bacilli  in,  61  Id 
Papillary  epithelioma  of  nose, 

L086 
Papillitis.     See  Ojiiir  neuritis. 
Papilloma  of  auricle,  000 
of  caruncle,  304 
of  conjunct  iva,  301 
of  cornea,  329 
of  eyelids,  248 
of  larynx,  L106 

removal  of,  1208 
Of  nose.   1081 
of  soft  palate.  1095 
of  trachea,  1115 
Papillo  -  macular    bundle,     117. 
478 
degeneration  of,  460 
Parabolic     glasses     in     conical 

cornea,   328 
Paracentesis  of  cornea,  324,  567, 
578,  58  1 
in  iritis,  343 
of  drum-membrane,  786 
in  acute  otitis  media,  722 
Paracondyloid  outgrowth,  633 
Paracusis,  776 
loci,  776 
Willissii.  666 
Parallactic    displacement,    373, 

504 
Paralysis  in  diphtheria,  1017 
laryngeal,  1160 
of  abductors  of  larynx,  1107 

of  vocal  cords,  1167 
of  arytenoideus,  L168 
of  external   rectus,  511,  513 
of  inferior  oblique,  511,  513 

rectus.  51  1.  513 
ot    internal  rectus,  511,  513 
of  ocular  muscles,  method  of 
diagnosing,  51 1,  515 
scheme  of  double  images 
in.  512 
of  oculomotor,  '.'51,  511.  515 
of  superior  laryngeal   nerve, 

I  Id- 
ol' superior  oblique,  51 1,  515 
of    tensors   and    adjusters    id' 

vocal  cords,  l  L68 
id'  throat,  --77 
of  i  ayro-arytenoidei  interni, 

L169 
pharyngeal,  1 15 1 
progressive,  of  insane.      See 
Paresis. 
Paralyt  LC  mydriasis.  150 

myosis,  150 
Paramastoid  outgrowth,  633 
Parasites  in  frontal  sinuses,  980 
Parenchymatous        tonsillil  is, 
acute,  923 
chronic,  929 
Paresl  hesia.  nasal,  1 1  13 
of  laryn  \.  1 l~>  i 
of  pharyn \,  1 152 
Parinaud's  conjunct  ivitis,  61  l< 
Pa  rosmia,  1 1  12 
Paroxysmal  sneezing,  1 1 19 
Pars  ciliaris  iridica,  26 
ni inse,  26,  60 


Pars  iridica  retina-.  64,  65 

optica  retinae,  65 
Passavant's  cushion,  81 1 

Pathogenic     bacteria,     relation 

of,  to  ear-disease,  651 
Pearly  tumor  of  the  drumhead, 
711 
Of  external  meatus.  057 
tumors.  489 
Pemphigus,  256 

of  conjunct  iva,  303 
Pencils,  L05 

asl  igmal  ic,  126 
Peiililoi'id   of  iron    in  atrophic 
rhinitis,  964 
in  chronic  subglotl  ic  laryn- 
gitis, 1011!) 
in  diphtheria,  994 
Perforation  in  acute  mastoiditis 
interna,  751 
of  tympanic  membrane,  077 
treatment.  688 
Perichondritis,  acute  laryngeal, 
995 
of  auricle,  655,  69 1 
of  larynx,  acute.  995 
of  nasal  septum,  acute.  899 
Perilymph,  function  of,  640 
Perimeter.  164,    199 
charts,  L65 
prismatic,  163 
self-registering,  165 
Perineuritis.    111.    154 
distal,  447 
optic.  135 
Periodontitis,  treatment,  974 
Periostitis,  mastoid,  7  19 
odontic,  t reatment  of,  071 
of  orbit,  525 
Periot  ic  region,  examination  of, 

672 
Periscopic  lens,  228 
Peritomy.  309,  566 
Peritonsillar     abscess,     evalua- 
tion of,  1207 
Perivasculitis  of  retinal  vessels, 

121 
Permanganate  of  potassium   in 

conjunctivitis,  2-0 
Peroxid  of  hydrogen,  242,  277, 
280 
in  diphtheria,  994 
in  epistaxis,  903 
in  sarcoma  of  soft    palate, 
L099 
Perpendicular  plate  of  ethmoid, 
830,  831 

fracture  of,  1 124 
Persistent   hyaloid  art >  r\ .  L90, 
103 
pupillary  membrane,  :!"1 
Persulphate  of  iron  in  croupous 
laryngitis,  991 
in  diphtheria,  994 
Pertussis  and  ear-disease,  * ►  t ; * 

Pes  and  <  IradenigO,  bacillus   of, 
in  at  rophic  rhinitis,  960 
Petit,  canal  ■ 

I  'el  rosal  _ v  e,  626 

sinus,  inferior,  62  I 
supei  ior,  623 
Petrous  hone,  fract area  of  an 
ditorv.  symptoms  of,  770 
Pfltiger's  letters,  155 
Pharyngeal  abscess,  evacuat  ion 
'  of,  i •■"; 
aponeurosis,  812 


1242 


/y />/■:. v. 


Pharyng  al  art*  ri(  s,  81  l 

bursa,  significance  of,  812,  949 

paralysis,  1154 

polypi,  hairy,  1093 

tonsil,  815 
enlargements   of,    removal 

of,  1202 
fnncl i"ii  of,  -to 

vault,  examination  of,  867 
lymphoid   hypertrophy  < >l . 
952 
Pharyngitis,    acute    catarrhal, 
939,  940 

chronic  catarrhal,  !>41 
follicular,  HI:.'.  943 

granular,  9 12 

lateralis,  942 

sicca,  943 
Pharyngo-inaxilhirv  interspace, 

921 
Pharyngo-mycosis,  94  1.  945 
Pharyngotomy,   1209,  1212 
Pharynx,  anatomy  of,  800 

anesthesia  of,  I  151 

hi 1  supply  of,  81 1 

constrictors  of,  813,  814 

deformil  ies  of,  1 139 

dermoid  cyst  of,  1094 

diseases  of,  938 

examination  of,  864 
in  car  disease.  678 

foreign  bodies  in,  1135 

hemorrhage  from,  9 1 1 

hyperesthesia  of,  1 151 

in  voice-production,  1 175 

injuries  of,  1 139 

Inpus  of,  1058 

lymphatics  of,  815 

lymphoid  si  ructure  of,  815 

m\  algia  of,  1 L53 

nerves  of,  815 

neuralgia  of,  1 153 

paresthesia  of,  1 152 

physiology  of,  B  II 

sensory  neuroses  of,  1151 

S|iasni  of,    1  153 

syphilis  of,  1069 

treatment,  1073 
tuberculosis  of,  lor,:, 

treat  ijk  ii t .  1057 
Phenacetin     in      acute      naso- 

pharyngil  is,  948 
Phenol      spray    in      laryngeal 

tuberculosis,  L050 
Phlebolith       of      conjunctiva] 

vein-,.   248 
Phlegmon.     Sec    Ibscess. 
Phlegmonous    inflammation    of 
t lie  an ricle,  655 
laryngitis,  acuti    988 
Phlyctena  pallida.  287 
Phlyctenular       conjunct  ivil  is. 
See    Conjunctivitis,   phlyc- 
•  la  r. 
keral  iti     Se<   Ki  i  atiti 

ficial. 
ill'-'  i.  :;n7 
Phlycti  null  .  306 
Phonation,  phj  siologj  of,  B39 
Phonat  l 158 

Phonori 

ind  perceiving    appai 
781 

"I  I  | 

158 


Phosphenes,  430 
Phosphorus       in       nasal      and 
pharyngeal   tuberculosis, 
1(157 
Photometer,  152,  15:5,  005 
Phthiriasis,  247 
Phthisis  bulbi,  356 

essential,  357 
Physiological  cup,  187 
excavation,   78.    See    Physio- 
logical en/). 
optics,  102 

salt  solution,  540,  1212 
Physiology  of  car.  634 

of  upper  air-passages,  835 
1'ial  sheal  li  of  opl  ic  nerve,  7!) 
Picric  acid.    159 
Pigments,  884 
in     laryngeal      tuberculosis, 
1050,   1052 
Pillars  of  fauces,  si  1.  930,  1205 
Pilocarpin    in    chronic   catarrh 
of  middle  ear,  738 
in  glaucoma,  38  1 
in  hemorrhage  in  to  labyrinth, 

780 
in    labyrinthitis    exudativa, 

781 
in    labyrinthitis     hyperplas- 
ia, 780 
in  vitreous  opacities,  400 
injections  in    retinal   detach- 
ment,  130 
muriate  in  rheumatic   condi- 
tions   of    upper  air-pas- 
sages, 875 
nil  rate    in    rheumatic  condi- 
tions   of   upper    air-pas- 
sages, 875 
sweats  in  choroiditis,  355 
in  iritis,  342 

in  optic-nerve  atrophy,  449 
Pince-nez,  239 
Pinguecula,  298 
Pin-hole  disk,  170,  208 

I 'ink  eye,  :J7<i 

Pinna,  625 

Piperazin   in   rheumatic  condi- 

t  ions  of  throat,  -7  I 
Pit,  auditory,  017 
Pitch,  635 
Pituitary  bodv,  138 
I'lacido's  disk,  I  15,  321,  :;•.-- 
Planes,  local.  01 

principal.  90,  116 
Plant-growth  in  ear,  057 

t  real  men  I  of,  686 
Plica  salpingo-palatina,  810 
salpingo-pharyngea,  809 
senilunaris,  31,  35.     See  also 
Semilunar  membrane. 
Plugging   of  posterior  nares  in 

epista  sis,  904 
Pneumatic  cells  of  the   petro- 
mastoid,  632,  750,  795 

PneumoCOCCl    in    corneal  ulcers. 

31  l 
Pneumococcus,  61  I" 
in    conjunctivitis,    275,    281, 

•  ;i  la 

in  ear,  653 

in  oropharyn \ .  846 
Pnenmonia,  136 
Points,  105 

cardinal.  92,  109 

of  optical  surface,  graphic 
mi  t  hod  for  locating,  1 13 


1'oints.  focal.  92 
nodal.   90,  93,    11  I,    110.    119, 
L20,   121,    123 
for  diilereiit  systems  of  sur- 
faces, 123 
principal.  90,  92,  93.  109,  110, 
111.1 16,  120,  123 
ford  liferent  systems  of  sur- 
faces, 123 
Politzer  acoumeter,  668 
Politzerization,  681 

in  acute  otit  is  media.  721 
in    perforation    of    tympanic 

membrane,  688 
in  salpingitis,  723 

Politzer's  experiment.  1178 

method  of  inllati 681 

Polycoria,  3.34 
Polyotia,  692 
Polypi,  aural,  6G1 

libro  mucous,     of     naso-phar- 

ynx,   1093 
hairy  pharyngeal,  1093 
in  frontal  sinuses,  080 
nasal,  1076 

removal  of,  1196 
of  auditory  canal,  705 
of  drumhead,  714 
of  larynx,  1 105 

removal  of,  1208 
of  maxillary  sinus.  1089 
of  trachea,  1115 
of    tympanum,    excision    of, 
792 
Polypoid  degeneration  of  max- 
illary sinus,  07  I 
hypertrophy  of  tonsil.  035 
Polypus,  aural.  (i(il 

Pons,    apoplexy   Of,    150 

l'ooley  White     operation      for 

ripening  cataract.  58  I 
Porus  opticus.     See  Optic  disk. 
Post-aural  abscess,  750 
Posl  -auricular  region,  examina- 
tion of,  672 
Posterior  cranial  fossa.  623 
nares,  occlusion    of,  operation 

for,  1199 
nasal  aperture.  832 
Posterula,  833 

Post-nasal  catarrh,  acute.  017 
chronic.  01- 
space,  autoscopj  of,  868 
examination  of,  866 
Potassium  bromid,   160 
in  acute  rhinitis,  893 
chlorid  in  chronic  laryngitis, 
1004 
Powder-blower,  88  1 
Powder-grains  in  cornea.  368 
Powders    in    the    air-passages, 

B84 
Predisposition    in    etislcgfj    cl 

•  :u  disease,  6  17 
Pregnancy,  391,  116 
I  'i  elachrymal  abscess,  268 
Presbycusis,  77'.' 
Presbyopia,  137,  212,  213,  232 
corn  cl  ion  of,  233 

ell'eet    of  asl  initial  i-ln   on,  23  I 

of  hyperopia  on,  233 
of  myopia  on,  233 
premal  are,  in  glaucoma,  381 

Pressinlis  cent  ripelals,  072 

l 'i.  jsure-probe,  736 
Primary  posil  ion,  to- 
ol' eyes,  101 


TNDEX. 


L243 


Prince's  single-suture  advance- 
ment, 592 
Principal  foci,  121 
focus,  11 1 
first,  109,  ll(i 
second,  L09,  110 
meridians  of  astigmatic  eye, 

22 1 
plane,  1 1  1 
planes,  90,  116 
point,  109,  lin 

points,   90,   92,   93,   114,    116, 
120,    L23 
for  different  systems  of  sur- 
faces, L23 
Prism,  130 
apex  of,  130 
base-apex  line  of,  130 
deviation  produced  by,  133 
nutation,  systems  of,  134 
obtuse-angled,  159 
passage  of  light-rays  through, 

131 
plane,   refraction  of  light  in 
the  principal  section  of, 
130 
principal  section  of,  130 
refracting  angle  of,  133 
revolving,  158 
use,  132 
Prism-convergence,  157,  503 
Prism-diopter,  133 

scale  of  Prentice,  133 
Prism-divergence,  157,  503 
Prism-test    for    feigned   blind- 
ness,   167 
Prismatic  lens,  testing  of,  240 
Prisms,  207 
exercises  with,  in  insufficien- 
cies   of    ocular    muscles, 
520 
for   insufficiencies   of   ocular 

muscles,  521 
numeration  bv  angular  devia- 
tion, 133 
numeration  of,  133 
overcoming,  199 
testing   ocular   muscles    with, 
156,  157.  504 
Probe,  nasal.  B60 

pressure-,  736 
Process,  fronto-nasal,  807 
globular,  807 
intermaxillary,  SOS 
styloid.  625 
Processes,  lateral  nasal,  808 
maxillary,  808 
mesial  nasal,  807 
Progressive    muscular  atrophy, 
150 
paralysis,  1 15,  177 
Projecting    auricle,    operation 

for,  783 
Prolapse   of  iris  after  cataract - 
ext  i'act  ion,  583 
treatment,  570 
Proptosis,  l  70 
Prosencephalon,  19 
Protect  ion,  function  of  larynx 
in,  843 
function  of  nose  in,  839 
Prothesis,    in   cicatricial   orbit, 
600 

oeuli.  599 

Protozoa,    parasitic,    in    trach- 
oma, 292 
I'm-  lak'a  pouch,  632 


Psammoma  of  the  optic  nerve, 

149 
Pseudo-diphtheria         bacillus, 
6146,   L019 
in    acute    croupous   tonsil- 
litis, 925 
in  atrophic  rhinitis,  960 
in     membranous    rhinitis, 
896 
Pseudo-glioma,  400,  194 
Pseudo  isochromatic   plates   of 
Stilling,  604 
tests  for  color-sense,  145 
Pseudo-ptosis,  185 
Psorophthalmia,  245 
Pterygium,  297 

operat  ions   for,  561 

treatment.  298 
Ptomain-poisoning,  visual   dis- 
turbances from,  165 
Ptomains,  135,  459 
Ptosis,  254,  465,  565 

adiposa,  operations  for,  560 

congenital,  242,  254 

operations  for,  557 

traumatic,  255 
Puerperal  septicemia,  528 

state.  355,  437 
Pug-nose,  operation  for,  1182 
Pulsating  exophthalmos,  534 
Pulsation  of  retinal  arteries  in 

optic  neuritis.  433 
Pulse  in  diphtheria,  1017 
Punctum  proximum.  See  Near- 
point. 

remotum.     See  Fur-point. 
Pupil,  61,  96,  147 

abnormal  reactions  of,  149 

action  of,  to  mydriatics,  149 
to  myotics,  149 

actions  of.  See  Pupil-reactions 

associated  action  of,  148 

average  diameter,  147 

cerebral  cortical  reflex  of,  151 

cerebral    origin   of  dilatation 
of,  150 

consensual  action  of,  148 

contraction  of,  150 

convergence-reaction  of,  1  18 

dilatation  of,  1  19 

dilator  of,  64,  96 

direct  reflex  act  ion,  1  H 

diseases    which   cause   dilata- 
tion of,  1  !!• 

eccentric  posit  ion  of,  334 

effect   of   accommodation   on 
conl  racl  ion  of,  l  19 

effect  of  convenience  on  eon 

traction  of,   1  18 
effect   of  disease  on,   1  19 

effect  of  irritation  of  sympa- 
thetic on,  150 

faulty,  334 

indirect  reflex  act  ion  of,   1  18 

in  disease,    1  19 

influence  of  age  on  size  of, 

1  17 
influence    of    refractioi 

size  of,  1  17 
meant]  remenl  of,  1  18 
nut  hods  of  tesl  ing   reactions 

of,  1  18 
occlusion  of,  337,341,  343 
opt  ica  1.  '•''<.  57  - 
orbicularis  act  ion  of,  [5] 
pain-react  ion  of,   1  10 
seclusion  of,  337,  341,  '■'•  1 1 


Pupil,  skin-reflex  of.  I  10 
special  phenomena  of,  151 
sphincter  of,  64,  96 
spinal  origin  of  dilatal  ion  of. 

loll 

varying  in  equality  of,  151 
Pupil-reactions,  1  1-,  l  in 

met  bods  "I'   1.  -I  nej,    1  18 
paradoxical,  151 
Pupil-reflex,    centrifugal     part 

of.   1  10 

centripetal  part  of,  1  10 
path  of,  1  10 
Pupillary    membrane,    23,    27, 
390 
persistent,  24,  301 
Pupillometers,  I  18 
Pupils  in  heiniaiiopia,  480 
Purkinje,  images  of.  98,  135 
Purkinje's  figures,  l  1 1 
Purpura,   I.'l 

Purpura  hemorrhagica,  .'ill 
Purulent  leptomeningitis  from 
tympanic    inflammation, 
758 
mastoiditis,  differential  diag- 
nosis of.  701 
otitis       media,       intracranial 
com  plica!  ions  of,  755 
Pyemia,  339,  355.    121,  528 

from  ear-disease,  759 
Py  ok  tan  in,     injections     of,     in 
carcinoma.  252 
in  lupous  laryngitis,  1066 
Pyramid,  631 
Pyriform  sinuses,  871 
Pyrozone  in  chronic  inflamma- 
tion   of     lingual    tonsil. 
934 
in  chronic    oaso-pharyngitis, 
051 

in  pharyngo-mycosis,  946 

mi  \  lit  vii  v  i .  tests  of  hearing, 

ooo 
Quality  of  sound-tones.  635 
Quantitative  tests  of  hearing, 

668 
Quinin,  159 

in     acute     inflammation    of 

middle  ear.  0-7 
in     acute     naso-pharyngitis, 

948 
in  acute  rhinitis,  893 
in    affections    of   upper    air- 

passagi  s,  B86 
in  anosmia,  1 1  1 1 
in  auditory  vertigo 
in  lupous  laryngil  is,  1066 
influence  on   I  he  ear,  05  | 

Quinin-amanrosis,  163 
Quinin-amblyopia,    temporary, 

163 
Quinsy,    925.      See    Circumton- 
sillar  inflammation,  urn/,-. 
evacual  ion  of  abscess  of,  1207 
lingual,  927 

I;  \  bbit's    conjunct  iva,    trans- 
plantation "f.  563 
cornea,    transplantation     of. 
323 
Rachitis,  387,  391 

and  ear-disease,  650 
Radiant,  102 
Radii,  1".:.  Hi-". 
Radius,  mi 


I  I'll 


INDEX. 


Radius  of  curvature  of  anterior 
surface  •<(  lens,  92 
!  uea,  92 
of  posterior  surface  of  Lens, 
92 
of  refracting  surface,  106 
Railway  sen  ice,   standards  of 
form     and     color-vision 
required  in,  606 
Kales  in  the  ear,  680 
Randall's  ophthalmoscope,  173 

types,  151 
Range  of  accommodation,  136 
Kay,  I'll 
incident,  105 
reflected,  L05 
refracted,  L05 
l;  iys,  l",", 

iiomocentric,  89 
Readjustment     and     resection. 

See    Idvancement,  590 
Real  images,  124 

i-  bypotynipanicus,  628 
Reclinal ion,  ill? 
Recti,  insufficiency  of  external, 
L57,  515 
insufficiency  of  internal.  157, 

517 
tenotomy  of.  .".-7.  5.-9 
Rectus  capitis  anticus  muscle, 
-l  l 
external,  39,  L01,  197,  502 

paralysis  of,  51 1.  513 
inferior,  39,  101,  197,  502 

paralysis  of,  511,  513 

internal.  39,  101,   197,  502 

paralv  ~is  of,  5]  1.  513 

superior,  39,  L01,  497,  502 
Recurrent  fever,  121 
laryngeal  nerve,  823 
paralysis  of,  1  L66 
Red-blindness,  603 
Red-gum  tablets,  886 
troches     in    acute    catarrhal 
pharyngit  is,  940 
Reduci  '1  e\ 

formation  of  images  in,  94 
3ion,  168 
Reflection,  L03,  105,  109 
angle  of,  105 

ol  corneal,  196 
132 
R<  fleet  ions  during  ophl  balmos- 

1-1 
Ri  flex,  foveal,  67 

neuroses  of  nose,  1 1  13 
Refracting     angle     of     prism, 
133 
surface,  radius  of,  106 
sing 
Ri  fraction,   103,  105 
abnormal,  212 
angle  of,  104,  L05,   106 

nination  of,  with  trial 
18,  209 
indi  •■.  of,  in" 

Helmut     of,     With      Oph- 

t  lialmoscopt  .  199 
mydriatics    in    determining, 

.'lu 
noi 

methods  Pot  meas- 
•  of,  L98 

m  pari  -  of  re- 
iining 


Refraction  of  eye,  methods  of 
determining,  196 
of  homocentric  rays,  90 
ophthalmoscopes,  17:; 
progressive  changes  in,  214 
static,  138,  139 

subjective   methods   of    test- 
ing, 207 
Refractive  errors,  183 
Reissner's  membrane,  619 
Rekoss's  disk.  17'-' 
Relapsing  fever,  339,  .'598 
Relative    accommodation,    137. 

1 55 
Resect  ion  of  larj  n  \.  1213 
Reserve-air  test  of  hearing,  669 
Resonance,  636 
Resonators  of  the  \  oice,  1171 
Resorcin    in    chronic    rhinitis, 
910 
in      laryngeal      tuberculosis, 

in.-)  I 
in  lupus  of  pharynx,  L059 
in  nasal  and    pharyngeal  tu- 
berculosis, 1057 
Respiration  in  disease  of  upper 
air-passages,  853 
pby  siology  of,  635 
Respiratory  organs,  relation  of, 
to  ear  disease.  649 
tract,  upper.  See  Air-passages, 
upper. 
Rest  in  affections  of  upper  air- 
passages,  881 
m  chronic  laryngitis,  1004 
Ret  icular  membrane,  020 

Retina,  65 

acuity  of  vision  of  peripheral 

parts  of,  168 
anemia  of,  106 

anesthesia  of,  410,  485 

aneurism     of    central    artery 
of,  410 

angioid  streaks  in.  427 

apoplexy  of,   120 

atrophy  of,  515 

bipolar  nerve-cell,  layer  of,  72 

hlood  \  essels  of,  78 

capillary  hyperemia  of.  108 

cenl  ml  arterj  of.  78,  86 

chants    in,    from    eve-strain. 
213 

changes  in  visual  field  in  dis- 
eases of,   l7-'i.  475 

concussion-injuries  of,  :;<>| 

concussion  of.   II  I 

nital     peculiarities     of, 
|(»:. 

congestion  of,  109 

c\  sticercus  of.  i:;i 

c\  -t>  of.  194 

derivation   of  essential   ner- 
vous elements  of,  22 

detachment    of,  222,  357,  :'.77. 
HH.  428,   I'll 
opera!  ions  for  relief  of.   130 

development  of.  •_'.-, 

diseases  of.  105 

disturbances   of  pigmenl    of. 
105 

edema  of,  in.  in 

.  I.  mi  ni -  ..i  mammalian,  7'.' 

.  miioi ism   of  ci  nt  i ;,i    :, 1 1,  i  \ 
..i    106    i  'I 
itabilitj  of.  :i- 

•  ■•.  1 1  rnal  limiting  membrane 


Retina,      external       plexiform 

layer  of,  71 
format  ion  of  images  on,  90 
fund  ions  of,  97 
ganglion-cell-layer  of,  74 
glioma  of,  356,  398,  400,  494 
hemorrhage  in.  364,  417.  420, 

128,  534 
from  cutaneous  burns,  421 
hyperemia  of.  408 
image  on.  89 
inner  nuclear  layer  of.  7'-' 

reticular  layers  of,  71 
internal    limiting  membrane 

of,  7.". 
plexiform  layers  of,  74 
irritation  id',  409 
layer  of  rods  and  cones  of,  69 
layers  of,  67 
light-sense   of   periphery   of, 

168 
lymphat  ics  of,  79 
macular  bundle  of.  75 
nerve-epithelium  of,  69 
nerve-fiber  layer  of,  74 
neuro-epit  belioma  of,  405 
neuroglia  of,  75 
non  -pigmented,    atrophy    of, 

126 
sclerosis  of.  126 
outer  reticular  layer  of,  71 
periphery  of,  189 
pigmentation  of,  from  injury, 

:;i;.-. 
pigmented  epithelium  of.  25 
sclerosis  of.     See   Retinitis, 

pigmentary. 
pigment-layer  of,  67 
pigment-si  rite  in,  427 
retained     inedtil  lated    nerve- 

lil.ers  in,  1!H.   195 

sclerosis  of,  424 

sensit  iveness  of.  to  colors,  99 
spider-cells  of,  75 
sustentacular  tissue  of,  75 
telangiectasia   of   \  essels  of, 

IHI 

thrombosis  of  central  arterv 
of,  408 
vein  of,  410,  421.  Ill 
traumatic  anesl  besia  of,  3G0 

detachment  of.  365 
tumors  of.    194 
v.-i  ricose  veins  of,  I  Hi 
visual  Held  in  detachment    if, 

171 

Ret  inal  artery,  cent  ral.  2  I 

epit helium,  pigmented,  22 
image,  B9 

in  amel  topia.   139 
in  emmet  ropia,  139 
si/.e  of.  125 
images,  distort  ion   ol',  l>v  cyl- 
inders. ■.':;n 

Vessels,  cut  w  hied.    1-1! 

light  reflex  from.  1-2,  185 
lvmph-she.it  h  of.  87 
Retinitis,  321,  410 
albuminuric,  105.  416,  137,458 
induction      of     premature 

labor  for  relief  of,  1 1* 
symptoms    and    pathology 
'  of.  in: 

visual  field  in.   17  I 
at  vpical  pigmentary,  426 
11  n  1 1.1 1  pu tictate,  122 

relapsing,  1 1 1 


INDEX. 


\-l\: 


Retinitis,  circinata,  122,  17~> 

diabetic,  119,  IT:. 

diffuse,  in 

embolic,  423 

forms,  l  in 

glycosuric,  1 1  i » 

hemorrbagic,  HO,  U5,  420 

Leukemic,  119      * 

macular,  121 

nephritic,  41*: 

nyctalopia,  412,  469 

of  Bright's  disease,  116 

parenchymatous,  1 15 

peripapillary,  II 1 

perivascularis,  U5 

pigmentary,  385,  122 
visual  field  in,  I?.; 

proliferans,  127 

punctata  albescens,  422 

purulent,  123 

renal,  1 16 

serous,  111 

simple.  411 

solar.   122 

striata,  428 

suppurative,  423 

sympathetic,  114 

syphilitic,  413 

unilateral  albuminuric,  416 

with  exudative  spots.  413 
Eetino-choroiditis,  414,  4-22 

syphilitic,  119,  426 
Retinoscopy.     See    skiascopy. 
Retractor  of  ala  nasi,  860 
Retrahens  auricula',  (i.'!<; 
Retrobulbar  neuritis.     Neuritis, 

retrobulbar. 
Retropharyngeal   abscess,  evac- 
uation of,  1207 
Rheostat.  B87,  888 
Rheumatic      diathesis,     throat 

and  nose  in,  874,  875 
Rheumatism,  261,  :;iit,  330,  436, 
441),  461,  511 

gonorrheal,  279 

irit is  from,  '■'>'■>'.> 
Rhinitis.  266 

acute,  891 

treatment.  S9I5 

atrophic,  !)■">? 
treatment,  963 

chronic  hypertrophic,  905 
treatment.  908 

cirrhotica,  957 

croupous,  896 

fibrinosa,  896 

membranous,  896 
treatment,  898 

sicca.  957 

tablets  t'-.r.  393 
Ehinoliths,   1129 
Rhino-pharynx,  809 
dependence      of     lachrymal 
disease  on  affections  of. 
272 
di»  ases  of.  246,  109 
in  phlyctenular  conjuncl  i- 

vitis,  -.'-6 
in    phlyctenular    keratitis, 
305 
Rhinoplasty,  ll-l 

<  01  man  and   French   in'  t  hod, 

1 1 85 
Indian  method,  I  I- I 
Italian  method,  1 186 

partial.    11-7 

Tagliacotian  method,  1186 


Rhinoscopic  mirror,  866 

Rhinoscopy,  855 

Rhodopsin,  69 

Rice-powder  in   eczema  of  ear, 

685 
Rima  glottidis,  B20 
Rhine's  tot,  670 

in  chronic  catarrh  of  mid- 
dle ear,  732 
Riolan,  muscle  of,  35 
Ripening  operations  for   inima 

ture  cataract.  58  I 
Risley's  rotary  prism.   L58 
Rivinian  segment .  628 
Roberts's  operation  for  deviated 

septum.  !)17 
Rodent  ulcer  of  cornea,  313 

of  eyelids,  251 
Rods  and  cones  of  retina,  69 
number  of.  71 
of  Corti,  619 
Rod-test    for    insufficiency    of 

ocular  muscles,  160 
Rod-visual  cell,  6!) 
Roe's  intranasal  spring,  1122 
laryngeal  dilator,  1209 
lingual  tonsillotomy,  1206 
metallic  form  for  fractures  of 

nose,  1121 
spiral-lever  extractor,  1138 
tracheal  forceps.  1134 
Rongeur  for  sphenoid   sinuses, 

983 
Rontgen  rays,  369 

location  of  foreign    bodies 

in  larynx  by,  873 
dangers  of,  (ill 
in  ophthalmic  surgery,  607 
influence  on  blind  eyes,  61 1 
practical  applical  ion  of,  607 
Roof  of  nasal  chamber,  826 
Rose-cold,  1 1  1 1 
Rosenmiiller's  fossa,  810 
Rotation,  center  of,  96 
Round  window,  620 
Rubinat    water    in    acute    rhi- 
nitis. 893 
Ruete's  perforated  mirror.  17".' 
Rupture  of  drumhead.  712 
Ruysch,  membrane  of,  .">!• 

Saccule,  development  of  617, 

(IIS 

Sacculus  laryngis,  820 
Saddle-bridge,  238 
Saemisch's  section,  315,  568 

Safety  tube,  631 
Salicin  in  acute  tonsillil  is  924 
in     laryngeal      tuberculosis. 

1048 
in  lupous  laryngil is.  linn! 
Salicylate  of  -odium   in  glau- 
coma, 38  l 

Salicylates    in    acute    catarrhal 

pharyngil  i-.  940 
in    rheumatic   conditions   of 

i  hroat,  -7 1 
Salicylic  acid,  159 

in  at  rophic  rhinil  i-.  964 
in  diphtheria,  1028 
in  eczema  of  auricle.  693 
in  pharj  tigo-mycosis,  9 hi 
in  rheumal  ic  d  ia  i  hi 
Saline  cat  lint  ic  in  acute  otitis 

media.  720 
laxatives    in    acute    suppura- 
tion of  middle  ear,  686 


Salivation,  nasal,   1  150 
Salol  in  acute  tonsillitis,  924 
in     laryngeal      tuberculosis, 

L048 
in  pharyngo-mycosis,  946 
Salol  camphor        in        chronic 

myringitis,  71  I 
Salpingil  is,  72.': 

Salt  solut ion  in  chronic  hyper- 
trophic rhinitis,  909 
in  diphtheria.  1026 
injection  or  i  ransfusion  of, 
1213 
Santonin,   159 

Santorini,  cartilage  of,  -16.  818 
Sarcoma,  metastal  ic,  of  choroid, 
193,  footnoti 
of  antrum.  L090 
of  C  iruncle,  oUl 
of  choroid,  191 
of  ciliary  body,  191 
of  conjuncl  iva,  301 
of  cornea,  329 
of  eyelids,  250 
of  iris,  190 

of  lachrymal  gland,  264 
Of  larynx,   L113 
of  naso-pbarynx,  L094 
of  nose,  1087 
of  opt  ic  disk,  496 
of  optic  nerve,  1 1!' 
of  orbit,  531,  532 
of  oropbarynx,  L102 
of  sclera,  330 
of  soft  palate,  1098 
of  tonsils,  1100 
Scala,  t vmpanic.  619 

vestibular,  619 
Scalds  of  nose,  111- 
Escarin:  ition  in  lar\  ngeal  tuber- 
culosis,  1051 
Scarlatina,    269,    275,    bid.    458, 

528 
Scarlet   fever,  arrested  ethmoid 
development  in.  828 
otitis  media  from,  717 
relation  of.  to  ear-disease, 
u.-.l 
Sciiech  s  cautery-handle,  888 
Schematic  eye,  92 

of   Listing.  1  22 
Schlemm's  canal.  55,  60,  61,  86, 
-7 
in  glaucoma.  .'176.  '!7T 
Schmidt-Rimpler's   method  of 
measuriug  refract  ion,  2<'l 
Schwabach's  test,  670 
Sohwartze's  operation,  7-:;.  7!'.': 
Schwartze  -  Stacke      operation. 

793,  7!";. 
Schwartze  -  Zaufal       operation. 

7:'::.  796 
Schweigger's    operation   of   re- 
sect ion   of  a    rectus  ten- 
don. :.''i 
Sclera,  ■">:: 
abscess  of  330 
blood -\ essels  of,  5 1 
development  of,  '.'7 
diseases  of,  329 
enchondroma  of.  330 
epithelioma  of,  '■'•■'•> < 
fibroma  of,  330 
I  \  mphatics  nf,  5  I 
melanosis  nf,  330 
nerves  of.  54 
osseous  degeneration  of.  :'••'!<> 


1246 


INDEX. 


Sclera,   perforation    of,   during 
tenotomy,  594 
ruptun  of,  361 
ta  of,  330 
sulcus  of,  19 
tumors  of,  330 
Scleral  corpuscles,  53 
processes,  ~>1 

puncture  in  glaucoma,  383 
ring,  66,  1-  l 
staphyloma,  - 1*  i  1 
wounds,  operations  for  clos- 
ing, 569 
Scleritis,  1 14,  324 
anterior,  330 
deep.  330 
gummatous,  '■'■'■'•" 

corneal    juncture,    the, 
54 
Scleronyxis,  580 
Sclerophthalmia,  '■'<■"> 

rosing  keratitis,  -".'.'I 
Sclerosis  of  mastoid  process  in 
chronic    suppuration    of 
the  middle  ear,  741.  751, 
793 
of  middle  ear,  727 
Sclerotic.    See  Sclera. 

■  \  ico-choroidit  is,  330 
itomy,  569,  570,  578 
anterior,  385 
in  glaucoma,  383 
posterior,  385,  570 
Scopolamin,  •-'"!' 
Scorbutus,  537 

Scotoma,  163,  169,  364,  110,  II  I. 
122,     133,    151,    470,    172, 
175,    186 
absolute,  169,  172 

mitral.   Hi!».  IKI.  111.   11."..   117. 

11-.  158,  466 
flickering,  183 
for  colors,  169 
in   disseminated    choroiditis, 

175 
in  embolism  of  central  artery 

of  retina.   17  1 
in  glaucoma,  380 
in     medullary     nerve-fibers, 

17'! 

negative,  169,  172 

paracenl  ral,  169 

peripheral,  169 

physiological,  169 

positive,  169,  172 

relative.  169,   17-' 

ring,  169 
in  svphilitic  chorio  retini- 
tis, 175 

-<-i 1 1 1  Ulan-  of  Listing,  183 
objects  for,  169 
i-test,  502,  504 

for    insufficiency    of    ocular 
muscli  s,  156 
rorm  in  1'n.utal  sinuses, 

Scrofula,  243,  246,  261,  319,  330, 

Sep. fill,,. i-  ophthalmia,  286,  305 
121 

■  ar  rlis 

i   1011 
of  aui 


Sebaceous  cysts  of  eyelids,  259 

of  orbit.  .".Ill 
Seborrhea,  2 1'! 
congestiva  of  larynx.  1060 
nigricans,  259 
of  eyelids,  258 
Seclusion  of  pupil,  ^-'17.  341,  343 
Second  sight,  222,  392 
Secondary  position,  198 
Seiler's  solution,  882,  883 
Semicircular  canals,  681 
<le\  elopment  of,  « ;  1 T 
Semilunar  membrane,  affections 

of,  304 
Septal   deformities   in  etiology 
of  nasal    obstl'UCl  ion.  8  19 
wall  of  nasal  chamber,  830 
Septic  affections  from  suppura- 
tion of  ear,  761 
Septicemia.    121 
Septometer,  861 

Septum,   abscess   of,   899.     See 
Absi 
hematoma  of,  899 
nasal,  deviation  of,  831.     See 

Nasal  septum. 
orbitale,  34 

vascular  neoplasms  of,  1079 
Sero-mucous      middle-ear      ca 
tai'ih.  pathology  of,  659 
Serpiginous    ulcer    of    cornea, 

31  I 
Serum-therapy,  286,  963,  1020 
Sex    in    etiology  of    car-disease. 

647 
St-xton's  forceps,  790 
Sexual    organs,    relation   of,   to 

ear-disease,  650 
Shadow-test.     Sec  Skiascopy. 

Shotted  silk   reflections,   1  82 

Shrapnell's  membrane,  628 

appearance  of,  676 
Siegle's    pneumatic    speculum, 

678 
Sigmoid  sulcus,  624 
Silver    nitrate   in   acute   naso- 
pharyngil  is.  948 
in  acute  toiisillit  is.  92  I 
in       chronic      catarrh       of 

Eustachian  tube.  7-'l"> 
in    chronic    catarrhal    pha- 
ryngitis, 941 
in     chronic     naso  pharyn- 
gitis, 952 
in  nodular  laryngitis,  1006 
in  pharyngo-mycosis,  946 
Simple   extraction    of   cataract. 

Singers'  nodes,  1  KH 
Sinisl  reversion,  500 
Sinn-,  inferior  pel rosal,  62 1 

of  Maier,  16 

superior  pel  rosal,  623 

t  ransverse,  624 
Sinus  i  nrombosis  from  ear  dis- 
759 

Op<  ration   for,  802 

Sinusil  is,    prema  sillary,  acute, 
with  stenosis,  969,  973 
acute,  without   stenosis,   969, 

972 
chronic,  973 

Rontflen  rays. 
Skiascopy,   17!'.    196,   202,    230, 

aberral  ion  in,  206 

hand-like  appearance  in.  206 


Skiascopy  in  emmetropia,  205 
in  hyperopia,  205 
in  irregular  astigmatism,  207 
in  regular  astigmatism,  206 
light  area  in.  204 
in  myopia,  205 
poinl  of  reversal  in,  203 
practical  application  of,  205 
with  concave  mirror,  203,  204 
with  plane  mirror.  203 
skin,  condition  of,  in  affections 
of     upper     air-passages, 
877 
Skin-flap,  grafting  of,  without 

pedicle.  .").".:; 
Skin-grafting      in    atresia    of 
external    auditory  canal, 
698 
Thiersch's  method  of,  553 
Skin-grafts,  243,  372,  551 

in  symblepharon,  563 
Skin-reflex  of  pupil,  1  19 
Skull,     opening    of,     in    brain- 
disease  from  ear.  803,  804 
Small-pox.     See  Variola. 

of  drumhead.  71  1 
Smell,     loss    of,    in    diseases  of 
upper  air-passages.  852 
sense  of,  838 
tesl  in,!_r  of.  858 
Snake-venom,  459 
Snare  for  intratympanic  polypi, 
792 
galvano-cautery,    in    fibroma 

of  naso-pharynx,  1092 
in  nasal  polypi.  1079 
in     vascular     neoplasms     of 
nasal  septum.  1080 
SneeziiiL;  in  lupus  ,,f  nose,  1058 

paroxysmal,  1 1 19 
Snell's  law,  103,  105.  107.  130, 

132 
Snellen's  (dam]..  782 
colored-letter  tesl  for  feigned 

blindness,  Hi7 
operal  ion  for  ptosis,  559 

for  senile  ectropion.   ."..".1 

of  tenotomy,  588 

test-types,   L39,   1  10 

types  for  accommodation,  155 
Snow  -blindness,  468 
Snuffs,  884 

Sodium    formate    in    lupus  of 
pharynx,   1059 
salicylate  in  acute  tonsillitis, 
925 
in   laryngeal     tuberculosis, 
1048 
Soft    cataract.      See     '  a  tar  act, 
congenital. 
palate,  carcinoma  of,  109!) 
fibroma  of,  1096 
in  voice-product  ion,  1 17»i 
papilloma  of,   1095 
ph  5  siology  of,  8  13 
sarcoma  of,  1098 

-lit,  1099 

Sound,  localizal  ion  of,  646 
Sound  colled  inp  apparatus,  <i.'l<; 
Sound-conducl  ing      apparal  us, 
637 

in  ol    788 
Sound-memorj .  6  16 
Sound-perceiving       apparatus. 
diseases  of,  765 
diagnosis,  '■  '■  - 
-\  mptomatology,  77~ 


INDEX. 


1247 


Sound-perceiving       apparatus, 

treatment,  780 
morphology  of,  705 
q  euro  tic    disturbances    of, 

776 
Sound-recording  apparatus,  640 
Sound-waves,     production    and 

propagal  ion  of,  >>'■>  I 
Soziodal    of    soda    in    chronic 

rhinitis,   910 
Space  of  Tenon,  13,  54,  -7 
Spaces  of  Fontana,    2S,   55,    SO, 

-7.  :;77 
Spasm  of  accommodation,  213, 

of  glottis,  995 
of  larynx.   1 155 

in  adults.   ]  156 
of  ocular  muscles,  method  of 

diagnosing,  51  1,  515 
of  pharynx,  1 153 
phonatory,  1 158 
Spasmodic  asthma.  11  18 
Spectacle-frames,  238 
Spectacle-front,    measurements 

for,  238 
Spectacle-lens,  236 
Spectacles     and    their    adjust- 
ment,    236.      See      also 
Glasses. 
stenopaic,  231 
Spectral  colors,  98 
Spectroscope,  lo4 
Specula,  nasal,  859 
Speculum,  ear-,  673 

Siegel's  pneumatic,  678 
Sphenoid    cavity,     disease    of, 
operative  treatment,  1201 
Sphenoid  sinus.  151 

neoplasms  of,  1091 
Sphenoidal  cells.  967 

chronic  empyema  of,  treat- 
ment, 983 
diseases  of,  982 
disease,  982 
fissure,  30,  39 
sinus,  examination  of,  864 
growths  in,  in  vading  orbit, 

Spheno-maxillary  fissure,  30 
Spheno  -  salpingo  -  staphylinus, 

810 
Sphere,  126 

spherical    aberration,    88,    96, 
230 
longitudinal,  108 
lens,  207 

testing  of.  240 

lel|SC<.     128 

Sphero-cylindrical  lens,  testing 

of,    -.MM 
lens, 

Sphincter  of  iris,  1  18 

lesion  of  nucleus  of.  i  pi 
rupture  of,  363 
pupillae,  64,96 

:  cells,   7.", 

Spinal  cord,  97 

hyperemia  of.  150 

myosis,  150 
Spiral  ganglion,  619,  620 

lamina,  619 

Spleen,   dl8<  aSI  -  of.    |J] 

Sponge-grafting  in  orbit,  573 
Spongioblasts,  7  I 

Spragui  'a    parac<  utesis    instru- 
ment. 722 


Spray-apparatus,  882 
Spraying  in  chronic  laryngitis, 
1003 

Sprays,  882 

In  chronic  hypertrophic  rhi- 
nitis, 909 
in     laryngeal      tuberculosis, 
K  ion.  1052 
Spring  catarrh,  287 
Spur-  of  nasal  septum,  B31 
Squama,  development  of,  622 
Squint.     See  Strabismus. 
Stacke's  gouge,  799 

operation,  T  *  '* ; .  798 
Stapedius  muscle.  631 

tenotomy  of.  7 — 
Sta i"  3,  excision  of,  7'.ii 
function  of.  <;:;- 
liberation   of,    in   chronic  ca- 
tarrh of  middle  ear,  7o7. 
738 
Staphylococci,  283,  288 
in  corneal  ulcers.  :!1 1 
Staphylococcus    albus    in    oro- 
pharynx, 847 
aureus,  :;':;7,  349 

in  acute    lacunar  tonsilli- 
tis, 923 
in  oro-pharynx,  847 
in  labyrinth,  767 
pyogenes  albus.  286,  6146 
aureus,  236,  61 16 
citreus,  iil  1'' 
Staphyloma.  170,  384 
ciliary,  330 

congenital,  of  cornea,  329 
of  cornea,  323,  343 

treatment.  :;7l 
operations  for,  570 
partial,  279 
posterior.   1-1.   192.   214,   221, 

330,  354,   17.". 
scleral,  :!<>1 
Static  refraction,  138,  139 
Steam  in  diphtheria,  !•!>•> 
Steam-disinfection       in       diph- 
theria, 1015 
Steam-inhalation  in  diphtheria, 
1027 
in  subglottic  laryngitis,  988 
Stearate   of  zinc    in    laryngeal 
tuberculosis,  1050 
with  alum  in  atrophic   rhi- 
nitis, 963 
with  boric  acid  in  atrophic 
rhinitis,  963 

Steele's  -ept  Utn-folcep-.    1  Id'.' 

Stellwag's  sign,  535 
Stenopaic  slit,  208,  329,  334 

spectacles,  231 
Stenosis  of  larynx,  1139 

dilatation  of.  L209 
of  naso  pharyn \.  t reatment, 

1199 
of      nostril,      operation       for. 

li-:; 
Stereoscopic  exercises,  lid 

\  ision,  loss  of,  510 
Sternothyroid  muscle  in  voice- 

producl  ion,  117:; 
Stevens's  classification  of  insuf- 
ficiencies of  ocular  mus- 
cles, 161 
operation   of  tendon-shorten- 
ing 
opi  rat  ion  of  tenotomy,  589 
phorometer,  158 


Stillicidium   lacrymarum.     See 
Epiphora. 

Stilling,  canal  of.     See   Hyaloid 

canal. 
Stilling'-     pseudo-isochromatic 

plati  -.  604 
Stirrup-ankylosis,  660 
Stomodoeum,  808 
Strabismus,  170,  --Ml,  157,  504 
advancement   in.  .",-.'1 
alternal  ing,  505 
angle  of.  505 
circumvergent,  505,  519 
constant.    Mil 
convergent,  500,  505,  515 
a   symptom   -if    hyperopia, 
216 
deorsumvergent,  505,  519 
divergent,  500,  505,  517 

in  myopia,  220 
dynamic,  156 
insertional.  510 
intermittent.  504 
measurement  of.  504 
with  perimeter,  505 
paralytic,  510 
s]iastic,  510 
structural.  510 
tenotomy  in,  521 
treatment.  520 
vertical.  518 
Strabismus-hooks,  595 
Strabometry,  504 
St  reatfeild-Snellen's    operation 
of  grooving  the  cartilage, 
551) 
Streptococcus  in  the  labyrinth, 
707 
pyogenes.  •.'-:;.  294,  295,  61  16 
in  corneal  ulcer-.  314,  61  16 
in  oro-pharynx.  847 
Streptococcus-diphtheria  of  the 

conjunctiva,  61  Ic 
Streptococcus-serum    in    malig- 
nant    disease    of     nose, 

1089,    note 

Streptothrix  Forsteri,  265 

Stria  vascularis.  619 
Striped  keratit  i-.  325 
strophantus  in  diphtheria,  994 
St  roschein's  flasks,  5  i:; 
St  ruma.     See  Scrofula. 
Strychnin    in    acute     rhinitis 
893 

in  acoustic  neurasthenia.   7-1 

in  anosmia,  1 1  1 1 

in  chronic  catarrh  of  middle 
ear.  738 

in  chronic  laryngitis,  1004 

in    chronic    suppuration    of 
middle  ear,  7I»J 

in  diphtheria.   1020 

in    insufficiencies    of   ocular 
muscles,  520 

in      laryngeal     tuberculosis, 
1048 

in  opt  ie  nerve  atrophy,    1  19 
si  urm's  local  interval,  '-"-'5 
-i  ■■ .  .     -.  .    Hordeolum. 
Si  \  loid  process,  625 
Stylo-pharyngeus,  -l  l 
Subconjunctival      he rrl 

5!  U 
injections  in  choroiditis 

in  corneal  ulcer-.  315 

in    irit  is,  342 

of  germicidi      "',;,; 


1248 


TNDEX. 


Subconjunctival    injections   of 
physiologic  salt  solul ion, 

Subglottic  laryngitis,  98fi 

chronic,  1008 
Subhyaloid  hemorrhage,  121 
Subhyoid  pharyngotomy,  1212 
Sublimate  alcohol  in    furuncu- 

solution  in  injuries  of  drum- 
head, 713 
Snl  in  it  rail-  of  bismuth  in  chron- 
ic rliinitis.  :U0 
in  eczema  of  auricle,  693 
in    laryngeal    tuberculosis, 
L050 
Sucking,  -  il 
Suction    method   of   operating 

for  cataract,  395 
Sulcus,  sigmoid,  62  1 
Sulphate   of   atropin    in   acute 
inflammation   of  middle 
i  ar,  687 
of  copper   in   chronic  laryn- 
gitis, L003 
in  chronic  subglol t  ic  laryn 
gitis,  1"'"., 
f.f  iron  in  laryngeal  tubercu- 
losis,  L050 
of  zinc  in  laryngeal  tubercu- 
losis,  1050 
in  singers'  nodes,  1  L05 
Sulphid  of  calcium,  2  1 1 
Sulphocarbolate  of  zinc  in  per- 
foration     of     tympanic- 
membrane,  688 
Sulphuric  acid  in  chronic  suppu- 
ration of  tin-  middle  ear. 
689 
Sulphurous-acid  disinfection  in 
diphtheria,  101 1 
troke,  138 
Suppuration   alter  cataract-ex- 
traction, 583 
nf  ear.  septic  affect  ions   from, 

761 
of  middle  ear.  treatment.  689 
Suppurative  tonsillitis,  925 
Supra-auricular  region,  exami- 
nation of,  (;?•_' 
Supra-choroidal  lymph-space,  57 
Supraglottic  laryngitis,  986 
Supraorbital  nerve,  37 
Surfaces,  astigmat  ic,  L26 
Sursumduction,    157. 

Suroumvergence,  157,  500,  503 

Sursumversion,  501 

Sii-p«  nsorj  folds  of  drum  mem- 

bram 
Sutures,  542 
Sycosis  tarsi    245 
Symblepharon,  25t 
ni  tal    mi 

dm-  tu  t  radium  - 

operations  for, 
Symmetrical  changes  at  macula 

lutea  in  infancy 
Sympathetic,  >■<  n  ical,  effect  of 

irritation  of,  >m  pupil,  L50 

:      I 

1  npathet- 

•  I 

irrl. 


Sympathetic  ophthalmitis,  347, 
366 
after      cataract-extraction, 

583 
caused  by  operations  on  eye, 

347 
operations  during,  351 
pathogenesis,  3  I!' 
prophylactic  treatment,  350 
symptoms,  348 
treatment,  350 
papillo-retinitis,  348 
retinitis,  414 
vibration,  636 
Synchisis  corporis  vitrei,  401 

scintillans,  101 
Syncope,  laryngeal,  1159 
Syndectiiinv,  .">fi(i 

Synechia  of  nasal  passages,  re- 
moval id',  1195 
Synechias,  1  Is.  315,  332 
anterior.  355 

detachment  of,  579 
posterior,  336,  343 

detachment  of,  579 
total  posterior,  :;:iti,  ."543 
S\  nechia-knives,  Tim 
Synechiotomy,  ."i7!( 
Synovitis  of  knee-joint  in  inter- 
stitial keratitis,  319 
Syphilides  of  conjunctiva.  :'.(i<i 
Syphilis,  243,  246,  261,  266,  310, 
:;i!».  :;:>•_'.  391,   399,    H3, 
II  I.    120,    427,    437,     161, 
177.  511,526 
iritis  from,  :;:;- 
of  air-pa>saures.   L067 
of  auricle,  695 

t  reatment,  ti~(i 
of  conjunctiva,  300 
of  drumhead,  71  I 
of    external   auditory    canal, 

7n7 
of  eyelids,  2 17 
of    internal     ear.     treatment, 

690 
of  labyrinth,  pathology,  mil 
of  lachrymal  glands,  263 
of  lachrymal   sac.  ■.'ii!» 
of  larynx,  1071 

treatment,  1073 
of  lungs,  1073 
of  ma  rillary  -inns.  976 
of  nose,  1067 

tn  atment,  1073 
of  pharynx,  1069 
treatment,  1073 
of  throal    gi  neral   treatment. 

876 
of  trachea,  1073 
ol  il  i-  media  from,  '.  1  - 
relation      of,      to     ear-disease. 

Syringe,  antitoxin,  in-.'."..   1026 
ear.  (17  I 

for  impacted  cerumen,  700 
Sj  ringomyelia,  177 

i   centered  optical,  1 1  I 
Systems,  combim  d,   of  optical 
Burfai '      i  i"' 

tfl  Ml-.  See        /  0C0 

miliar  nt.i 

Tagliacotian    mi  thod  of  i  hino- 

plasty,  i  186 
Tampons   in   atrophia    rhinitis, 
964 


Tannic  acid  in  epistaxis,  903 
in    laryngeal    tuberculosis, 
1050,   1052 
Tannin  in  acute  catarrhal  laryn- 
gitis, !•>(! 
in  atrophic  rliinitis.  964 
in  chronic  laryngitis,  1003 
in  chronic  rhinitis.  910 
in  lingual  tonsillitis.  927 
Tannogenin  laryngeal  tuhercu- 

losis.  1051 
Tapetum  cellulosum,  59 

lihrosuiii.  Tilt 
Tarsal  asthenopia,  1 10 
cartilage.    See  Tarsus. 
glands.    See  Meibomian. 
tumor.     See  Chalazion. 
Tarsitis,  252 

syphilil ic,  252 
Tarsorrhaphy,  536,  538,  547 
Tarsus.  .",:; 

Tattooing  of  cornea.  323,  568 
Tea,  159 

Teale's  operation  for  symbleph- 
aron, 562,  563 
Tectorial   membrane,    function 

of.  t;n 
Telangiectatic   tumors  of    con- 
junctiva. 300 
Temperature      in     diphtheria, 

1(117 
Temporal  bone,  anatomy  of,  622 

(istcophleliit  is  of,  7(il 
Tenderness  in  lirain-ah-cess.  763 
Tenon,  capsule  of.   13 
space  of.    13,  5  I.  87 

Tenonitis,  529 

Tenon's     capsule,    hemorrhage 

into.  537 
after  tenotomy,  59 1 
Tenotomy,   accidents   and   coin- 
plicat  ion-  of.  ,"i!t  I 
Complete.  587 

graduated,  589 

in    insufficiencies    of    ocular 
muscles,  521 

of  extornu-.  588 

of  interim-,  587 

of  stapedius,  788 

of  superior  and  inferior  rectus, 

589 
of  tensor  tympani  muscle,  788 
partial,  589 
subconjunct  ival,  587 
Ti  Qsion,  170,  :;7:; 

normal  int  raocula  r.  "-Ill 
symbols  for.  L70 
Tensor  i  horoidea.  60,   134 
Tensor  palati.  (1:11,  810 
tarsi.    17 

t  \ -iiipaui   muscle,  function  of, 
i;:;7 
tenotomy  of.  788 
Tensors  of  vecal   cords,  paral- 
ysis of.  1 168 
Test.   Bing's,  672 

'Il  lie'-.  672 
Kiniie's  670 
Schwabach's,  (170 
Weber's,  670 
id.  151 
Test  types,  151 
Dennett's,  I  10 
for  illiterate,  152 
ii'-.  137 

M v.  i  -    I  10 

Randall's,  151 


INDEX. 


1249 


Test-types,  Snellen's  139,  L40 
Tests  of  hearing,  668 
Tetanus,  572 
Thalamencephalon,  H» 
Theobald's  knife,  703 

lachrymal  probes,  270 
Therapeutics  of  ear-disease,  68  I 
Thermocauter;  in  Lupus  of  aur- 
icle, 686 
Thiersch  grafts,  243,  372,  553 
in  symblepharon,  563 

Third    nerve.     See    Oculo-motor 
nerve. 
ventricle.  Ill 
Thomson's  ametrometer,  207 
met  hod    for    color-blindness, 

604 
test  for  color-blindness,  154 
Throat    and     nose,     rheumatic 
conditions  of,  874 
examination  of,  864 
fatigue  of,  876 
hysteria  of,  1169 
neuralgia  of,  treatment,  876 
paralysis  of,  -7? 
physiology  of,  HI 
syphilis    of,     general    treat- 
ment, 876 
Thrombosis    of     brain-sinuses, 
150,  43(i.  759,  801 
of  cavernous  sinus,  529 
of  central   artery   of    retina, 

408 
of  central  vein  of  retina,  421 
of  orbital  veins,  355 
of  retinal  veins,  410,  444 
of  umbilical  veins,  355 
Thymol  in  atrophic  rhinitis,  963 
Thyro-arytenoid  ligaments,  820 
Thyro-arytenoid  muscles.  822 
in  voice-production.  1  L73 
Thyro- arytenoid  ei  in  tern  i. 

paralysis  of,  1 169 
Thyro-epiglottic  ligament,  819 
Thyro-hvoid  ligaments,  lateral. 
819 
membrane,  B19 
muscle    in    voice-production, 
1173 
Thyroid  arteries,  823 

cartilage,  816 
Thyrotomy,  1209,  1212 
Timbre,  635 

Tincture  of  chlorid  of  iron  in 
chronic  myringitis,  Tl  1 
in  diphtheria,  994 
in  erysipelas  of  nose,  902 
in  lupous  laryngitis,  L066 
in  membranous  rhinitis, 

398 
in  new  growl  hs  of  drum- 
head, 71  1 
of  iodin   in   perichond rii  is  of 
auricle,  695 
Tinea  tarsi,  245 
Tinnitus  as  a  symptom,  666 
in  acute  otitis  media,  719 
in  chronic  catarrh  of  middle 

ear,  730 
nervous.  777 
Tip  of  nose,  restoration  of,  1 1-7 
Tobacco,  111.  II-.  159 
effect  of,  on  the  ea  r,  65 1 
in    affections  of    upper    air- 
passages,  Bfi  i 
Tobacco-amblyopia,  160 
Tongue-depressors,  864,  865 

79 


Tonometer,  170,  373 
Tonsil,  calculi  of,  935 
feudal,  815,  921 
pathology  of,  850 
polypoid     hypertrophy    of, 

935 
removal  of,  1202,  1204 
foreign  bodies  in,  936 
lingual,  815 

operations  on,  1206 
pharyngeal,  815 
supernumerary,  1097 
Tonsillar        abscess,        chronic 
encysted,  935 
inflammations,  acute,  922 

chronic,  928 
ring,  921 
Tonsillitis,  acute  croupous,  925 
acute  lacunar,  922 
acute  parenchymatous,  923 
acute  ulcerative,  927 
chronic,  due   to  bacillus    coli 

communis,  929 
chronic  lacunar,  928 
chronic  lingual,  932 
chronic  parenchymatous,  929 
lingual,  926 
suppurative,  925 
Tonsillitis-tablets,  886,  924 
Tonsillotome,      Roe's      lingual, 

1206 
Tonsillotomy.  1204 

in   chronic    inflammation   of 

lingual  tonsil,  934 
in    chronic    parenchymatous 

tonsillitis.  931 
in  pharyngo-mycosis,  946 
Tonsils,  carcinoma  of,  1101 
diseases  of,  921 
hypertrophied,    galvano-cau- 

tery  in.  888 
physiology  of,  842 
sarcoma  of,  1 100 
structure  of,  921 
Toric  lenses,  126 
Torsion,  inward,  497 

of  eye,  100 

Torsion -diplopia,  500 
Torsion -movement,    498,    foot- 
note 
Torus,  L26 
Total  reflection,  132 
Toxic  conjunctivitis,  295 
Toxicants  and  ear-disease,  654 
Trachea,  acute  affections  of,  985 
anatomy  of,  82 1 
carcinoma   of,   111") 
chronic  affections  of,  L009 

development   of,  809 

ecchondrosis  of,  1 1 L5 
fibroma  of,  1115 
foreign  bodies  in.  1 129 
in  voice-producl ion,   117  1 
neoplasms  of,  1115 

papilloma  of,    L115 

polypi  of,  ill"' 

sj  philis  of,  1073 
Trachi  il  is,    acute  catarrhal.  996 
Tracheotomy,  1209 

in  diphtheria.    L031 
Trachoma,  257,  258,  289.  308 

acute,  290 

chronic.   290 

corneal  complications  in,  290, 
291 

descripti f  stages  of,  290 

diagnosis,  292,  293 


Trachoma,  duration,  291 
etiology,  292 

excision  of  cul  de  sac  for  re- 
lief of,  565 
follicular,  '.".hi 
geographical    distribution    of, 

292 
operation   of  expression    for, 

564 
operations  for,  563 
pathology,  292 
prognosis,  293 
racial  disi  ribution  of,  292 
treatment.  293 
Trachoma-bodies,  290 
Trachoma-coccus,  292,  61  Ic 
Trachoma-glands,  35 
Traction-hook  for  foreign  bodies 

in  ear,  702 
Tract  us.   179 
Tragicus  muscle-,  636 
Traitement   par   morcellement, 

931 
Transillumination    of    larynx, 
872 
of  maxillary  antrum.  862 
Transmitted  light,  examination 

of  media  by,  L78 
Transverse  sinus,  tl'.'  1 
Transversus  muscle,  637 
Traumatic  epistaxis,  903 
Trial-case,  207 
Triangular  cartilage,  830 

fracture  of,  1121 
Trichiasis,  246,  257,  293,  308 
operations  for,  548 
treatment.  257 
Trichloracetic  acid.  --7 

in  acute  follicular  pharyn- 
gitis, 943 
in  atrophic  rhinitis.  96  I 
in  chronic  myringil is,  711 
in    new    -row  t  os  of  drum- 
head. 7  1  I 
Trichlorid  of  iodin,  540 
Trichosis  of  caruncle,  274,  304 
Trigeminus  ner\  e,  245,  254 
Troches,  885 

Trochlea  of  tensor  tympani,  631 
Trochlear   nerve,    paralysis  of, 

511,  513 
Trochlearis.     See   Oblique  supe- 
rior. 
Tropacocain,  5  13 
Tropometx  r,  1 70 
Trypsin  in  diphtheria,  994 
Tscherning's  theory  of  accom- 

modat  ion,  L35 
Tubal  cell,  632 
Tube,  cochlear.  <I  17 

Tubercle-bacillus,  302, 356,  61  16, 
1034 
in  lupous  laryngil is,  L062 
in  lupus  of  a i r-passages,  1059 
in  nasal  passages,  1053 
Tubercle  impar,  B09 
Tuberculin    in    tuberculosis   of 

larynx,  1047 
Tuberculosis,  246,  319,  339 
of  choroid.  '■'•'>>'< 
of  conjunctiva,  302 
of  cornea,  318 
ol  iris,  340 

of  lachrymal  passages,  269 
of  larynx,  1034,  l  L08 
diagnosis,  10 1 1 
etiology,  L034 


L250 


TNDEX. 


Tuberculosis  of  larynx,  formu- 
lary in    1052 
pathological  anatomj .  1037 
predisposing  causes,  1037 
prognosis  and  course,  1045 
symptoms,  1038 
treatment,  1046 
of  nasal  passages,  1053 

treatment,  1057 
of  optic  nerv< .  150 
of  pharynx,  1055 
treatment,  L057 
relation  of,  to  ear-disease,  653 
wiili   suppuration   of  middle 
ear,  662 
Tubo-tympanic  cavity,  li-.'fi 
Tumor,  intraocular,  17<> 
of    brain.    See    Brain,    tumor 

Tumors,   dermoid,  oi   conjunc- 
tiva, '-'7  I 
inl  raocular,  :;i~ 
of  acoustic  nerve,  769 
of  antrum,  1090 
of  brain.     See  Brain-tumors. 
of  cerebellum,  520 
of  ethmoid  sinuses,  L090 
of  eyelids,  2 18 
of  frontal  sinuses,  1090 
of  maxillary  sinus.  975,   L089 
of  naso-pharynx,  HUM 
of  nose,  L076 
of  optic  nerve,  l  19 
of  orbit,  255 
of  trachea,  1 115 
Tuning-fork,  Dench's,  669 
Tuning-forks   in    testing    hear- 
ing, 669 
Turbinal  bone,  abscess  of,  evacu- 
ation of,  L198 
ill  \  elopmenl  of,  808 
examination  of,  B60 
varix.   1080 
Turbinals,       hypertrophy      of, 

treatment,  912,  91  i 
Turbinated  bones,  clinical  anat- 
omy of,  B28,  329 
deformities    of,    operations 

for,   1194 
hypertrophy  of,  treatment, 
'  1194 
Turck's  tongue-depressor,  B64 
Tympanic   cavity,   acute  affec- 
tions of,  715 
deafness  in,  7H> 
pain  in.  715 
treatment,  720 
pathology  ")'.  659 
inflammation,    complical  ions 
of,  749 
pachymeningitis      externa 
in.  756 
membrane,     629.      See    also 
head. 
changes  in  color  of,  I 
changes  in  posil ion  of,  '17'! 

ination  of,  »i7*i 

loss  of  substance  of,  677 
opacity  ol 

pi'     appearances    of, 

pathi 

•  it    oi'.    treatment, 

ol    637 


Tympanic  suppuration,  excision 
of  conducting  mechanism 

for,  7-!' 
Tympano-mastoid  exenteration, 

796 
Tympanotomy,  exploratory,  739 
Tympanum,  627.    See  Tympanic 
cavity  and  Middle  car. 
granulations  of,   removal  of. 

7!  i-J 
opening  of,  through  skull,  mi:; 
operations  on,  T -^ t ; 

in>t  ruments  tor,  790 
polypi  of.  removal  of,  7!>"J 
Typhoid    fever,   339,   391,   436, 
528 
middle-ear     disease     from, 

717 
relation  of.    to   ear-disease. 
652 
Typhus  fever.  339,  355,  436,  528 
Tyrrell's  hook,  577 

[JLCEE  of  cornea,  1  15,  245,  279, 
•.".':;,  313,  527,  614c.  See 
also  ( 'ornea,  ulcer  of. 

in  purulenl  conjunctivitis, 
316 

in  small-pox,  -'!17 

micro-organisms  in.  314 

phlyctenular,  307 

relation  of  micro-organisms 
to  transparent,  309 

of  eyelids.  243 
Ulcerative  tonsillitis,  acute.  927. 

See  Tonsillitis. 
1  fleers  of  cornea,  24."),  313 
Umbilical  veins,  thromboses  of, 

355 
Umbo,  637 

I   in  -mate     process    of    ethmoid. 
Underlying  conns.  194 
Unilateral    abductor    paralysis, 

1167 
Upper  air-passages,  anatomj  of, 
307 
general  el  iology  and  pathol- 
ogy of,  8 1 1 
neoplasms  of,  1075 
phj  siology  of,  835 
I  terine  disease,  llo 
Utricle,    development    of,    617, 

618 
Uveal  tract.  .">.. 
Uveitis,  anterior,  320 

metastatic,   195 
Uvula,  diseases  of,  937 
enlargi  d,  938 
inflammation  of,  937 
in  voice  prod  net  ion,  1 17d 
malformations  of,  937 
physiology  of,  S  13 
pupilloina  of,  L095 
Uvulitis,  937 
Uvulotomj .  1207 

Vaccini  blepharitis,  -.'i  l 
Vagus     nerve,     lesions    of,    in 

laryngeal    paralysis,    11. 

66 
Valsalva's  mel  bod  of  tnflal  ion, 

681 
Valve  of  I la-iier.  18 
Vapoi  - 
Variola,    244,     269,     275,    339, 

136 
Vai  ix,  lingual,  934 


Vascular    neoplasm     of    nasal 
septum,  luTii 
system,    relation    of,    to    ear- 
disease.  649 
Vaselin  in  frost-bite  of  auricle, 

696 
Vegetal  ions,  adenoid,  952.    See 

Lymphoid  hypertrophy. 
\  i  in.  mastoid  emissary,  624 
Wins,  ciliary,  87 

of  pharv  ii  x.  814 
Vena-  vorticosa?,  58,  87 
Venous  pulsation  in  glaucoma, 

374 
Ventilation,    function    of    nose 
in,  8  10 
in    affections    of   upper    air- 
passages,  879 
Ventricle  of  larynx,  820 
Ventricular  bands,  816,  820 
Vernal  conjunctivitis.    See  Con- 
junctivitis, vernal. 
Verrucosities,  151 
Vertigo,  509 

as  a   symptom  of  ear-disease, 

667 
in  brain-abscess,  763 
in   chronic  catarrh  of  middle 

ear.  72! I 
laryngeal,  1 159 
Vesicle,  lens,  20 
optic,  retinal  layer  of,   .'1 
otic,  (ill 

secondary  optic,  :-'<> 
\  esicles,  primary  cerebral.   18, 
19 
secondary  cerebral,  1!* 
Vestibular  aqueduct,  623 

scala,  619,  620 
Vicarious  epistaxis,  902 
Vidian  artery,  81 1 
Vienna  mask.  612 
method  of  enucleation,  .~>7 1 
paste,  597 
Virtual    foCUS  of  concave    lens. 
124 
images,  l\M 
Visceral  arches,  cephalic,  809 

clefts,  cephalic.  309 

Vision,  absolute,  field  of,  166 
amblyopia  of  field  of,  170 

anomalies  of   Held   of,    17".' 

binocular,  230 
field  of,  167,  171 

binocular  single,  156,   !!»!• 

changes  in  field  of,  <\nc  to  op- 
tic hindrance.    \~'.', 

changes  in   field  of,  in  affec- 
tions of  Optic   mrve.    I7<i 

changes   in    field   of,    in   dis- 
eases  of  choroid,  175 

changes   in    held   of,    in   dis. 
eases  of  retina,   l7o 

color  field  of,  \>>1 

conl  rait  ion  of  field  of,   172 

direct,  L62 

disturbances  of,  without  oph- 
t  ha  I scopic  change,  l">7 

effeel  of  refract  ion  on  size   of 
field  of,  L66 

false    projection    of   held  of, 

51 1!  I 

field  of,  162,  170 
held  of  binocular  single,  502 
field  of,  in  glaucoma,  '■'•~').  176 
in  optic-nerve  at  rophy,  1 16, 

117 


INDEX. 


1251 


Vision,  formula  for,  151 
general  physiology  of,  88 
indirect,  162 
line  of,  128 
minimal  field  of.  166 
monocular,   from  suppression 

of  image,  199 
of  astigmatic  eyes,  22 1 
of   colors,    measurement    of, 

153 
of  peripheral  parts  of  retina, 

168 
relative,  field  of,  166 
size  of  field  of,  165 
standard  required  in  railway 

service,  608 
stereoscopic,  loss  of,  510 
testing  acuteness  of,  151 
Visual  acuity.  138 
formula  for,  l  10 
methods  of  measuring,  140 
angle,  138,  139 
axis  96,  100 
cells,  25 

field.     See  Vision,  field  of . 
ganglia,  primary,  479 
line,  100 
pathway,  478 
purple,  66,  69.  88,98 
radiations,  17H 
Vitiligoidea,  248 
Vitreous,  82,  B9 
artificial,  572 

blood-vessel  formation  in,  402 
body,  development  of,  28 
cells  of,  83 

chamber,  primitive.  -_'l 
cholesterin-crystals  in,  401 
detachment  of,  403 
direct  galvanization  of,  401 
diseases  of,  391,  398 
entozoa  in,  102 
fattv  degeneration  of,  103 
fluidity  of.  401 
foreign  bodies  in,  369 
hemorrhage  into.  4<>1 
humor,     transplantation     of 

ral>bit-'.  130 
index  of  refraction  of,  89,  92 
inflammation   of.       Sec   Hy- 

alitis. 
location  of  opacity  in.  by  re- 
fraction of  eye.  17*.  201 
membrane.  Sec  Lamina  vitrea. 
migratory  leukocytes  of,  83 


Vitreous,  opacities  in.  -.'1  1.  ■.".'■J. 
:;:?.  399 
spontaneous  hemorrhage  into. 

mi 
spontaneous  inflammation  of. 
398 
Vocal    conl-..    examination    of. 
871 
raise,  -Hi.  B20 
in  voice-production,  1 1 72 
paralysis  of  abductors  of. 

1107 
paralysis  of  tensors  ami  ad- 
justers of.  l  L68 
true.  -It!,  -'.'ii 
processes  of  arytenoid.  -Is 
Voice,  hygiene  of,  1 177 
in  chronic  laryngitis,  1000 
in  laryngeal  affections,  852 
in  nasal  disease,  B52 
production   ami    hygiene  of, 
1171 
Voice-formation,  - 13 
Voice-production,    1171 

resonators  in.   1 171 
Voice-training,  117- 
Vomer.  B25,  830 
fracture  of.  1124 

Von     Hipper s    operation     for 
transplanting  cornea.  569 

Von  Troltsch  plan  for  gargling, 
'.itn 

Warts.    See  Papilloma. 
Watered-silk  reflections,  182 

Wave-length,  034 
Weber's  canaliculus-knife,  270 
test,  670 

in  chronic  catarrh  of  middle 

ear,  I'.yl 
Weeks'  bacillus.  276,  -.'-1.  014<; 
Weiss's  reflex,  182,  188 
Wernicke's  symptom,  480 
Whiskey    in     diphtheria,    994, 

1 I 121 1 
White's  palate-retractor,  869 
Whooping-cough,  136,  51  l 

otitis  media  from,  718 
Wilder'-   operation    for    ptosis, 

558 
Williams's     antitoxin  -  syringe, 

1 1 125 
Wire     -nan-     in     hypertrophic 

rhinitis.  912 
Wolfe's    method   of   grafting   a 


skin-flap      without       a 
pedicle,  553 
Wolffberg's  test  picture-.  152 

Wolff's  operation  lor  ptosis,  559 
Wood's  operation,  1 188 

i  -  blindness     in    brain-ab- 
763 
Word-deafness,  770 

in  brain-abscess,  763 
Wounds  of  auricle.  697 
treatment.  7-:; 
of  external    auditory   canal, 

708 
of  no-c.   ]  ]ii 

treatment.  111- 
Wrisberg's  cartilage,  -10,  818 

Xanthelasma,  248 

Xanthoma.  248 
Xanthopsia,  168 
Xerophthalmia,  168 
Xerophthalmos.     See  .V.  rosis. 
Xerosis,  291 

bacillus  of.  296.  61  16 

conjunctiva'.  296.  318 
Xerostomia,  (.»:;ti 
A"- rays.     See  Kontgen  rays. 

location  of  foreign  bodies  in 
eye  by,  607 

location  of  foreign   bodies  in 
larynx  by,  -7:; 

YELLOW    oxid     of   mercury   in 
eczema  of  auricle,  693 
in   furuncle    of    external 

auditory  canal,  703 
ointment  of.  -.'17.  250,  307, 
322 
spots.     See  Macula  lutea. 
Yellow-vision,  168 

Zinc      chlorid      in     lnpus    of 
pharynx,   1059 

solution  in  acute  ulcerative 
tonsillitis,  928 
salt-    in     chronic     catarrhal 
pharyngitis,  I'll 
Zinn,  circle  of.  54 

zone  of.  p.i.  B0,  84.  85 
Zonula,  rupture  of,  365 
Zottenkrebs,  1086 
Zwaardemaker's     olfactometer, 

- 
Zygomatic     process,     develop- 
ment of.  622 


CATALOGUE 

OF   THE 

MEDICAL  PUBLICATIONS 

OF 

W-  B,  SAUNDERS  &  CO., 

No.   925   WALNUT   STREET,   PHILADELPHIA^ 
Arranged  Alphabetically  and  Classified  under  Subjects. 


THE  books  advertised  in  this  Catalogue  as  being  sold  by  subscription  are  usually  to  be 
obtained  from  travelling  solicitors,  but  they  will  be  sent  direct  from  the  office  of  pub- 
lication (charges  of  shipment  prepaid)  upon  receipt  of  the  prices  given.     All  the  other 
books  advertised  are  commonly  for  sale  by  booksellers  in  all  parts  of  the  United  States;  but 
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sent  in  any  other  way  is  at  the  risk  of  the  sender. 

See  pages  32,  33  for  a  L'st  of  Contents  classified  according  to  subjects. 

■'  » 

LATEST  PUBLICATIONS. 


American  Students*  Medical  Dictionary.     See  page  34. 

American  Text-Book  of  Physiology — Second  (Revised)  Ed.     Page  7. 

Friedrich  and  Curtis  on  Nose,  Throat,  and  Ear.     See  page  34. 

Le  Roy's  Histology.    See  page  34. 

Ogden  on  the  Urine.     See  page  34. 

Pyle's  Personal  Hygiene.     See  page  34. 

Salinger  and  Kalteyer's  Modern  Medicine.     See  page  34. 

Stoney's  Surgical  Technic  for  Nurses.     See  page  34. 

Hyde   and  Montgomery's  Syphilis   and  Venereal   Diseases — Revised 

and  Enlarged  Edition.     See  page  15. 
International  Text-Book  of  Surgery.     See  page  15. 
Garrigues'  Diseases  of  Women — Third  (Revised)  Edition.     Page  13. 
American  Text-Book  of  Dis.  of  Eye,  Ear,  Nose,  and  Throat.     Page  5. 
Saunders'  American  Year-Book  for  1900.    See  page  8. 
Levy  and  Klemperer's  Clinical  Bacteriology.     See  page  17. 
Scudder's  Treatment  of  Fractures.     See  page  26. 
Senn's  Tumors — Second  Edition.     See  page  27. 
Beck  on  Fractures.     See  page  9. 
Watson's  Handbook  for  Nurses.     See  page  31. 
Heisler's  Embryology.     See  page  15. 
Nancrede's  Principles  of  Surgery.     See  page  20. 
Jackson's  Diseases  of  the  Eye.     See  page  16. 
Kyle  on  the  Nose  and  Throat.     See  page  M. 

Penrose's  Diseases  of  Women — Third  (Revised  I  Edition.     Page  20. 
Warren's  Surgical  Pathology— Second  (Revised)  Edition.     Page  31. 
Saunder's  Medical  Hand-Atlases.     See  pages  2,  3,  4. 
American  Pocket  Medical  Dictionary— Third  (Revised)  Ed.     Page  12. 


SAUNDERS' 

MEDICAL  HAND-ATLASES. 


The  series  of  books  included  under  this  title  consists  of  authorized 
translations  into  English  of  the  world-famous  Lehmann  Medicinische 
Handatlanten,  which  for  scientific  accuracy,  pictorial  beauty,  com- 
pactness, and  cheapness  surpass  any  similar  volumes  ever  published. 
Each  volume  contains  from  50  to  100  colored  plates,  executed  by  the 
most  skilful  German  lithographers,  besides  numerous  illustrations  in  the 
text.  There  is  a  full  and  appropriate  description  of  each  plate,  and 
each  book  contains  a  condensed  but  adequate  outline  of  the  subject  to 
which  it  is  devoted. 

One  of  the  most  valuable  features  of  these  atlases  is  that  they  offer  a 
ready  and  satisfactory  substitute  for  clinical  observation.  To  those 
unable  to  attend  important  clinics  these  books  will  be  absolutely  indis- 
pensable. 

In  planning  this  series  of  books  arrangements  were  made  with  the  rep- 
resentative publishers  in  the  chief  medical  centers  of  the  world  for  the 
publication  of  translations  of  the  atlases  into  different  languages,  the  litho- 
graphic plates  for  all  these  editions  being  made  in  Germany,  where  work  of 
this  kind  has  been  brought  to  the  greatest  perfection.  The  expense  of 
making  the  plates  being  shared  by  the  various  publishers,  the  cost  to  each 
one  was  materially  reduced.  Thus  by  reason  of  their  universal  transla- 
tion and  reproduction,  the  publishers  have  been  enabled  to  secure  for  these 
atlases  the  best  artistic  and  professional  talent,  to  produce  them  in  the 
most  elegant  style,  and  yet  to  offer  them  at  a  price  heretofore  unap- 
proached  in  cheapness.  The  success  of  the  undertaking  is  demonstrated 
by  the  fact  that  the  volumes  have  already  appeared  in  thirteen  different 
languages — German,  English,  French,  Italian,  Russian,  Spanish,  Japanese, 
Dutch,  Danish,  Swedish,  Roumanian,  Bohemian,  and  Hungarian. 

In  view  of  the  striking  success  of  these  works,  Mr.  Saunders  has  con- 
tr :h  ted  with  the  publisher  of  the  original  German  edition  for  one  hun- 
dred thousand  copies  of  the  atlases.  In  consideration  of  this  enormous 
undertaking,  the  publisher  has  been  enabled  to  prepare  and  furnish  special 
additional  colored  plates,  making  the  series  even  handsomer  and  more 
complete  than  was  originally  intended. 

As  in  indication  of  the  practical  value  of  the  atlases  and  of  the  favor 

with  which  they  have  been  received,  it  should  be  noted  that  the  Medical 

Department  of  the  U.S.  Army  has  adopted  the  "Atlas  of  Operative 

its  standard,  and  has  ordered  the  book  in  large  quantities  for 

distribul  •  !    and  army  posts. 

The  same  careful  and  competent  editorial  supervision  has  been 
ired  in  the  English  edition  .-is  in  the  originals,  the  translations  being 
l>y  the  leading  American  specialists  in  the  different  subjects. 


SAUNDERS'  MEDICAL  HAND-ATLASES. 


VOLUMES  NOW  READY. 
Atlas  and   Epitome  of    Internal  Medicine  and    Clinical    Diagnosis. 
By  Dr.  Chr.  Jakob,  of  Erlangen.  Edited  by  Augustus  A.  Eshner,  M.D., 
Professor  of  Clinical  Medicine,  Philadelphia  Polyclinic.    With  68  colored 
plates,  64  text-illustrations,  and  259  pages  of  text.     Cloth,  S3. 00  net. 
"  The  charm  of  the  book  is  its  clearness,  conciseness,  and  the  accuracy  and  beauty  of  its 
illustrations.     It  deals  with  facts.     It  vividly  illustrates  those  facts.     It  is  a  scientific  work 
put  together  for  ready  reference." — Brooklyn  Medical  Journal. 

Atlas  of  Legal  Medicine.    By  Dr.  E.  R.  von  Hofmann,  of  Vienna.    Edited 

by  Frederick  Peterson,  M.D.,  Chief  of  Clinic,  Nervous  Dept,  College 

of  Physicians  and  Surgeons,  New  York.    With  120  colored  figures  on  56 

plates,  and  193  beautiful  half-tone  illustrations.      Cloth,  S3. 50  net. 

"  Hofmann's  'Atlas  of  Legal  Medicine  '  is  a  unique  work.    This  immense  field  finds  in  this 

book  a  pictorial  presentation  that  far  excels  anything  with  which  we  are  familiar  in  any  other 

work." — Philadelphia  Medical  Journal. 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.  By  Dr.  L.  Grunwald, 
of  Munich.  Edited  by  Charles  P.  Grayson,  M.D.,  Physician-in- Charge, 
Throat  and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania. 
With  107  colored  figures  on  44  plates,  25  text- illustrations,  and  103  pages 
of  text.  Cloth,  $2.50  net. 
"  Aided  as  it  is  by  magnificently  executed  illustrations  in  color,  it  cannot  fail  of  being  of 

the  greatest  advantage  to  students,  general  practitioners,  and  expert  laryngologists." — St. 

Louis  Aledical  and  Surgical  Journal. 

Atlas  and  Epitome  of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl, 
of  Vienna.  Edited  by  J.  Chalmers  DaCosta,  M.  D.,  Professor  of 
Practice  of  Surgery  and  Clinical  Surgery,  Jefferson  Medical  College, 
Philadelphia.  With  24  colored  plates,  217  text-illustrations,  and  395 
pages  of  text.     Cloth,  $3.00  net. 

"  We  know  of  no  other  work  that  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of 
operative  surgery." — Munchener  medicinische  Wochenschrift. 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Diseases.  By  Prof. 
Dr.  Franz  Mracek,  of  Vienna.  Edited  by  L.  Bolton  Ban<;s,  M.D., 
Professor  of  Genito-Urinary  Surgery,  University  and  Bellevue  Hospital 
Medical  College,  New  York.  With  71  colored  plates,  16  black-and- 
white  illustrations,  and  122  pages  of  text.      Cloth,  S3. 50  net. 

"A  glance  through  the  book  is  almost  like  actual  attendance  upon  a  famous  clinic." — 
Journal  of  the  American  Medical  Association. 

Atlas    and    Epitome  of  External   Diseases  of  the  Eye.     By  Dr.  O. 

Ham;,  of  Zurich.  Edited  by  G.  E.  DE  Schweinitz,  M.D.,  Professor  of 
Ophthalmology,  Jefferson  Medical  College,  Philadelphia.  With  76 
colored  illustrations  on  40  plates,  and  228  pages  of  text.    Cloth,  $3.00  net. 

"  It  is  always   difficult  to  represent  pathological  appearances  in  colored  plates,  but  this 
work  seems  to  have  overcome  these  difficulties,  and  the  plates,  with  one  or  two  except 
are  absolutely  satisfactory." — Boston  Medical  and  Surgical  Journal, 

Atlas  and  Epitome  of  Skin  Diseases.     By  Prof.  Dr.  Franz  Mracek, 

of  Vienna.     Edited  by  Henry  W.  Stelwagon,  M.D.,  Clinical  I'm:- 

of  Dermatology, Jefferson  Medical  College,  Philadelphia.  With  63  colored 

plates,  39  half-tone  illustrations,  and  200  pages  of  text.    Cloth.  $3.50  net. 

"The   importance  of  personal  inspection  of   cases  in  the  study  of  cutaneous  diseases  is 

readily  appreciated,  and  next  to  the  living  subjects  are  pictures  which  will  show  the  ap|>ear- 

ance  of  the  disease  under  consideration.     Altogether  tin-  work  will  be  found  of  very  ^reat 

value  to  the  general  practitioner." — Journal  of  the  American  Medical  Association. 

3 


SAUNDERS'  MEDICAL  HAND-ATLASES. 

VOLUMES  JUST   ISSUED. 
Atlas  and  Epitome  of   Special  Pathological  Histology.     By  Dr.  H. 

Durck,  of  Munich.  Edited  by  Ludvig  Hektoen,  M.  D.,  Professor  of 
Pathology,  Rush  Medical  College,  Chicago.  In  Two  Parts.  Part  I. 
fust  Ready,  including  the  Circulatory,  Respiratory,  and  (Gastro- 
intestinal Tract,  with  120  colored  figures  on  62  plates  and  158  pages 
of  text.     Price,  $3.00  net.      Parts  sold  separately. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.  By  Dr.  Ed. 
Golebiewski,  of  Berlin.  Translated  and  edited  with  additions  by 
Pearce  Bailey,  M.  D.,  Attending  Physician  to  the  Department  of  Cor- 
rections and  to  the  Almshouse  and  Incurable  Hospitals,  New  York. 
With  40  colored  plates,  143  text-illustrations,  and  600  pages  of  text. 

Atlas  and  Epitome  of  Gynecology.  By  Dr.  O.  Schaffer,  of  Heidel- 
berg. Edited  by  Richard  C.  Norris,  A.  M.,  M.  D.,  Gynecologist  to 
the  Methodist  Episcopal  and  the  Philadelphia  Hospitals ;  Surgeon-in- 
Charge  of  Preston  Retreat,  Philadelphia.  With  90  colored  plates,  65 
text-illustrations,  and  308  pages  of  text. 

IN  PRESS  FOR  EARLY  PUBLICATION. 
Atlas  and  Epitome  of  Obstetrical    Diagnosis  and  Treatment.     By 

Dr.  O.  Schaffer,  of  Heidelberg.  Edited  by  J.  Clifton  Edgar, 
M.  D.,  Professor  of  Obstretics  and  Clinical  Midwifery,  Cornell  Univer- 
sity Medical  School.  72  colored  plates,  numerous  text-illustrations, 
and  copious  text. 

Atlas  and  Epitome  of  the  Nervous  System  and  its  Diseases.  By 
Prof.  Dr.  A.  von  Strumpell,  of  Erlangen.  Edited  by  Edward  D. 
Fisher,  M.  D.,  Professor  of  Diseases  of  the  Nervous  System,  Univer- 
sity and  Bellevue  Hospital  Medical  College,  New  York.  8^  plates  and 
a  copious  text. 

Atlas  and  Epitome  of  General  Pathological  Histology.  With  an 
Appendix  on  Pathohistological  Technic.  By  Dr.  H.  Durck,  of 
Munich.  Edited  by  Ludvig  Hektoen,  M.  D.,  Professor  of  Path- 
ology, Rush  Medical  College,  Chicago.  With  So  colored  plates, 
numerous  text-illustrations,  and  copious  text. 

IN  PREPARATION. 
Atlas  and   Epitome  of  Orthopedic  Surgery. 
Atlas  and   Epitome  of  Operative  Gynecology. 
Atlas  and   Epitome  of  Diseases  of   the  Ear. 
Atlas  and   Epitome  of  General  Surgery. 
Atlas  and   Epitome  of  Psychiatry. 
Atlas  and   Epitome  of  Normal   Histology. 
Atlas  and  Epitome  of  Topographical  Anatomy. 


THE  AMERICAN  TEXT-BOOK  SERIES. 

AN  AMERICAN  TEXT=BOOK  OF  APPLIED  THERAPEUTICS. 

By  43  Distinguished  Practitioners  and  Teachers.  Edited  by  James  C. 
Wilson,  M.D.,  Professor  of  the  Practice  of  Medicine  and  of  Clinical 
Medicme  in  the  Jefferson  Medical  College,  Philadelphia.  One  hand- 
some imperial  octavo  volume  of  1326  pages.  Illustrated.  Cloth, 
#7.00  net;  Sheep  or  Half  Morocco,  $8.00  net.     Sold  by  Subscription. 

"As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  ol 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician." — Chicago  Clinical  Review. 

"  The  whole  field  of  medicine  has  been  well  covered.  The  work  is  thoroughly  prac- 
tical, and  while  it  is  intended  for  practitioners  and  students,  it  is  a  better  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpful." — The  Indian  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  DISEASES  OF  CHILDREN. 
Second  Edition,  Revised. 

By  65  Eminent  Contributors.  Edited  by  Louis  Starr,  M.  D.,  Con- 
sulting Pediatrist  to  the  Maternity  Hospital,  etc.  ;  assisted  by  Thomp- 
son S.  Westcott,  M.  D.,  Attending  Physician  to  the  Dispensary 
for  Diseases  of  Children,  Hospital  of  the  University  of  Pennsyl- 
vania. In  one  handsome  imperial  octavo  volume  of  1244  pages, 
profusely  illustrated.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
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"  This  is  far  and  away  the  best  text-book  on  children's  diseases  ever  published  in  the 
English  language,  and  is  certainly  the  one  which  is  best  adapted  to  American  readers. 
We  congratulate  the  editor  upon  the  result  of  his  work,  and  heartily  commend  it  to  the 
attention  of  every  student  and  practitioner." — American  Journal  of  the  Medical  Sciences. 

AN  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  THE  EYE,  EAR, 
NOSE,  AND  THROAT. 

By  58  Prominent  Specialists.  Edited  by  G.  E.  de  Schweinitz.  M.D  , 
Professor  of  Ophthalmology  in  the  Jefferson  Medical  College,  Phila- 
delphia; and  B.  Alexander  Randall,  M.D.,  Professor  of  Diseases 
of  the  Ear  in  the  University  of  Pennsylvania.  Imperial  octavo,  125T 
pages ;  766  illustrations,  59  of  them  in  colors.  Cloth,  £7.00  net ;  Sheep 
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Iflustrated  Catalogue  of  the  "American  Text-Books"  sent  free  upon  application. 


6        Medical  Publications  of  W.  B.  Saunders  &  Co. 

AN  AMERICAN   TEXT-BOOK   OF   GEN1TO-URINARY  AND  SKIN 
DISEASES. 

By   47    Eminent   Specialists   and   Teachers.     Edited   by  L.   Bolton 
Bangs,   M.  I).,   Professor  of  Genito- Urinary  Surgery,  University  and 
Bellevue  Hospital    Medical  College,   New  York  ;    and  W.  A.   Hard- 
awav,   M.  I).,   Professor  of   Diseases   of  the    Skin,  Missouri    Medical 
College.     Imperial  octavo  volume  of  1229  pages,  with  300  engravings 
and  20  full-page  colored  plates.     Cloth,  $7.00  net;    Sheep  or  Half 
Morocco,  $8. 00  net.     Sold  by  Subscription. 
"This  volume  is  one  of  the  best  yet  issued  of  the  publisher's  series  of 'American  Text- 
Books.'     The  list  of  contributors  represents  an    extraordinary  array  of  talent  and  extended 
experience.     The   book  will  easily  take  the  place    in   comprehensiveness  and  value  of  the 
half  dozen  or  more  costly  works  on  these  subjects  which  have  heretofore  been  necessary  to 
a  well-equipped  library." — New  York  Polyclinic. 

AN  AMERICAN  TEXT=BOOK  OF  GYNECOLOGY,  MEDICAL  AND 
SURGICAL.     Second  Edition,  Revised. 

By  10  of  the  Leading  Gynecologists  of  America.     Edited  by  J.   M. 
Baldy,  M.  D.,  Professor  of  Gynecology  in  the  Philadelphia  Polyclinic, 
etc.     Handsome  imperial  octavo  volume  of  718  pages,  with  341   illus- 
trations in  the  te\t,  and  38  colored  and  half-tone  plates.     Cloth,  $6.00 
net;  Sheep  or  Half  Morocco,  $7.00  net.     Sold  by  Subscription. 
"  It  is  practical  from  beginning  to  end.     Its  descriptions  of  conditions,  its  recommen- 
dations for  treatment,  and   above  all  the  necessary  technique  of  different  operations,  are 
clearly  and  admirably  presented.     .     .     .     It  is  well  up  to  the  most  advanced  views  of  the 
day,  and  embodies  all  the  essential  points  of  advanced  American  gynecology.     It  is  destined 
to  make  and  hold  a  place  in  gynecological   literature  which  will  be  peculiarly  its  own." — 
Medical  Record,  New  York. 

AN  AMERICAN  TEXT-BOOK  OF  LEGAL  MEDICINE  AND  TOXI- 
COLOGY. 

Edited  by  Frederick  Peterson,  M.D.,  Clinical  Professor  of  Mental 
Diseases  in  the  Woman's  Medical  College,  New  York  ;  Chief  of  Clinic, 
Nervous  Department,  College  of  Physicians  and  Surgeons,  New  York ; 
and  Walter  S.  Haines,  M.D.,  Professor  of  Chemistry,  Pharmacy, 
and  Toxicology  in  Rush  Medical  College,  Chicago.     In  Preparation. 

AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS. 

By  15  Eminent  American  Obstetricians.  Edited  by  Richard  C.  Nor- 
ris,  M.D.;  Art  Editor,  Robert  L.  Dickinson,  M.D.  One  handsome 
imperial  octavo  volume  of  1014  pages,  with  nearly  900  beautiful  colored 
and  halt-tone  illustrations.  Cloth,  $7.00  net;  Sheep  or  Half  Morocco, 
$8.00  net.      Sold  by  Subscription. 

"  l'ermit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers." — Ai.f.xander 
J.  C.  SKENE,  Professor  of  Gynecology  in  the  Long  Island  College  Hospital,  Brooklyn,  N.  Y. 

"  Tlii-  is  the  most  .sumptuously  illustrated  work  on  midwifery  that  has  yet  appeared.  In 
the  number,  the  excellence,  and  the  beauty  of  production  of  the  illustrations  it  far  surpasses 
every  other  book  upon  the  subject.  This  feature  alone  makes  it  a  work  which  no  medical 
library  should  omit  to  purchase." — British  Medical  Journal. 

"  .U  an  authori  ok  of  reference,  as  a  '  working  book  '  for  the  student  or  prac- 

titioner, wt  commend  it  because  we  believe  there  is  no  better." — American  Journal  of  the 
Medical  Si  iei 

Illustrated  Catalogue  of  the  "American  Text-Books  "  sent  free  upon  application. 


Medical  Publications  of  W.  B.  Saunders  &  Co. 


AN  AMERICAN  TEXT-BOOK  OF  PATHOLOGY. 

Edited  by  Ludvig  Hektoen,  M.  D. .  Professor  of  General  Pathology 
and  of  Morbid  Anatomy  in  the  University  of  Pennsylvania ;  and 
David  Riesman,  M.  D.,  Demonstrator  of  Pathological  Histology  in 
the  University  of  Pennsylvania.     ///  preparation. 

AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY. 

By  10  of  the  Leading  Physiologists  of  America.  Edited  by  William 
H.  Howell,  Ph.D.,  M.D.,  Professor  of  Physiology  in  the  Johns  Hop- 
kins University,  Baltimore,  Md.  Second  edition,  revised  and  enlarged, 
in  two  volumes. 

"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  subjects." — London  Lancet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  exposition  of  the  present  status  of  the  science  of  physiology  in  the 
English  language." — American  Journat  of  the  Medical  Sciences. 

AN   AMERICAN   TEXT=BOOK   OF   SURGERY.     Third  Edition. 

By  n  Eminent  Professors  of  Surgery.  Edited  by  William  YV.  Keen, 
M.D.,  LL.D.,  and  J.  William  White,  M.D.,  Ph.D.  Handsome  im- 
perial octavo  volume  of  1230  pages,  with  496  wood- cuts  in  the  text, 
and  37  colored  and  half-tone  plates.  Thoroughly  revised  and  enlarged, 
with  a  section  devoted  to  "  The  Use  of  the  Rontgen  Rays  in  Surgery." 
Cloth,  $7.00  net;  Sheep  or  Half  Morocco,  $8.00  net. 

«'  Personally,  I  should  not  mind  it  being  called  THE  Text-Book  (instead  of  A  Text- 
Book)  ,  for  I  know  of  no  single  volume  which  contains  so  readable  and  complete  an  account 
of  the  science  and  art  of  Surgery  as  this  does." — Edmund  Owen,  F.R.C.S.,  Member  of 
the  Board  of  Examiners  of  the  Royal  College  of  Surgeons,  England. 

"  If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  most 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  practice." — 
London  Lancet. 

AN  AMERICAN  TEXT=BOOK  OF  THE  THEORY  AND  PRACTICE 
OF  MEDICINE. 

By  12  Distinguished  American  Practitioners.  Edited  by  William 
Pepper,  M.D.,  LL.D.,  Professor  of  the  Theory  and  Practice  of  Medi- 
cine and  of  Clinical  Medicine  in  the  University  of  Pennsylvania.  Two 
handsome  imperial  octavo  volumes  of  about  1000  pages  each.  Illus- 
trated. Prices  per  volume :  Cloth,  $5.00  net ;  Sheep  or  Half  Morocco, 
$6.00  net.      Sold  by  Subscription. 

"  I  am  quite  sure  it  will  commend  itself  both  to  practitioners  and  students  of  medicine, 
and  become  one  of  our  most  popular  text-books." — Alfred  Loomis,  M.D.,  LL.D.,  Pro- 
fessor of  Pathology  and  Practice  of  Medicine,  University  of  the  City  of  New  York. 

"  We  reviewed  the  first  volume  of  this  work,  and  said  :  '  It  is  undoubtedly  one  of  the 
best  text-books  on  the  practice  of  medicine  which  we  possess.'  A  consideration  of  the 
second  and  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work 
is  in  our  opinion  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see." — New  York  Medical 
Journal. 

Illustrated  Catalogue  of  the  "American  Text-Books "  sent  free  upon  application. 


Medical  Publications  of  W.  B.  Saunders  <£-  Co. 


AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SURGERY. 

A  Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  Foreign  authors  and 
investigators.  Arranged  with  critical  editorial  comments,  by  eminent 
American  specialists,  under  the  general  editorial  charge  of  GEORGI  M. 
Gould,  M.I).  Volumes  for  1896,  '97,  '98,  and  '99.  One  imperial 
octavo  volume  of  about  1200  pages.  Cloth,  56.50  net  ;  Half  Morocco, 
S7.50  net.  Year-Book  of  1900  in  two  volumes — Vol.  L,  including 
General  Medicine;  Vol.  II.,  General  Surgery.  Prices  per  volume: 
Cloth,  53- 00  net;   Half  Morocco,  83-75  net.     Sold  by  Subscription. 

"  It  is  difficult  to  know  which  to  admire  most — the  research  and  industry  of  the  distin- 
guished band  of  experts  whom  Dr.  Gould  his  enlisted  in  the  service  of  the  Year-Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  .  .  .  It  is  much  more  than  a  mere  compilation  of  abstracts,  for, 
as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the  advant- 
age of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers  fully 
qualified  to  perform  these  tasks.  ...  It  is  emphatically  a  book  which  should  find  a  place  in 
every  medical  library,  and  is  in  several  respects  more  useful  than  the  famous  'Jahrbiicher' 
of  Germany." — London  Lancet. 

ABBOTT  ON  TRANSMISSIBLE   DISEASES. 

The  Hygiene  of  Transmissible  Diseases ;  their  Causation, 
Modes   of    Dissemination,  and  Methods  of  Prevention.     By  A. 

C.  Abbott,  M.D..  Professor  of  Hygiene  and  Bacteriology,  University 
of  Pennsylvania;  Director  of  the  Laboratory  of  Hygiene.  Octavo 
volume  of  311  pages,  containing  a  number  of  charts  and  maps,  and 
numerous  illustrations.      Cloth,  82.00  net. 

THE  AMERICAN   POCKET  MEDICAL  DICTIONARY. 

[See  Dor  I  and' 's  Pocket  Dictionary,  page  12.] 

ANDERS'  PRACTICE  OF  MEDICINE.  Third  Revised  Edition. 
A  Text-Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine,  Medico-Chirurgical  College,  Philadelphia.  In  one 
handsome  octavo  volume  of  1292  pages,  fully  illustrated.  Cloth, 
$5.50  net;  Sheep  or  Half  Morocco,  $6.50  net. 

"  It  is  an  excellent  book, — concise,  comprehensive,  thorough,  and  up  to  date.     It  is  a 
credit  to  you  ;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia — to  us." 
I   .  WILSON,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  fefferson 
Medical  College,  Philadelphia. 

ASHTON'S  OBSTETRICS.     Fourth  Edition,  Revised. 

Essentials  of  Obstetrics.  By  W.  Easterly  Ashton,  M.D.,  Pro- 
fessor of  Gynecology  in  the  Medico-Chirurgical  College,  Philadelphia. 
Crown  octavo,  252  pages;  75  illustrations.  Cloth,  Si. 00  net;  inter- 
leased  for  1  25    net. 

Saunders'  Question- Compends,  page  23.] 

whole  subject  in  a  nut-shell.     We  cordially  recommend  it  to  our  read 
ers." — Chicago  Medical  Tim 


Medical  Publications  of  W.  B.  Saunders  &  Co.        9 


BALL'S  BACTERIOLOGY.     Third  Edition,  Revised. 

Essentials  of  Bacteriology  ;  a  Concise  and  Systematic  Introduction 
to  the  Study  of  Micro-organisms.  By  M.  V.  Ball,  M.D.,  Bacteriol- 
ogist to  St.  Agnes'  Hospital,  Philadelphia,  etc.  Crown  octavo,  218 
pages;  82  illustrations,  some  in  colors,  and  5  plates.  Cloth,  Si. 00; 
interleaved  for  notes,  $1.25. 

[See  Saunders'  Question-  Con/fends,  page   23.] 

"  The  student  or  practitioner  can  readily  obtain  a  knowledge  of  the  subject  from  a  perusal 
of  this  book.     The  illustrations  are  clear  and  satisfactory." — Medical  Record,  New  York. 

BASTIN'S  BOTANY. 

Laboratory  Exercises  in  Botany.  Bv  Edson  S.  Bastin,  M.A., 
late  Prof,  of  Materia  Medica  and  Botany,  Philadelphia  College  of  Phar- 
macy.    Octavo  volume  of  536  pages,  with  87  plates.    Cloth,  $2.00  net. 

"  It  is  unquestionably  the  best  text-book  on  the  subject  that  has  yet  appeared.  The 
work  is  eminently  a  practical  one.  We  regard  the  issuance  of  this  book  as  an  important 
event  in  the  history  of  pharmaceutical  teaching  in  this  country,  and  predict  for  it  an  unquali- 
fied success." — Alumni  Report  to  the  Philadelphia  College  of  Pharmacy. 

BECK  ON  FRACTURES. 

Fractures.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's  Hospital 
and  the  New  York  German  Poliklinik,  etc.  225  pages,  170  illustratione. 
Cloth,  $  net. 

BECK'S  SURGICAL  ASEPSIS. 

A  Manual  of  Surgical  Asepsis.  By  Carl  Beck,  M.D.,  Surgeon  to 
St.  Mark's  Hospital  and  the  New  York  German  Poliklinik,  etc.  306 
pages;  65  text-illustrations,  and  12  full-page  plates.     Cloth,  $1.25  net. 

"  An  excellent  exposition  of  the  '  very  latest '  in  the  treatment  of  wounds  as  practised 
by  leading  German  and  American  surgeons." — Birmingham  (Eng. )  Medical  Review. 

"  This  little  volume  can  be  recommended  to  any  who  are  desirous  of  learning  the  details 
of  asepsis  in  surgery,  for  it  will  serve  as  a  trustworthy  guide." — London  Lancet. 

BOISLINIERE'S  OBSTETRIC  OCCIDENTS,  EMERGENCIES,  AND 
OPERATIONS. 
Obstetric  Accidents,  Emergencies,  and  Operations.     By  L.  Ch. 

Boisliniere,  M.D.,  late  Emeritus  Professor  of  Obstetrics,  St.  Louis 
Medical  College.    381  pages,  handsomely  illustrated.    Cloth,  32.00  net. 

"  A  manual  so  useful  to  the  student  or  the  general  practitioner  has  not  been  brought  to 
our  notice  in  a  long  time.  The  field  embraced  in  the  title  is  covered  in  a  terse,  interesting 
way." —  Yale  Medical  Journal. 

BROCKWAY'S  MEDICAL  PHYSICS.     Second  Edition,  Revised. 
Essentials  of   Medical   Physics.     By  Fred  J.  Brockwav,  M.D., 
Assistant  Demonstrator  of  Anatomy  in  the  College  of  Physicians  and 
Surgeons,  New  York.     Crown  octavo,  330  pages;   155  fine  illustrations. 
Cloth,  gi.oo  net ;  interleaved  for  notes,  $1.25  net. 

[See  Saunders'  Question- Contends,  page   23.] 

"We  know  of  no  manual  that  affords  the  medical  student  a  better  or  more  concise 
exposition  of  physics,  and  the  book  may  be  commended  as  i  mosl  satisfactory  presentation 
of  those  essentials  that  are  requisite  in  a  course  in  medicine." —  Medical  Journal. 


Medical  Publications  of  W.  B.  Saunders  &  Co. 


BUTLER'S  MATERIA  MEDICA,  THERAPEUTICS,  AND  PHAR- 
MACOLOGY. Third  Edition,  Revised. 
A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Ph.G.,  M.D.,  Professor  of  Materia 
Medica  and  of  Clinical  Medicine  in  the  College  of  Physicians  and 
Surgeons,  Chicago ;  Professor  of  Materia  Medica  and  Therapeutics, 
Northwestern  University,  Woman's  Medical  School,  etc.  Octavo,  874 
pages,  illustrated.      Cloth,  $4. 00  net;    Sheep,  §5.00  net. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory 
of  any  single-volume  works  on  materia  medica  in  the  market." — Journal  of  the  American 
Medical  Association. 

CERNA  ON  THE  NEWER  REMEDIES.  Second  Edition,  Revised. 
Notes  on  the  Newer  Remedies,  their  Therapeutic  Applications 
and  Modes  of  Administration.  By  David  Cerna,  M.D.,  Ph.D., 
formerly  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics 
in  the  University  of  Pennsylvania;  Demonstrator  of  Physiology  in  the 
Medical  Department  of  the  University  of  Texas.  Rewritten  and 
greatly  enlarged.     Post-octavo,   253  pages.     Cloth,  $1. 00  net. 

"The  appearance  of  this  new  edition  of  Dr.  Cerna's  very  valuable  work  shows  that  it 
is  properly  appreciated.  The  book  ought  to  be  in  the  possession  of  every  practising  physi- 
cian."— New  York  Medical  Journal. 

CHAPIN  ON  INSANITY. 

A  Compendium  of  Insanity.  By  John  B.  Chapin,  M.D.,  LL.D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  late  Physi- 
cian-Superintendent of  the  Willard  State  Hospital,  New  York ;  Hon- 
orary Member  of  the  Medico-Psychological  Society  of  Great  Britain, 
of  the  Society  of  Mental  Medicine  of  Belgium.  i2mo,  234  pages, 
illustrated.     Cloth,  $1.25  net. 

"  The  practical  parts  of  Dr.  Chapin's  book  are  what  constitute  its  distinctive  merit.  We 
desire  especially  to  call  attention  to  the  fact  that  on  the  subject  of  therapeutics  of  insanity 
the  work  is  exceedingly  valuable.  It  is  not  a  made  book,  but  a  genuine  condensed  thesis, 
which  has  all  the  value  of  ripe  opinion  and  all  the  charm  of  a  vigorous  and  natural  style." — 
Philadelphia  Medical  Journal. 

CHAPMAN'S  MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY. 
Second  Edition,  Revised. 
Medical  Jurisprudence  and  Toxicology,  By  Henry  C.  Chapman, 
M.D.,  Professor  of  Institutes  of  Medicine  and  Medical  Jurisprudence 
in  the  Jefferson  Medical  College  of  Philadelphia.  254  pages,  with  55 
illustrations  and  3  full-page  plates  in  colors.     Cloth,  $1.50  net. 

"The  best  book  of  its  class  for  the  undergraduate  that  we  know  of." — Nnv  York 
AMtclical  Times. 

CHURCH  AND  PETERSON'S  NERYOUS  AND  MENTAL  DISEASES. 

Second  Edition. 

Nervous  and  Mental  Diseases.      By  Archibald  Church,  M.  D., 

Professor  of  Clinical  Neurology,  Mental  Diseases,  and  Medical  Juris- 

prudence  in  the  Northwestern    University  Medical  School,  Chicago; 

!    ederick   Peterson,  M.  !>.,  Clinical   Professor  of  Mental   Dis- 

.'.  iman'      Medical    College,    V   Y.  ;    Chief  of  Clinic,  Nervous 

1  of  Physicians  and  Surgeons,  N.  Y.     Handsome  octavo 

;;  pagi    ,   profusely  illustrated.     Cloth,  £5. 00  net;  Half 

J6.1  0  oet. 


Medical  Publications  of  W.  B.  Saunders  &  Co.      11 


CLARKSON'S  HISTOLOGY. 

A   Text-Book    of    Histology,    Descriptive   and    Practical.      By 

Arthur  Clarkson,  M.B.,  C.M.  Edin.,  formerly  Demonstrator  of 
Physiology  in  the  Owen's  College,  Manchester ;  late  Demonstrator  of 
Physiology  in  Yorkshire  College,  Leeds.  Large  octavo,  554  pages; 
22  engravings  in  the  text,  and  174  beautifully  colored  original  illustra- 
tions.     Cloth,  strongly  bound,  $4.00  net. 

"The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text- books, 
and  is  to  be  highly  recommended.'" — New  York  Medical  Journal. 

"This  is  one  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the 
book  will  attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 

CLIMATOLOGY. 

Transactions  of  the  Eighth  Annual  Meeting  of  the  American 
Climatological  Association,  held  in  Washington,  September  22—25, 
1 89 1.  Forming  a  handsome  octavo  volume  of  276  pages,  uniform  with 
remainder  of  series.      (A  limited  quantity  only.)     Cloth,  $1.50. 

COHEN  AND  ESHNER'S  DIAGNOSIS.  Second  Edition,  Revised. 
Essentials  of  Diagnosis.  By  Solomon  Solis-Cohen,  M.D.,  Pro- 
fessor of  Clinical  Medicine  and  Applied  Therapeutics  in  the  Philadel- 
phia Polyclinic  ;  and  Augustus  A.  Eshner,  M.D. ,  Professor  of  Clinical 
Medicine  in  the  Philadelphia  Polyclinic.  Post-octavo,  417  pages;  55 
illustrations.      Cloth,  gi.oo  net. 

[See  Saunders1  Question- Comjends,  page   23.] 

"  We  can  heartily  commend  the  book  to  all  those  who  contemplate  purchasing  a  'com- 
pend.'  It  is  modern  and  complete,  and  will  give  more  satisfaction  than  many  other  works 
which  are  perhaps  too  prolix  as  well  as  behind  the  times." — Medical  Review,  St.  Louis. 

CORWIN'S  PHYSICAL  DIAGNOSIS.     Third  Edition,  Revised. 

Essentials  of  Physical  Diagnosis  of  the  Thorax.  By  Arthur 
M.  Corwix.  A.M.,  M.D.,  Demonstrator  of  Physical  Diagnosis  in  Rush 
Medical  College,  Chicago  ;  Attending  Physician  to  Central  Free  Dis- 
pensary, Department  of  Rhinology,  Laryngology,  and  Diseases  of  the 
Chest,  Chicago.    219  pages,  illustrated.   Cloth,  flexible  covers,  $1.25  net. 

"It  is  excellent.  The  student  who  shall  use  it  as  his  guide  to  the  careful  study  of 
physical  exploration  upon  normal  and  abnormal  subjects  can  scarcely  fail  to  acquire  a  good 
working  knowledge  of  the  subject." — Philadelphia  Polyclinic. 

"A  most  excellent  little  work.  It  brightens  the  memory  of  the  differential  diagnostic 
signs,  and  it  arranges  orderly  and  in  sequence  the  various  objective  phenomena  to  logical 
solution  of  a  careful  diagnosis. ' ' — Journal  of  Nervous  and  Mental  Diseases. 

CRAGIN'S  GYN/ECOLOGY.     Fourth  Edition,  Revised. 

Essentials  of  Gynaecology.  By  Edwin  B.  Cragin,  M.  D.,  Lecturer 
in  Obstetrics,  College  of  Physicians  and  Surgeons,  New  York.  Crown 
octavo,  200  pages;  62  illustrations.  Cloth,  Si. 00  net;  interleaved  tor 
notes,  Si- 25  net. 

[See  Saunders'  Question- Compcnds,  page  23.] 
"  A  handy  volume,  and  a  distinct  improvement  on  students'  compends  in  general.     No 
a«thor  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the  student  s  needs 
so  thoroughly  as  Dr.  Cragin  has  done." — Medical  Record,  New  \  ork. 


12      Meaical  Publications  of  W.  B.  Saunders  <$r  Co. 


CROOKSHANK'S  BACTERIOLOGY.     Fourth   Edition,  Revised. 

A  Text-Book  of  Bacteriology.  By  Edgar  M.  Crookshank,  M.B., 
Professor  of  Comparative  Pathology  and  Bacteriology,  King's  College, 
London.  Octavo  volume  of  700  pages,  with  273  engravings  and  22 
original  colored  plates.     Cloth,  $6.50  net;   Half  Morocco,  $7.50  net. 

"  To  the  student  who  wishes  to  obtain  a  good  resume  of  what  has  been  done  in  bacteri- 
ology, or  who  wishes  an  accurate  account  of  the  various  methods  of  research,  the  book  may 
be  recommended  with  confidence  that  he  will  find  there  what  he  requires." — London  Lancet. 

Da  COSTA'S  SURGERY.  Second  Ed.,  Revised  and  Greatly  Enlarged. 
Modern  Surgery,  General  and  Operative.  By  John  Chalmers 
DaCosta,  M.  D.,  Professor  of  Practice  of  Surgery  and  Clinical  Surgery, 
Jefferson  Medical  College,  Philadelphia ;  Surgeon  to  the  Philadelphia 
Hospital,  etc.  Handsome  octavo  volume  of  911  pages,  profusely  illus- 
trated.    Cloth,  $4.00  net;   Half  Morocco,  $5.00  net. 

"We  know  of  no  small  work  on  surgery  in  the  English  language  which  so  well  fulfils 
the  requirements  of  the  modern  student." — Medico-Chirurgical  Journal,  Bristol,  England. 

DE  SCHWEINITZ  ON  DISEASES  OF  THE  EYE.      Third  Edition, 
Revised. 
Diseases  of   the  Eye.     A  Handbook   of   Ophthalmic   Practice. 

By  G.  E.  de  Schweinitz,  M.D.,  Professor  of  Ophthalmology  in  the 
Jefferson  Medical  College,  Philadelphia,  etc.  Handsome  royal  octavo 
volume  of  696  pages,  with  256  fine  illustrations  and  2  chromo-litho- 
graphic  plates.     Cloth,  $4.00  net ;  Sheep  or  Half  Morocco,  $5.00  net. 

"  A  clearly  written,  comprehensive  manual.  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering 
upon  the  study  of  this  special  branch  of  medical  science." — British  Medical  Journal. 

"  A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.  I  am  satisfied  that  unusual  success  awaits  it." — William 
Pepper,  M.I).,  Professor  of  the  Theory  and  Practice  of  Medicine  and  Clinical  Medicine, 
University  of  Pennsylvania, 

DORLAND'S  DICTIONARY.     Third  Edition,  Revised. 

The  American  Pocket  Medical  Dictionary.  Containing  the  Pro- 
nunciation and  Definition  of  all  the  principal  words  and  phrases,  and  a 
large  number  of  useful  tables.  Edited  by  W.  A.  Newman  Dorland, 
M.  1 ).,  Assistant  1  )emonstrator  of  ( )bstetrics,  University  of  Pennsylvania] 
Fellow  of  the  American  Academy  of  Medicine.  518  pages  ;  handsomely 
bound  in  full  leather,  limp,  with  gilt  edges  and  patent  index.  Price, 
$1.00  net;   with  thumb  index,  Si. 25  net. 

DORLAND'S  OBSTETRICS. 

A  Manual  of  Obstetrics.  By  W.  A.  Newman  Dorland,  M.D., 
Assistant  Demonstrator  of  Obstetrics,  University  of  Pennsylvania; 
Instructor  in  Gynecology  in  the  Philadelphia  Polyclinic.  760  pages; 
163  illustrations  in  the  text,  and  6  full-page  plates.     Cloth,  $2.50  net. 

"  By  far  the  b<  I  thai  has  ever  come  to  our  notice." — American 

A/ediral  R< 

"  It  hi-  rarely  1  een  <>nr  duty  t"  review  a  book  which  has  given  us  more  pleasure  in  its 
prrusal  and  >  ■    mi  n    criticism.  rital  i<  encyclopedia  of  knowledge, 

a  gold  mine  "!   practical,  concise  thoughts." — American  Medico-Surgical  Bulletin. 


Medical  Publications  of  W.  B.  Saunders  &  Co.       13 


FROTHINGHAM'S  GUIDE  FOR  THE  BACTERIOLOGIST. 

Laboratory  Guide  for  the  Bacteriologist.  By  Langdon  Froth- 
ingham,  M.D.V.,  Assistant  in  Bacteriology  and  Veterinary  Science, 
Sheffield  Scientific  School,  Yale  University.    Illustrated.    Cloth,  75  cts. 

"  It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  neces- 
sary for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking 
up  the  various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — Ameri- 
can Medico- Surgical  Bulletin. 

GARRIGUES'  DISEASES  OF  WOMEN.  Third  Edition,  Revised. 
Diseases  of  Women.  By  Henry  J.  Garrigues,  A.M.,  M.D.,  Pro« 
fessor  of  Gynecology  in  the  New  York  School  of  Clinical  Medicine; 
Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dispensary, 
New  York  City,  etc.  Handsome  octavo  volume  of  783  pages,  illus- 
trated by  367  engravings  and  colored  plates.  Cloth,  $4.00  net; 
Sheep  or  Half  Morocco,  §5.00  net. 

"  One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language  ;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners  to  whom  experienced  consultants 
may  not  be  available  will  find  in  this  book  invaluable  counsel  and  help." — Thad.  A. 
Reamy,  M.D.,  LL.D.,  Professor  of  Clinical  Gynecology,  Medical  College  of  Ohio. 

GLEASON'S  DISEASES  OF  THE  EAR.  Second  Edition,  Revised. 
Essentials  of  Diseases  of  the  Ear.  By  E.  B.  Gleason,  S.B., 
M.D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Philadelphia  ;  Surgeon-in-Charge  of  the  Nose,  Throat,  and  Ear  Depart- 
ment of  the  Northern  Dispensary,  Philadelphia.  208  pages,  with  114 
illustrations.     Cloth,  $1.00  net;  interleaved  for  notes,  $1 .25  net. 

[See  Saunders'  Question- Compends,  page   23.] 

"It  is  just  the  book  to  put  into  the  hands  of  a  student,  and  cannot  fail  to  give  him  a 
useful  introduction  to  ear-affections  ;  while  the  style  of  question  and  answer  which  is  adopted 
throughout  the  book  is,  we  believe,  the  best  method  of  impressing  facts  permanently  on  the 
mind. ' ' — Liverpool  Medico-  Chirurgical  Journal. 

GOULD  AND  PYLE'S  CURIOSITIES  OF  MEDICINE. 

Anomalies  and  Curiosities  of  Medicine.  By  George  M.  Gould, 
M.D.,  and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collection  of 
rare  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an 
exhaustive  research  of  medical  literature  from  its  origin  to  the  present 
day,  abstracted,  classified,  annotated,  and  indexed.  Handsome  im- 
perial octavo  volume  of  968  pages,  with  295  engravings  in  the  text, 
and  12  full-page  plates. 

POPULAR   EDITION:  Cloth,  S3. 00  net;  Half  Morocco,  $4.00  net. 

"  One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far 
as  we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for 
the  medical  profession  has  this  volume  value:  it  will  serve  as  a  book  of  reference  for  all  who 
are  interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical 
Journal. 

"This  is  certainly  a  most  remarkable  and  interesting  volume.  It  stands  alone  among 
medical  literature,  an  anomaly  on  anomalies,  in  that  there  is  nothing  like  it  elsewhere  in 
medical  literature.  It  is  a  book  full  of  revelations  from  its  first  to  its  last  page,  and  cannot 
but  interest  and  sometimes  almost  horrify  its  readers." — American  Medico-Surgical BulUttn. 


Medical  Publications  of  W.  B.  Saunders  &  Co. 


GRAFSTROM'S   MECHANOTHERAPY. 

A  Text-Book  of  Mechano-Therapy  (Massage  and  Medical  Gym- 
nastics .  By  Axel  V.  Grafstrom,  B.  Sc,  M.  I).,  late  Lieutenant  in 
the  Royal  Swedish  Army;  late  House  Physician  City  Hospital,  Black- 
weirs  Island,  New  York.    i2mo,  139  pages,  illustrated.    Cloth,  gi.oo  net. 

GRIFFITH  ON  THE  BABY.     Second  Edition,  Revised. 

The  Care  of  the  Baby.  By  J.  P.  Crozer  Griffith,  M.D.,  Clini- 
cal Professor  of  Diseases  of  Children,  University  of  Pennsylvania; 
Physician  to  the  Children's  Hospital,  Philadelphia,  etc.  nmo,  404 
pages,  with  67  illustrations  in  the  text,  and  5  plates.     Cloth,  $1.50  net. 

"  The  best  book  for  the  use  of  the  young  mother  with  which  we  are  acquainted.  .  .  . 
There  are  very  few  general  practitioners  who  could  not  read  the  book  through  with  advan- 
tage. ' ' — Archives  of  Pediatrics. 

"The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a 
master  hand.  It  can  be  read  with  benefit  not  only  by  mothers  but  by  medical  students  and 
by  any  practitioners  who  have  not  had  large  opportunities  for  observing  children." — Ameri- 
can Journal  of  Obstetrics. 

GRIFFITH'S  WEIGHT  CHART. 

Infant's  Weight  Chart.  Designed  by  J.  P.  Crozer  Griffith,  M.  D. , 
Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Penn- 
sylvania, etc.      25  charts  in  each  pad.      Per  pad,  50  cents  net. 

GROSS,  SAMUEL  D.,  AUTOBIOGRAPHY  OF. 

Autobiography  of  Samuel  D.  Gross,  M.  D.,  Emeritus  Professor  of 
Surgery  in  the  Jefferson  Medical  College,  Philadelphia,  with  Remi- 
niscences of  His  Times  and  Contemporaries.  Edited  by  his  Sons, 
Samuel  W.  Gross.  M.D.,  LL.D.,  and  A.  Haller  Gross,  A.M.  Pre- 
ceded by  a  Memoir  of  Dr.  Gross,  by  the  late  Austin  Flint,  M.D. 
Two  handsome  volumes,  over  400  pages  each,  demy  octavo,  gilt  tops, 
with  Frontispiece  on  steel.      Price  per  volume,  $2.50  net. 

HAMPTON'S  NURSING.  Second  Edition,  Revised  and  Enlarged. 
Nursing:  Its  Principles  and  Practice.  By  Isabel  Adams  Hamp- 
TON,  Graduate  of  the  New  York  Training  School  for  Nurses  attached 
to  Bellevue  Hospital ;  late  Superintendent  of  Nurses  and  Principal  of 
the  Training  School  for  Nurses,  Johns  Hopkins  Hospital,  Baltimore, 
Md.     12  mo,  512  pages,  illustrated.     Cloth,  $2.00  net. 

"Seldom  have  we  perused  a  book  upon  the  subject  thnt  has  given  u>  so  much  pleasure 
as  the  one  before  us.  \Ye  would  strongly  urge  upon  the  members  of  our  own  profession  the 
need  of  a  book  like  this,  for  it  will  enable  each  of  us  to  hecome  a  training  school  in  him- 
self."—  Ontario  Medical  Journal. 

HARE'S  PHYSIOLOGY.  Fourth  Edition,  Revised. 

Essentials  of  Physiology.  By  II.  A.  Hark,  M.D.,  Professor  of 
Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical  College  of 
Philadelphia.  Crown  octavo,  239  pages.  Cloth,  $1.00  net;  inter- 
leaved  for  notes,  $1.25  net. 

[See  Saunders*  Question-  Compends,  page  23.] 

"  Th(  lensatiorj  ol    physiological   knowledge  we   have  yet  seen." — Medical 

Recot  1  '>rk. 


Medical  Publications  of  W.  B.  Saunders  <Sr  Co.       15 


HART'S  DIET  IN  SICKNESS  AND  IN  HEALTH. 

Diet  in  Sickness  and  in  Health.  By  Mrs.  Ernest  Hart,  formerly 
Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London  School 
of  Medicine  for  Women  ;  with  an  Introduction  by  Sir  Henry 
Thompson,  F.R.C.S.,  M.D.,  London.     220  pages.      Cloth,  $1.50  net. 

"  We  recommend  it  cordially  to  the  attention  of  all  practitioners  ;  both  to  them  and  to 
their  patients  it  may  be  of  the  greatest  service." — New  York  Medical  Journal. 

HAYNES'  ANATOMY. 

A  Manual  of  Anatomy.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Depart- 
ment of  the  New  York  University,  etc.  680  pages,  illustrated  with  42 
diagrams  in  the  text,  and  134  full-page  half-tone  illustrations  from 
original  photographs  of  the  author's  dissections.      Cloth,  $2.50  net. 

"  This  book  is  the  work  of  a  practical  instructor — one  who  knows  by  experience  the 
requirements  of  the  average  student,  and  is  able  to  meet  these  requirements  in  a  very  satis- 
factory way.      The  book  is  one  that  can  be  commended." — Medical  Record,  New  York. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.D.,  Pro- 
fessor of  Anatomy  in  the  Medico-Chirurgical  College,  Philadelphia.  Oc- 
tavo volume  of  405  pages,  handsomely  illustrated.    Cloth,  $2.50  net. 

HIRST'S  OBSTETRICS.  Second  Edition. 

A  Text=Book  of  Obstetrics.  By  Barton  Cooke  Hirst,  M.  D., 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome 
octavo  volume  of  848  pages,  with  618  illustrations,  and  7  colored 
plates.     Cloth,  $5.00  net;   Sheep  or  Half  Morocco,  $6.00  net. 

"  The  illustrations  are  numerous  and  are  works  of  art,  many  of  them  appearing  for  the 
first  time.  The  arrangement  of  the  subject-matter,  the  foot-notes,  and  index  are  beyond 
criticism.  As  a  true  model  of  what  a  modern  text-book  on  obstetrics  should  be,  we  feel 
justified  in  affirming  that  Dr.  Hirst's  book  is  without  a  rival." — New  York  Medical  Record. 

HYDE  AND  MONTGOMERY  ON  SYPHILIS  AND  THE  VENEREAL 
DISEASES.  Second  Edition,  Revised  and  Enlarged. 
Syphilis  and  the  Venereal  Diseases.  By  James  Nevins  Hyde, 
M.  D.,  Professor  of  Skin  and  Venereal  Diseases,  and  Frank  II.  Mon  1- 
gomery,  M.  D. ,  Lecturer  on  Dermatology  and  Genito-Lrinary  Diseases 
in  Rush  Medical  College,  Chicago,  111.  Octavo,  nearly  600  pages,  with 
14  beautiful  lithographic  plates  and  numerous  illustrations. 

"  We  can  commend  this  manual  to  the  student  as  a  help  to  him  in  his  study  of  venereal 
diseases. " — Liverpool  Medico-Chirurgical  Journal. 

"The  best  student's  manual  which  has  appeared  on  the  subject." — St.  Louis  Medical 
and  Surgical  Journal. 

INTERNATIONAL  TEXT-BOOK  OF  SURGERY.  In  two  volumes. 
By  American  and  British  authors.  Edited  by  J.  COLLINS  Wai 
M.D.,  LL.D.,  Professor  of  Surgery,  Harvard  Medical  School.  Boston; 
and  A.  Peakcf.  Gould,  M.S.!  K.R.C.S.,  Lecturer  on  Practical  Sur- 
gery and  Teacher  of  Operative  Surgery,  Middlesex  Hospital  Mi 
School,  London,  Eng.  Vol.  I.  General  Surgery. — Handsome  octavo, 
947  pages,  with  458  beautiful  illustrations  and  >,  lithographic  plates. 
Vol.  II.  Special  or  Regional  Surgery.  -Handsome  octavo,  107  j  pages, 
with  471  beautiful  illustrations  ,in<l  8  lithographic  plates.  Prices  per 
volume:   Cloth.  $5. 00  net;   Half  Morocco,  $6.00  net. 


Medical  Publications  of  W.  B.  Saunders  &  Co. 

JACKSON'S  DISEASES  OF  THE  EYE. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.M., 
M.D.,  sometime  Professor  of  Diseases  of  the  Eye  in  the  Philadelphia 
Polyclinic  and  College  for  Graduates  in  Medicine,  nrao  volume  of 
535  PaSes>  witn  178  beautiful  illustrations,  mostly  from  drawings  by  the 
author.     Cloth,  $2.50  net. 

JACKSON  AND  GLEASON'S  DISEASES  OF  THE  EYE,  NOSE,  AND 
THROAT.  Second  Edition,  Revised. 
Essentials  of  Refraction  and  Diseases  of  the  Eye.  By  Edward 
Jackson,  A.M.,  M.D.,  Professor  of  Diseases  of  the  Eye  in  the  Phila- 
delphia Polyclinic  and  College  for  Graduates  in  Medicine  ;  and — 
Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  Bald- 
win Gleason,  M.D.,  Surgeon-in-Charge  of  the  Nose,  Throat,  and 
Ear  Department  of  the  Northern  Dispensary  of  Philadelphia.  Two 
volumes  in  one.  Crown  octavo,  290  pages;  124  illustrations.  Cloth, 
Si. 00  net;  interleaved  for  notes,  $1.25  net. 

[See  Saunders'  Question- Compends,  page  22.] 

"  Of  great  value  to  the  beginner  in  these  branches.  The  authors  are  both  capable  men, 
and  know  what  a  student  most  needs." — Medical  Record,  New  York. 

KEATING'S  DICTIONARY.     Second  Edition,  Revised. 

A  New  Pronouncing  Dictionary  of  Medicine,  with  Phonetic 
Pronunciation,  Accentuation,  Etymology,  etc.  By  John  M. 
Keating,  M.D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia, and  Henry  Hamilton  ;  with  the  collaboration  of  J.  Chal- 
mers DaCosta,  M.D.,  and  Frederick  A.  Packard,  M.D.  With  an 
Appendix  containi  g  Tables  of  Bacilli,  Micrococci,  Leucomaines, 
Ptomaines,  etc.  One  volume  of  over  800  pages.  Prices,  with  Ready- 
Reference  Index:  Clcth,  $5.00  net;  Sheep  or  Half  Morocco,  $6.00 
net.  Without  Patent  Index:  Cloth,  $4.00  net;  Sheep  or  Half  Morocco, 
$5.00  net. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommend- 
ing it  to  my  classes." — Henry  M.  Lyman.  M.  D.,  Professor  of  the  Principles  and  Practice 
if  Medicine,  Rush  Medical  College,  Chicago,  III. 

KEATING'S    LIFE    INSURANCE. 

How  to  Examine  for  Life  Insurance.  By  John  M.  Keating, 
M.  D.,  Fellow  of  the  College  of  Physicians  of  Philadelphia;  Vice- 
President  of  the  American  Pediatric  Society;  Ex- President  of  the 
Association  of  Life  Insurance  Medical  Directors.  Royal  octavo,  211 
pages;  with  two  large  half-tone  illustrations,  and  a  plate  prepared  by 
Dr.  McClellan  from  special  dissections ;  also,  numerous  other  illustra- 
tions.    Cloth,  $2.00  net. 

KEEN'S  OPERATION  BLANK.     Second   Edition,  Revised  Form. 
An  Operation  Bl'iik,  with   Lists  of  Instruments,  etc.,  Required 
in  Various  Operations.     Prepared  by  W.  W.  Keen,  M.D.,  LL.D., 
Professor  .of  the   Principles  of  Surgery  in  Jefferson  Medical  College, 
Philadelphia.      Price  per  pad,  blanks  for  fifty  operations,  50  cents  net. 


Medical  Publications  of  W.  B.  Saunders  <&  Co.       17 


KEEN  ON  THE  SURGERY  OF  TYPHOID  FEVER. 

The    Surgical   Complications  and   Sequels  of   Typhoid    Fever. 

By  Wm.  W.  Keen,  M.D.,  LL.D.,  Professor  of  the  Principles  of  Sur- 
gery and  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadelphia; 
Corresponding  Member  of  the  Societe  de  Chirurgie,  Paris;  Honorary 
Member  of  the  Societe  Beige  de  Chirurgie,  etc.  Octavo  volume  of 
386  pages,  illustrated.     Cloth,  S3. 00  net. 

"  This  is  probably  the  first  and  only  work  in  the  English  language  that  gives  the  reader 
a  clear  view  of  what  typhoid  fever  really  is,  and  what  it  does  and  can  do  to  the  human 
organism.  This  book  should  be  in  the  possession  of  every  medical  man  in  America." — 
American  Medico-Surgical  Bulletin. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.D., 
Clinical  Professor  of  Laryngology  and  Rhinology,  Jefferson  Medical 
College,  Philadelphia ;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital.  Handsome  octavo  volume  of  about 
630  pages,  with  over  150  illustrations  and  6  lithographic  plates.  Price, 
Cloth,  $4.00  net;    Half  Morocco,  $5.00  net. 

LAINE'S  TEMPERATURE  CHART. 

Temperature  Chart.  Prepared  by  D.  T.  Laine,  M.D.  Size  8x13^ 
inches.  A  conveniently  arranged  Chart  for  recording  Temperature, 
with  columns  for  daily  amounts  of  Urinary  and  Fecal  Excretions, 
Food,  Remarks,  etc.  On  the  back  of  each  chart  is  given  in  full  the 
method  of  Brand  in  the  treatment  of  Typhoid  Fever.  Price,  per  pad 
of  25  charts,  50  cents  net. 

"  To  the  busy  practitioner  this  chart  will  be  found  of  great  value  in  fever  cases,  and 
especially  for  cases  of  typhoid.'" — Indian  Lancet,  Calcutta. 

LEVY   AND    KLEMPERER'S   CLINICAL  BACTERIOLOGY. 

The  Elements  of  Clinical  Bacteriology.  By  Dr.  Ernst  Lew,  Profes- 
sor in  the  University  of  Strassburg,  and  Felix  Klf.mperer,  Privat  docent 
in  the  University  of  Strassburg.  Translated  and  edited  by  Augustus 
A.  Eshxer,  M.D.,  Professor  of  Clinical  Medicine  in  the  Philadelphia 
Polyclinic.     Octavo,  440  pages,  fully  illustrated.     Cloth,  $2.50  net. 

LOCKWOOD'S  PRACTICE  OF  MEDICINE. 

A  Manual  of  the  Practice  of  Medicine.  By  George  Roe  Lock- 
wood,  M.D.,  Professor  of  Practice  in  the  Woman's  Medical  College 
of  the  New  York  Infirmary,  etc.  935  pages,  with  75  illustrations  in 
the  text,  and  22  full-page  plates.     Cloth,  $2.50  net. 

"Gives  in  a  most  concise  manner  the  points  essential  to  treatment  usually  enumerated 
in  the  most  elaborate  works." — Massachusetts  Medical  Journal. 

LONG'S  SYLLABUS  OF  GYNECOLOGY. 

A  Syllabus  of  Gynecology,  arranged  in  Conformity  with  "  An 
American  Text-Book  of  Gynecology."     By  J.   W.    Long,   M.D  . 

Professor  of  Diseases  of  Women  and  Children,  Medical  College  of 
Virginia,  etc.      Cloth,  interleaved,  §1.00  net. 

"The  book  is  certainlv  an  admirable  resume  of  what  .-very  gynecological  student  and 
practitioner  should  kwow,  and  will  prove  of  value  not  only  to  those  who  hav^  the  '  American 
Text-Book  of  Gynecology,'  but  to  others  as  well." — Brooklyn  Medical  Journal. 

2 


Medical  Publications  of  ^Y.  B.  Saunders  &  Co. 


MACDONALD'S  SURGICAL  DIAGNOSIS  AND  TREATMENT. 

Surgical  Diagnosis  and  Treatment.  By  J.  W.  Macdonald,  M.D. 
Edin.,  F.R.C.S.,  Edin.,  Professor  of  the  Practice  of  Surgery  and  of 
Clinical  Surgery  in  Hamline  University;  Visiting  Surgeon  to  St. 
Barnabas'  Hospital,  Minneapolis,  etc.  Handsome  octavo  volume  of 
800  pages,  profusely  illustrated.  Cloth,  $5.00  net;  Half  Morocco, 
$6.00  net. 

"  A  thorough  and  complete  work  on  surgical  diagnosis  and  treatment,  free  from  pad- 
ding, full  of  valuable  material,  and  in  accord  with  the  surgical  teaching  of  the  day." — The 
Medical  Neivs,  New  York. 

••  The  work  is  brimful  of  just  the  kind  of  practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  bock  because  of  its  intrinsic 
valuo  to  the  medical  practitioner."  —  Cincinnati  Lancet- Clinic 

MALLORY  AND  WRIGHT'S  PATHOLOGICAL  TECHNIQUE. 

Pathological  Technique.  A  Practical  Manual  for  Laboratory  Work 
in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies.  By  Frank 
B.  Mallorv,  A.M.,  M.D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  K.  Wright,  A.M., 
M.D.,  Instructor  in  Pathology,  Harvard  University  Medical  School, 
Boston.  Octavo  volume  of  396  pages,  handsomely  illustrated.  Cloth, 
$2.50  net. 

"  I  have  been  looking  forward  to  the  publication  of  this  book,  and  I  am  glad  to  say  that 
I  find  it  to  be  a  most  useful  laboratory  ami  post-mortem  guide,  full  of  practical  information, 
and  well  up  to  date.'" — William  II.  Welch,  Professor  of  Pathology,  Johns  Hopkins  I  di- 
versity, Baltimore-,  Mid. 

MARTIN'S  MINOR  SURGERY,  BANDAGING,  AND  VEINEREAL 
DISEASES.  Second  Edition,  Revised. 
Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of 
C-eni  to  -Urinary  Diseases,  University  of  Pennsylvania,  etc.  Crawn 
01  tavo,  [66  pair's,  with  78  illustrations.  Cloth,  $1.00  net;  interleaved 
for  notes,  $1.25  net. 

[See  Sounders'  Question- Compends}  page  23.] 

'•  A  very  practical  and  systematic  study  of  the  subjects,  and  shows  the  author's  famil- 
iarity with  the  oeeds  of  students." — Therapeutic  Gazette. 

MARTIN'S  SURGERY.     Seventh  Edition,  Revised. 

Essentials  of  Surgery.  Containing  also  Venereal  Diseases,  Surgi- 
cal Landmarks,  Minor  and  Operative  Surgery,  and  a  complete  de- 
scription, with  illustrations,  of  the  Handkerchief  and  Roller  Bandages. 
By  Edward  Martin,  A.M.,  M.D.,  Clinical  Professor  of  Genito- 
urinary I )imm  -..  Univei  it)  1  Pennsylvania,  etc.  Crown  octavo,  342 
es,  illustrated  V\  ith  an  Appendix  on  the  preparation  of  the  materials 
din   Antiseptic  Sui  ,  and  a  chapter  on  Appendicitis.    Cloth, 

o  net;  interleaved  for  notes,  $1.25  net 

Saunders*  Question-  Compends,  page  23.] 

•    sentials  of  modern  surgery  in  a  comparatively  small  space. 
t,  an  1  its  illustrations  are  admirable." — Medical  and  Surgical  Ret 


Medical  Publications  of  W.  B.  Saunders  &  Co.       1!» 


McFARLAND'S  PATHOGENIC  BACTERIA.  Second  Edition,  Re- 
vised and  Greatly  Enlarged. 
Text=Book  upon  the  Pathogenic  Bacteria.  By  Joseph  McFar- 
LANDj  M.  I).,  Professor  of  Pathology  and  Bacteriology  in  the  Medico- 
Chirurgical  College  of  Philadelphia,  etc.  Octavo  volume  of  497  pages, 
finely  illustrated.     Cloth,  $2.50  net. 

"  Dr.  McFarland  has  treated  the  subject  in  a  systematic  manner,  and  has  succeeded  in 
presenting  in  a  concise  and  readable  form  the  essentials  of  bacteriology  up  to  date.  Alto 
gether,  the  book  is  a  satisfactory  one,  and  I  shall  take  pleasure  in  recommending  it  to  the 
students  of  Trinity  College." — H.  B.  Anderson,  M.D. ,  Professor  of  Pathology  and  Bac- 
teriology, Trinity  Medical  College,  Toronto. 

MEIGS  ON  FEEDING  IN  INFANCY. 

Feeding  in  Early  Infancy.  By  Arthur  V.  Meigs,  M.D.  Bound 
in  limp  cloth,  flush  edges,  25  cents  net. 

"  This  pamphlet  is  worth  many  times  over  Its  price  to  the  physician.  The  author's 
experiments  and  conclusions  are  original,  and  have  been  the  means  of  doing  much  good." — 
Medical  Bulletin. 

MOORE'S  ORTHOPEDIC  SURGERY. 

A  Manual  of  Orthopedic  Surgery.  By  James  E.  Moore,  M.D., 
Professor  of  Orthopedics  and  Adjunct  Professor  of  Clinical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo 
volume  of  356  pages,  handsomely  illustrated.      Cloth,  $2.50  net. 

"A  most  attractive  work.  The  illustrations  and  the  care  with  which  the  book  is  adapted 
to  the  wants  of  the  general  practitioner  and  the  student  are  worthy  of  great  praise." — Chicago 
Medical  Recorder. 

"A  very  demonstrative  work,  every  illustration  of  which  conveys  a  lesson.  The  work  is 
a  most  excellent  and  commendable  one,  which  we  can  certainly  endorse  with  pleasure." — 
St,  Louis  Medical  and  Surgical  Journal. 

MORRIS'S  MATERIA  MEDICA  AND  THERAPEUTICS.  Fifth 
Edition,  Revised. 
Essentials  of  Materia  Medica,  Therapeutics,  and  Prescription- 
Writing.  By  Henry  Morris,  M.D.,  late  Demonstrator  of  Thera- 
peutics, Jefferson  Medical  College,  Philadelphia;  Fellow  of  the  College 
of  Physicians,  Philadelphia,  etc.  Crown  octavo,  288  pages.  Cloth, 
$1.00  net;  interleaved  for  notes,  $1.25  net. 

[See  Saunders''  Question- Compends,  page   22.] 

"This  work,  already  excellent  in  the  old  edition,  has  been  largely  improved  by  reyi- 
sion." — American  Practitioner  and  News. 

MORRIS,  WOLFF,  AND  POWELL'S  PRACTICE  OF  MEDICINE. 
Third  Edition,  Revised. 
Essentials  of  the  Practice  of  Medicine.  By  Henry  Morris,  M.D., 
late  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia ;  with  an  Appendix  on  the  Clinical  and  Microscopic  Examina- 
tion of  Urine,  by  Lawrence  Wolff,  M.D.,  Demonstrator  of  Chemistry, 
Jefferson  Medical  College,  Philadelphia.  Enlarged  by  some  300  essen- 
tial formulae  collected  and  arranged  by  William  M.  Powell,  M.D. 
Post-octavo,  488  pages.      Cloth,  51.50  net. 

[See  Saunders'   Question- Compends,  page    22. ] 

"  The  teaching  is  sound,  the  presentation  graphic  ;  matter  full  as  can  be  desired,  rvac, 
style  attractive." — American  Practitioner  and  News. 


20       Medical  Publications  of  W.  B.  Saunders  &  Co. 

MORTEN'S  NURSE'S  DICTIONARY. 

Nurse's  Dictionary  of  Medical  Terms  and  Nursing  Treat- 
ment. Containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms  and  Abbreviations;  of  the  Instruments,  Drugs,  Diseases,  Acci- 
dents, Treatments,  Operations,  Foods,  Appliances,  etc.  encountered 
in  the  ward  or  in  the  sick-room.  By  Honnor  Morten,  author  of 
"  How  to  Become  a  Nurse,"  etc.     i6mo,  140  pages.    Cloth,  $1.00  net. 

"  A  handy,  compact  little  volume,  containing  a  large  amount  of  general  information,  all 
of  which  is  arranged  in  dictionary  or  encyclopedic  form,  thus  facilitating  quick  reference. 
It  is  certainly  of  value  to  those  for  whose  use  it  is  published." — Chicago  Clinical  Keznew. 

NANCREDE'S  ANATOMY.  Sixth  Edition,  Thoroughly  Revised. 
Essentials  of  Anatomy,  including  the  Anatomy  of  the  Viscera. 
By  Charles  B.  Nancrede,  M.D.,  LL.D.,  Professor  of  Surgery  and 
of  Clinical  Surgery  in  the  University  of  Michigan,  Ann  Arbor.  Crown 
octavo,  420  pages:  151  illustrations.  Based  upon  Grafs  Anatomy. 
Cloth,  $1.00  net;  interleaved  for  notes,  $1.25  net. 

[See  Saunders1  Question-  Compends,  page  23.] 

"  For  self-quizzing  and  keeping  fresh  in  mind  the  knowledge  of  anatomy  gained  at 
school,  it  would  not  be  easy  to  speak  of  it  in  terms  too  favorable." — American  Practitioner. 

NANCREDE'S  ANATOMY  AND  DISSECTION.     Fourth  Edition. 
Essentials  of  Anatomy  and    Manual  of    Practical    Dissection. 

By  Charles  1!.  Nancrede,  M.D.,  LL.D.,  Professor  of  Surgery  and  of 
Clinical  Surgery,  University  of  Michigan,  Ann  Arbor.  Post-octavo; 
500  pages,  with  full-page  lithographic  plates  in  colors,  and  nearly  200 
illustrations.     Extra  Cloth  (or  Oilcloth  for  dissection-room),  $2.00  net. 

"  It  may  in  many  respects  be  considered  an  epitome  of  Gray's  popular  work  on  general 
anatomy,  at  the  same  time  having  sonic  distinguishing  characteristics  of  its  own  to  commend 
it.  The  plates  are  of  more  than  ordinary  excellence,  and  are  of  especial  value  to  students 
in  their  work  in  the  dissecting  room'.'' — Journal  of  the  American  Medical  Association. 

NANCREDE'S  PRINCIPLES  OF  SURGERY. 

Lectures  on  the  Principles  of  Surgery.  By  Chas.  B.  Nancrede, 
M.D  .  LL.D.,  Professor  of  Surgery  and  of  Clinical  Surgery,  Univer- 
sity of  Michigan,  Ann  Arbor.  Octavo  volume  of  398  pages,  illustrated. 
Cloth,  52. 50  net. 

NORRIS'S  SYLLABUS  OF  OBSTETRICS.  Third  Edition,  Revised, 
Syllabus  of  Obstetrical  Lectures  in  the  Medical  Department 
of  the  University  of  Pennsylvania.  By  Richard  C.  Norkis, 
A.M.,  M.D.,  Demonstrator  of  Obstetrics,  University  of  Pennsylvania. 
Crown  octavo,  222  pages.      Cloth,  interleaved  for  notes,  $2.00  net. 

PENROSE'S  DISEASES  OF  WOMEN.     Third  Edition,  Revised. 
A  Text-Book  of  Diseases  of  Women.     By  Charles  B.   Penrose, 
M.I).,   Ph.D.,   Formerly   Professor  of  Gynecology  in  the   University 
of   Pennsylvania;    Surgeon   to  tin-  Gynecean    Hospital,    Philadelphia. 
Octavo  volume  of  531  pages,  handsomely  illustrated.    Cloth,  $3.75  not. 

"I   shall  value  very    highly  the  copy  of    Penro         '  Diseases  of  Women'   received. 
ommended  it  to  my  class  as  THE  BEST  book." — Howard  A.  Kelly, 

I'rofessor  oj  and  Obstetrics,  Johns  Hopkins  I  .   Baltimore,  Md. 


Medical  Publications  of  W.  B.  Saunders  <$:  Co.      21 


POWELL'S  DISEASES  OF  CHILDREN.     Second   Edition. 

Essentials  of  Diseases  of  Children.  By  William  M.  Powell, 
M.D.,  Attending  Physician  to  the  Mercer  House  for  Invalid  Women 
at  Atlantic  City,  X.  J.  ;  late  Physician  to  the  Clinic  for  the  Diseases  of 
Children  in  the  Hospital  of  the  University  of  Pennsylvania.  Crown 
octavo,  222  pages.     Cloth,  $i.oonet;  interleaved  for  notes,  Si. 25  net. 

[See  Saunders1  Question- CompenJs,  page   21.] 

"Contains  the  gist  of  all  the  best  works  in  the  department  to  which  it  relates."— 
American  Practitioner  and  News, 

PRINGLE'S  SKIN  DISEASES  AND  SYPHILITIC  AFFECTIONS. 
Pictorial  Atlas  of  Skin  Diseases  and  Syphilitic  Affections 
(American  Edition).  Translation  from  the  French.  Edited  by 
J.  J.  Pringle,  M.B.,  F.R.C.P.,  Assistant  Physician  to  the  Middlesex 
Hospital,  London.  Photo-lithochromes  from  the  famous  models  in 
the  Museum  of  the  Saint-Louis  Hospital,  Paris,  with  explanatory  wood- 
cuts and  text.  In  12  Parts.  Price  per  Part,  S3. 00.  Complete  in 
one  volume,  Half  Morocco  binding,  S4°-°o  net. 

"  I  strongly  recommend  this  Atlas.  The  plates  are  exceedingly  well  executed,  and 
ivill  be  of  great  value  to  all  studying  dermatology." — Stephen  Mackenzie,  M.D. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — Xew  York  Medical  Journal. 

PRYOR— PELVIC  INFLAMMATIONS. 

The  Treatment  of    Pelvic  Inflammations  through  the  Vagina. 

By  W.  R.  Pryor,  M.D.,  Professor  of  Gynecology  in  New  York  Poly- 
clinic.     i2mo,  248  pages,  handsomely  illustrated.     Cloth,  $2.00  net. 

"This  subject,  which  has  recently  been  so  thoroughly  canvassed  in  high  gynecological 
circles,  is  made  available  in  this  volume  to  the  general  practitioner  and  student.  Nothing  is 
too  minute  for  mention  and  nothing  is  taken  for  granted  ;  consequently  the  book  is  of  the  utmost 
value.    The  illustrations  and  the  techniqueare  beyond  criticism.'" — Chicago  Medical  Recorder. 

PYE'S  BANDAGING. 

Elementary  Bandaging  and  Surgical  Dressing.  With  Direc- 
tions concerning  the  Immediate  Treatment  of  Cases  of  Emergencv. 
For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S.,  late 
Surgeon  to  St.  Mary's  Hospital,  London.  Small  nmo,  with  over  8c 
illustrations.      Cloth,  flexible  covers,  75  cents  net. 

"The  directions  are  clear  and  the  illustrations  are  good." — London  Lancet. 
"  The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  port- 
able, although  the  paper  and  type  are  good." — British  Medical  Journal. 

RAYMOND'S  PHYSIOLOGY. 

A  Manual  of  Physiology.  By  Joseph  H.  Raymond,  A.M.,  M.D., 
Professor  of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in 
the  Long  Island  College  Hospital;  Director  of  Physiology  in  the 
Hoagland  Laboratory,  etc.  382  pages,  with  102  illustrations  in  the 
text,  and  4  full-page  colored  plates.     Cloth,  $1.25  net. 

"  Extremely  well  gotten  up.  and  the  illustrations  have  been  selected  with  care.  The 
text  is  fully  abreast  with  modern  physiology." — British  Medical  Journal. 


Saunders' 
Question 
Compends 


Arranged  in  Question  and 
Answer  Form. 


qpHE  MOST  COMPLETE  AND  BEST 
ILLUSTRATED  SERIES  OF 

COMPENDS  EVER  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature  .... 

with  Students  and  Practitioners  in  every  City  of  the  United  States  and  Canada. 


O*- 


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-o 


THE  REASON  WHY. 

They  are  the  advance  guard  of  "Student's  Helps" — that  DO  HELP.  They  are  the 
ei  ial  line,  well  and  authoritatively  written  by  able  men,  who,  as  teachersin 
the  large  colleges,  know  exactly  what  is  wanted  by  a  student  preparing  for  his  examinations. 
The  ju.l  I  in  the  selei  tion  of  authors  is  fully  demonstrated  by  their  professional 

standing.  Chosen  from  the  ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of 
them  have  become  Professors  and  Lecturers  in  their  respective  colleges. 

I  h  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250  pages, 
profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  <>n  fine  paper. 

The  'mi!  numbering  twenty-three  volumes,  has  been  kept  thoroughly  revised 

and  enlarged  when  necessary,  many  of  the  books  being  in  their  fifth  and  sixth  editions. 

TO  SUM  UP. 

Alt!  n  ther  Quizzes,  Manuals,  Aids,  etc.  in  the  market,  none  of 

h  the   "  l;'  |"   and    tlie   claim    is   made  for  the 

■  ■:    •    cell  nee  : 
1.     I  1  distinction  and  reputation  of  authors. 

and  sounds  tment. 

3.    Quality  of  illustrations,  paper,  printing,  and  binding. 

Any  of  these  Compends  will  be   mailed  on  receipt  of  price  (see  next  page  for  List). 


oaunders'  (^uestion-Compend  beries* 

Price,  Cloth,  $1.00  net  per  copy,  except  when  otherwise  ordered. 

"Where   the  work   of  preparing  students'  manuals   is   to  end  we   cannot   say,  but   the 
Saunders  Series,  in  our  opinion,  bears  off  the  palm  at  present."—  New  York  Medical  Record. 


1.  ESSENTIALS  OF  PHYSIOLOGY.     By  H.  A.  Hare,  M.D.    Fourth  edition, 

revised  and  enlarged. 

2.  ESSENTIALS  OF  SURGERY.     By  Edward  Martin,  M.  D.     Seventh  edition, 

revised,  with  an  Appendix  and  a  chapter  on  Appendicitis. 

3.  ESSENTIALS   OF   ANATOMY.      By  Chart.es  B.   Nancrede,  M.D.      Sixth 

edition,  thoroughly  revised  and  enlarged. 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

By  Lawrence  Wolff,  M.D.     Fifth  edition,  revised. 

5.  ESSENTIALS  OF  OBSTETRICS.     By  W.  Easterly  Ashton,  M.D.     Fourth 

edition,  revised  and  enlarged. 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY.     By  C.  E. 

Armand  Semple,  M.D. 

7.  ESSENTIALS  OF   MATERIA  MED1CA,  THERAPEUTICS,  AND   PRE- 

SCRIPTION=WRITING.    By  Henry  Morris,  M.D.       Fifth  edition,  revised. 

8.  9.    ESSENTIALS   OF    PRACTICE    OF   MEDICINE.      By   Henry   Morris, 

M.D.  An  Appendix  on  Urine  Examination.  By  Lawrence  Wolff,  M.D. 
Third  edition,  enlarged  by  some  300  Essential  Formulae,  selected  from  eminent 
authorities,  by  Wm.  M.  Powell,  M.D.     (Double  number,  $'1.50  net.) 

10.  ESSENTIALS  OF  GYN/ECOLOGY.      By  Edwin  B.  Cragin,  M.D.      Fourth 

edition,  revised. 

11.  ESSENTIALS  OF  DISEASES  OF  THE  SKIN.     By  Henry  W.  Stelwagon, 

M.D.     Fourth  edition,  revised  and  enlarged. 

12.  ESSENTIALS  OF  MINOR  SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.     By  Edward  Martin,  M.D.     Second  ed.,  revised  and  enlarged. 

13.  ESSENTIALS  OF  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

By  C.  E.  Armand  Semple,  M.D. 

14.  ESSENTIALS  OF   DISEASES  OF  THE   EYE,  NOSE,  AND  THROAT. 

By  Edward  Jackson,  M.D.,  and  E.  B.  Gleason,  M.D.     Second  ed.,  revised. 

15.  ESSENTIALS  OF  DISEASES  OF  CHILDREN.     By  William  M.  Powell, 

M.  D.     Second  edition. 

16.  ESSENTIALS   OF   EXAMINATION   OF   URINE.     By   Lawrence  Wolff, 

M.D.     Colored  "  Vogel  Scale."      (75  cents  net.) 

17.  ESSENTIALS  OF  DIAGNOSIS.     By  S.  Solis  Cohen,  M.D.,  and  A.  A.  Eshner, 

M.D.      Second  edition,  thoroughly  revi 

18.  ESSENTIALS  OF  PRACTICE   OF   PHARMACY.     By   Lucius   E.    Sayre. 

Second  edition,  revised  and  enlarged. 

20.  ESSENTIALS  OF  BACTERIOLOGY.     By  M.  V.  Ball,  M.D.     Third  edition, 

revised. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.     By  John  C. 

Shaw,  M.D.     Third  edition,  revised. 

22.  ESSENTIALS  OF   MEDICAL  PHYSICS.      By    Fred  J.    Brockway,   M.D. 

Second  edition,  revised. 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.    By  David  D.  Stewart,  M.D., 

and  Edward  S.  Lawrance,  M.D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE   EAR.      By  E.  B.  Glkason,  M.D. 

Second  edition,  revised  and  greatly  enlarged. 


Pamphlet  containing  specimen  pages,  etc.  sent  free  upon  application. 


.  **00 


Saunders" 

New  Series 
of  Manuals 


for  Students 
and 
Practitioners, 


'  I  'riAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading  branches 
of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the  favor  with  which 
the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been  received  by  medical 
students  and  practitioners  and  by  the  Medical  Press.  These  manuals  are  not  merely 
condensations  from  present  literature,  but  are  ably  written  by  well-known  authors 
and  practitioners,  most  of  them  being  teachers  in  representative  American  colleges. 
Each  volume  is  concisely  and  authoritatively  written  and  exhaustive  in  detail,  without 
being  encumbered  with  the  introduction  of  "cases,"  which  so  largely  expand  the 
ordinary  text-book.  These  manuals  will  therefore  form  an  admirable  collection  of 
advanced  lectures,  useful  alike  to  the  medical  student  and  the  practitioner:  to  the 
latter,  too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
wants  to  know,  they  will  prove  of  inestimable  value ;  to  the  former  they  will  afford 
safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  OF  MANUALS  are  conceded  to  be  superior 
to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so  much  infor- 
mation in  such  a  concise  and  available  form.  A  liberal  expenditure  has  enabled  the 
publisher  to  render  the  mechanical  portion  of  the  work  worthy  of  the  high  literary 
■tondard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page  for  List). 


Saunders'  New  Series  of  Manuals* 


VOLUMES    PUBLISHED. 

PHYSIOLOGY.  By  Joseph  Howard  Raymond,  A.M.,  M.D.,  Professor  of  Physiolog> 
and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long  Island  College  Hospital; 
Director  of  Physiology  in  the  lloagland  Laboratory,  etc.     Illustrated.     Cloth,  $1.25  net. 

SURGERY,  General  and  Operative.— By  John  Chalmers  DaCosta,  M.D.,  Pro- 
fessor of  Practice  of  Surgery  and  Clinical  Surgery,  Jefferson  Medical  College,  Philadel- 
phia; Surgeon  to  the  Philadelphia  Hospital,  etc.  Second  edition,  thoroughly  revised 
and  greatlv  enlarged.  Octavo,  91 1  pages,  profusely  illustrated.  Cloth,  $4.00  net; 
Half  Morocco,  $5.00  net. 

DOSE-BOOK    AND    MANUAL    OF    PRESCRIPTION=WRITING.      By   E.    Q. 

Thornton,   M.D.,  Demonstrator  of  Therapeutics,  Jefferson  Medical  College,  Phila- 
delphia.    Illustrated.      Cloth,  31.25  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's  Hospital  and 
to  the  New  York  German  Polildinik,  etc.     Illustrated.      Cloth,  31-25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.D.  Professor  of  Insti- 
tutes of  Medicine  and  Medical  Jurisprudence  in  the  Jefferson  Medical  College  of  Phila- 
delphia.    Illustrated.     Cloth,  3i-5Q  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James  Nevins  Hyde,  M.D., 
Professor  of  Skin  and  Venereal  Disea=<*s,  and  Frank  H.  MONTGOMERY,  M.D., 
Lecturer  on  Dermatology  and  Genito-Urinary  Diseases  in  Rush  Medical  College, 
Chicago.     Second   edition,  thoroughly  revised   and  greatly  enlarged. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.D.,  Professor  of 
Practice  in  the  Woman's  Medical  College  of  the  New  York  Infirmary;  Instructor  in 
Physical  Diagnosis  in  the  Medical  Department  of  Columbia  College,  etc.  Illustrated. 
Cloth,  32.50  net. 

MANUAL  OF  ANATOMY.  By  IRVING  S.  Haynes,  M.D.,  Adjunct  Professor  of 
Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department  of  the  New  York 
University,  etc.      Beautifully  illustrated.      Cloth,  32.50  net. 

MANUAL   OF  OBSTETRICS.      By   W.  A.    Newman    Dorland,    M.D,   Assistant 

Demonstrator  of  Obstetrics,  University  of  Pennsylvania;  Chief  of  Cynecological  Dis- 
pensary, Pennsylvania  Hospital,  etc.     Profusely  illustrated.     Cloth,  S2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton.  F.  R.  C.S.,  Assistant  Surgeon  to 
Middlesex  Hospital  and  Surgeon  to  Chelsea  Hospital,  London;  and  ARTHUR  E. 
Giles,  M.  D.,  B.Sc.  Lond.,  F.R.C.S.  Edin.,  Assistant  Surgeon  to  Chelsea  Hospital, 
London.     Handsomely  illustrated.     Cloth,  32.50  net. 


VOLUMES   IN  PREPARATION. 

NERVOUS  DISEASES.     By  Charles  W.  Burr,  M.D.,  Clinical  Professor  of  Nervous 
Diseases,    Medico-Chirurgical  College.   Philadelphia;    Pathologist  to   the   Orthopaedic 
Hospital  and   Infirmary  for  Nervous   Diseases;  Visiting  Physician  to  the  St   ] 
I  lospital,  etc. 

***  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully-prepared  worJck 
on  various  subjects  by  prominent  specialists. 


Pamphlet  containing  specimen  pages,  etc.  sent  free  upon  application. 


Medical  Publications  of  W.  B.  Snunders  &  Co. 


S  AUNDBY'S  RENAL  AND  URINARY  DISEASES. 

Lectures  on  Renal  and  Urinary  Diseases.  By  Robert  Saundby, 
M.D.  Edin.,  Fellow  of  the  Royal  College  of  Physicians,  London,  and 
of  the  Royal  Medico-Chirurgical  Society  ;  Physician  to  the  General 
Hospital ;  Consulting  Physician  to  the  Eye  Hospital  and  to  the  Hos- 
pital for  Diseases  of  Women;  Professor  of  Medicine  in  Mason  College, 
Birmingham,  etc.  Octavo  volume  of  434  pages,  with  numerous  illus- 
trations and  4  colored  plates.     Cloth,  $2.50  net. 

"  The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fortified  by  evidence  drawn  from  the  most  recent  sources.  The  book  may  be  cordially 
recommended." — British  Medical  Journal. 

SAUNDERS'  MEDICAL  HAND=ATLASES. 

For  full  description  of  this  series,  with  list  of  volumes  and  prices,  see 
page  2. 

"  Lehmann  Medicinische  Handatlanten  belong  to  that  class  of  books  that  are  too  good 
to  be  appropriated  by  any  one  nation." — Journal  of  Eye,  Ear,  and  Throat  Diseases. 

"  The  appearance  of  these  works  marks  a  new  era  in  illustrated  English  medical 
works." — The  Canadian  Practitioner. 

SAUNDERS'   POCKET  MEDICAL   FORMULARY.     Sixth  Edition, 

Revised. 

By  William  M.  Powell,  M.D.,  Attending  Physician  to  the  Mercer 
House  for  Invalid  Women  at  Atlantic  City,  N.  J.  Containing  1800 
formulas  selected  from  the  best-known  authorities.  With  an  Appen- 
dix containing  Posological  Table,  Formulas  and  Doses  for  Hypo- 
dermic Medication,  Poisons  and  their  Antidotes,  Diameters  of  the 
Female  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet  List  for  Various 
Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment 
of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables  of 
Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  flexible  morocco,  with  side  index,  wallet,  and  flap. 
$1.75  net. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and,  as  the  name  of  the  author  of  each  prescription 
is  given,  is  unusually  reliable." — Medical  Record,  New  York. 

SAYRE'S  PHARMACY.     Second  Edition,  Revised. 

Essentials  of  the  Practice  of  Pharmacy.  By  Lucius  E.  Sayre, 
M.D.,  Professor  of  Pharmacy  and  Materia  Medica  in  the  University  of 
Kan  a  .  Crown  octavo,  200  pages.  Cloth,  $1.00  net;  interleave<  for 
notes,  Si. 2 5  net. 

[See  Saunders1  Question-  Compends,  page  21.] 

"The  topics  are  treated  in  a  simple,  prai  tii  al  manner,  and  the  work  forms  a  very  useful 
student's  manual." — Boston  Medical  and  Surgical  Journal. 

SCUDDER'S  FRACTURES. 

The    Treatment  of    Fractures.      B)    CHAS.    L.    SCUDDER,  M.D.,    \s- 

in    Clinical  and  Operative  Surgery,   Harvard  Medical  School. 

:  •  ;  vith  nearly  600  original  illustrations.    Cloth,  $4.50 


Medical  Publications  of  W.  B.  Saunders  &  Co. 


SEMPLE'S  LEGAL  MEDICINE,  TOXICOLOGY,  AND  HYGIENE. 

Essentials  of    Legal    Medicine,  Toxicology,  and   Hygiene.     By 

C.  E.  Armand  Semple,  B.  A.,  M.  B.  Cantab.,  M.  R.  C.  P.  Lond., 
Physician  to  the  Northeastern  Hospital  for  Children,  Hackney,  etc. 
Crown  octavo,  212  pages;  130  illustrations.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  $1.25  net. 

[See  Saunders'  Question- Compends,  page  21.] 

"  No  general  practitioner  or  student  can  afford  to  be  without  this  valuable  work.  The 
subjects  are  dealt  with  by  a  masterly  hand." — London  Hospital  Gazette. 

SEMPLE'S  PATHOLOGY  AND  MORBID  ANATOMY. 

Essentials    of    Pathology    and    Morbid    Anatomy.      By  C.    E. 

Armand  Semple,  B.A.,  M.B.  Cantab.,  M.R.C.P.  Lond.,  Physician  to 
the  Northeastern  Hospital  for  Children,  Hackney,  etc.  Crown  octavo,  1 74 
pages;  illustrated.     Cloth,  $1.00  net;  interleaved  for  notes,  #1.25  nl. 

[See  Saunders"  Question- Compends,  page  21.] 

"  Should  take  its  place  among  the  standard  volumes  on  the  bookshelf  of  both  student 
and  practitioner." — London  Hospital  Gazette. 

SENN'S  GENITOURINARY  TUBERCULOSIS. 

Tuberculosis  of  the  Genito=Urinary  Organs,  Male  and  Female. 

By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D.,  Professor  of  the  Practice  of 
Surgery  and  of  Clinical  Surgery,  Rush  Medical  College,  Chicago. 
Handsome  octavo  volume  of  320  pages,  illustrated.     Cloth,  $3.00  net. 

"  An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reporter. 

"  A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

SENN'S  SYLLABUS  OF  SURGERY. 

A  Syllabus  of  Lectures  on  the  Practice  of  Surgery,  arranged 
in  conformity  with  »  An  American  Text=Book  of  Surgery."    By 

Nicholas  Seen,  M.  D.,  Ph.D.,  Professor  of  the  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College,  Chicago.     Cloth,  $1.50  net. 

"  This  syllabus  will  be  found  of  service  by  the  teacher  as  well  as  the  student,  the  work 
being  superbly  done.  There  is  no  praise  too  high  for  it.  No  surgeon  should  be  without 
it. " — New  York  Medical  Times. 

SENN'S  TUMORS.     Second   Edition,   Revised. 

Pathology  and  Surgical  Treatment  of  Tumors.  By  \.  Si  w, 
M.D,  Ph.D.,  LL.I).,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Rush  Medical  College;  Professor  of  Surgery,  <  hicago  Polyclinit  ; 
Attending  Surgeon  to  Presbyterian  Hospital;  Surgeon-in-Chief,  St. 
Joseph's  Hospital,  Chicago.  Second  Edition ,  Thoroughly  Revised.  0< 
tavo  volume  of  718  pages,  with  478  illustrations,  including  1:  full  ] 
plates  in  colors.      Prices:   Cloth,  $5.00  net  ;   Hall  Mot $6.00  net. 

"  The  most  exhaustive  of  any  recent  book  in  1  ■  a  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  a.s  ihc  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  and  the  author  has  given  a 
notable  and  lasting  contribution  to  surgery.'' — •Journal  of  the  American  'ion. 


Medical  Publications  of  W.  B.  Saunders  &  Co. 

SHAW'S  NERVOUS  DISEASES  AND  INSANITY.  Third  Edition, 
Revised. 
Essentials  of  Nervdus  Diseases  and  Insanity.  By  John  C. 
Shaw.  M.D.,  Clinical  Professor  of  Diseases  of  the  Mind  and  Nervous 
System,  Lohl;  Island  College  Hospital  Medical  School;  Consulting 
Neurologist  to  St.  Catherine's  Hospital  and  to  the  Long  Island  College 
Hospital.  Crown  octavo,  186  pages;  48  original  illustrations.  Cloth, 
$1.00  net;  interleaved  for  notes,  si. 25  net. 

[See  Saunders'  Question- Coinpends,  page  21.] 

"Clearly  and  intelligently  written." — Boston  Medical  and  Surgical  Journal. 
"There  is  a  mass  of  valuable  material  crowded  into  this  small  compass." — American 
Medico-Surgical  Bulletin. 

STARR'S  DIETS  FOR  INFANTS  AND  CHILDREN. 

Diets  for  Infants  and  Children  in  Health  and  in  Disease.     By 

Louis  Starr,  M.D.,  Editor  of  "An  American  Text-Book  of  the 
Diseases  of  Children."  230  blanks  (pocket-book  size),  perforated 
and  neatly  bound  in  flexible  morocco.      $1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant  life  ;  each 
blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food,  the  latter  directions  being 
left  for  the  physician.  After  the  seventh  month,  modifications  being  less  necessary,  the  diet 
lists  are  printed  in  full.      Formulae  for  the  preparation  of  diluents  and  foods  are  appended. 

STELW AGON'S  DISEASES  OF  THE  SKIN.  Fourth  Ed.,  Revised. 
Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.D.,  Clinical  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia;  Dermatologist  to  the  Philadelphia  Hospital; 
Physician  to  the  Skin  Department  of  the  Howard  Hospital,  etc. 
Crown  octavo,  276  pages;  88  illustrations.  Cloth,  $1.00  net;  inter- 
leaved for  notes,  $1.25  net. 

[See  Saunders'  Question- Compends,  page   21.] 
"  The  best  student's  manual  on  skin  diseases  we  have  yet  seen." — Times  and  Register. 

STENGEL'S  PATHOLOGY.      Second  Edition. 

A  Text- Book  of  Pathology.  By  Alfred  Stengel,  M.D.,  Professor 
of  Clinical  Medicine  in  the  University  of  Pennsylvania ;  Physician  to 
the  Philadelphia  Hospital;  Physician  to  the  Children's  Hospital,  etc. 
II  octavo   volume  of  848  pages,  with   nearly  400   illustrations, 

of   them    in   colors.     Cloth,  #4.00   net;    Half  Morocco,  $5.00 
net. ' 

STEVENS'   MATERIA    MEDICA    AND   THERAPEUTICS.      Second 

Edition,   Revised. 

A  Manual   of    Materia    Medica   and  Therapeutics.       By  A.   A. 

Steven  .  A.M.,  Ml)..   Lecturer  on  Terminology  and    Instructor  in 

Physical  Diagnosis   in  the  University  of   Pennsylvania;    Professor  of 

the  Woman's   Medical  College  oi    Pennsylvania.     Post- 

I  lexible  leather,  $2.00  net. 

•'The  author  has  faithfully  pr<  dern  therapeutii     in  b  comprehensive  work, 

i,„  the  use  ol    tud(  nl  .  il  will  be  found  a  n  liable  guidi  and 
I  i  the  physician  in  practice." — University  Medical  Magazine. 


Medical  Publications  of  W.  B.  Saunders  &  Co.      29 


STEVENS'  PRACTICE  OF  MEDICINE.  Fifth  Edition,  Revised. 
A  Manual  of  the  Practice  of  Medicine.  By  A.  A.  Stevens,  A.  M., 
M.  D.,  Lecturer  on  Terminology  and  Instructor  in  Physical  Diagnosis 
in  the  University  of  Pennsylvania;  Professor  of  Pathology  in  the 
Woman's  Medical  College  of  Pennsylvania.  Specially  intended  for 
students  preparing  for  graduation  and  hospital  examinations.  Post- 
octavo,  519  pages;   illustrated.     Flexible  leather,  $2.00  net. 

"  The  frequency  with  which  new  editions  of  this  manual  are  demanded  bespeaks  its 
popularity.  It  is  an  excellent  condensation  of  the  essentials  of  medical  practice  for  the 
student,  and  maybe  found  also  an  excellent  reminder  for  the  busy  physician." — Buffalo 
Medical  Journal. 

STEWART'S  PHYSIOLOGY.      Third  Edition,  Revised. 

A  Manual  of  Physiology,  with  Practical  Exercises.  For 
Students  and  Practitioners.  By  G.  N.  Stewart,  M.A.,  M.D., 
D.Sc. ,  lately  Examiner  in  Physiology,  University  of  Aberdeen,  and 
of  the  New  Museums,  Cambridge  University ;  Professor  of  Physiology 
in  the  Western  Reserve  University,  Cleveland,  Ohio.  Octavo  volume 
of  848  pages;  300  illustrations  in  the  text,  and  5  colored  plates. 
Cloth,  $3.75  net. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  one 
of  the  very  best  English  text-books  on  the  subject." — London  Lancet. 

"Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so 
nearly  comes  up  to  the  ideal  as  does  Prof.  Stewart's  volume." — British  Medical  Journal. 

STEWART  AND  LAWRANCE'S  MEDICAL  ELECTRICITY. 

Essentials  of  Medical  Electricity.  By  D.  D.  Stewart,  M.D., 
Demonstrator  of  Diseases  of  the  Nervous  System  and  Chief  of  the 
Neurological  Clinic  in  the  Jefferson  Medical  College ;  and  E.  S. 
Lawrance,  M.D.,  Chief  of  the  Electrical  Clinic  and  Assistant  Demon- 
strator of  Diseases  of  the  Nervous  System  in  the  Jefferson  Medical 
College,  etc.  Crown  octavo,  158  pages;  65  illustrations.  Cloth, 
$1.00  net;  interleaved  for  notes,  $1.25  net. 

[See  Saunders'  Questioti-Compends,  page  21.] 

"  Throughout  the  whole  brief  space  at  their  command  the  authors  show  a  discriminating 
knowledge  of  their  subject." — Medical  News. 

STONEY'S  NURSING.     Second  Edition,  Revised. 

Practical  Points  in  Nursing.     For  Nurses  in  Private  Practice. 

By  Emily  A.  M.  Stoney,  Graduate  of  the  Training-School  for  Nurses, 
Lawrence,  Mass.;  late  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  illustrated 
with  73  engravings  in  the  text,  and  8  colored  and  half-tone  plates. 
Cloth,  $1.75  net. 

"There  are  few  books  intended  for  non-professional  readers  which  can  be  so  cordially 
endorsed  by  a  medical  journal  as  can  this  one."  —  Therapeutic  Gazette. 

"  This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  ran 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise,  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — American  J<>um<i!  of  Obstetrics  an 
Women  and  Children. 

"  It  is  a  work  that  the  physician  can  place  in  the  hands  of  hi-  private  aurses  with  th< 
assurance  of  benefit." — Ohio  Medical  Journal. 


Medical  Publications  of  W.  B.  Saunders  &  Co. 


STONEY'S   MATERIA   MEDICA    FOR   NURSES. 

Materia  Medica  for  Nurses.  By  Emily  A.  M.  Stoney,  Graduate  of 
the  Training-School  for  Nurses,  Lawrence,  Mass.  ;  late  Superintendent 
of  the  Training-School  for  Nurses,  Carney  Hospital,  South  Boston,  Mass. 
Handsome  octavo  volume  of  306  pages.      Cloth,  $1.50  net. 

The  present  book  differs  from  other  similar  works  in  several  features,  all  of  which  are 
intended  to  render  it  more  practical  and  generally  useful.  The  general  plan  of  the  contents 
follows  the  lines  laid  down  in  training-schools  for  nurses,  but  the  book  contains  much  use- 
ful matter  not  usually  included  in  works  of  this  character,  such  as  Poison-emergencies, 
Ready  Dose  list.  Weights  and  Measures,  etc.,  as  well  as  a  Glossary,  defining  all  the  terms 
used  in  Materia  Medica,  and  describing  all  the  latest  drugs  and  remedies,  which  have  been 
generally  neglected  by  other  books  of  the  kind. 

SUTTON  AND  GILES'  DISEASES  OF  WOMEN. 

Diseases  of  Women.  By  J.  Bland  Sutton,  F.R.C.S.,  Assistant 
Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital, 
London;  and  Arthur  E.  Giles,  M.D.,  B.Sc.  Lond. ,  F. R. C.S.  Edin., 
Assistant  Surgeon  to  Chelsea  Hospital,  London.  436  pages,  hand- 
somely illustrated.     Cloth,  £2.50  net. 

"The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  day." — Journal  of  the 
American  Medical  Association. 

THOMAS'S  DIET  LISTS.     Second  Edition,  Revised. 

Diet  Lists  and  Sick=Room  Dietary.  By  Jerome  B.  Thomas, 
M.D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and 
Children  and  to  the  Newsboys'  Home;  Assistant  Visiting  Physician  to 
the  Kings  County  Hospital.     Cloth,  $1.25  net.     Send  for  sample  sheet. 

THORNTON'S  DOSE=BOOK  AND  PRESCRIPTION=WRITING. 

Dose=Book  and  Manual  of    Prescription=Writing.       By   E.    Q. 

Thornton,   M.D.,   Demonstrator  of  Therapeutics,  Jefferson  Medical 

College,  Philadelphia.      334  pages,  illustrated.     Cloth,  $1.25  net. 

"  Full  of  practical  suggestions;  will  take  its  place  in  the  front  rank  of  works  of  this 
sort." — Medical  Record,  New  York. 

VAN  VALZAH  AND  NISBET'S  DISEASES  OF  THE  STOMACH. 
Diseases  of  the  Stomach.     By  William  YV.  Van  Valzah,  M.D. , 
Professor  of  General    Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood;  New  York  Polyclinic ;  and  J.  Dougi  vs  Nisbet,  M.D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive 

and  the  Blood,  New  York  Polyclinic.      Octavo  volume  of  674 

llustrated.      Cloth.  S3. 50  net. 

"  Its  chief  claim  lies  in  its  clearnr^  ami  general  adaptability  to  the  practical  needs  of 
the  general  practil  In  tli.-sc  relations  it   i>  probably  the  best  of  the  recent 

special  worl  ,\  the  stomach." — Chicago  Clinical  Review. 

VECKI'S   SEXUAL   IMPOTENCE. 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor 
G.  Vi.  ki.  M  I  >.  From  tip  ...ml  Cerman  edition,  revised  and  en- 
large!     Demi-octavo,  (  loth.  $2.00  n<'t. 

ct  of  impol  eldom  been  treated  in  tbi    country  in  the  truly  scientific 

Dr.  ivorably  known,  and  the  <  lerman 

n       I  In-  .-■mi. -II  1-  trn  1  mil'  translation, 

•  I  .-n  th«  German  edition,  it  has  been  entirely  rewritten  in  English, 


Medical  Publications  of  W.  B.  Saunders  &  Co.      31 


VIERORDT'S  MEDICAL  DIAGNOSIS.  Fourth  Edition,  Revised. 
Medical  Diagnosis.  By  Dr.  Oswald  Vierordt,  Professor  of  Medi- 
cine at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  fifth  enlarged  German  edition,  with  the  author's  permission, 
by  Francis  11.  Stuart,  A.  M.,  M.D.  Handsome  royal  octavo  volume 
of  603  pages;  194  fine  wood-cuts  in  text,  many  of  them  in  colors. 
Cloth,  $4.00  net;  Sheep  or  Half  Morocco,  $5.00  net. 

"  Rarely  is  a  book  published  with  which  a  reviewer  can  find  so  little  fault  as  with  the 
volume  before  us.  Each  particular  item  in  the  consideration  of  an  organ  or  apparatus,  which 
is  necessary  to  determine  a  diagnosis  of  any  disease  of  that  organ,  is  mentioned;  nothing 
seems  forgotten.  The  chapters  on  diseases  of  the  circulatory  and  digestive  apparatus  and 
nervous  system  are  especially  full  and  valuable.  The  reviewer  would  repeat  that  the  book  is 
one  of  the  best — probably  the  best — which  has  fallen  into  his  hands." — University  Medical 
Magazine. 

WATSON'S  HANDBOOK  FOR  NURSES. 

A  Handbook  for  Nurses.  By  J.  K.  Watson,  M.D.,  Edin.  Ameri- 
can Edition,  under  supervision  of  A.  A.  Stevkns,  A.M.,  M.D..  Lecturer 
on  Physical  Diagnosis,  University  of  Pennsylvania.  i2mo,  413  pages, 
73  illustrations.      Cloth,  $1.50  net. 

WARREN'S  SURGICAL  PATHOLOGY.     Second  Edition. 

Surgical  Pathology  and  Therapeutics.  By  John  Collins  Warren, 
M.D.,  LL.D.,  Professor  of  Surgery,  Harvard  Medical  School.  Hand- 
some octavo,  832  pages;  136  relief  and  lithographic  illustrations,  33  in 
colors;  with  an  Appendix  on  Scientific  Aids  to  Surgical  Diagnosis,  and 
a  series  of  articles  on  Regional  Bacteriology.  Cloth,  $5.00  net;  Plait 
Morocco,  $6.00  net. 

"  A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without 
exception,  from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their  coloring 
and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the  barrel 
of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery. 

WOLFF  ON  EXAMINATION  OF  URINE. 

Essentials  of  Examination  of  Urine.  By  Lawrence  Wolff,  M.D., 
Demonstrator  of  Chemistry,  Jefferson  Medical  College,  Philadelphia, 
etc.  Colored  (Vogel)  urine  scale  and  numerous  illustrations.  Crown 
octavo.      Cloth,  75  cents  net. 

[See  Saunders"  Question- Compends,  page  21.] 
"  A  very  good  work  of  its  kind — very  well  suited  to  its  purpose." — Times  and  Rt 

WOLFF'S  MEDICAL  CHEMISTRY.     Fifth  Edition,  Revised. 

Essentials    of    Medical    Chemistry,    Organic    and     Inorganic. 

Containing  also  Questions  on  Medical  Physics,  Chemical   Physiology, 
Analytical    Processes,    Urinalysis,    and    Toxicology.      By    Lawrei 
Wolff,  M.D.,  Demonstrator  of  Chemistry,  Jefferson  Medical  College, 
Philadelphia,  etc.     Crown  octavo,  222  pages.    Cloth,  51.00  net  ;  inter- 
leaved for  notes,  51.25  net. 

[See  Saunders'1   Question-  Compends.  page   21.] 

"The  scope  of  this  work  is  certainly  equal  to  that  of  the  best  course  of  lectures  on 
Medical  Chemistry." — Pharmaceutical  Era. 


CLASSIFIED    LIST 

OF    Till 

Medical  Publications 


W.  B.  SAUNDERS  &  COMPANY, 

925  Walnut  Street,  Philadelphia. 


ANATOMY,  EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A  Text-Book  of  Histology, 
Haynes — A  Manual  of  Anatomy,  .  .  . 
Heisler —  \  Text-Book  of  Embryology, 
Nancrede — Essentials  of  Anatomy,  .  . 
Nancrede — Essentials  of  Anatomy  and 
Mauua;  of  Practical  Dissection,  .  .  . 
Semple  —  1 

BACTERIOLOGY. 

Ball — Essentials  of  P..;  .... 

Crookshank — A   Text- Hook  of  Bacteri- 

ologv,  .  

Frothingham  -Laboratory  Guide,    .    . 
Levy  and  Klemperer's  Clinical   ! 



Mallory    and    Wright  —  Pith' logical 

Technique, 

McFarland—  P  icteria,    .    . 

CHARTS,  DIET-LISTS,  ETC. 

Griffith— I  Jit  Chart,        .    . 

Hart — Diet  in  S  in  Health,  . 

Keen  

Laine  I  bait,       .    . 

Meigs 

Starr  !ren,  . 

Thomas-    ,  

CHEMISTRY    \M>  PHYSICS. 

Brockway- 

.    .    . 
Wolff  mistry, 

CHILDREN. 

An  American  Text-Book  of  Di 

....  

Griffith     I  

Griffi::  hart,   .    .    . 

Mei^' 

Powell      1 

Starr  and  <  Ibildi 

1)1  \d\o-l- 
Cohen  and  Eshner  —  Essentials  of  Di- 


Corwi:.  ... 

Macdonald  a  n  d 



Vien  .    .    . 

DICTION  tRIES. 

... 


10 


EYE,  EAR,  NOSE,  AND  THROAT. 

An  American  Text- Book  of  Diseases 

ol  I  .     Eye,  I   ir,  Nose,  and  Throat,    .  5 

De  Schweinitz  —  Diseases  of  the  Eye, .  12 

Gleason— Essentials  of  Dis.of  the  Ear,  13 

Jackson  — Manual  of  Diseases  of  Eye,  .  16 
Jackson   and    Gleason — Essentials  of 

Diseases  of  the  Eye,  Nose,  and  Throat,  16 

Kyle — Diseases  of  the  Nose  and  Throat,  1 7 

GENITOURINARY. 

An  American  Text-Book  of  Genito- 
urinary ami  Skin  Diseases, 6 

Hyde  and  Montgomery — Syphilis  and 

the  Venereal  Diseases '5 

Martin — Essentials   <>l"   Minor   Surgery, 

Bandaging,  and  Venerea]  1  leases,  .  18 
Saundby — Renal  and  Urinary  Diseases,  26 
Senn  -Genito-Urinaiy  Tuberculosis,  .  27 
Vecki — Sexual   Impotence 30 

GYNECOLOGY. 

American  Text-Book  of  Gynecology,  6 

Cragin — Essentials  of  Gynecology,    .    .  n 

Garrigues — Diseases  of  Women,  ...  13 

Long — Syllabus  of  Gynecology,     ...  17 

Penrose— Diseases  of  Women 20 

Pryor — Pelvic  Inflammations 54 

Sutton  and  Giles  — I  diseases  of  Women,  30 

MATERIA  MEDICA,  PHARMACOL- 
OGY, AM)  THERAPEUTICS. 

An  American  Text-Book  of  Applied 

srapeutics 5 

Butler— Text-Book  of  Materia  Medica, 

Therapeutics  and  Pharmacology, .  .  .  10 
Cerna  —  Notes  on  the  Newer  Remedies,  10 
Griffin  Materia  Med  and  Therapeutics,  14 
Morris  Medica 

and  1  beraj  ....    19 

Saunders'   Pocket    Medical   Formula^ 
Sayre     1  Pharmacy,         .    .    26 

Steven-  |    dica 

and  Therapeutics, 28 

Stoin 

Thornton      1  and   Manual  of 

on-Writing, 30 

MEDICAL   JURISPRI  DENCE   AND 
rOXICOLOGY. 

Chapman — Medii  al   Jurisprudence  and 

.    .    .    .    1  ■  1 
Semple      I                        I  •  gal   Medicine, 



Medical  Publications  of  W.  B.  Saunders  &  Co.      33 


NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Burr — Nervous  Diseases, 9 

Chapin — Compendium  of  Insanity,  .  .  10 
Church    and    Peterson — Nervous  and 

Mental  Diseases, 10 

Shaw — Essentials  of   Nervous  Diseases 

and  Insanity, 28 

NURSING. 

Griffith— The  Care  of  the  Baby,    ...  14 

Hampton — Nursing, 14 

Hart — Diet  in  Sickness  and  in  Health,  15 

Meigs — Feeding  in  Early  Infancy,     .    .  19 

Morten — Nurse's  Dictionary 20 

Stoney — Materia  Medica  for  Nurses,  .    .  30 

Stoney — Practical  Points  in  Nursing,    .  29 

Watson — Handbook  for  Nurses,    ...  31 

OBSTETRICS. 

An  American  Text-Book  of  Obstetrics,  6 

Ashton — Essentials  of  Obstetrics,  ...  8 

Boisliniere — Obstetric  Accidents,  ...  9 

Dorland — Manual  of  Obstetrics,    ...  12 

Hirst — Text-Book  of  Obstetrics,    ...  15 

Norris — Syllabus  of  Obstetrics,  ....  20 


PATHOLOGY. 

An  American  Text-Book  of  Pathology, 

Mallory  and  Wright  —  Pathological 
Technique 

Semple — Essentials  of  Pathology  and 
Morbid  Anatomy, 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 

Stengel — Text-Book  of  Pathology,    .    . 

Warren — Surgical  Pathology  and  Thera- 
peutics,    

PHYSIOLOGY. 

An  American  Text-Book  of  Physi- 
ology,   

Hare — Essentials  of  Physiology,  .  .  . 
Raymond — Manual  of  Physiology,  .  . 
Stewart — Manual  of  Physiology,  .    .    . 

PRACTICE  OF  MEDICINE. 

An  American  Text-Book  of  the  The- 
ory and  Practice  of  Medicine 

An  American  Year-Book  of  Medicine 
and  Surgery,       

Anders — Text-Book  of  the  Practice  of 
Medicine, 

Lockwood — Manual  of  the  Practice  of 
Medicine, 

Morris — Essentials  of  the  Practice  of 
Medicine, 

Stevens — Manual  of  the  Practice  of 
Medicine, 

SKIN  AND  VENEREAL. 

An  American  Text-Book  of  Genito- 
urinary and  Skin  Diseases, 

Hyde  and  Montgomery — Syphilis  and 
the  Venereal  Diseases, 


Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,    . 

Pringle — Pictorial   Atlas   of   Skit 
eases  and  Syphilitic  Affections,   .    . 

Stelwagon— Essentials  of  Diseases  of 
the  Skin, 

SURGERY. 

An  American  Text-Book  of  Surgery, 

An  American  Year-Book  of  Medicine 
and  Surgery 

Beck — Fractures, 

Beck — Manual  of  Surgical  Asepsis,  .    . 

DaCosta — Manual  of  Surgery 

International  Text-Book  of  Surgery,  . 

Keen — Operation  Blank, 

Keen — The  Surgical  Complications  and 
Sequels  of  Typhoid  Fever 

Macdonald — Surgical  Diagnosis  and 
Treatment, 

Martin — Essentials  of  Minor  Surgery, 
Bandaging,  and  Venereal  Diseases,    . 

Martin — Essentials  of  Surgery, .... 

Moore — Orthopedic  Surgery 

Nancrede — Principles  of  Surgery,    .    . 

Pye — Bandaging  and  Surgical  Dressing, 

Scudder — Treatment  of  Fracture-,    .    . 

Senn — I  lenito-Urinary  Tuberculosis,     . 

Senn — Syllabus  of  Surgery 

Senn — Pathology  and  Surgical  Treat- 
ment of  Tumors, 

Warren — Surgical  Pathology  and  Ther- 
apeutics,       


URINE  AND  URINARY  DISEASES. 

Saundby — Renal  and  Urinary  Diseases,  26 
Wolff — Essentials    of    Examination    of 
Urine, 31 


MISCELLANEOUS. 

Abbott — Hygiene  1  f  Transmissible  Dis- 
eases,   

Bastin — Laboratory    Exercises   in    Bot- 
any,             

Gould  and  Pyle — Anomalies  and  Curi- 
osities of  Medicine, 

Grafstrom — Massage 

Keating — How   to    Examine 

Insurance,      

Rowland    and    Hedley— Archives    of 
the  Roenl  

Saunders' Medical  Hand-Atlases,    .2,  j 

Saunders'  New  Series  of  Manuals,     J4. 

Saunders'  Pocket  Medical  Fonnul 

Saunders'  Qjiestion-Cbmpends, 

Senn — Pathology   and                     lreat- 
menl  ol    I  umors 

Stewart  and  Lawrance— Essentials  of 
Medii    II    ectricity 

Thornton  -Dose-Book  and  Manual  of 
...  ... 

Van  Valzah  and  Nisbet  —  Disc  1 
the  Stomach, 


BOOKS  JUST  ISSUED. 

IMli    AMERICAN    ILLUSTRATED   MEDICAL    DICTIONARY. 

For  Students  and  Practitioners.     A  Complete  Dictionary  of  the  Terms  used  in  Medi- 
cine and  the  Allied  Sciences,  with  a  large  number  of  Valuable  Tables  and    Nunv 
Handsome  Illustrations. \  Edited  by  W.  A.  Newman  Dorland,  M.  1).,  Editor  of  the 
Am  I      Icet  Medical   Dictionary.      Handsome  large  octavo,  800  und  in 

full  limp  leather, -ami  printed  on  thin  paper  oi  the  finest  quality,  forming  a  handy 
volume,  only  i#    inches  thick. 

This  is  an  entirely  new  and  unique  work,  intended  to  meet  the  need  of  practitioners  and  students  for  a 
complete,  up-to-date  dictionary  of  moderate  price.  The  book  is  designed  to  furnish  a  maximum  amount  of 
matter  in  a  minimum  space  and  at  the  lowest  possible  cost.  It  contains  double  the  material  in  the  ordinary 
students'  dictionary,  and  yet,  by  the  use  of  a  clear,  condensed  type  and  thin  paper  of  the  finest  quality,  is  only 
i  \  inches  in  thickness.  It  is  bound  in  full  flexible  leather,  and  is  just  the  kind  of  a  book  that  a  man  will  want 
to  keep  on  his  desk  for  constant  reference.  The  book  makes  a  special  feature  of  the  newer  words,  and 
defines  hundreds  of  important  term--  not  to  be  found  in  any  other  dictionary.  It  is  especially  full  in  the 
-.  .  ontaining  more   than   a  hundred  of  great   practical   value.     A  new  feature  is  the  ii 

of  numerous  handsome   illustrations,  many  of  them  in  colors,  drawn   and   engraved  specially  foi  this  1 k. 

ive  been  chosen  with  great  care  and  add  infinitely  to  the  value  of  the  work.     The  book  will  appeal 
to  both   practitioners  and  studen'-.  [es  a  complete  vocabulary,  it  gives  to  the  more  important 

subjects  extended  consideration  of  an  encyclopedic  character. 

BOHM,  DAVIDOFF,  AND    HUBER'S    HISTOLOGY. 

A  Text>Book  of  Human  Histology.  Including  Microscopic  Technic.  By  Dr. 
A.  A.  BbHM  and  I)k.  M.  VON  DAVIDOFF,  of  Munich,  and  G.  C.  HUBER,  M.I>. 
Jun:  of  Anatomy  and  Histology,  University  of  Michigan. 

FRIEDRICH  AND  CURTIS  ON  THE  NOSE,  THROAT,  AND  EAR. 

Rhinology,  Laryngology,  and  Otology  in  their  Relations  to  General 
Medicine,     by  Dr.    E     1'.    FrIedrich,  of  the    University   of  Leipsig.     Edited    by 

II.  HOLBROOK  Cn;ih.  M.  D.,  Consulting  Surgeon  to  the  New  York  Nose  and  Throat 
1 1  spital. 

LEROY'S    HISTOLOGY. 

The  Essentials  of  Histology.  By  Loi  is  Leroy,  M.D..  Professor  of  Histology 
and  Pathology,  Vanderbilt  I  iville,  Tenni 

OGDEN    ON    THE    URINE. 

Clinical  Examination  of  the  Urine.     By  J.  Bergei  M.  D.,  Assistant 

in  '  .  Harvard  Medical  School.     I  landsome  octavo  volume  of  over  408  j 

with  54  iH  tud  1  1  full-page  plates,  many  in  colors. 

PYLE'S   PERSONAL  HYGIENI  . 

\    Manual  of  Personal   Hygiene.     Edited   by  Walter    L.  Pyle,  M.  D.,  Assist 

I         '  '  '■  Ocl  lvo    volume    of   344    j 

full) 

INGER    AND    KALTEYER'S   MODERN   MEDICINE. 

Modern  Medicine.     By   Julii       L.    Salinger,    M.Il.    Demonstj  Clinical 

1      I.    Kalteyer,  M.  D.,  Assistant   Demon- 
1 1  vi  lumi  1  1 

fully  illusti 

-   SUROICAL  TECHNIC   FOR    NURSES. 

1   1  clinic  for  Nurses.  1  wily  a    m.  Stoney,  lat<    Superintei 

:  ■    Its. 


Date  Due 

. 

QFP   4 

1974 

C  l 

1974 

MOI       1 

ir*jn  ^  r\w 

Wt-OL    !  I'JiVHIM 

31Q 

dec  1 : 

JUL  1  * 

U978 

» 

ph.nted.n  u.s.a.              CAT     NO     24    161                SB 

°°0  230  746 


DUU6a 

)eSchveinitz, 
American  texl  -        Lsei 

eye,  err,  nose  and  thrr 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


